PAIN IN PRIMARY OSTEOARTHRITIS OF THE · HELAL: The Pain in Primary Osteoarthritis of the Knee and...

POSTGRAD. MED. J. (1965), 41, 172

THE PAIN IN PRIMARY OSTEOARTHRITISOF THE KNEE

ITS CAUSES AND TREATMENT BY OSTEOTOMY

BASIL HELAL, M.Ch.(Orth.)., F.R.C.S.Senior Registrar, St. George's Hospital and the Woking and Chertsey Group of Hospitals.

MIJCH of the pathology of primary osteoarth-ritis has been unravelled. The present studywas carried out in an attempt to answer twoquestions:What produces the pain in osteoarthritis? andWhy is the pain so often relieved by osteo-

tomy?I believe that the answers to these questions

shed light on the aetiology of primary osteo-arthritis.The knee joint was selected for this investiga-

tion because it is affected by primary osteo-arthritis more frequently than any other joint(Kellgren, Lawrence, Aitken and Swan, 1957).Indeed, a study of human remains of the archaicperiod of Egyptian civilization (3000 BC)reveals that, even then, the knee was the jointmost frequently damaged by osteoarthritis.(Ruffer, 1921).

Clinical MaterialThe investigation is based on 116 patients with

primary osteoarthritis of the knee. These patientswere collected from the David Lewis NorthernHospital, Liverpool, and the Rowley Bristow Ortho-paedic Hospital, Pyrford. Their ages range from 39to 86. 65 (56%) were female and 51 (44%) weremale.

The investigationIn the history-taking special regard was paid to

the evolution of symptoms and to the earliest signsnoticed by the patients. In addition to the clinicalexamination and routine X-rays, intraosseous veno-graphy was carried out on all those patients whoagreed to this test after the procedure and its pur-pose had been explained to them.An analysis of the findings revealed several features

of interest. I will concentrate upon two in this paper.

PainThis was the leading symptom and was pre-

sent in all the cases. Three distinct types of painwere described.

I have termed these "muscular", "capsular"and "venous".

All three types could occur together.

Muscular. This was a cramp-like pain feltin the quadriceps mass during activity andcontinuing for a few moments after stoppingexercise. This was the most trivial pain of thethree described and complaint about it waselicited only by cross examination. This paincould be elicited by static exercise of the quad-riceps in those patients who suffered from it.

Capsular. A sharp pain usually felt on theinner side or the back of the knee upon movingthe joint. This could be reproduced by forcedextension, flexion, or sometimes by rotation ofthe affected knee, and temporarily relieved byinjections of local anesthetic into the capsuleand ligaments of the joint.

Venous. A dull aching or throbbing painfelt diffusely around the knee, usually worsetowards the end of the day and persisting fora while after retiring to bed. In the early stagesof osteoarthritis this pain was felt only whenthe subject was tired; later in the disease it wasaggravated by fatigue. This pain could bereproduced by artificially raising the intra-medullary pressure in the bones adjacent to theaffected joint (vide infra).

THE INCIDENCE OF THE VARIETIES OF PAINCombined muscular, capsular and

venous: 4 patientsCapsular and venous: 59 patientsCapsular only: 47 patientsVenous only: 6 patientsOf 15 patients in this series requiring surgery

for their osteoarthritic knees, 14 had the''venous'' element of pain.

Venous VaricosityThere was a striking association between

lower limb varicosities and osteoarthritis of theknee (Fig. 1).

In this series 48 patients had marked super-ficial varicosities and 35 had had symptomsfrom these. All but two of these 48 patientshad had the "venous" element of pain asso-ciated with their osteoarthritic knees. That is,no less than 67% of patients with osteoarthritis

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HELAL: The Pain in Primary Osteoarthritis of the Knee

and the venous variety of pain also had vari-cose veins. Also of considerable interest wasthe fact that in 21 patients with unilateral osteo-arthritis, the varicose veins were either confinedto or were worse on the osteoarthritic side(F,ig. 1).The history of vein disease always predated

the osteoarthritic symptoms by 3 to 18 years.To draw a comparison with the incidence of

lower limb varicose veins in a similar agegroup 100 outpatients attending for complaintsnot referable to the lower limbs, were examined.22 had varicose veins. Cockett and Dodd (1956)quote a 26% incidence of varicose vein dis-ease in their survey of the general population.Intraosseous VenographyThis technique is now well established and

has been employed for over twenty years, not-ably by Schobinger (1960) who used it to dis-play the deep venous system. I employ themethod primarily to display the intraosseousvenous sinusoids. Provided precautions aretaken to guard against iodine sensitivity, theprocedure is without hazard and no complica-tions have occurred.Technique:A routine iodine patch test is done. If this is

negative, I ml. of 45% hypaque is given intraven-ously 6 hours 'before venography to confirmn theabsence of sensitivity. The venography is performedin the operating theatre under aseptic conditions.Local or light general anasthetic is used. It has beenfound that the best position is with a 200 foot-downtable tilt.A special self-tapping needle with a screw end

has been developed (Fig. 2). When this is screwedinto the medulla of the bone, the threads help toprevent leak-back of dye. After making sure thereis a free flow of blood from the medulla 45%hypaque is injected. 5 ml. is usually adequate to dis-play the pattern of medullary veins, sinusoids, andthe adjacent deep veins. A total of 40 ml. of hypaquehas been used with no ill-effect. An X-ray is takenas the dye is being injected.The investigation has been carried out on 22 patients

in the above series. It has #lso been carried out onpatients with normal limbs, with Paget's diseaseand with secondary osteoarthritis.At various times the dye has been injected into

bone at the upper and lower ends of both tibiaand femur and into the olecranon.

ResultsPressure and Pain:When venography has been performed under

local anmsthetic it was found that a rise in theintramedullary pressure always caused pain,whose intensity rose in proportion to the pres-sure at which the fluid was injected. Similarobservations have been made by Robson andVan Miert (1962). Presumably the pain is due

to deformation of the sinusoids which stimul-ates the vaso-sensory endings described byBazett and McGlone (1928) and by Seguira(1958). Two patients from *the series withprimary osteoarthritis of the knee elected tohave the venography carried out under localanesthetic. The pain was described as identicalwith the dull, diffuse aching pain from whichthey were suffering.Three patients with normal limbs subjected

to this manoeuvre experienced pain of thesame character.One patient with Paget's disease of the tibia

complained of pain similar to that which shenormally felt throughout the bone. The veno-graph in this case showed the dye to be fillingthe whole of the medulla.

Substitution of saline for hypaque in thesecases produced no change in the pain response.Only in those patients with osteoarthritis and

congestive pain have the following character-istics been observed:

1. The medullary sinusoids are dilated. Thisis most noticeable in the subchondral zone.Adjacent to a normal joint this area of boneremains free of dye (Fig. 1).

2. In this group of patients there is disten-sion of the deep veins as compared with theopposite side, when this is normal. The dis-tension of the deep veins may occur in theabsence of superficial venous varicosities.

3. The insertion of the needle is consistentlyeasier in the bones with congested sinusoidsthan in normal bones; this would suggest thatthe bones with engorged venous sinusoids aresofter.

The Relief of Pain by OsteotomyRichard Volkmann in 1875 was the first to

use osteotomy to correct tibial deformity. Thereis no record in the literature of tibial osteotomybeing performed for osteoarthritis of the kneeuntil Jackson and Waugh published their seriesof 10 cases in 1961. Their results were encourag-ing and were confirmed by Wardle (1962) whohad followed up his cases for 16 years.

In 1962, during a routine Out-Patient Clinic,I saw a patient who had been operated on byProfessor McMurray in 1943. The leg had beenosteotomised for osteoarthritis of the knee withdeformity. (Although there was no "record inthe literature", osteotomy was being performedfor osteoarthritis). The patient was currentlyattending with a traumatic effusion, havingslipped on an icy patch and fallen on to hisknee. It was obvious from the series of radio-graphs that there had been complete loss of

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174 POSTGRADUATE MEDICAL JOURNAL April, 1965

FIG. 1.-Only the right knee is painful. There is bothsuperficial and intraosseous venous engorgement.The left knee shows a striking absence of dye

in the subarticular area.

-4~~... ... ...

N'°

0. .n..h

FIG. 1.-Right Knee



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April, 1965 HELAL: The Pain in Printary Osteoarthritis of the Knee 175

.. ..o........

'~~~~~~~~~~~. ;...:::......... .......,

........i. :............

'~~ ~ ~ ~ ~ ~ ...i........t-1ijit . .. . 8

*. ..... ..X-..... .'. :.

FIG. 1.-Left Knee.

'F.^,'';'... '.''....

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FIG. 2.-A self-tapping needle with a screw end isused in intraosseous injections.

the correction before union of the osteotomy.Despite "malunion" of the osteotomy, thepatient's knee had been completely painlessthroughout the intervening 19 years.Another patient, a dock labourer, had

bilateral tibio-fibular osteotomies for osteo-arthritis 8 years previously. Despite non-unionof the osteotomy on one side, both knees hadbecome and had remained free of pain; eachhad a range of movement from 170°-800.The success of osteotomy is usually explained

by the mechanical advantages it produces(Osborne and Fahrni, 1950). In the two casesdescribed, the relief of symptoms must be dueto some factor other than a correction ofdeformity.

Venographic studies were made on 3 post-osteotomy patients. The oldest osteotomy hadbeen carried out 3 years before and his X-raysshow (Fig. 3 a, b):

1. decongestion of the bone sinusoidsadjacent to the joint.

2. the persistence of a vascular discon-nection at osteotomy level by whatWardle has aptly termed a "medullaryplug".

The Acrylic PlugIn view of the findings described above, it

was felt that a permanent artificial medullary



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176 POSTGRADUATE MEDICAL JOURNAL

ATh s pati en hadthhad leLIS iIceltad -- - X Lri:cose veI.clgestiveC pjiin aridX intraossOUS Vein dl tilatatil.

Alter oteoLnoxm\:&Iatation is redceIdCCL 11and thlecongestive pain relieved,

Similarly after acrylic plugging.FIG. 3.

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plug might prove an effective alternative toosteotomy. (Fig. 3c, d). This plugging opera-tion has been done in selected cases of osteo-arthritis of the knee and hip. The patientsselected were those with "venous" pain, sinu-soidal engorgement displayed by venographyand some contra-indication to osteotomy suchas imnmobilisation in bed or in plaster of Paris.

Technique:A slot is cut in the cortex, usually the lateral surface

of the tibia, at tibial tubercle level (or, for the hip,the lateral surface of the femur at intertrochantericlevel). All cancellous bone is removed and acryliccement is used to plug the medulla.The only complication was delayed healing

of the wound in the first case due to inadvertentburning of the skin by the exothermic reaction of theacrylic while this was setting.

ResultsThis procedure has been carried out in 9

patients for osteoarthritis of the knee. Thelongest follow up is eighteen months. All thepatients have had maintained relief from"venous" pain. None has so far required anyfurther treatment. A more detailed appraisalof the method awaits more cases and a longerfollow up period.

DiscussionThree questions in particular arise out of the

above findings and demand further explanation:1. Why should bone venous sinusoids

become distended?2. Why, for example, is the knee joint,

which is placed at the proximal end of the tibia,so liable to osteoarthritis whilst the anklejoint, placed at the other extreme, is spared?

3. Why does osteotomy result in decon-gestion of previously distended bone sinusoidsas well as the relief of pain and arrest of theprogress of osteoarthritis?

1. The first point to be established is thereason for distension of the sinusoids. Normallythe medulla can discharge a large influx ofblood without difficulty. Dickerson and Duthrie(1963) have anastomosed arteries to the bonemedulla; the bone effluents were apparentlyable to cope with the increased intake of bloodwithout any disturbance of anatomy orphysiology. Hulth (1958), in venographicstudies on the hip saw pooling of dye in theintramedullary veins and no filling of the deepveins and suggested that there was an "obstruc-tion" to the outflow of blood from the medulla.This impression can be obtained because dyeis rapidly cleared from the deep veins, especiallyif the subject is horizontal or in some head-

down tilt, or if there is any delay between theinjection and the X-ray. It is also evident thatto accommodate dye placed in a rigid medullarychamber an equivalent volume of blood mustbe displaced. I have not encountered anyresistance to the outflow of blood from boneduring the venogram procedure.To emphasise the fact that there is no short-

age of effluents and no "obstruction" to theevacuation of dye from the medulla of bonesadjacent to osteoarthritic joints, the followingexperiment was performed:A cannula was inserted into each of a pair

of cadaveric tibie. The first had normal joints,the second an osteoarthritic knee '(with typicalenlarged sinusoids). A pint of fluid was allowedto run through each of these bones underidentical conditions. It flowed out of theabnormal tibia more rapidly. This experimentwas repeated on a second pair of tibix withthe same result.

It seems reasonable to conclude that theeffluent channels are larger than normal in boneadjacent to these osteoarthritic joints and thatthere is no obstruction to the outflow of bloodfrom such bones, therefore distension of thebone sinusoids follows upon increased pressurein the extraosseous deep veins.

2. To understand the reason for theimmunity of the ankle joint from osteoarthritisan investigation of the effluent patterns of thetibia and other bones was done. I have foundthat the pattern of venous channels emergingfrom the medulla of a bone is constant for aspecific bone, but varies with different bones.

Effluent patterns are shown for cadaver tibieand a femur (Fig. 4 a, b, c). It can be seen thatvenous blood flow in the tibia is proximnal-itis evacuated at the upper end. As the medullarysystem is valveless this upward flow is simplydue to the comparatively large transcorticalveins at the proximal end of the tibia.

It seems clear that an increase in venouspressure is transmitted to sinusoids in the bonemedulla, particularly in a situation like theupper end of the tibia where there is a concen-tration of effluents. An explanation for theimmunity of subarticular bone of the anklejoint may be that because of small transcorticalveins, the sinusoids near the ankle joint arespared the turbulence that occurs in the uppertibia.

3. It is my opinion that osteotomy mayrelieve pain in two ways:

(a) by taking stress off the capsule of a jointwhen deformity is corrected and

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Na.

A B

c

FIG. 4.-Vertically held cadaver bones. Dye injectedinto the medullae at mid shaft level.A. This proximal flow of dye is constant in the

tibia.

B. Three 7/64" holes had to be drilled at thelower end before the dye would flow distally.The proximal flow is entirely due to theconcentrate of transcortical effluents at thetop end.

C. The femoral pattern is quite different.



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(b) by producing the decongestion of adjacentsinusoids and a partition of the bonemedulla, as demonstrated by veno-graphy (vide supra).

The features described in (b) prompted anenquiry into the way blood is evacuated frombone.A series of medullary pressure measure-

tnents were made on patients at the time ofvenography. Pressures were found to bemarkedly labile and great fluctuations wereproduced by a large number of factors, mainlythose which had an effect on the generalsystemic venous pressure.One finding which I believe is of great sig-

nificance was obtained in this manner:A simple tube manometer is allowed to fill

with tibial medullary blood until steady andthen this is followed by a sustained voluntarycontraction of the calf muscle. There is a smallinitial rise of pressure followed by a rapid andlarge fall in pressure which then slowly returnsto its original level.

This suggests an active evacuation of bloodfrom the medulla. This is similar to the evacua-tion of the superficial system of veins (Walkerand Longland, 1956). Stannard (1963) suggeststhat the hydrostatic means by which this isaccomplished is the so-called Venturi effect-that is a suction effect produced by fluid inmotion. This vacuum effect is exerted by thedeep veins on the medullary effluents. Withthe medullary chamber partitioned followingosteotomy or acrylic plugging its size is reduced.A more efficient active withdrawal of bloodfrom the smaller compartment therefore takesplace. This, together with the fact that someblood destined for evacuation through thissmaller compartment is diverted by the partitionformed at the osteotomy site, will result in amean fall in the medullary pressure.The sequelk are:

1. loss of the "venous" element of pain,2. an improved circulation especially to

subchondral bone and its overlyingcartilage, which will then enjoy a betternutrition.

ConclusionThe findings in this study strongly suggest

a link between a specific symptom ("venous"pain) and the presence of distended bone sinu-soids in patients with primary osteoarthritis.Many of these pa-tients have associated super-ficial varicose veins. An explanation is offeredfor the dilatation of the sinusoids in bone (videsupra).

After osteotomy a partition forms in themedulla of the bone at the osteotomy site. Thepreviously distended bone sinusoids return tonormal size, and venous pain is relieved.

In discussions of the etiology of osteoarthritisa good deal of attention has focussed upon thechanges in arterial patterns in bone. Harrison,Schajowicz and T'rueta (1953) studied thehistology of injected postmortem femoral headsand femoral heads excised at operation. Theycommented in particular upon the change inarteriolar patterns and believe that much of thepathology is a result of this arteriolar responseto damaged tissue. This, they felt, was nature'soverzealous attempt at repair. Their prepara-tions (Figs. 40-43, p. 619 of their paper) alsoshow distended sinusoids, especially in regionsof bone cavitation.

Altogether scant attention has been directedto the venous changes in the bone adjacent toosteoarthritic joints. (Bernstein (1933) reportedexperiments on dogs in which obstruction tothe venous drainage resulted in osteoarthritis).The close association between lower limb super-ficial varicose veins and a subgroup of primaryosteoarthritic knees is, I think, significant par-ticularly as the venous disorders constantlyantedate the arthritis.

It may well be that the venous changes arenot merely the source of much of the pain inosteoarthritis but in some cases may even bethe primary cause of primary osteoarthritis.

I therefore venture to suggest a different trainof events which may lead to osteoarthritis.Man's upright posture, a comparatively late

acquisition in his evolution (Darwin, 1888),imposes great stress on the venous system ofhis lower limbs. This stress is further aggravatedby any rise in intrathoracic or intra-abdominalpressure. The increased venous pressure istransmitted to the sinusoids in the bone medulla,particularly where there is a concentration ofeffluents, as at the upper end of the tibia. Aspressure rises in, for example, the proximaltibial sinusoids, they distend at the expense ofthe adjacent trabecule. The overlying cartilagesuffers as venous stasis robs it of some of itsnutrition, and trabecular erosion disturbs itsuniform bony support. (Fig. 5 a, b).

After, for example, tibial osteotomy a par-tition forms which results in diversion of blooddestined for evacuation at the upper end ofthe tibia and there is also a more efficient activewithdrawal of blood from the smaller compart-ment so formed. A mean fall of medullarypressure occurs and an improved circulationresults. The long-term consequences are that

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A

CARTILAGE

BONE

FIG. 5.-A. Shows the normal arcades of 'bone at osteochondral junction.B. The trabecular distortion in osteoarthritis.

Diagrammatic Representation of Fig. 5.

NORMAL

Trabeculae

I{~, II jj ~BoneCartilage

1 1 IX T T T Bonethe sinusoids become less distended and, withthe improved circulation, the subchondral boneand the overlying cartilage enjoy betternutrition. Restoration of lost trabecule occursas the sinusoids decrease in size. Thus the stepsalong one of the paths leading to osteoarthritisare retraced: a degenerative process is reversed.

OSTEOARTHRITICTrabeculum

Under Overcompressed compressed

+ f Bone

Cartilage

Bone

Summary1. Some results of a clinical investigation

of patients with osteoarthritis of the knee aredescribed.

2. The different varieLies of pain whichoccur in osteoarthritis are detailed.

3. A sub-group of patients with primary



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April, 1965 HELAL: The Pain in Primary Osteoarthritis of the Knee 181

osteoarthritis of the knee is described. In thisgroup "venous" pain predominated; the veno-graphic appearances are typical, and in a largeproportion of cases the veins outside the boneare manifestly abnormal.

4. It is suggested that venous congestionwithin the bone results from extra-osseus veindisturbances, and leads to congestive bone painand to progressive joint degeneration.

5. The mechanism by which osteotomy pro-duces relief of pain is analysed and discussed.

6. A simple procedure which reproducessome of the benefits of osteotomy is described.The bulk of this investigation was carried out while

working at the David Lewis Northern Hospital,Liverpool, and presented as part of a thesis for theM.Ch.(Orth.).The work was continued at the Rowley Bristow

Orthopwdic Hospital.I am indebted to Mr. E. N. Wardle, Mr. G. E.

Thomas, Mr. A. Graham Apley, Mr. F. A. Simmondsand Mr. G. Hadfield for access to their patients.

I am grateful to Dr. Stannard of the PhysicsDepartment, University College, London, for his helpwith the physics of Fluid Motion, and to Mr. H. K.Vincent of Chase Farm Hospital for making thevenogram needles.

It gives me great pleasure to record my sincerethanks to Mr. E. N. Wardle who has imparted muchof his special knowledge of the subject and a gooddeal of encouragement; and also to Mr. A. GrahamApley for his support and advice in preparing thispaper.

REFERENCESBAZETr, H. C., and McGLONE, B. (1928): Notes onPain Sensations Which Accompany Deep Punctures,Brain, 51, 18.

BERNSTEIN, M. A. (1933): Experimental Productionof Arthritis by Artificially Produced Passive Con-gestion, J. Bone Jt Surg., 15, 661.

DARWIN, C. (1888): The Descent of Man, 2, 51.London: John Murray.

DICKERSON, R. C., and DUTHRIE, R. E. (1963): TheDiversion of Arterial Blood Flow to Bone, J. BoneJt Surg., 45A, 356.

DODD, H., and COCKETr, F. B. (1956): The Pathologyand Surgery of Veins of the Lower Limb. London:E. & S. Livingstone.

HARRISON. M. H., SCHAJOWICZ, F., and TRUETA, J.(1953): Osteoarthritis of the Hip, J. Bone Jt Surg.,35B, 598.

HULTH, A. (1958): Circulatory Disturbances in Osteo-arthritis of the Hip, Acta. orthop. scand., 28, 81.

JACKSON, J. P., and WAUGH, W. (1961): Tibial Osteo-tomy for Osteoarthritis of the Knee, J. Bone JtSurg., 43B, 746.

KELLGREN, J. H., LAWRENCE, J. S., AITKEN, J., anidSWAN, J. (1957): Radiological Assessment ofOsteoarthritis, Ann. rheum. Dis., 16, 494.

MCPHERSON, A. (1963): Personal Communication.MCPHERSON, A., SCALES, J. T., GORDON, L. H. (1961):Methods of Estimating Qualitative Blood Flow inBone, J. Bone Jt Surg., 43B, 791.

OSBORNE, G. V. and FAHRNI, W. H. (1950): ObliqueDisplacement Osteotomy for Osteoarthritis of theHip Joint, ibid, 32B, 148.

RAY, R. D. (1963): Paper on Circulatory Dynamicsof Bone. 9th Meeting of Society Internationale deChirurgie Orthopadique et de Traumatologie (Sicot)Vienna.

ROBSON, P. N., and VAN MIERT, P. J. (1962): Treat-ment of Osteoarthritis of the Hip by InterstitialCobalt 60 Irradiation, Brit. J. Surg., 49, 624.

RUFFER, Sir M. A. (1921): Studies in the Palmopath-ology of Egypt. Chicago: University of ChicagoPress.

SCHOBINGER, R. A. (1960): Intraosseous Venography.New York and London: Grune & Stratton.

SEGUIRA, Y. (1958): Morphological and PhysiologicalStudy of Bone Sensitivity, Archiv fur japanischeChirurgie (Tokyo), 27, 597.

STANNARD, F. R. (1963): Personal Communication.VOLKMANN, R. (1875): Osteotomy for Knee Joint

Deformity, Berliner klinische Wochenschrift. Orgatnfur practische Aerzte, Berlin, 629-631.

WALKER, A. J. and LONGLAND, C. J. (1950): VenousPressure Measurements in the Foot in Exercise asan Aid to Investigation of Venous Disease in theLeg, J. clin. Sci, 9, 101.

WARDLE, E. N. (1962): Osteotomy of the Tibia andFibula, Surg. Gynec. Obstet., 115, 61.

WARWICK, W. T. (1931): The Rational Treatment ofVaricose Veins and Varicocoele. London: Faber& Faber.



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