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Osteoarthritis knee,, pain management
- 1. Osteoarthritis knee Dr RaviShankar Sharma Fellow (Daradia)
- 2. Anatomy of kneejoint
- 3. Anatomy • Type –Hinge type synovial joint • Femoropatellar and femorotibial joint
- 4. • The articularcapsule has a synovial and a fibrous membrane separated by fatty deposits. • Synovial membrane have multiple extensions which includes suprapatellar bursa.
- 5. Ligaments Intracapsular and extracapsular •Intracapsular o Anterior cruciate ligament (ACL) o Posterior cruciate ligament (PCL) o Transverse ligament o Anterior and posterior meniscofemoral ligament o Coronary ligament
- 6. Extracapsular • Petallar ligament •Medial collateral ligament • Lateral collateral ligament • Oblique popliteal ligament • Arcuate popliteal ligament
- 7. Meniscus • Medial meniscus •Lateral meniscus Structure • Fibrous cartilate • Outer 1/3rd blood supply Function
- 8. Nerve supply • Femoral-throughits branches in vasti medialis • Sciatic(through genicular branches) • Obturator nerve-through its posterior division
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- 10. Osteoarthritis • Degenerative jointdisease affecting joint cartilage and subchondral bone,leading to the formation of bony spurs and subchondral cyst. • Age above 60 years • Female more after menopause
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- 12. Overview: Risk Factors •Age • Female • Obesity ( most important modifiable) • Previous knee injury • Lower extremity malalignment • Repetitive knee bending • Hereditory and nodal OA • Low level of vitamin C and D • Muscle weakness( quardiceps)
- 13. Pathophysiology Biomechanical stress affecting thearticular cartilage and subchondral bone leading to wear and tear
- 14. WHY PAIN ? •PERIPHERAL SENSITIZATION : • mediator induced inflammation of articular nociceptors • Secondary to synovitis • Stretching of joint capsule and ligaments • Periosteal irritation due to osteophytes • Trabeculae microfractures • Intraosseous hypertension • Muscle spasm CENTRAL SENSITIZATION
- 15. Signs and symptoms •Pain • Morning stiffness • Swelling • Decreased range of motion • Swelling • Sounds- crepitation
- 16. Clinical examination • Gait •Swelling • Deformity • Tenderness over joint line • Active and passive ROM painful • Hard end feel • Bony crepitations
- 17. Diagnosis of KneeOA Classic Clinical Criteria • established by ACR, 1981 • sensitivity 95%, specificity 69% knee pain plus at least 3 of 6 characteristics: • > 50 yrs • Morning stiffness < 30 min • Crepitus • Bony tenderness • Bony enlargement • No palpable warmth 5
- 18. Kellgren and Lawrenceclassification Grade 0 No radiographic features of osteoarthritis Grade 1 Possible joint space narrowing and osteophyte formation Grade 2 Definite osteophyte formation with possible joint space narrowing Grade 3 Multiple osteophytes, definite joint space narrowing, sclerosis and possible bony deformity Grade 4 Large osteophytes, marked joint space narrowing, severe sclerosis and definite bony deformity
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- 20. Treatment • Non pharmacological •Pharmacological-pcm, NSAIDS,disease modifying agents like collagenase inhibitor, elastase inhibitors,and narcotics • Intervention • Surgery
- 21. Intraarticular injections • Corticosteroids-max. 3-4 times in a year • Hyaluronic acid in major co-morbid conditions
- 22. Prolotherapy • Proliferation therapyor regenerative injection therapy involves injecting an otherwise non-pharmacological or non-active irritant solution into knee joint • Dextose • Prolozone • Platelet rich plasma
- 23. Platelet Rich Plasma(PRP) • Platelet derived growth factor • Transforming growth factor B • Fibroblast growth factor • Insulin like growth factor 1&2 • Vascular endothelial growth factor • Epidermal growth factor • Keratinocyte growth factor • Connective tissue growth factor All these promote cartilage repair
- 24. Genicular nerve block& RF neurotomy Indications • Chronic knee pain secondary to OA • Patients with failed knee replacement • Patients unfit for knee replacement • Patients who want to avoid surgery
- 25. Surgery • Arthoscopy debridement •Osteotomy - malalignment • Knee replacement