1. Non Arthroplasty Management of
Osteoarthritis Knee
Dr.Abdul G.Suhail
MBBS, D.Ortho, MS(Ortho), Fellowship(Arthroplasty)

2. •Physical Modalities
•Braces
•Medications
•Intra articular injections
•Surgical Options

3. Weight Reduction

4. • TENS
• Acupuncture
• Heat/Ice thermotherapy
• Quadriceps strengthening

5. Orthotics

6. Walking Stick
Lateral Wedge Insoles

7. • Medial or lateral
unloading
Off loader Braces

8. Pharmacological

9. • Paracetamol, max 3-4 gm/day
analgesic of choice 1st line and long term
• Topical NSAIDs
• NSAIDs— For Pts not responding to
Pmol and for exacerbations
• Tramadol
• Codeine
• SYSADOA - No role
Glusosamine SO4
Chondroitin SO4
Diacerin
Oral Therapy

10. •Steroids
•Hyaluronic acid
•PRP
Intra articular Injection

11. Intra-articular
Corticosteroids
• Beneficial in KNEE
• Short-duration benefits: 2-4 weeks
• Every 3 months ,not effective at 2 years

12. • Delayed effect (4 weeks)
• Long duration (6 months)
• 1-5 weekly injections
Not recommended
J Bone Joint Surg Am, 2013 Oct
Intra-Articular Hyaluronic Acid
(IAHA)
“viscosupplement”

13. IAHA: Mechanism of Action
• Increased synovial fluid HA conc.
• Increased cartilage
lubrication/elasticity
• Chondrocyte proliferation
• Decreased inflammatory mediators
Devine, Shaffer. Use of viscosupplementation
for knee osteoarthritis: an update. Curr Sports Med Rep 2011

14. Platelet-Rich Plasma in Knee
OA
• Kon et al 2010 and Filardo et al 2011 , series n=115
• Three 5ml PRP; improved at 6 and 12 months
• Sampson et al 2010 series n=14
• PRP at 0/4/8 wks; pain reduction out to 52 weeks in majority
• Wang-Saegusa et al 2011 series n=261
• PRP at 0/2/4 wks; improved pain/fxn/QOL to 6 mos w/o AdvEfx
• Sanchez et al. 2008 case/cont
• PGRF vs Hyaluronic acid (HA), weekly x3
• At 5 weeks, 33% decrease pain w/ PRGF, 10% w/ HA
• Spakova et al 2012 case/cont, n=120
• PRP vs HA, weekly x3; At 3 & 6 mo, PRP better WOMAC/VAS
• Kon & Mendelbaum et al 2011 case/cont n=150
• LMW HA vs HMW-HA vs PRP at weekly x3
• PRP better than HA at 6 mo
• Age > 50 and severe OA: PRP = LMW-HA
• Age<50 with cartilage lesions, and mild OA: PRP best
• Li & Zhang et al, 2011 RCT n=30
• PRP vs HA at 0/3/6 weeks; PRP more effective at 6 mo

15. Arthroscopy

16. Arthroscopic Debridement ??
• “In a controlled trial involving patients with
osteoarthritis of the knee, the outcomes after
arthroscopic lavage or arthroscopic débridement
were no better than those after a placebo
procedure”.
Moseley, RB et al., Arthroscopic Surgery for Osteoarthritis of the Knee?. NEJM 2002 359:
1169-1170
Kirkley A et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee.
NEJM Sep 2008;359:1097

19. Osteotomy

20. Dr. Mark Coventry of the Mayo Clinic who first described osteotomy
for degenerative arthritis. The original paper published in 1965
continues to be clinically relevant.
Coventry, M. Osteotomy of the Upper Portion of the Tibia
For Degenerative Arthritis of the knee: A PRELIMINARY
REPORT. J. Bone and Joint Surgery 1965 47:984-990

21. HTO-Indications
• Active lifestyle
• ≤ 60 yrs
• Uni compartment disease
• ≤ 10° Fixed flexion deformity
• ≥ 90° flexion

22. Types of Osteotomy
Coventry Closing Wedge 1960s

23. HTO

24. Disadvantages of Closing
Wedge Osteotomy
• Removes bone from metaphysis
• Requires fibular osteotomy
• Peroneal neuropathy 15%
• Lateral tibiofemoral instability 15%
• Patella Baja
• Increases difficulty of later TKA

25. Opening Wedge Osteotomy
1990s
Noyes FR, Goebel SX, West J: Opening wedge tibial osteotomy:
The 3-triangle method to correct axial alignment and tibial slope. Am J Sports Med 33:378-387, 2005.)

26. Advantages of Opening Wedge
Osteotomy
• Adds bone to tibial metaphysis
• No lateral knee instability
• Rare peroneal neuropathy
• Later TKA no more difficult than usual

27. J Bone Joint Surg Am, 2013 Oct 16;95(20):1885-1886

29. AAOS 2013
Recommendations
Strongly Recommended
• Strengthening
• low-impact aerobic exercises
• Regular physical activity
• Topical or oral NSAIDs (nonsteroidal
anti-inflammatory drugs) or Tramadol

30. AAOS 2013
Recommendations
Moderately Recommended
• Weight loss in patients with body mass
index > = 25
• Proximal tibial osteotomy for medial
compartment osteoarthritis

31. AAOS 2013
Recommendations
Cannot Recommend the Following
(Strong Rating)
• Glucosamine and chondroitin
• Viscosupplimentation- Hyaluronic acid
• Acupuncture
• Arthroscopy with lavage or
debridement

32. AAOS 2013
Recommendations
Cannot Recommend
(Moderate Rating)
• Needle lavage
• Lateral wedge insoles in patients with
medial compartment osteoarthritis

33. AAOS 2013
Recommendations
Inconclusive Evidence to Support for or
Against
• Use of a (PRP)
• medial compartment unloader brace
• Arthroscopic partial meniscectomy in patients with
knee osteoarthritis and torn meniscus
• Intraarticular corticosteroids

34. Differences between 2008 and
2013 Recommendations
• With viscosupplementation and
injection of hyaluronic acid.
• In 2008 guidelines –
rating: inconclusive.
• In 2013 with a "strong" rating against
based on new evidences.

35. Medial OA

36. Kinespring

38. When patient presents late Arthroplasty is
the only option to improve quality of life.

41. Thank You