Technology in Treatment: Advancements in Knee Pain Care in Singapore

Non-Surgical Treatment Options

Medications are a useful adjunct to other non-surgical treatments and can help patients avoid surgery. Paracetamol is a universally recommended analgesic. Glucosamine and chondroitin supplements have recently become popular. Although the evidence to support their use is not substantial, the general consensus is that they are not harmful and may benefit some patients. Anti-inflammatory medications can be very effective. For patients with osteoarthritis, NSAIDs are generally safe and well tolerated, but often only provide short-term relief and can cause side effects. The use of COX-2 inhibitors has decreased due to safety concerns. Topical anti-inflammatory and rubefacient preparations are an option for patients who wish to avoid oral medications. It is best to consult with a physician before commencing any of these medications.

Physical therapy aims to increase the strength and flexibility of the muscles that support the knee. A program may involve walking, swimming, and other exercises to help improve strength and flexibility. Other exercises may be of the closed kinetic chain variety, such as leg presses and squats. These exercises cause minimal discomfort, and functional activity is encouraged. Increased muscle strength will lead to better shock absorption and will reduce the forces acting upon the knee, thereby relieving pain and improving function. Flexibility exercises are also important and will help restore or increase the full motion in the knee. It is always best to see a professional to get an individualized program of exercises that are tailored to your own specific needs. Over time, the patient should be able to learn self-maintenance techniques.

Physical Therapy

At the end of each session, pain relief modalities can be used to relieve pain incurred during the session. For example, ice therapy and TENS.

Later stages of physical therapy concentrate on muscle strengthening to stabilize the knee joint. The knee joint is supported by the ligaments and surrounding muscles. When these muscles are weak, there is a greater impact on the joint surfaces. Controlled movement of the muscles allows the joint to slide and rotate in a smooth and stable manner. Exercises are also given to increase the proprioception in the knee joint. This is highly effective in preventing a repeat injury to the knee.

In the first stage of physical therapy, the therapist will work on increasing the range of motion in the knee. When a patient has knee pain, there is a tendency to limp, which can be harmful to the knee joint. By limping, the patient puts more pressure on the knee joint, which increases the rate of wear and tear. Pressure on the knee joint can result in the malalignment of the kneecap, which is a common cause of knee pain and also a greater risk of osteoarthritis.

Physical therapy is an integral part of the treatment for knee pain. It helps the patient regain strength and movement in the knee, and aids in faster recovery after surgery by increasing blood flow to the knee, which aids the healing process.

Medications

Anti-Inflammatory Medications: NSAIDs (Non Steroidal Anti-Inflammatory Drugs) function by reducing the body’s production of prostaglandins, which are substances that can cause inflammation and pain. Aspirin, ibuprofen, and naproxen are some examples of NSAIDs and are available over the counter. Selective COX-2 inhibitors are a specific type of NSAIDs which act on the COX-2 enzyme and are less likely to cause irritation of the stomach or erosion of the GI mucosa. Studies have shown that there is no significant difference in pain relief between nonselective NSAIDs and COX-2 inhibitors. The use of NSAIDs should be weighed against its potential risks, including stomach pain, ulcers, and bleeding, and an increase in risk of cardiovascular events. In light of this, the FDA has recommended that high doses and long-term use of NSAIDs be avoided. As can be seen, NSAIDs can provide pain relief, but their use may pose risk of further medical problems.

Most medications fail to provide significant pain relief. A positive outlook and a realistic understanding of the medication’s potential effects are both important. Some medications may be contraindicated for patients with specific medical conditions or who are taking specific types of medications. It is important for patients to communicate with their providers and not to abruptly stop taking medications without consulting their provider. Duration of use for each type of medication can vary.

Injections

A variety of injections are used in treating knee pain. The most common injection is a cortisone shot. Cortisone is a powerful anti-inflammatory medication. It helps to reduce the inflammation in the knee. Cortisone can begin to work within a few days, and its effects can last for several weeks to several months. Despite its usefulness, there is some controversy over the use of cortisone injections in the knee. Repeated use of cortisone can lead to degeneration of the tendons and ligaments in the knee. There is also evidence that it can lead to thinning of the cartilage in the knee and an increased rate of joint deterioration. Because of these factors, most physicians will not give a patient more than 3-4 cortisone injections in a single knee in a one-year period. Another type of injection that is becoming more popular for mild arthritis in the knee is viscosupplementation. The knee contains a small amount of a thick fluid known as synovial fluid. This fluid acts as a lubricant and shock absorber in the joint. In a knee with arthritis, this fluid is not as thick and does not provide the same level of lubrication. Viscosupplementation injections consist of a gel-like fluid that is injected into the knee in an attempt to restore the rheological properties of the synovial fluid. This can improve the knee’s shock absorbing ability and enable it to more effectively carry out its natural lubricating function. Viscosupplementation injections are given weekly, with a total of 3-5 injections. They are often useful for an older patient with mild knee arthritis who is trying to delay the need for more aggressive treatment such as joint replacement.

Surgical Treatment Options

Arthroscopy

Arthroscopy is a procedure that is often used for treating knee pain. It is minimally invasive and is often used for diagnosing knee pain. The word arthroscopy comes from two Greek words, “arthro” (joint) and “skopein” (to look). The term literally means “to look within the joint”. During the procedure, your surgeon will make a small incision in your skin and then insert a pencil-sized instrument that has a small lens and light system to magnify and illuminate the structures inside your knee. High-quality images are displayed on a screen, allowing your surgeon to look at the inside of your knee in great detail. This will help your surgeon determine the cause of your knee pain. A small incision is made to insert the arthroscope, a small flexible tube with a light and video camera. Miniature instruments are inserted through other incisions to make the necessary repairs. Because the arthroscope and surgical instruments are so small, this is a much less traumatic surgery for the patient. The benefits of less invasive procedures include less pain from surgery, less time spent in the hospital, and quicker recovery times.

Partial Knee Replacement

Partial knee replacement was first performed in the 1960s, but because of design and technique issues, it failed to prove successful in the long run. With recent advances in materials and technology, partial knee replacement is proving to be an increasingly attractive option. In a partial knee replacement, only the damaged part of the knee is replaced with metal and plastic implants. This surgery is less invasive than total knee replacement and is performed with a smaller incision. Because only the damaged part of the knee is operated on, the healthy bone and tissue is left undisturbed. This often results in better knee function and less pain. Patients who have partial knee replacement usually have a shorter hospital stay, and the rehabilitation process is quicker. Often, patients are able to walk without the assistance of a cane or walker within two weeks of the surgery. Partial knee replacement has shown to be a highly successful procedure for the treatment of arthritis. It has a high success rate with more than 90% of implants still functioning well 10 years after the surgery. This procedure has proved to be a cost-effective treatment for arthritis as the overall cost is significantly less than total knee replacement. With the benefits of less pain, improved knee function, quick recovery and successful long-term results, partial knee replacement is a viable option for patients with knee arthritis.

Total Knee Replacement

Total knee replacements are designed to relieve pain caused by the deterioration of cartilage due to injury, trauma, bone/joint infection, and progressive diseases like osteoarthritis. The decision to proceed with surgery must be well thought out between the patient and his/her healthcare provider after exhausting all other alternative measures. Ideal candidates for a TKR are in good mental and emotional health, generally active, and have strong upper leg muscles. In recent years, a growing number of the general public were attracted to the procedure to relieve chronic pain and disability. This is due to the fact that in comparison to the early last century, individuals have a longer life expectancy and are a lot more active in their later years. This growing positive outlook has led to authors such as Vince (2007) to approximate the increase in demand for the procedure by 673% in the U.S in the next two decades.

A total knee replacement (TKR) is one of the most successful procedures in all of medicine. In the last 40 years, improvements in surgical materials and techniques have greatly increased its effectiveness. Total knee replacements are most commonly performed on individuals 60 and older, but the operation can be very successful for adults of all ages. The procedure involves cutting away damaged bone and cartilage from your thighbone, shinbone, and kneecap and replacing it with an artificial joint (prosthesis) made of metal alloys, high-grade plastics, and polymers.

Robotic-Assisted Knee Surgery

Although these robotic arm platforms are currently focused on knee replacement, as technology and confidence in it grows, this may well be applied to hip replacements and other joint-preserving surgery.

Haptic robotic guidance is essentially a robotic arm that, with the use of sensors in the joint, can guide the surgeon and apply resistance to stop the resection of healthy bone or prevent an implant from being put in a suboptimal position.

An example of a robotic platform is the CASPAR system (computer-assisted surgical planning and robotics). The patient-specific implant is defined before the operation using the 3D model. The key with robotics, though, is during the operation with haptic feedback that can actually aid the surgeon in bone resection to implant positioning, which is significantly more accurate, as has been shown in trials comparing with conventional techniques.

When we say robotic, this can be a bit misleading. Essentially, these are platforms to aid the surgeon in being more accurate as a preparation to carry out the knee replacement. Usually, the patient will have a preoperative Computed Tomography scan of the knee. This is used to create a 3D model of the knee, which is patient-specific and aids the surgeon in preoperative planning.

Robotic arm-assisted surgery is now about enhancing still further the key principles underpinning partial knee and total knee replacement, i.e. accurate replication of normal knee function and rapid rehabilitation through improved patient-specific implant design and greater accuracy in implantation.

Robotic arm-assisted surgical treatment has been growing day by day. This has coincided with robotic platforms developed specifically for orthopedic surgery. Pioneering work using these platforms has already seen clinical application, and we are really at the beginning of realizing their potential.

Future Innovations in Knee Pain Care

3D printing for the manufacture of knee products is an exact way to reproduce a designed shape built from a patient’s scan, such as a custom implant for knee replacement or a specific tool or jig for surgical use. It is already proven to be more accurate than creating a mold and bending metal to match, as is the current method for most knee replacements or manual tool design. The cost of 3D printing technology will reduce over time to become cost-effective for mass production of cheap disposable items and single-use custom tools. As 3D printing becomes more affordable and accurate, it will become an integrated part of surgery for complex cases and eventually become the new standard.

Currently, most stem cell treatments are classed as a medical procedure, and insurance does not cover the costs. As the evidence for its effectiveness grows over the next few years, it is likely that insurance companies will start paying for it, and the government will promote it as a cheaper alternative to surgery. Currently, knee replacements are very standardized and not tailored to an individual patient. In ten years’ time, stem cell therapy will be used to repair knees so effectively that knee replacement will become a last resort rather than the only option. At this stage, individualized knee replacement parts will likely be designed using 3D printing as an offshoot from the technology used in cartilage repair.

Stem Cell Therapy

Research studies have shown that delivery of mesenchymal stem cells to an injury site can stimulate the migration of endogenous stem cells to the area and also have the potential to differentiate into cells of the target tissue. In addition, mesenchymal stem cells have an immunosuppressive quality which can alleviate swelling and pain. These attributes can regenerate tissue of the same type and potentially, in the case of knee cartilage, the final damaged tissue will be replaced by the mesenchymal stem cells with new cartilage instead of scar tissue. This mechanism can result in a robust and long-lasting repair. At present, the best evidence for this comes from anecdotal reports or case series with some MRI evidence to support. The effectiveness can be difficult to measure due to the variable natural history of different conditions and there being few good therapeutic alternatives. However, it is generally regarded as a safe procedure with a potential efficacy that will greatly improve with further research.

The use of stem cell therapy to treat orthopaedic injuries and degeneration is still in its early days. This type of treatment holds much promise, particularly in the area of knee care where current surgical approaches have varying success. There are a few different types of stem cells which can be used to effectively reduce inflammation, halt the progressive nature of the condition, and repair or regenerate damaged tissue. This ranges from bone marrow-derived stem cells, adipose (fat tissue)-derived stem cells, and amniotic-derived stem cells. Currently, we are more inclined to use bone marrow-derived stem cells, which are harvested from the patient’s pelvic bone, then concentrated and injected into the affected area.

3D Printing in Implant Manufacturing

This should all lead to a better future for knee replacement patients, helping them get rid of the most discomfort caused by knee pains compared to when off-the-shelf implants were the only choice.

Custom knee implants are relatively new in the market, though they are becoming more popular among the elderly. With the advancements in 3D printing, it brings us to the next step: printing the implant directly from the 3D model of the knee. This is in hopes to further improve the feasibility and cost-effectiveness of custom knee implants. By doing this, the knee pain doctor Singapore needs to only order the implant once the final diagnosis is made from the 3D model, as opposed to the current method of creating the implant and then ordering the appropriate size. High expenses and time consumption of going for a custom implant may adapt to make it the standard choice for knee replacements.

In the past, implants were much more generic and produced in limited sizes, even though each individual’s bones and knees are different. This increased the difficulty of the surgery and tended to cause some discomfort for the patient. More recently, better technology has surfaced to create custom knee implants. This is done by examining MRI images and creating a 3D model of the knee, from which an appropriate size and shape implant is created. This helps the patient in terms of comfort, as it’s much easier for the doctor to insert a more natural feeling implant compared to when the doctor had a limited range of sizes to choose from.

It is apparent that artificial knee replacement is an effective way to eliminate pain and restore knee function. With the aging population, the number of knee replacement surgeries has increased significantly. The increase in surgeries causes an increase in demand for knee implants. Tens of thousands of knee replacement operations are performed each year in Singapore, making it a common ailment affecting people of all ages.

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