Arthritis – Knee Pain – A suitable solution

22 Mar

We have recently celebrated “world Arthritis Day” in big way.

The fact that 15 percent of the Indian population suffers from this crippling disease is alarming and arthritis deserves immediate attention.

“Arthritis” means inflammation of joint, that means there is pain , swelling, tenderness around joint. This simple looking word arthritis is of many types. This is important to know which kind of “Arthritis” I am suffering from. This will make you able to nip in the bud and control deadly disease of “Arthritis” easily.

In India  osteoarthritis ie degenerative arthritis which affects the knee is more prevalent in the country with every third person above the age of 70 years affected, , the incidence of rheumatoid arthritis is little less than in the West.

More then 20 crore Indians are suffering from Arthritis. Let us talk how to manage  osteoarthritis. Since this is a degenerative in nature so we should all understand how to prevent it. We can prevent by followings

  1. Reducing weight – keeping weight in normal limit according to age, height , sex and frame of body ( small, medium, large).
  2. Regular physiotherapy – strengthening muscles around knee like quadriceps and hamstrings
  3. Maintaining strong bones by keeping normal Bone Mineral Density  ( Normal value is T score  – 1 and above). Regular walking.
  4. Maintaining normal vitamin D 3 levels. Recent survey showed that health personnels are vitamin D 3 deficient to the tune of 65%. This is an eye opener report as we think that medical illness are not meant for us.

In spite of all preventive measures osteoarthritis affect people and person feels following features.

  1. Pain while climbing stairs more on coming down.  Person look for railing to catch hold.
  2. Seeking for some support to get up from sitting on ground.
  3. Experiences some cracking sound while bending knees.
  4. Avoid going to Indian toilet and prefers western commode.
  5. Usually feels pain on inner side of knee joints.
  6. Stiffness around knee joint.

And when you see there knees you find there is disturbed knee alignment.

Normal knee                                                                     Osteo-artheritic knee

Normal Knee, Dr Agrawal

You might have observed that if knee is aligned normally then there is about 7  degrees of valgus  between   femur and tibia that is leg goes outward from thigh by 7 degrees. In osteoarthritis this valgus alignment is reversed to Knee varus ie leg comes inside from thigh. Look following pictures which are self explanatory.

Cartilage is circular covering whole knee joint area and taking part in weight bearing

you can observe that weight bearing line is passing from centre and whole knee joint cartilage (circular surface ) is taking part in weight bearing.

Cartilage left is not taking part in weight bearing as the weight bearing axis is shifted to area where there is no cartilage.

Observe that in osteoarthritis inner joint space is reduced. There is extra pressure on medial side of joint. Cartilage is denuded underlying pain nerve endings are exposed and gives pain. Weight bearing line is shifted to medial or inner side of knee . therefore whatever cartilage is left is not taking part in weight bearing. Weight is borne by the inner small point focused area where there is cartilage is denuded so nerve endings are exposed to give you pain, the moment person puts weight on it.

To bring

  1. Healthy remaining cartilage to take part in weight bearing .
  2. So that weight is borne by the healthy cartilage and pain is avoided .
  3. And to off load medial or inner angle of knee joint from excess pressure.

We need to change present alignment of knee and bring back to normal one which is 7 degrees of valgus . High Tibial Osteotomy does this safely and simply. One of the ways to do HTO is shown here. A triangular piece of bone has been removed to realign the knee joint.

Inner angle is off loaded, excess pressure is removed

when you close the wedge normal alignment is achieved . By its virtue following things happen.

  1. Normal healthy cartilage start taking part in weight bearing so pain of the person goes away.
  2. Excess pressure from medial (Inner) cartilage goes away.
  3. Since inner angle is off loaded therefore cartilage  get pressure free environment to grow freely.

see the real x-ray pictures showing how they look in affected knee and what happens when HTO is performed.


x-ray of osteo arthritic deformed                                                          After HTO- knee is aligned

knee with excess pressure at inner                                                        weight bearing is redistributed

angle                                                                                                                   to whole knee surface, so pain goes away









Similar problem can be tackled by Total Knee replacement surgery also especially when all three compartment of knee cartilage are damaged. In this we shave of ends of femur and tibia and replace by an artificial metal joint, which has certain life.


Advantages of HTO surgery.

  1. Since it is not performed at joint level so the knee joint movements are not restricted.
  2. Your god given natural cartilage is not excised.
  3. Cartilage is provided suitable pressure free atmosphere to grow.
  4. Cheaper.
  5. Can be performed in all operation theatres.
  6. Complications are negligible and are never dreadful.
Quality of Life after Knee Surgery

                        let us see how we Indians are different from west.

   How we       Indians                                    are different                                  from west  ?


  • Don’t keep health budget.                                     Health insured
  • Go very late to doctors.                                         Approach doctor early
  • Good tolerance.                                                         Low tolerence
  • Very conservative                                                   Not conservative.
  • Afraid of big surgery.                                              Fear less
  • Miserly spend on health.                                        Don’t bother as are insured
  • Don’t’want to leave sitting habits and               Social custom are different

other social customs

What is the need in todays senerio is to provide best and customized treatment which is most suited to that particular person. Still there is  huge common cohort of osteoarthritic  people who can be offered either TKR or HTO. Responsibilities lie upon we doctors to see what procedure suits most to that particular person, rather then driven by many other things.

 HKO-TKR Overlap

Now world is changing , more and more importance is being given to the conservation of natural , god given things. HTO is one of these natural cartilage preserving technique . This should be used in abundance in suitable persons to provide relief to arthritic population our country ( rather whole Indian subcontinent )  who has different social customs then west.

About the Author:





Orthopedic and Joint replacement Surgeon

MBBS (Gold Medalist), M.S. (Orth.), MCh.(Orth.)


AO International Fellow (Switzerland)

Fellow N.U.H. (Singapore)

Fellow Stanford Hospital ( USA )


Satya Trauma & Maternity Centre,Barra, Kanpur  &

Dr A K Agrawal is a renowned Orthopedic  and Joint replacement surgeon in Kanpur, North India. After doing his medical graduation and post graduation with gold medal from GSVM Medical College Kanpur he joined prestigious Jaslok Hospital & Research Centre, Mumbai. Later he joined Bombay Hospital, Mumbai where he worked with Dr K T Dholakia. He also worked in Central Institute of Orthopedics ,safdarjang Hospital,  and Dr R.M.L.Hospital, New Delhi.

Dr Agrawal did his fellowship from prestigious B G Unfall Klinik, Tubingen , Germany.

Dr Agrawal was awarded fellowship by National University Hospital , Singapore. Dr Agrawal has papers published in reputed journals . He has delivered many talks. He has travelled widely in India and abroad.

At present Dr Agrawal is consultant Ortho and joint replacement surgeon and director of Satya Trauma Centre,  Kanpur.


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