Management of OA

1. Management of
osteoarthritis
Capt. Aye Chan Nyo

2. Objectives
General : to improve function and to reduce patients
symptoms
Specific :
To reduce pain
To maintain joint movements
To maintain and Strengthen muscle power
To prevent and correct deformities and stability
To promote Heath related quality of life of patients

3. Treatment options
Non-operative treatment
• Health and behavior modification
• Physical therapy and exercise
• Pharmacological treatment
• Intra-articular injections
Operative treatment
• Arthroscopic debridement
• Osteotomy
• Arthrodesis
• Arthroplasty

4. Health and behavior modification
 weight reduction
 minimizing activities
 patient education
Physical therapy and exercise
 Exercise – strengthens muscles and strong muscle
protect the joints
 Three type of exercise – range-of-motion exercise,
strengthening exercise and aerobic exercise
Non-operative treatment

5.  Physical Therapy
Rest
Heat and cold
Electrotherapy -Electrical stimulation
-TENs
-Laser therapy
Hydrotherapy
Ultrasound
Infrared radiation
Exercise therapy
Occupational therapy

6.  Mechanical aids
Wrapping the knee with special therapeutic tape
Wearing shock absorbing soles in shoes or
orthopaedic shoes
Splints or braces
Canes, crutches

7. Pharmacological treatment
Most effective when combined with non-
pharmacological treatment
(a) Simple analgesic e.g., paracetamol
(b) NSAIDs COX2 inhibitors e.g., celecoxib
(c) Narcotics e.g., morphine and pethidine
-for acute excerbations
-for some patients when other
treatments are failed or inappropriate
(d) Tramadol

8. (e) Disease modifying agents
Glucosamine sulphate – chrondroprotective effect
 Glucosamine – more anabolic
 Chondroitin – more anti-catabolic
 Possible actions:
Inhibit cartilage enzyme activity
Stimulate chrondrocytes
 Status-comparable to NSAIDs , but more safer

9. Intraarticular Injection
1. Steroids
= Methyl prednisolone
= Triamcinolone hexacetonide
2. Hyaluronic Acid Derivatives
= Hyalgon
= Synvise

10. EFFICACY OF LOCAL INJECTION ( I.A.C. )
Short term benefit
Evidence showed not significant superior benefit than
placebo
Only in mild radio-morphology of O.A
Presence of effusion i.e. acute synovitis
Adjusted or restriction of weight bearing after injection
American College of Rheumatology guideline suggested
not more than 3-4 injections within a year
Masking of pain-care not to overuse of affected joints

11. EFFICACY OF LOCAL INJECTION of Hyaluronic
acid
Viscosupplementation
Widely used in developed countries
Mechanism of action is incompletely understood
Lubricant action for slow movements, Shock
absorber for fast movements
Anti-inflammatory effect (high dose)
3-5 injections administered weekly
Status-comparable to NSAIDs and corticosteroids

12. OPERATIVE TREATMENT
- Arthroscopic debridement
- Osteotomy
- Arthrodesis
- Arthroplasty

13. -A variety of procedures from arthroscopic lavage
and debridement to total knee arthroplasy
-Choice of procedure depends on the patient's age, activity
expectations, the severity of the disease and the number
of knee compartments involved.

14. DEBRIDEMENT
Removal Limited Synovectomy
Excision of Osteophytes
Removal of Loose Bodies
Removal of Damaged Menisci
Open ( rarely used )
Arthroscopic

15. ARTHROSCOPIC DEBRIDEMENT
The advantages:
-Small procedure with few risks
-Removes mechanical and chemical irritants
-Allows the surgeon to examine the knee joint
The disadvantages:
-Offers seldom a lasting cure
-Unnecessarily postpone a total knee replacement

16. ARTHROSCOPIC DEBRIDEMENT
Outcome assessment
Good Poor
Short duration Long duration
Mechanical symptoms Rest pain
Medial tenderness Lateral tenderness
Normal alignment Malalignment
Ligament stable Ligament unstable
Unicompartmental Bi- or tri

17. ARTHROSCOPIC DEBRIDEMENT
Indications ;
 active , older adults with mild to moderate OA
after conservative treatment is exhausted
Most report success rates about 70% & favorable
outcomes longer lasting than lavage alone
60 to 70 % of the patients were pain free for 5 years

18. Osteotomy
(1) proximal tibial osteotomy
(2) distal femoral osteotomy
(3) others
(4) proximal femoral osteotomy

19. (1) PROXIMAL TIBIAL OSTEOTOMY
High tibial osteotomy is a well established procedure for
the treatment of unicompartmental osteoarthritis of the
knee
80 % satisfactory results 5 years after osteotomy
BIOMECHANICAL RATIONALE
Unloading of the involved joint compartment by
correcting the malalignment and redistributing the
stresses on the knee joint

21. Indications
Pain and disability significantly interfere with
employment and recreation
Confined to one compartment with a corresponding varus
or valgus deformity
Ability of patient to use crutches after the operation
Good vascular status

22. Contraindications
Narrowing of lateral compartment cartilage space
Lateral tibial subluxation > 1 cm
Medial compartment bone loss > 2 or 3mm
Flexion contracture > 15 degrees
Knee flexion < 90 degrees
> 20 degrees of correction needed
Rheumatoid Arthritis

23. Advantages
It is made near the deformity
It is made through the cancellous bone
It permits to be held firmly in position by one or two
staples
It permit exploration of the knee through same incision

24. COVENTRY TECHNIQUE
W = diameter x 0.02 x angle or tangent table

25. Other methods
 High tibial osteotomy with osteotomy jig
 Opening wedge osteotomy hemicallotasis

26. Complication
 Recurrence of deformity
 Peroneal nerve palsy
 Nonunion
 Infection
 Knee stiftness or instability
 Intraarticular fracture
 DVT
 Compartment syndrome
 Patella infera
 AVN

27. (2) DISTAL FEMORAL OSTEOTOMY
Valgus deformity > 12 to 15 degrees
The plane of the knee joint deviates from the horizontal
by more than 10 degrees

28. (3) Other Osteotomies
Barrel-vault osteotomy
Open wedge osteotomy

29. (4)Proximal femoral osteotomy
Goal of reconstructive osteotomy
to restore nearly normal anatomy as possible, returning
joint pressures and loading to normal
Goal of Salvage osteotomy
To relieve pain and improve function enough to delay
THA

32. ARTHRODESIS
Severe disability in young, active patients
The last operation after a failed total knee prosthesis.
Bilateral knee arthrodesis is never indicated

33. Arthrodesis
 Indications
i. Confined to one hip
ii. Destruction is severe
iii. Marked limitation of motion
iv. Ineffective medical treatment
v. Absence of ipsilateral knee pain or chronic
lumbosacral pain
vi. Patient is willing to accept a stiff for pain relief

34.  It can be used in young patients:
Willing to modify life-styles
Do not place heavy elements at hips at work or
Understands well that THA will most certainly needed
during lifetime
in OA of DIPJ,
in OA of 1st metatarsophalangeal joint
Arthrodesis in young, active patients with severe post
traumatic OA of shoulder joint

35. Arthroplasty
(1) Partial arthroplasty
(2) Total arthroplasty
(3) Resurfacing arthroplasty

36. Unicompartmental knee arthroplasty
 indications;
(1) OA Limited to one compartment
(2) older than 60 yrs
(3) low activity
(4) body wt > 180 lb
(5) minimal pain at rest
(6) flexion 90˚
(7) no angular deformity > 15˚

37. Advantages;
(1) preservation of bone stock and intraarticular
structure
(2) simultaneous bilateral arthroplasty
(3) easier revision to TKA
(4) comparable result to osteotomy
Disadvantages;
(1) more difficult procedure
(2) inferior result to TKA

38. UNICOMPARTMENTAL KNEE REPLACEMENT

39. TOTAL KNEE ARTHROPLASTY
The name "Total Knee Replacement" is a misnomer.
removes only the damaged surfaces of the knee joint and
then covers them with surface shells made of metal and
polyethylene.
The proper name would thus be "the surface replacement
of the knee joint"

40. The goals of a total knee replacement
 the relief of pain
 the correction of knee joint deformity
 the restoration of knee joint motion
 the restoration of knee joint function
 the creation of a stable knee joint.

42. INDICATION
If the pain is severe and the X-ray pictures demonstrate
impairment of the knee joint, that patient is a candidate
for the total knee replacement
Pain in the knee is so severe that it impairs sleep
The pain killing medicines do not work or work only for a
short time
In general, the patients with more advanced X-ray
changes have also more pain in their knee joints.

43. Total hip arthroplasty
Treatment of choice for advance OA in patient over 50 years of
age with severe pain and limitation of movement unrelieved by
medication and nonsurgical support treatment.
Noncemented technique with bony ingrowth and the development
of new ceramic material are allowing total hip arthroplasty to
be use in younger patients with an anticipated reasonable
longevity of the implant.

44. Evolving Therapeutic Procedure
1.Arthroscopic abrasion chrondroplasty
2.Marrow stimulation
3.Graft
4.Implatantion procedure

45. (1) ARTHROSCOPIC ABRASION
CHONDROPLASTY
To stimulate cartilage regeneration
Trim away or stabilize the damage cartilage
2 months of non-weight-bearing after surgery

46. (2) MARROW STIMULATION
Attempt to repair a small cartilage defect using the body's
own marrow stem cells
Repair tissue (fibrocartilage) develops from cells brought
to the area with blood deep in the bone underneath the
cartilage
Small holes made through the bone by abrasion, drilling,
or using a small pic to create microfractures

47. MESENCHYMAL STEM CELL STIMULATION
• Penetration of subchondral bone by drilling ,abrasion, or
microfractures to stimulate cartilage repair.

48. (3. a) OSTEOCHONDRAL AUTOGRAFT
Removes a small section of the patient's own cartilage
along with the underlying bone plug.
Obtained from an area that does not bear a lot of weight
The size of the defect treatable with this method is usually
between 1 and 2 cm2
Only 30 % success rate

49. (3. b) OSTEOCHONDRAL ALLOGRAFT
For very large defects that involve bone and cartilage loss
The advantage - the implant includes both bone and fully
developed cartilage for the repair

50. (4) AUTOLOGOUS CARTILAGE CELL
IMPLANTATION
Used for the repair of articular cartilage defects in the
knee greater than 2 cm2
Restrict activity for 12 months
Two-stage procedure:
 Biopsy
 Implant

51. A small biopsy of healthy cartilage is harvested
arthroscopically and sent to Genzyme Biosurgery
Cells are cultured to increase the number of cells from a few
hundred thousand to over 10 million cells ( 5 weeks )
The chondral defect is debrided back to healthy tissue.
The periosteal patch, harvested from proximal tibia, is
sutured into place.

52. Foot and ankle
 Polyarticular OA can cause symptoms severe enough to
justify fusion of one or more joints.
 Surgery is indicated for monoarticular arthritis of ststic or
traumatic origin as in hallux valgus, hallux rigidus, pes
planus or malunion.
Spine
 OA of spine is usually part of generalized arthritis.
 The entire spine and SI joints may be involved.
 Conservative treatment is appropriate.

53. Shoulder
 Less common and quite disabling.
 In elderly patients – total shoulder arthroplasty.
 In young active patients – arthrodesis.
Wrist
 All join that make up the wrist are usually affected.
 Radiocarpal arthritis can be treated by resection
arthroplasty , implant arthroplasty, or arthrodesis.