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Left Knee Arthralgia

Short summary

65-year-old female that suffers from pain in the left knee underwent examinations that showed femoral-tibial arthrotic manifestations, external degenerative meniscal tear and moderate joint effusion. A diagnosis of external degenerative meniscal tear was established. Further medical tests showed marked degeneration of the meniscal fibrocartilage, diffuse femoral-tibial arthrotic abnormalities, subchondral cysts and edema of the spongious bone, as well as rarefaction of the cartilage matrix, and manifestations of chondropathy. Lumbosacral spine X-ray showed spondyloarthrosis, reduced regional lordosis, and reduction in the intersomatic spaces. Knee X-ray showed signs of left gonarthrosis. The specialist also observed marked valgus and advised to carry out kinesitherapy, a course of infiltrations with jointex starter, and a knee motor rehabilitation.

Patient's questions

1) What diagnosis do you infer?

2) What therapy could you advise? In particular, is a surgical operation to take into consideration? In the event of affirmative answer, what kind of operation would it be?

3) Prognosis?

Medical Background

Sex: F, Age: 65 years old

In 1999 diagnosis of postural backache.
Since approx. 2001, metatarsalgia (left>right) with hallux valgus of low degree; for this reason she wears arch supports to relieve weight from the metatarsal heads with great relief.

Onset of pain in the left knee in May 2006 without apparent reason; a therapy with systemic and local NSAIDs was carried out for a few days with temporary relief. The patient, therefore, underwent instrumental examinations:

- Left knee X-ray dated 06/2006 - “first femoral-tibial arthrotic manifestations characterized by the sharpening of the intercondylar eminences and subchondral sclerosis of the tibial plateaus. The patello-femoral articulation is essentially uncompromised. No current focal bone lesions are noted.”

- Left knee musculoskeletal NMR dated 06/2006: “medial meniscus of normal morphology, with substantially regular signal. External degenerative meniscal tear, particularly evident at the level of the body and in particular of the front horn. No pathological evidence involving the patella tendon, the quadricipital tendon, the collateral ligaments and the cruciate ligaments.

Presence of moderate joint effusion. No evident abnormalities in the osteochondral structures of the articular heads.”

Following these examinations she underwent an orthopedic specialist examination on 06/2006. The specialist confirmed the diagnosis of “external degenerative meniscal tear” advising:

- Isometric tonification of the quadriceps;
- Swimming (with the exclusion of breaststroke);
- Mobic 15 mg tablet (1 tablet daily on a full stomach for 20 days).

As the symptomatology persisted the patient returned to a specialist examination on 01/2007. Professor G. objectively found: “left knee moderately tumefied due to effusion. Hypotrophic quadriceps muscle compared to the contralateral. Complete joint motion (pain reported when bending at the highest degrees only under load). Absence of unsteadiness. Pain when palpating the lateral femoral-tibial medial joint line.” The following therapy was, therefore, recommended:

- OKI packet 80 mg (1 packet twice a day on a full stomach for 10 days, then 1 packet daily for 10 days)

- Isometric tonification of the quadriceps muscle.

- When the inflammatory phase has been solved a course of infiltrations with hyaluronic acid is recommended (Verivisc vials).The infiltrations have not been carried out by the patient.

As the disorders continued further medical tests have been carried out:

Left knee MRN dated 09/2009:
No images referable to lesions of the collateral ligaments and the central pivot ligaments. A moderate amount of articular effusion is present, of synovitic reactive type, in the intercondylar throat with no evident gastrocnemius-semimembranosus bursa fluid distension.

Marked degeneration of the anterior horn of the lateral meniscal fibrocartilage and also of the posterior horn, with clear fluid distension of the meniscal recesses, either anterior or posterior, always on the lateral side. Moreover, on the external side there are findings of diffuse femoral-tibial arthrotic abnormalities more evident on the external side, with associated presence of subchondral cysts and edema of the spongious bone due to overload. Moreover, there are findings of rarefaction of the cartilage matrix.

Also the medial meniscal fibrocartilage has degenerated. Patella and Hoffa’s adipose body are within normal limits.

The patella is on axis with moderate manifestations of chondropathy but without any osteochondral lesions. Effusion along the paracondylar recesses.

Lumbosacral spine X-ray dated 09/2009:

- No evidence of current trauma or focal bone lesions.
- Signs of spondyloarthrosis.
- Reduced regional lordosis.
- Reduction in the intersomatic spaces from L1 to L3.

Knee X-ray dated 09/2009:
- Signs of left gonarthrosis.
- The left femoral-tibial articular rima on the external side is reduced.

On 09/2009 orthopedic visit where, besides taking note of the results of the above-mentioned examinations, a marked valgus has been observed advising to carry out: kinesitherapy to strengthen the femoral quadriceps + course of 3 infiltrations with jointex starter in the left knee.

On 09/2009 the patient underwent specialist physiatric examination with prescription of: a course of 10 sessions of right and left knee motor rehabilitation (proprioceptive rehabilitation, isometric and isotonic tonification of the femoral quadriceps).

Medical opinion

On the basis of the information available it is seem that the patient suffers of osteoarthritis of the left knee or in another word: Gonarthrosis. This means a degenerative process of the cartilage surface and the menscii.

The X-ray dated 9/09 showing narrowing of the lateral joint compartment and valgus of 10°, confirm a degeneration of the cartilages as shown also in the MRI study.

Assuming the radiograph was not done in standing position I would recommend to do this again while the patient is standing with weight baring on the left leg. This may show the actual joint space.

In any case the treatment options are either conservative: which is actually what has been done so far, or operative.

There are two main operative options:
1. Joint preservation: supra-condylar osteotomy. In this operation we are fixing the mechanical axis of the knee to unload the lateral compartment of the knee. The success rate is about 80% and it takes few months to recover out of this operation, using crutches and physiotherapy. A success of this option is relieving pain for 8-10 years (after which the next option will be needed).

2. The second option is Total Knee Replacement (TKR). In this operation we cut the cartilage surfaces on both side of the knee and replace it with artificial joint made of metal and plastic. The success rate of this operation is about 95% and the prognosis is very good for about 15 years. After that, the probability of loosening raise up and a revision operation may be needed.

Based on the data available I would recommend to continue with non operative treatment – basically, to take non steroidal medicine according to pain level, along with glucoseaminsulfat (like Megagluflex).

When there will be a substantial reduction in life quality – I would go for TKR.