You Are An Ironman...

An Ironman is a 140.6 mile race that most would agree is the ultimate test of will and endurance.  2.4 mile swim, 112 mile bike, and 26.2 mile run--it's all a bit crazy isn't it?  Well for the last year everyone in our office has been a witness to the preparation, skill, and unbelievable determination it takes to compete an Ironman Triathlon. My friend, and our co-worker Elise just finished her first and we all couldn't be more proud of her.  I thought this might be a good opportunity to both congratulate Elise, as well as use her as an example of cross-training at its extreme.

We often have patients that are runners, this may consist of anyone from someone training for their first 5K to competitive club triathletes like Elise.  The runner may have a variety of lower leg complaints depending on their level of conditioning.  A few of the most common are anterior knee pain and medial tibial stress syndrome (shin splints).  Anterior knee pain is pain over the front of the knee in the area of the knee cap also know as the patella.

The patella is positioned in the front of the knee and has attachments for the quadriceps tendon at its superior portion and the patellar tendon at its inferior. The patella is involved in the flexing and bending of the knee, and with repetitive motions both the patella and the groove it sits in can become irritated or damaged.  As you can image running is one of these activities, actually any activity that involves flexing your knee puts pressure on the knee cap. Squatting, kneeling, jumping, running, wearing high heels (mom :) all put increased pressure on your patella.  In order to treat pain involving the patella you have to first find the reason for the pain.  This can include weakness in muscle groups around the knee, wear in the cartilage on the patella, patella alignment issues, or even modifying the very activities we love to do.  


Medial Tibial Stress Syndrome (MTSS) is what many of know as shin splints.  Symptoms include a painful inflamed area along the inside border of the shin bone (tibia).  Often the person experiencing these symptoms has recently changed their level of activity in some way.  I personally experienced MTSS in high school basketball after running on our hard court/hallways.  As medical providers we always have to remember to rule out a stress fracture in anyone that has the symptoms of MTSS.  There is too much overlap in the symptoms and if you ignore MTSS it can lead to a stress fracture.  If x-rays are negative for fracture treatment will often consist of ice, rest, stretching, possible physical therapy, and modification of activities, as well as a good foot wear analysis.    

 

Standing with her finisher medal

I always tell you about the conversations I have on a daily basis with patients.  Activity modification is another common topic.  This is where Elise comes to light again--Swim, Bike, then Run.  I am a strong supporter of cross-training to allow the knee to recover after activity.  Runners love to run!  However, for the life of a knee taking miles off of the joint with none pounding exercise like swimming, elliptical, and cycling is important.  I consider these "knee friendly" cardio conditioning.  Perhaps if more of our runners turned into triathletes we would have less knee pain.  Will we ever know?


Next Blog Topic: Osgood Schlatter Disease-It Hurts When I Jump!

Elise crossing the finish line.

Total Knee Replacements--Why so Spooky?

This topic is brought to you by popular demand!  I've had great deal of requests for a topic on total knee replacements or as we call them in the ortho world TKAs (Total Knee Arthroplasty).  TKAs can seem overwhelming and downright SPOOKY if you are faced with the possibility of surgery.  Let's see if we can dust some cobwebs off the common myths about TKAs and reveal the truth hidden underneath!

I have a conversation about the compartments of the knee with patients on a weekly basis, so this may sound familiar to some of you.  The knee is separated into three compartments, the inside of the knee (Medial compartment) outside of the joint (Lateral compartment) and the knee cap joint (Patellofemoral compartment).   The knee may wear in one, two, or all three of those compartments and the amount of wear determines what surgery is recommended.

There are two types of cartilage within the knee. The Meniscus the large shock absorber between the bones and Articular cartilage which covers the ends of the bones.  Articular cartilage acts in a similar way to enamel on our teeth, it in itself does not feel pain, but when it is worn away the bone beneath feels pain.  This is considered arthritis (just like a cavity in your tooth) and can be very painful.

When you have this break down in cartilage in one of the compartments in the knee that one area of the knee can be replaced.  This is called a Unicompartmental Arthroplasty or "Half Knee."   I personally think we should call them "1/3 knee replacements" but my opinion doesn't seem to count for much!  The problem is when individuals begin to develop damage in two sometimes all three compartments of the knee.  This is global or total knee arthritis, and is when surgeons recommend a TKA to replace the entire knee.

By the time a patient needs a total knee replacement it is usually easy to see on xray studies.  As you can see on my background images for the blog the patients' knees are pretty healthy with good space between the thigh bone (femur) and shin bone (tibia).  He did not need a TKA he was actually a young healthy teenager.  In contrast, this knee shown below, has no joint space at all in the medial compartment, or "bone on bone" arthritis.  The patient also has bone spurs that have formed at the ends of the femur and tibia at the joint line.  The body will try to put down bone in areas where cartilage has been worn away.  It is a protective mechanism in the body but unfortunately backfires and causes us to lose range of motion.     

Total knee arthroplasties as we know them were developed in the early 1970s.  The surgery continues to be tweaked and modified on a regular basis but many of the concepts are the same.  We still replace the end of the femur and the tibia with metal components and a plastic spacer replaces the meniscus.  There are many companies on the market today and most will tell you their knee components are the best around.  I compare this to care manufactures.  Many are built on similar constructs with different bells and whistles, but all will drive you from one place to another.  I  think the most important concept is that your surgeon is comfortable working with the implant.  Most joint surgeons have a preferred brand or two that they feel works best for their patients and has had the best outcomes in their hands.


There are two major distinctions when it comes to total knee replacement implants--cemented vs press fit components.  The type of component a surgeon uses often is related to where he/she was trained.   A "press-fit" component get its name because it is actually impacted or pressed onto the ends of the bones.  The idea is that the patient's own bone will actually adhere or grow into the metal components forming a stable construct.  This is good for younger patients who may need a second replacement procedure early in their lifetime because revising these implants is a little easier.  A cemented implant requires gluing or cementing the metal onto the bone.  This also forms a stable construct, and maybe good for older patients or patients with poor quality bone.  The cement allows for a secondary fixation when poor quality bone may not be quite enough.

TKAs are a fascinating topic and relevant to so many people.  I hope this provides a background on the procedure and need for a replacement.  As I began writing this article it became clear that it would be too large for one post.  We have so much more to discuss!! Hospital stays, rehabilitation, risks vs benefits of surgery.   I will have to post a TKA Part Two in the near future.  Feel free to ask questions if you would like them included in that article.

Next post in two weeks is a surprise...     

   

For more info on TKAs check out the AAOS webpage here





Sources
Ranawat, C. (2002). History of Total Knee Replacement. J South Orthopedics Assoc, 11(4), 218-26. Retrieved September 22, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/12597066