Presenation about managment of knee osteoarthritis from conservative and total knee replacment

1. MANAGEMENT OF
OSTEOARTHRITIS OF THE
KNEE
Dr Ehab Elzayyat
Consultant of orthopedic Surgery

2. Persons in Our countries tend to remain physically active and
participate in demanding activities well into their fifth, sixth,
and even seventh decades.
However, with this increase in activity comes an increased risk
of developing a chondral injury that may lead to early onset
of arthritis in the knee.
The recent literature on osteoarthritis (OA) in patients aged 40
to 60 years indicates that successful outcomes can be gained
with surgical treatment.

3. These vary from person to
person. People may
experience:
• Pain
• Stiffness
• Swelling
• Reduced function
• Weakening of the muscles
PRESENTATION OF KNEE
OSTEOARTHRITIS?

4. Physical exam
 inspection
 body habitus
 gait
 often an increased adductor moment to the limb during gait
 antalgic gait associated with knee arthritis

 knee is maintained in flexion
 shortened stride length
 compensatory toe walking
 limb alignment
 Effusion
 skin (e.g. scars)
 range of motion
 lack of full extension (>5 degrees flexion contracture)
 lack of full flexion (flexion <110 degrees)
 ligament integrity (varus and valgus)

5.  Osteoarthritis is sometimes described as degenerative joint disease
 Age is often the leading cause of osteoarthritis
 Women tend to be more affected by knee osteoarthritis than men
 Previous injury such as fractures or surgery
 Other factors that can predispose someone to knee osteoarthritis include: their
occupation, genetics and excess body weight, which can contribute to the onset of
joint pain.
WHAT ARE THE CAUSES?

6. CLASSIFICATION
Kellgren & Lawrence (based on AP weightbearing XRs)
•Grade 0 •No joint space narrowing (JSN) or reactive changes
•Grade 1 •Possible osteophytic lipping + doubtful JSN
•Grade 2 •Definite osteophytes + possible JSN
•Grade 3
•Moderate osteophytes + definite JSN + some
sclerosis + possible bone end deformity
•Grade 4
•Large osteophytes + marked JSN + severe sclerosis
+ definite bone end deformity

7. TYPES OF PATIENTS WITH KNEE OA
Knee joint OA
Knee-only OA: Symptomatic OA in one or
both knees only.
Multiple-joint OA*: Symptomatic OA of the
knee(s) in addition to other joints (e.g., hip,
hand, spine, etc
Co-Morbidity
No co-morbidities: The individual with OA
has no pertinent co-morbid health
concerns.
Co-morbidities: The individual with OA has
any of the following pertinent co-morbid
health concerns: diabetes; hypertension; CV
disease; renal failure; gastrointestinal (GI)
bleeding; depression; or physical
impairment limiting activity, including
obesity.

8. CO-MORBID KNEE OA PATIENTS
Moderate Risk
The individual with OA has any of the
following pertinent co-morbid health
concerns: diabetes; advanced age;
hypertension; CV disease; renal failure; GI
complications; depression; or physical
impairment limiting activity, including
obesity.
High Risk
The individual with OA has risk factors
such as history of GI bleed, myocardial
infarction, chronic renal failure, etc.

10. NONSURGICAL MANAGEMENT
In an effort to delay major surgery, many younger patients with
early knee OA are offered a variety of nonsurgical modalities, such
as
exercise and weight loss programme
and physical therapy,
 bracing, orthoses,
nonsteroidal anti-inflammatory drugs (NSAIDs),
and intraarticular viscosupplementation or corticosteroid
injection.

11. AAOS CLINICAL PRACTICE GUIDELINE
Strong
Evidence from two or more “High” quality
studies with consistent findings for
recommending for or against the
intervention. Also requires no reasons to
downgrade from the EtD framework
Moderate
Evidence from two or more “Moderate”
quality studies with consistent findings or
evidence from a single “High” quality study
for recommending for or against the
intervention. Also requires no or
only minor concerns addressed in
the EtD framework.
Limited
Evidence from one or more “Low” quality
studies with consistent findings or evidence
from a single “Moderate” quality study
recommending for or against the
intervention. In addition, higher strength
evidence can be downgraded to limited
because of major concerns addressed in the
EtD framework
Consensus
There is no supporting evidence, or
higher quality evidence was downgraded because of
major concerns addressed in the EtD
framework. In the absence of reliable
evidence, the guideline work group
is making a recommendation based
on their clinical opinion

12. In general, the goals of these therapeutic options
are to decrease pain and improve function.
Appropriate use of specific nonsurgical modalities
requires knowledge of evidencebased practice
guidelines, careful patient selection, patient
education, and adequate long-term follow-up

13. EXERCISE
• Several large randomized controlled
trials have shown that exercise reduces
pain and improves function in patients
with early OA.
• Two recent meta-analyses also
demonstrate that muscle strengthening
and aerobic exercise are important in
the management of OA.
• Muscle strengthening exercises are
superior for specific impairment-related
outcomes, such as pain, but aerobic
exercise contributes to better long-term
functional outcomes.
• An individualized, multimodal approach
tailored to specific symptoms and
patient expectations is recommended
to maximize pain relief and functional
outcomes.

14. • Patient compliance with a
regimen of exercise or physical
therapy is a significant concern.
• The best available evidence
shows that supplementation of a
home exercise program with
supervised exercise classes
results in the largest gains in
pain relief and locomotion at
12-month follow-up.
• Exercise must also be sustained
because any beneficial effects are lost 6
months after an exercise program is
terminated.
• Strength of recommendation:
Strong
• Implication: Practitioners should
follow a Strong recommendation
unless a clear and compelling
rationale for an alternative approach
is present.

15. LEVEL 1

16. LEVEL 2

17. LEVEL 3

18. WEIGHT LOSS
Weight loss should be addressed
as part of the management of knee OA.
Strength of recommendation: Moderate.
Framingham Study by Felson et al[10] demonstrated
that women with an approximately 5 kg weight loss
had a 50% reduction in the risk of development of
symptomatic knee OA.

19. Christensen et al used a meta-regression analysis of
randomized controlled trials to evaluate if there were
changes in pain and function when overweight patients
with knee OA achieve a weight loss.
The study concluded that disability could be
improved when weight was reduced > 5.1% over a 20-
period, or at the rate of 0.24% reduction per week

20. Riddle et al[12] found there to be a
significant dose-response relationship between the
extent of percentage change in body weight and the extent of
change in WOMAC index for physical function score.
Specifically those who gained ≥ 10% of body weight had
worse WOMAC physical function score.
It has also been associated with MRI changes as
Teichtahl et al showed that obese individuals with
OA who lost as little as 1% of their body weight were
able to reduce the amount of medial femorotibial
cartilage volume loss

21. BIOMECHANICAL INTERVENTIONS
Knee braces and sleeves
 Brace treatment could be used to
improve function, pain, and
quality of life in patients with
knee osteoarthritis.
 Strength of recommendation:
Moderate.
 Implication: Practitioners should
generally follow a Moderate
recommendation but remain
alert to new information and be
sensitive to patient preferences.
Cane
 Canes could be used to improve
pain and function in patients
with knee osteoarthritis.
 Strength of recommendation:
Moderate.
 Implication: Practitioners should
generally follow a Moderate
recommendation but remain
alert to new information and be
sensitive to patient preferences.
Lateral wedge insoles
 Lateral wedge insoles are not
recommended for patients
with knee osteoarthritis.
 Strength of recommendation:
Strong
 Implication: Practitioners
should follow a Strong
recommendation unless a
clear and compelling
rationale for an alternative
approach is presen

22. ORAL/DIETARY SUPPLEMENTS
The following supplements may be helpful in reducing
pain and improving function for patients with mild-tomoderate knee osteoarthritis;
however, the evidence is inconsistent/limited, and additional research clarifying the
efficacy of each supplement is needed.
 • Turmeric
 • Ginger extract
 • Glucosamine
 • Chondroitin
 • Vitamin D
Strength of recommendation: Limited. (downgrade)
Implication: Practitioners should feel little constraint
in following a recommendation labeled Limited, exercise
clinical judgment, and be alert for emerging evidence that
clarifies or helps to determine the balance between benefits and potential harm. Patient
preference should have a
substantial influencing role.

23. TOPICAL TREATMENTS
Topical nsaids should be used to improve function and quality of life for
the treatment of osteoarthritis of the knee, when not contraindicated.
Strength of recommendation: strong.
Implication: practitioners should follow a strong recommendation unless
a clear and compelling rationale for an alternative approach is present.

24. Neuromuscular training
• Neuromuscular training (ie, balance, agility, and coordination) programs in
combination with exercise could be used to improve performance-based function
and walking speed for the treatment of knee osteoarthritis.
• Strength of recommendation: Moderate. (downgrade)
• Implication: Practitioners should generally follow a Moderate recommendation but
remain alert to new information and be sensitive to patient preferences.

25. Self-management
Patient education programs are
recommended to improve pain in
patients with knee osteoarthritis.
Strength of recommendation:
Strong.
Implication: Practitioners should
follow a Strong recommendation
unless a clear and compelling
rationale for an alternative approach
is present.
Patient Education
Patient education programs are
recommended to
improve pain in patients with knee
osteoarthritis.
Strength of recommendation:
Strong.
Implication: Practitioners should follow
a Strong
recommendation unless a clear and
compelling rationale
for an alternative approach is present.

26. Manual Therapy
• Manual therapy in addition to an
exercise program may be used to
improve pain and function in patients
with knee osteoarthritis.
• Strength of recommendation:
Limited
Massage
• Massage may be used in addition to
usual care to improve pain and function
in patients with knee osteoarthritis.
• Strength of recommendation:
Limited.

27. .
LASER
• Laser Treatment FDA-approved laser
treatment may be used to improve pain
and function in patients with knee
osteoarthritis.
• Strength of recommendation:
Limited. (downgrade)
TENS
• Transcutaneous Electrical Nerve
Stimulation Modalities that may be
used to improve pain and/or function
in patients with knee osteoarthritis
include a. Transcutaneous electrical
nerve stimulation (pain)
• Strength of recommendation:
Limited

28. Oral NSAIDs
 Oral NSAIDs are
recommended to improve
pain and function in the
treatment of knee
osteoarthritis when not
contraindicated.
 Strength of
recommendation:
Strong
Oral Acetaminophen
 Oral acetaminophen is
recommended to improve
pain and functions.
 Strength of
recommendation:
Strong
Oral Narcotics
 Oral narcotics, including
tramadol, result in a
notable increase of adverse
events and are not
effective at improving pain
or function for the
treatment of osteoarthritis
of the knee.
 Strength of
recommendation:
Strong

29. ECSW
 Extracorporeal shockwave
therapy may be used to
improve pain and function
for the treatment of
osteoarthritis of the knee.
 Strength of
recommendation:
Limited
Hyalurinic Acid
 Hyaluronic acid intra-articular
injection(s) is not
recommended for routine
use in the treatment of
symptomatic osteoarthritis of
the knee.
 Strength of recommendation:
Moderate
Intra-Articular
steriod
 Intra-articular corticosteroids
could provide short-term
relief for patients with
symptomatic osteoarthritis of
the knee.
 Strength of recommendation:
Moderate

30. Platelet-rich Plasma
Platelet-rich plasma may reduce pain and
improve function in patients with
symptomatic osteoarthritis of the knee.
Strength of recommendation: Limited
Denervation Therapy
Denervation therapy may reduce pain and
improve function in patients with
symptomatic osteoarthritis of the knee.
Strength of recommendation: Limited

31. Acupuncture
Acupuncture may improve pain and
function in patients with knee
osteoarthritis.
Strength of recommendation:
Limited
Dry Needling
In the absence of reliable evidence, it is the
opinion of the work group that the
utility/efficacy of dry needling is unclear
and requires additional evidence.
Strength of recommendation:
Consensus

32. SURGICAL MANAGEMENT
Knee
replacment
 Unicompartme
ntal
 Total knee
replacement
Knee
arthroscopy
 Irrigation and
lavage
 Partial
menisectomy
Knee
Osteotomy
High tibial
osteotomy
Tibial tubercle
osteotomy
Distal femur
osteotomy

33. Knee arthroscopy
Usually may be indicated in mild to moderate knee arthritis
Need preserved joint space.
Positive MRI finding (meniscal tear or meniscal degenation)
Strength of recommendation: Limited

34. Knee osteotomy
High Tibial Osteotomy (HTO) is a surgical procedure that is
performed to correct angular deformities of the knee to prevent
development or progression of unicompartmental osteoarthritis.
It is predominately done to correct for varus deformities in young
patients but can also be done to correct valgus deformities.
Contraindications include inflammatory arthritis, flexion
contracture > 15 degrees, bicompartmental osteoarthritis, and
ligamentous instability.

35.  Use
 predominately done for varus
deformities
 less common for valgus deformities
 Angular deformity in the knee leads to
abnormal distribution of weight bearing
stresses
o can accelerate wear in medial or lateral
compartments of the knee and lead to
degeneration
o HTO is commonly combined with
cartilage restoration procedures to
provide better mechanical environment
for biologic repair

36. Mechanical axis of lower
extremity
can be assessed by
drawing straight line
from center of femoral
head to the center of
the ankle joint line axis
should pass just medial
to the medial tibial
spine

37. Indications
• young, active patient (<50 years) in
whom an arthroplasty would fail due to
excessive wear
• healthy patient with good vascular
status
• non-obese patients
• pain and disability interfering with daily
life
• only one knee compartment is affected
• compliant patient that will be able to
follow postop protocol
General contraindications
• inflammatory arthritis
• obese patient BMI>35
• flexion contracture >15 degrees
• knee flexion <90 degrees
• procedure will need >20 degrees of
correction
• patellofemoral arthritis
• ligament instability
• varus thrust during gait

38. Lateral closing wedge Medial opening wedge

39. Unicompartment Knee replacement
• When only one
compartment of the
knee is involved.
• For isolated medial,
isolated lateral or
isolated
patellofemoral
osteoarthritis.
• The most common
reasons for
conversion to a total
knee arthroplasty are
the progression of
osteoarthritis and
aseptic loosening.
• Incidence
5% of surgeries
where knee
arthroplasty is
indicated are
unicompartmental
knee replacements
• Anatomic location
medial
compartment is
most common
• Fixed-bearing
historical standard
of care
• Mobile-bearing

40. ADVANTAGES
Compared to TKA
• faster rehabilitation and quicker
recovery
• less blood loss
• less morbidity
• less expensive
• lower rates of PJI, wound complications
• preservation of normal kinematics
Compared to HTO
• faster rehabilitation and quicker
recovery
• improved cosmesis
• higher initial success rate
• fewer short-term complications
• lasts longer
• easier to convert to a TKA

41. Indications
• controversial and vary widely as an
alternative to TKA or osteotomy for
unicompartmental disease
• classicaly reserved for older (>60),
lower-demand, and thin (<82 kg)
patients
• 6% of patient's meet the above criteria
with no contraindications
Contraindications
• inflammatory arthritis
• ACL deficiency
 absolute contraindication for mobile-bearing UKA and
lateral UKA
 controversial for medial fixed-bearing
• fixed varus deformity > 10 degrees
• fixed valgus deformity >5 degrees
• restricted motion arc of motion < 90°
• flexion contracture of > 5-10°
• previous meniscectomy in other compartment
• tricompartmental arthritis (diffuse or global pain)
• younger high activity patients and heavy laborers
• grade IV patellofemoral chondrosis (anterior knee pain)

42. • avoid overcorrections
• undercorrect the mechanical axis by 2-3 degrees
• overcorrection places excess load on
unresurfaced compartment
• remove osteophytes (peripheral and notch)
• resect minimal bone
• avoid extensive releases
• avoid edge loading
• prevent tibial spine impingement with proper
mediolateral placement
• avoid making a varus tibial cut which increases
the chance for loosening
• use caution when placing the proximal tibial
guide pins to avoid stress fractures
• correct varus deformity to 1-5 degrees of valgus
This Photo by Unknown Author is licensed under CC BY
Surgical tips and
tricks

43. Complications
• Aseptic loosening
 most common cause of early failure (5 years) at somewhere between 25%-
45.3%
• Stress fractures
 always involve tibia
 associated with high activity and patient weight
 clinically there will be a pain free interval followed by spontaneous pain
with activity
 blood commonly found on joint aspiration
 risk factors
penetrating posterior tibial cortex with guide pin,
placing guide pin medial in periphery, re-drilling for guide pin,
 and under-sized tibial component
• Intra-operative fractures
 associated with forceful impacting of implant

45. TOTAL KNEE REPLACMENT

46. •indications
•symptomatic knee osteoarthritis
•failed non-operative treatments
•techniques
•cruciate retaining vs. crucitate sacrificing
•implants show no difference in outcomes
•patellar resurfacing
•no difference in pain or function with or without patella resurfacing
•lower reoperation rates with resurfacing
•drains are not recommended

47. GOALS OF TOTAL KNEE
Restoration of
mechanical
alignment
Maintain the
joint line
Achieve ligaments
balance
Normal patellar
tracking

48. RESTORATION OF MECHANICAL
ALIGNMENT

49. MAINTAIN THE JOINT LINE

50. LIGAMENT BALANCING

51. NORMAL PATELLAR TRACKING

52. TOTAL KNEE SURGICAL APPROACHES
Medial para[atellar
Medial subvastus
Midvastus

53. BONE CUTS

54. This Photo by Unknown Author is licensed under CC BY-NC This Photo by Unknown Author is licensed under CC BY
posterior cruciate-retaining

55. This Photo by Unknown Author is licensed under CC BY-NC
posterior-stabilized

56. An overview of revision knee prostheses on the market illustrating different constraint mechanisms. (A to G)
Represent bicruciate-retaining, posterior cruciate-retaining, highly congruent (anterior-stabilized), posterior-
stabilized, varus–valgus constrained (condylar constrained knee), rotating hinge, and pure (rigid) hinge
prostheses. The upper line indicates the polyethylene insert, and the lower line indicates the contact pattern
of condylar and tibial components.
Types of constrained total knee
arthroplasty