osteoarthritis knee priyank

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  • 1. SEMINAR ON OSTEOARTHRITIS KNEE DEPTT. OF ORTHOPAEDICS M.L.B.Medical College,Jhansi
  • 2. OSTEOARTHRITIS KNEE
    • MODERATOR:
    • Prof. Dr. D.K. Gupta M.S
    • Prof. Dr. R.P. Tripathi M.S.
    • Dr.Saurabh Agarwal M.S.
    • Dr. Mayank Bansal M.S.
    • Dr. Amit Sehgal M.S.
    • Dr. Paras Gupta M.S.
    • SPEAKER: PRIYANK GUPTA
  • 3. PAIN,DEFORMITY & DEPRESSION
  • 4. NORMAL ANATOMY:KNEE JOINT
    • Knee is a complex synovial joint formed between femoral condyles,tibial condyles & patella.
    • Stabilised by variety of ligaments.
    • Active movement at the knee are flexion,extension,medial rotation & lateral rotation.
  • 5. OA-Risk Factors
    • Age
    • Strongest risk factor
    • OA can start in young adulthood Risk increases with age
    • Female Gender
    • Affects more women than men
    • In men commonly before age 45, women after age 45
    • Joint Alignment
    • Abnormal alignment or motion predisposes joint to OA
    • Bow legs, dislocations
  • 6.
    • RISK FACTORS Contd…
    • Hereditary gene tendency
    • Joint injury/Overuse from physical labor or sports
    • Trauma to any joint increases risk of OA
    • Ligament or meniscus tears
    • Repeated movements in certain jobs increase risk
    • Obesity
    • Joint overload is among strongest risks for knee OA
    • Indian habits : cross-legging & squatting
  • 7. IF RISK FACTORS CONTINUES……….
  • 8. So Osteoarthritis is………
    • Osteoarthritis is a degenerative , noninflammatory joint disease characterised by destruction of articular cartilage and formation of none at the joint surfaces & margins .
  • 9. CLINICAL FEATURES
    • - Pain : Steady/intermittent in a joint - Stiffness : follows periods of inactivity, such as sleep or sitting
    • - Swelling/tenderness : in one or more joints
    • - Crepitus : Crunching feeling or sound of bone rubbing on bone
    • - Locking
    • - Limitation of movements
    • - Deformity : valgus/varus
  • 10. Sequence of pathological events
    • Disease process usually begins in anteromedial compartment of knee
    • Fibrillation d/t loss of water of wt. bearing articular cartilage
    • This puts pressure on underlying bone which causes sclerosis
    • Cysts& microfracture
    • New bone & osteophyte formation
  • 11.
    • Function of Articular Cartilage
    • Reduce friction at the joint
    • Act as a cushion to absorb the shock associated with joint use
    • Transmit weight loads to the underlying bone.
  • 12. Development of O.A.
    • imbalance between the destructive and reparative or synthetic processes of the articular cartilage
  • 13. Mechanical axis of knee
  • 14. Mechanical explanation of O.A. knee
    • The mechanical axis of the knee is a line extending from the center of the hip joint  to the middle of the ankle joint. This line is practically perpendicular to the ground.
    • In a healthy, well aligned knee joint, the mechanical axis  passes through the middle of the knee.
    • Only when the mechanical axis passes through the center of the knee joint, the stresses on the knee joint surfaces are uniform in all areas of the joint and well balanced.
    • In many knee joint diseases, the mechanical axis is disturbed and does not pass through the center of the joint . This disturbance results in the overload of distinct areas of the knee joint leading to their damage . The patella lies not symmetrically in its groove.
  • 15.
    • Views
      • Standing anteroposterior (weight bearing)
      • Lateral
      • Notch patellar views (Sunrise view)
        • Posteroanterior intracondylar (PAIC)
        • Tangential patellar
    • Findings
      • Joint space narrowing
        • Medial tibiofemoral joint space narrowing
        • Patellofemoral joint space narrowing
        • Lateral joint space narrowing to lesser extent
      • New subchondral bone formation
      • Tibia lateral subluxation
      • Osteophyte formation
        • Medial osteophytes are most prominent initially
    RADIOLOGICAL EXAMINATION
  • 16. STAGES OF OSTEOARTHRITIS
    •   
    • The best way to see if osteoarthritis is present and see the severity is by looking at x-rays of the knee. Osteoarthritis is classified into 5 stages or "Grades":
    • Grade 0:      · Normal knee joint      · No loss of cartilage and no deformation Grade 1:      · Some loss of articular cartilage      · If severe loss of cartilage, joint space narrows      ·  Osteophytes  may be seen Grade 2:      · More activity in the bone under the cartilage      · Increased activity can lead to bone hardening (sclerosis) and cysts      · Change in bone density (whitening of bone on x-ray) Grade 3:      · Some deformations on edge of bone      · Rough edges      · Increased joint narrowing Grade 4 :      · Complete loss of joint space      · Definite deformity of bone ends      · Changes in joint shape mean the bone contour has been altered
  • 17. O.A. STAGES
  • 18. O.A. STAGES contd.
  • 19. OTHER INVESTIGATIONS
    • COLORISED X-RAY OF O.A. KNEE
  • 20.
    • MRI
    • MRI  is very sensitive to bony and soft tissue changes.
    • MRI can also demonstrate reactive bone edema or soft tissue swelling as well as small cartilage or bone fragments in the joint. .
  • 21.
    • CT Scanning
    • CT   is excellent for demonstrating the degree of osteophytes (bone spur) formation and its relationship to the adjacent soft tissues. -CT is also useful to provide guidance for therapeutic and diagnostic procedures.
  • 22.
    • ULTRASONOGRAPHY
    • Ultrasound is extremely sensitive for identifying synovial cysts and outpouches that can form in association with osteoarthritis.
    • Ultrasound can also be used to image articular cartilage in patients who cannot tolerate an MRI examination.
    • Can also be used to guide for diagnostic and therapeutic procedures.
  • 23.
    • RADIONUCLIDE BONE SCAN
    • Radionuclide Bone Scans are very sensitive in detecting reactive bone edema association with osteoarthritis.
    • For multiple sites of arthritic involvement.
  • 24. Arthroscopic examination
    • Diagnosis : Normal Articular Cartilage
    • Osteoarthritic cartilage with exposed subchondral bone
  • 25. TREATMENT
    • Treatment directed at symptoms and slowing progress of the condition
    • Goals: 4 R’s
    • R elieve pain
    • R estore function
    • R educe disability
    • R ehabilitation
    • URICE (Ultrasound, Rest, Ice, Compression and Elevate)
  • 26. TREATMENT STAGES
    • EARLY Tt.
    • PHYSIOTHERAPY
    • LOAD REDUCTION
    • ANALGESICS
    • INTERMEDIATE Tt.
    • JOINT DEBRIDEMENT
    • AUTOLOGOUS CHONDROCYTE GRAFTING
    • REALIGNMENT OSTEOTOMY
    • LATE Tt.
    • ARTHROPLASTY
    • ARTHRODESIS
  • 27. PHYSIOTHERAPY
    • Aim is to maintain joint mobility & improving muscle strength
    • Includes:
    • Exercises
    • Massage
    • Application of warmth
  • 28. Load reduction
    • LIFE STYLE CHANGES:
    • Western commode
    • Shock absorbing shoes
    • Walking sticks
    • Weight reduction in obese
    • DIET
    • Omega-3 fatty acids
    • vitamin C
    • Vitamin D
    • Vitamin E
  • 29. Pain Management
    • Analgesics : NSAID ‘s
    • Corticosteroid Injection
    • Reduce inflammation around joints More rapid effect than NSAIDs
    • Visco- supplement
      • Intraarticular hyaluronan therapy
      • Increase viscosity & elasticity of fluid
  • 30. Role of diacerein & glucosamine
    • Diacerein is IL-1 inhibitor
    • Disease modifying effect on O.A.
    • Prophylactic use of diacerein leads to lower degree of articular stiffness when compared to glucosamine
    • prophylactic chondroprotective effects of diacerein and glucosamine are histologicaly similar
  • 31. SURGERY
    • INDICATIONS:
    • Pain refractory to conservative measures.
    • History of frequent locking episodes
    • Haemarthroses d/t loose bodies or osteochondral fractures.
    • Deformity usually genu varum
    • Joint disability
    • Progressive limitation of knee motion
  • 32. SURGICAL METHODS
    • Arthroscopic debridement
    • Proximal tibial osteotomy
    • Distal femoral osteotomy
    • Chondral resurfacing procedure
      • Autologous chondrocyte grafting
      • Mosaicplasty
    • TKR
    • Arthrodesis
    • Patellectomy
    • UKA
  • 33. Arthoscopic techniques
    • Simple lavage
    • Debridement
    • Abrasion chondroplasty
  • 34. Arthroscopic debridement
    • PATIENT SELECTION:
    • Active , older adults with mild to moderate osteoarthritis knee after conservative Tt has been exausted.
    • Based on history, physical examination, radiographic finding
  • 35.  
  • 36. OSTEOCHONDRAL & AUTOLOGOUS CHONDROCYTE TRANSPLANTATON
    • Healthy chondrocytes are harvested from an uninvolved area of injured knee
    • Grown in tissue culture
    • Injected into knee cartilage defect
    • Sealed over with a periosteal flap from proximal medial tibia
    • Still experimental
  • 37. PROXIMAL TIBIAL OSTEOTOMY
    • PRINCIPLE:
    • In Pt with unicompartmental O.A. of knee it causes “unloading” of involved jnt compartment by correcting malalingnment & redistributing the stresses on the jnt.
  • 38.
    • INDICATIONS:
    • Pain & disability interfering high demand employment
    • Radiographic evidence of involvment of 1 compartment
    • Valgus/varus deformity
    • Ability of the Pt. to use crutches after operation
    • Good vascular status
  • 39.
    • CONTRAINDICATIONS :
    • Narrowing of lateral compartment.
    • Lateral tibial subluxation of more than 1cm.
    • Medial compartment bone loss of> 2-3 cm.
    • Flexion contracture of >15°
    • Knee flexion of < 90 °
    • More than 20 ° of correction needed
    • Rheumatoid arthritis
  • 40. Types of osteotomy
    • Medial opening wedge
    • Lateral closing wedge
    • Dome
    • Medial opening hemicallotasis
  • 41. LATERAL CLOSING WEDGE OSTEOTOMY
    • Calculation of size of bone wedge
  • 42. HTO with use of osteotomy jig
    • Incision
    • Positioning transverse osteotomy guide
  • 43.
    • Placement of oblique osteotomy guide & performing osteotomy
    • Application of compression clamp & L- plate
  • 44.
    • Fixation of bone after osteotomy can be done by :
    • Staples
    • Plate
    • Screws
    • tomofix
  • 45. TomoFix
    • With the principle of the Locking Compression Plate (LCP) system with angular stable screws locked within the new TomoFix™ plate, anatomically designed for the medial high tibial valgus correction, stable fixation of the osteotomy without bone grafts or bone substitutes may be achieved.
    • the plate functions like a bridging internal fixator
  • 46. MEDIAL OPEN WEDGE TIBIAL OSTEOTOMY
    • Recommended if extremity shortening is 2mm. Or more
  • 47. OPENING WEDGE HEMICALLOTAXIS
    • Positioning of fixator
    • Medial & lateral fixator pins
  • 48.
    • OSTEOTOMY GUIDE ATTACHED & OSTEOTOMY DONE
    • DISTRACTION OF OSTEOTOMY
  • 49. DISTAL FEMORAL OSTEOTOMY
    • COVENTARY TECHNIQUE
  • 50.
    • SUPRACONDYLAR V- OSTEOTOMY
  • 51. ARTHROPLASTY
    • U.K.A.
    • ADVANTAGES OVER OSTEOTOMY:
    • Preservation of bone stalk
    • Immedite wt. bearing
    • Shorter recovery time
    • Easier revision to TKR
    • DISADVANTAGES:
    • Technical difficulty
    • Prosthesis loosening & failure
  • 52. TKR
    • When entire knee jnt is involved that cause incapacitating pain & disability .
  • 53.  
  • 54. ARTHRODESIS
    • Indicated for severe disability esp. in young & active Pt. whose activity desire might severly limit the longevity of TKR Techniques of Arthrodesis:
    •   - External Fixation :   - Intramedullary Nailing Arthrodesis :   - Plate Fixation :
  • 55. Patellofemoral joint osteoarthritis
    • Roughening of contiguous articular surfaces of patella & femur.
    • Aching pain behind patella
    • TREATMENT:
    • conservative
    • Surgical options :
      • Lateral release
      • Chondroplasty
      • Maquet osteotomy
      • Patellar osteotomy
      • Patellar resurfacing
      • Patellectomy
      • Patellofemoral joint replacement
  • 56. PAINFREE,MOBILE & HAPPY LIFE
  • 57. THANK YOU