Hip and knee surgery



OSTEOARTHRITIS : INTRODUCTION

Arthrosis is not an ageing fatality : it is an abnormal degenerative process of the joints. Arthrosis is the most common type of arthritis. When arthrosis appears, it produces permanent damages to the cartilage that can get cracked or can get an ulceration. At the end of the process, the cartilage could totally disappear creating a very painful and stiffness joint.


HOW DOES YOUR HIP JOINT WORK ?

The hip is the stronger and the bigger joint of your body. Powerful muscles are attached to the hip to make it actionable in most of your movements. The mechanical structure of this joint is awesome. There is a curved head at the top of your femur (the bone of your thigh) that perfectly fit into a cavity of your pelvis, so-called the acetabulum. When the joint works properly, the cartilage fully covers the femur’s head and the cotylar as well. This elastic cartilage absorbs all your movement constraints and makes the two bones sliding smoothly during your movements.
To make these movements even more frictionless, the healthy hip has got a bucket, so-called the capsule, that produces a fluid named synovia. This fluid acts as an unguent to lubricate the joint and make it very smooth. The two bones are also attached with strong ligaments.
Each time you are walking, bending, sitting, going to bed, biking, running… your hip is working. When your hip is healthy, you won’t notice it but for sure, you are “hip dependent”. If your hip starts to be stiff or painful, you will be more or less disabled during your daily activities and you will understand what “freedom of movement” means.








HIP ARTHROSIS


When arthritis appears, you will likely feel, more or less, the following symptoms :
  • pain spots in your hip, your inguinal zone, your buttock, along your thigh, or even in your knee
  • a reduction of your joint mobility: for example, you will feel pain when you cut your foot nails, when you put your shoes, …
  • a limping when you exercise, an extra tiredness when you walk, the need of a walking stick to relieve your pain

All these symptoms will modify your daily activities and will limit the freedom of your movements : as a result, you will feel old.








HIP ARTHROSIS TREATMENT

Hygiene and diet guidelines

  • Weight loss in case of extra weight
  • It is not recommended to stop your physical activities. It’s even better to practice sports such as walking, biking or swimming in a gentle way
  • You can use a cane to relieve your pain, especially during arthrosis crisis. You have to use your cane on the healthy hip side
  • You could use a heelpiece if your lower limbs are uneven. However, you have to be cautious with your lower back : heelpiece could favor arthrosis within lumbar vertebrae and then create a painful side-effect. Your surgeon will give appropriate advice for this matter

Long-term and disease-modifying arthrosis treatment

  • Anti-pain drugs
    According to you pain, your doctor could prescribe you some level 1 antalgics (such as paracetamol) or level 2 antalgics (such as tramadol or opium-based drugs). These drugs could be combined with anti-inflammatory drugs for a short period of time with a specific posology such as one pill every 2 days or every three days
  • Chondro-protector
    These drugs are elaborated with soy and avocado (Piasclédine®), and also with some extracts of cartilage (chondroïtine sulfate-Structum®, Chondrosulf®) or with extracts of plants (diacéréine - ART 50®, ZONDAR®). These drugs are not reimbursed by the French social security anymore. Their efficiency is pretty variable depending on the patient physiology. Their healing effects could also be pretty slow
  • Regarding infiltrations : Few doctors, more radiologists than rheumatologists, propose to inject medical liquid directly inside your joint : these liquids are mostly based on corticoids or hyaluronic acid. Are these infiltrations efficient ? From my own experience, that is aligned with most of international medical studies, the answer is “no”. In fact, to the contrary of the knee infiltration, the ROI of hip infiltration is pretty negative because they are increasing the risk of infection when a prosthesis will be installed. Even if the patient stops the injection 6 months before the surgery, the infection risks are still present. Hence, I do not recommend to use infiltration for the hip arthrosis

Surgery

Getting a surgery becomes necessary if all others healing techniques don’t work well. This surgery will consist of installing a prosthesis.
No other option, such as osteotomy, is possible nowadays. You can click here to skip to the associated section about hip surgery.


HOW DOES YOUR KNEE JOINT WORK ?


Your knee joint represents the junction between your femur and your lower leg. This joint is composed of three main elements, that enable the flexion and the extension of your knee. The mechanical structure of your knee joint is pretty complex.


Your knee gets its stability through the perfect adaptation between these 3 components : if one has a defect, your knee will lose its agility. In addition, your muscles and your kneecap are also providing the rigidity to your knee. At last, but not least, the ligaments are key elements for your knee performance especially the crucial ones (anterior and posterior crucial ligament).





THE KNEE ARTHROSIS


What is the function of the cartilage ?

The cartilage is the sliding element of your knee joint. This element is filled in with a fluid, the synovia liquid. The cartilage will also absorb chocks and vibration when you are walking or running.

Arthrosis means the cartilage is damaged

When Arthrosis appears, the cartilage is getting thinner up to a partial or complete vanishing point. After this point, bones will have some friction wear and geodes into bones will appear. Actually, the joint mobility depends on the good shape of this cartilage.

What are the main cause of Arthrosis ?

  • A misalignment of the thigh with the lower leg: a varum knee (hooked legs), a valgum knee (cross legs)
  • An overload of the joint due to either an intense physical activities or an overweight
  • After-effects of a previous trauma or accident, especially with the rupture of the anterior crucial ligament
  • After-effects of a previous joint infection (sometimes during the childhood).
Sometimes, arthrosis could be genetic.

Arthrosis crisis

In most cases, the course of the arthrosis consists in sudden crisis. When it occurs, the knee is pretty painful, hot and swollen. This crisis is likely to appear when there is a joint overload due to :

  • A spotty intense physical activity
  • A weight gain
  • A bad fall or an awkward movement
  • Or nothing : that's the natural evolution of the disease.

It is very essential to visit your surgeon right after your arthrosis crisis. In fact, it is well estalished that this type of crisis creates serious damages within the cartilage that can not be reversed.












KNEE ARTHROSIS TREATMENT


The treatment of your arthrosis will depend on its stage of maturity and if you experience any arthrosis crisis.

What are the different options to heal arthrosis crisis ?


  • Get rest : You have to avoid any overload of your joint such as : standing still for a long time, sport activities, stairs, housekeeping, long haul travel… In some cases, a sick leave can be necessary
  • Strict rest : in some cases with a very painful crisis, you will have to stay in your bed
  • The use of a splint (for few days only), of ice for cooling down your joint, of one or two crutches
  • The use of a knee pad : they are different types of knee pad with respect of your arthrosis type, your knee shape…
  • The use of orthopedics soles: your doctor will assess and prescribe the type of soles you need with respect of your leg issues
  • Sometimes, none of these options will calm your arthrosis crisis. In this case, your doctor will prescribe you drugs.
    Your doctor knows what type of drugs you need with respect of your allergies or the counter indications affecting your health.
    Usually, physicians prescribe level 1 antalgics (such as paracetamol) or level 2 antalgics (such as tramadol or opium-based drugs).
    These drugs could be combined with anti-inflammatory drugs for a short period of time with a specific posology such as one pill every 2 days or every three days. Anti-inflammatory drugs can provoke digestive issues such as ulcers or renal failures and are used only for a short period of time.

  • If all these treatments are ineffective, you will have to consider an injection of corticoids directly into your knee.
  • This light intervention is not painful and can be done at my office whatever your current drugs treatment is (anti-coagulants are not a counter-indication). You can go back home by your own and you can even drive your car right after the infiltration. The only thing is to be cautious about extra load of your joint.
    This injection usually creates an instant relief : this treatment is well suited for crisis and is not recommended for long term treatment.
    You can’t have this treatment many times on a short period of time.
    Actually, the use of corticoid do not allowed any knee surgery for a TKA (total knee arthroplasty) during the next 6 months since it can favor infection.
    This type of infection (sceptic arthritic) is pretty rare, 1 infection out of 70 000 cases. This is why this injection will be performed by a very strict sterilized way.

What can I do between arthrosis crisis ?


You have to take advantage of this temporary lull period to exercise your joint to avoid any future stiffness. You could get some physio sessions or practice some exercise by yourself.
You can click here to get more information.

The remission-inducing treatment of arthrosis consists in :
  • the use of drugs: Again, these drugs usually are level 1 antalgics (such as paracetamol) or level 2 antalgics (such as tramadol or opium-based drugs). These drugs could be combined with anti-inflammatory drugs for a short period of time with a specific posology such as one pill every 2 days or every three days.
  • anti-rheumatic osteoarthritis joint
    These drugs are elaborated with soy and avocado (Piasclédine®), and also with extracts of cartilage (chondroïtine sulfate-Structum®, Chondrosulf®) or with extracts of plants (diacéréine - ART 50®, ZONDAR®). These drugs are not reimbursed by the French social security anymore. Their efficiency is pretty variable depending on the patient physiology. Their relief effects could also be pretty slow.
  • Injection using hyaluronic acid
    These infiltrations are so-called the “viscosupplementation” technique. The hyaluronic acid is a naturel component of the synovia liquid which enables to protect the cartilage and provides an antifriction mean. When Arthrosis appears, this liquid is losing its full mechanical properties. Therefore, the cartilage is less lubricated and the arthrosis will expand. In 6 out of 10 cases, this technique is effective to relieve the knee pain. If injections are effective, you can get them done once a year. But this acid prevents any surgery for 2 months following the injection. I perform these injections 3 times in a row with a one week period of time between each injection. As for the corticoid injection, you will be able to drive back home by your own, while avoiding extra load on your joint. The only complication is the very rare infection, that occurs one case out of 70 000. This is why this injection has to be performed by a strict sterilized way.
  • Injection of PRP (Plasma Rich Platelet)
    This is a real innovation since this technique is the only one that may reverse arthrosis development.
    Today, these PEP can’t be legally combined with the use of stem cells. The French FDA doesn’t have enough in-the field data to assess the efficiency of this blended mix and didn’t give this authorization yet. But, the use of PEP only is authorized and I’m used to perform this type of injection since 2014. You can get further information by clicking here : PEP (Plasma enriched Platelet)

At last, if none of these treatments is effective and none relieves your pain, you could get a joint wash under arthroscopy. This light surgery is performed using an ambulatory process : your surgeon will drill 2 small holes into your knee : one for the arthroscope and the other one for the camera. With the arthroscope tool, your surgeon will be able to wash your knee to clean it from cell debris, calcium fragments and toxic enzymes.
This light surgery lasts for 10 minutes or so. You have to be accompanied when you go out the hospital since you won’t be authorized to drive by yourself. This is due to the general anesthesia.
The pain reliefs are almost instant and last for a time length that depends on each patient.


Surgery


Getting a surgery becomes necessary if all others healing techniques don’t work well.

  • Tibia osteotomy

    This surgery is only possible in some specific cases. Actually, this is the case if your arthrosis has only damaged your internal tibia-femoral compartment (bow legs), and sometimes only your external tibia-femoral compartment (cross legs), and if the other knee zones are healthy. You must be under the 40’s.
    This surgery consists in removing or adding a bone pad to the superior part of your tibia bone. The recovery is pretty lengthy since you’ll have to wait several weeks before walking with a full weight bearing.
  • Knee prosthesis

    They are many different types of knee prosthesis. Your surgeon will choose the right one depending on your age, your leg geometry and alignment, your joint laxities, … All these elements are thoroughly analyzed during your visit at my office with the study of your X-ray images. 60,000 TKA are performed each year in France. Their lifetime is about 15 to 20 years.
    You can click here to go directly to the TKA section of this website.

    When the prosthesis is worn or unsealed, it can be replaced. This procedure is more delicate and have to be performed in a specific hospital that is fully armed with dedicated equipment and a reanimation medical team. The experience of your surgeon will be key to make this complex surgery successful.
    This type of surgery, so-called a “revision”, counts for 20% of the total surgeries I’m practicing. I perform revisions only in Marseilles, either at the private hospital “la Residence du Parc” or at the private hospital “Clairval”.
    You can get further information about these types of surgeries by clicking here : prosthesis revision.