Vol 43 # 3 September 2011 - Kma.org.kw

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Osteoarthritis of the Knee: Review of Risk Factors and Treatment Programs ...
September 2011
closed and fixed by staples or a plate [95, 96] . In the callus
distraction technique, a tibial osteotomy is performed
and the osteotomy is locked by an external fixator.
The correction is performed after surgery by slowly
opening the osteotomy by adjusting a screw located
on the external fixator, about 1 mm each day, until
the full correction is achieved [97] . The results by high
tibial osteotomy are almost as good as those by total
knee arthroplasty and complications are few if the
procedure is performed by experienced surgeons [98] .
As most of the OA is medially located (bow leg) a
tibial osteotomy converts a knee from mild varus
to mild valgus. The draw back for the patient is a
certain postoperative valgus of the limb as some
overcorrection of the hip knee ankle axis is intended.
This is, however, the aim of the procedure, to move
the lower limb axis from the diseased medial cartilage
to the more healthy lateral cartilage.
Modern principles of knee arthroplasty are in
use for more than 30 years [99] . The results of the first
total condylar knee was favorable [100] and local series
have shown similar results [101] . In national registers,
the pain relief is good and the incidence of revision
is low (around 5% after 10 years) [46] . The incidence
of deep infection is around 0.5% [46]. In the early days,
the prosthetic designs were of hinged or linked
surface replacements but now, all primary prostheses
are surface replacements of total or occasionally
unicompartmental knee design. Most designs are
femoral and tibial components of metal with a plastic
insert fixed on the tibial component [99] . The metal
material is mostly vitallium which is composed of
chrome, cobalt and molybdenum while the plastic
insert is made of high density polyethylene. The
standard fixation of the metal components to bone
is by special cement, a two component glue, which
is mixed during surgery, and becomes hard and
fully stabilizes the components after 10 - 15 minutes.
There are guide instruments for bone cutting and
occasionally computer navigation may be used. The
correct patient selection for the procedure is now better
understood. A young patient with a potential for high
activity level postoperatively has a relative high risk
for a premature loosening / material failure. On the
other hand, a biologically old patient with a limited
ability to take part in the postoperative rehabilitation
will not benefit from a knee replacement, as there is
often, too little muscular motor power to drive the
artificial knee [99] .
From 1984 until 2007, 577 knee prosthetic operations
were performed in Al-Razi Orthopedic Hospital
in Kuwait [17] . An increase in the number of these
operations occurred during the last years and in 2007
there were almost 100 knee arthroplasties performed.
There are no certain statistics of the annual incidence
of knee arthroplasty operated Kuwaiti people as
patients are also operated in private hospitals within
and outside the country. It is estimated that about
200 - 250 knee prosthetic operations are performed
on Kuwaitis annually. In order get more exact
epidemiological data and in order to improve the
quality assurance of knee prosthetic replacements in
Kuwait, we have proposed that a national register
of knee prosthesis is organized [17] . Similar national
registers are in use in many other countries.
SUMMARY
Knee OA has a slow disease progress and it is the
final result of many different disease patterns which
occur in the knee joint. OA primarily affects the
cartilage but involves by time, the bone, ligaments,
muscles and the joint capsule. Often the patients
are affected by other diseases like obesity, diabetes,
hypertension or other organ failures. Symptoms of
knee OA are pain, stiffness and muscle weakness.
The main symptom is pain on walking which is often
intermittent with better or worse periods.
The basic treatment of knee OA is self-management
by information about the disease, regular exercise
usually walking, muscle training and weight control.
Patient participation in an OA school is an advantage
and OA schools are therefore recommended to be
introduced in Kuwait. An OA school is best organized
by the primary care doctor, but actually all doctors,
nurses and other health care employees can be involved
in the implementation of the treatment program. If the
compliance of the program is good many patients are
satisfied with self-management / OA School. The key
issue is an active lifestyle where level walking is the
easiest and most natural activity. Mankind has in earlier
times always been used to daily labour and our locomotor
system is planned for such a life. At that time
long level walks, almost to the level of the capacity of
the individual, gave the joints the necessary loading.
Exercise also has a positive effect for most organs, not
the least for the psychological well-being. Today, in
many countries, exercise practice is written down by
a doctor, in the same way as a prescription for drugs.
Physiotherapy is recommended for a limited time
period and one main issue is to encourage the patient
to find a personal activity program.
However, OA patients of today are used to tablets
of different types as a quick solution for their problem.
The pharmacological modalities of non-operative
treatment are analgesics / NSAIDs, injection by
steroids / hyaloronic acid and glucosamine. Most
of these pharmacological treatment programs
have a temporary and usually a small, maximum
intermediate, effect on the pain due to knee OA.
The same type of effect can be achieved by selfmanagement
/ physiotherapy and weight reduction
(Table 4).