Extern conference Ext.ธัญนันท์ 14 ก.ย. 61

1. EXTERN CONFERENCE
Ext.Thunyanun Poonnawiwat

2. CASE
• ผู้ป่วยหญิงไทย อายุ64 ปี , No underlying disease
• CC : ปวดเข่าขวามากขึ้น10ปี PTA
• PI :
• - 10ปีPTAผู้ป่วยมีอาการปวดเข่าทั้ง2ข้างโดยปวดเข่าขวา >ซ้าย มักปวดเวลาเปลี่ยนจากท่านั่งเป็นยืน มักเป็น
มากขึ้นขณะเดินลงบันได รับประทานยาแก้ปวดแล้วอาการปวดลดลง
• - 2ปีPTA ผู้ป่วยมีอาการปวดเข่าทั้ง2ข้างมากขึ้นรับประทานยาแก้ปวดแล้วอาการปวดไม่ดีขึ้น นอกจากนี้เวลาเดิน
ผู้ป่วยรู้สึกได้ยินเสียงกรอบแกรบในข้อ อาการปวดเข่าทั้ง2ข้างเป็นมากขึ้น รบกวนชีวิตประจาวันของผู้ป่วย ผู้ป่วย
จึงไปพบแพทย์แพทย์ได้ให้การรักษาเป็นรับประทานยา แก้ปวด , ยาฉีดเข้าข้อ แต่อาการปวดเข่าไม่ดีขึ้น จึงมา
โรงพยาบาล

3. CASE
• PH :
• - No underlying disease
• - No history of trauma both knee
• - History of Lt. TKAn26/7/61
• - No smoking
• - No drinking alcohol
• - Current medications : Naproxen(250) 1x2 po pc ,
omeprazole(20) 1x1 po ac , Norgesic 1x1 po pc

4. PHYSICAL EXAMINATIONS
• Vital signs : BT = 36.6C , PR = 80bpm , RR = 16/min ,
BP = 132/84mmHg
• HEENT : Not pale conjunctivae , anicteric sclerae
• Heart : Normal S1S2 , no murmur
• Lungs : Clear , no adventitious sound
• Abdomen : No distension , soft , not tender

5. • Affected part : Right knee
• Genu varus appearance, mild swelling, no
erythema, no tenderness on palpation, limit knee
flexion and extension, crepitus on movement

6. X-RAY

7. LABORATORY
• CBC
• - Hct = 33.6%
• - Hb = 11.1 g/dL
• - WBC 6,900 (PMN = 54.7% , L = 35% )
• - Platelet count = 421,000
• BUN = 10.3 mg/dL , Cr = 0.63 mg/dL
• ESR = 37 mm/hour , CRP = 2.39 mg/L

8. LABORATORY
• Electrolyte
• Sodium = 138.1 mEq/L
• Potassium = 4.73 mEq/L
• Chloride = 100.4 mEq/L
• Bicarbonate = 25.9 mEq/L
• Anti-HIV = Negative
• UA WBC = 0-1 , Leukocyte = negative

9. POST-OPERATION

10. OSTEOARTHRITIS

11. OSTEOARTHRITIS
• Most common form of arthritis in the knee
• It is a degenerative,"wear-and-tear" type
• Occurs most often in people 50 years of age and older
• As the cartilage wears away, it becomes frayed and rough
• The protective space between the bones decrease
• Bone rubbing on bone
• Painful bone spurs

13. SYMPTOMS
• The joint may become stiff and swollen, making it difficult to bend and
straighten the knee
• Pain and swelling may be worse in the morning, or after sitting or resting
• Vigorous activity may cause pain to flare up
• Loose fragments of cartilage and other tissue can interfere with the
smooth motion of joints
• The knee may "lock" or "stick" during movement
• It may creak, click, snap or make a grinding noise (crepitus)
• Pain may cause a feeling of weakness or buckling in the knee

14. PHYSICAL EXAMINATIONS
• Joint swelling, warmth, or redness
• Tenderness about the knee
• Decreased range of motion (active + passive)
• Instability of the joint
• Crepitus (a grating sensation inside the joint) with movement
• Pain when weight is placed on the knee
• Problems with your gait (the way you walk)
• Any signs of injury to the muscles, tendons, and ligaments surrounding
the knee
• Involvement of other joints (an indication of rheumatoid arthritis)

15. 2010 EULAR CRITERIA FOR
DIAGNOSIS OA KNEE
Zhang W , Doherty M , Peat G , et al. EULAR evidence-based recommendations for
the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010;69(3):483-489
** EULAR : European League Against Rheumatism

20. VictorRexCarlson,AlvinChuaOng,FabioRamiroOrozco,VictorHugo Hernandez,Rex William Lutz,Zachary Douglas Post. Compliance
With the AAOS Guidelines for Treatment of Osteoarthritis of the Knee: A Survey of the American Association of Hip and Knee
Surgeons. Journal of the American Academy of Orthopaedic 2018; 26(3): .

21. NONSURGICAL TREATMENT
•Lifestyle modifications
•Physical therapy - Quadriceps exercise ,
Heat therapy
•Assistive devices - knee support
•Medications - NSAIDs
•Alternative therapies - Acupuncture

22. SURGICAL THERAPY
•Arthroscopy
•Cartilage grafting
•Synovectomy
•Osteotomy
•Total or partial knee replacement (arthroplasty)

23. VictorRexCarlson,AlvinChuaOng,FabioRamiroOrozco,VictorHugo Hernandez,Rex William Lutz,Zachary Douglas Post. Compliance
With the AAOS Guidelines for Treatment of Osteoarthritis of the Knee: A Survey of the American Association of Hip and Knee
Surgeons. Journal of the American Academy of Orthopaedic 2018; 26(3): .

24. DavidS.Jevsevar,PeterB.Shores,KyleMullen,DanielleM.Schulte,GregoryA. Brown,Deborah S. Cummins. Mixed Treatment Comparisons for Nonsurgical
Treatment of Knee Osteoarthritis: A Network Meta-analysis. Journal of the American Academy of Orthopaedic 2018; 26(9): .

25. COMPLICATION OF TKA
• Venous thromboembolism (VTE) - high
morbidity and mortality rate , preventable condition
• Bleeding
• Infection
• Stiff knee

26. VENOUS THROMBOEMBOLISM (VTE)
• Prevention of VTE - Mechanical and Pharmacological prophylaxis
• Mechanic prophylaxis - Early ambulation , Ankle pumping ,
Walker assisted device
• Pharmacological prophylaxis - aspirin, unfractionated heparin
(UFH), low molecular weight heparin (LMWH), adjusted dose
vitamin k antagonist (VKA), synthetic pentasaccharide factor
Xa inhibitor (fondaparinux) และ newer oral anticoagulants

27. REFERENCE