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OA KNEE (1) osteoarthritis of knee for undergraduate and post graduate RDJM.pptx
- 1. OSTEOARTHRITIS OF KNEE JOINT PRESENTER- DR SUMIT(SENIOR RESIDENT) MODERATOR- DR SANJEEV(ASST. PROF)
- 2. Anatomy of The Knee
- 4. • Osteoarthritis is non inflammatory degenerative condition of joints. • Occurs due to • uncoupling of balance between cartilage degeneration and regeneration, • characterized by focal loss of cartilage with periarticular bone response, • clinically presents as joint pain and crepitus, • radiologically decreased joint space, osteophytes and a variety of deformities.
- 5. Epidemiology • World wide: • Prevalence in patients age 45 and older • 5.9 and 13.5 percent in men • 7.2 and 18.7 percent in women. (AAOS 2013) • India : • Prevalence of 22% to 39% in India. • Prevalence of 28.7% (CP Pal et al. IJO 2016) • Prevalence increases drastically with age(45% by the age of 65) • 80% have limitations
- 6. CLASSIFICATION OF OSTEOARTHRITIS PRIMARY OA • More common than secondary OA • Cause- Unknown • Common in elderly population where there is no previous pathology. • Its mainly due to wear and tear changes occurring in old ages mainly in weight bearing joints.
- 7. SECONDARY OA Due to factors such as : • Trauma • Malalignment. • Post septic knee. • Chondrocalcinosis. • Synovial chondromatosis. • Pigmented villonodular synovitis. • Osteonecrosis.
- 8. Systemic risk factors Multifactorial entity. • Ethnicity: Knee osteoarthritis is more common in Asians. • Age and sex: Prevalence increases significantly after age of 40 in women and 50 in men. • Hormonal status: Estrogen has a protective role. • Postmenopausal women are at a higher risk. • Bone density: A high bone mineral density is associated with increased prevalence. • osteoporosis may have a protective effect. • Metabolic and nutritional factors: • Hyperglycemia and high serum cholesterol are associated with increased frequency. • Vitamin D deficiency impairs the reparative process of bone against the damage of the disease process.
- 9. Local biomechanical factors • Obesity: Overweight persons have higher risk of developing osteoarthritis and increased risk of radiographic progression. • A loss of 5 kg decreases risk of knee Osteoarthritis by 50%. • Acute joint injury and joint deformity: Joint instability due to torn ligaments and menisci, joint dysplasia and fractures are aggravating factors. • Occupational factors: Jobs that involve repetitive overloading of joint or heavy physical labour lead to an increased risk of osteoarthritis. • Sports: Competitive sports participation (e.g. Football) that demand high intensity, acute, direct joint impact increase the risk. • Muscle weakness: Quadriceps weakness is a risk factor for structural joint damage and osteoarthritis progression.
- 10. PATHOPHYSIOLOGY OA is a degenerative condition affecting • Articular cartilage • Bone Synovial membrane • Capsule • Ligament • Muscles Articular cartilage. • First structure to be affected • Erosion occurs often central and frequently in weight bearing areas. • Fibrillation - softening, splitting and fragmentation of cartilage occur • Collagen fibres split and there is disorganization of the proteoglycan collagen relationship.
- 11. Bone – eburnation • Bone surface becomes hard and polished due to loss of protection of cartilage • Cystic cavities form in subchondral bone as eburnated bone is brittle and microfractures occur • Venous congestion occurs in subchondral bone • Osteophytes form at the margins of articular surface. • May get projected into capsule. • Alteration in shape of bones-tibial condyles becomes flattened
- 12. Synovial membrane • Undergoes hypertrophy and becomes edematous (cold effusions) • Reduction of synovial fluid secretion results in loss of nutrition and lubrication articular cartilage • Capsule undergoes fibrous degeneration and there are low grade inflammatory changes
- 13. Ligament,muscles and synovial fluid. • Undergoes fibrous degeneration. • Low grade chronic inflammation becomes contracted or elongated Muscles : • Undergoes atrophy due to restricted movements and function. • Synovial fluid- viscosity becomes high, wbc-200-2000 per mm.
- 15. CLINICAL FEATURES • Pain: Steady or intermittent • Stiffness: follows periods of inactivity, such as sleep or sitting. • Swelling and tenderness. • Crepitus: Crunching feeling or sound of bone rubbing on bone • Locking: Limitation of movements • Deformity: valgus or varus
- 17. Clinical Approach to Knee Pain Tests • CBC, ESR, RF • Arthrocentesis • X-rays (3 views) • Weight-bearing AP • Lateral • Tangential Patellar (Sunrise) CT SCANNOGRAM
- 18. Diagnosis of Knee OA Classic Clinical Criteria • established by ACR, 1981 • sensitivity 95%, specificity 69% Knee pain plus at least 3 of 6 characteristics: • > 50 years • Morning stiffness < 30 min • Crepitus • Bony tenderness • Bony enlargement • No palpable warmth
- 19. Diagnosis of Knee OA
- 20. KELLGREN AND LAWRENCE Radiological grading of Osteoarthrosis of knee joint • Grade 0: No radiographic features of OA are present • Grade 1: Doubtful joint space narrowing (JSN) and possible osteophytic lipping • Grade 2: Definite osteophytes and possible JSN on anteroposterior weight bearing radiograph • Grade 3: Multiple osteophytes, definite JSN, sclerosis, possible bony deformity • Grade 4: Large osteophytes, marked JSN, severe sclerosis and definite bony deformity
- 21. Management: Lifestyle • Weight loss • Nutrition referral • Exercise Program • PT referral • Quadriceps strengthening • ROM exercises • Low impact activities e.g. swimming, biking • Ambulatory assist devices • Cane • Walker • Insoles • Unloader knee braces
- 22. Management: Lifestyle Varus (bowlegged) vs Valgus (knock-knee) G2 Unloader Brace
- 23. MANAGEMENT NON-SURGICAL TREATMENTS • Physical therapy and exercise (strengthening of quadriceps and hamstrings) • Activity modification (avoid squatting, crossed legged sitting, climbing of stairs etc) • Periodic rest • Warm or cold compress (wax bath). • Weight loss. • Analgesics. Pain relievers, such as acetaminophen Non-steroidal anti- inflammatory drugs (NSAIDs). • Patient education
- 24. Management: Medical • Glucosamine/Chondroitin • Acetaminophen • NSAIDs • Cox-2 inhibitors • Opioids • Intraarticular injections • Glucocorticoids • Hyaluronans
- 25. Management: Medical • Glucosamine/Chondroitin • 1500 mg/1200 mg daily • Glucosamine: building block for glycosaminoglycans • Chondroitin: glycosaminoglycan in articular cartilage • GAIT study, NEJM, Feb 23, 2006 • Multicenter, double blind, placebo-controlled, 24 wks, N=1583 • Symptomatic mild or moderate-severe knee OA • Infrequent mild side effects e.g. bloating • For mild OA, not better than placebo • For moderate-severe OA, combination showed benefit • Patient satisfaction
- 26. Management: Medical • Acetaminophen • Indication: mild-moderate pain • 1000 mg Q6h Pro re nata • Better than placebo but less efficacious than NSAIDs • Caution in advanced hepatic disease • NSAIDs • Indication: moderate-severe pain, failed acetaminophen • GI/renal/hepatic toxicity, fluid retention • If risk of GIB, use anti-ulcer agents concurrently • Agents have highly variable efficacy and toxicity
- 27. Management: Medical • Cox-2 inhibitors • Indication: mod-severe pain, failed NSAID, risk of GIB • OA pain relief similar to NSAIDs • Fewer GI events e.g. symptomatic ulcers, GIB • Celecoxib 200 mg daily • GI/renal toxicity, fluid retention • Increased risk of CV events.
- 28. Management: Medical • Opioid Analgesics • Indication: • Moderate-severe pain • Acute exacerbations • NSAIDs/Cox-2 inhibitors failed or contraindicated • Oxycodone synergistic with NSAIDs • Tramadol/acetaminophen vs codeine/acetaminophen • Similar pain relief • Avoid long-term use • Caution in elderly • Confusion, sedation, constipation
- 29. Injections for Knee Osteoarthritis • Intra-articular steroid therapy as adjunctive therapy to a conventional management program. INDICATIONS FOR INTRASYNOVIAL CORTICOSTEROIDS • To provide pain relief and suppress the inflammation of synovitis. • To provide adjunctive therapy for one or two joints not responsive to other systemic therapy. • To facilitate a rehabilitative and physical therapy program or orthopedic corrective procedures • To prevent capsular and ligamentous laxity (large knee effusion). • To treat patients unresponsive to or intolerant of oral systemic therapy. • To treat acute effusions occurring with associated crystal deposition disease
- 30. Intraarticular Injections • Glucocorticoids • Indication: pain persists despite oral analgesics • 40 mg/mL triamcinolone (kenalog-40) • Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL) • Limit to Q3months, up to 2 yrs • Effective for short-term pain relief < 12 wks • Acute flare w/in 48 hrs post-injection
- 31. Intraarticular Injections • Technique • 22 gauge 1.5 inch needle • Approach accuracy: • Lateral mid-patellar 93% • Patient supine • Leg straight • Manipulate patella • Angle needle slightly posteriorly • Inject after drop in resistance or fluid aspirated
- 32. RELATIVE CONTRA-INDICATIONS TO INTRA-ARTICULAR THERAPY • Infection (local or systemic) • Anticoagulant therapy • Hemorrhagic effusions • Uncontrolled diabetes mellitus • Severe joint destruction and/or deformity COMPLICATIONS OF INTRA-ARTICULAR THERAPY. • Infection • Post injection flare • Crystal-induced synovitis • Cutaneous atrophy (local) • Steroid arthropathy (rare)
- 33. VISCO SUPPLEMENTATION • Adjunct to lubricate the joint • Different molecular weights provide different levels of lubrication • Restores elastic properties of pathologically altered synovial fluid • Direct analgesic activity by reducing bradykinin and substance P • Forms a barrier around the pain receptors (nociceptive receptors) and reduces pain • Provide pain reduction for up to 24 weeks in early OA • Cost effectiveness is a concern
- 34. INTRA-ARTICULAR HYALURONATE (HYALURONIC ACID) • Synovial fluid is an ultrafiltrate of plasma composed of water and LMW solutes transuded from blood. • Hyaluronate is secreted by the synovial cells as a long chain polymer of about 5000 repeating disaccharide units of N-acetyl-D-glucosamine and beta-glucuronic acid. • The HAs are administered intra-articularly in 1,3,4, or 5 injection series, depending on the agent.
- 35. ROLE OF PRP IN OA • AIM- is to restore the anabolic and catabolic imbalance seen in OA by increasing the growth factors derived from activated platelets • The various growth factors include: TGF beta, PDGF, VEGF, Insulin like GF, EGF. • PRP is safe and gives symptomatic relief in early OA knee • Improvement noted by 2 to 3 weeks which gradually improves over 3 months • Early OA shows better results than late OA
- 36. Complementory and Alternative Medicine GLUCOSAMINE • Amino-monosaccharide and constituent of the articular cartilage GAGs. • Glucosamine is reduced in osteoarthritic cartilage • Replenishing glucosamine by taking dietary supplements is appealing. • Potential beneficial mechanism of action in OA. • include countering enzymatic or inflammatory processes leading to degradation of cartilage.
- 37. CHONDROITIN SULPHATE • Important constituent of normal joint tissue. • CS levels are altered in OA cartilage, plasma, and synovial fluid, • Contributes to structural integrity. TOPICAL ANALGESICS • Topical agents with significant local effects tried as home remedies, • including menthol rubs, alcohol rubs, and substances such as camphor.
- 38. SURGICAL METHODS Arthroscopic Debridement • Degenerating articular cartilage and synovium release proinflammatory cytokines • induce chondrocytes to release lytic enzymes leading to type II collagen and proteoglycan degradation. • Arthroscopic lavage and debridement may wash out or dilute these. • Those who appear to benefit most present with a history of mechanical symptoms, symptoms of short duration (i.e., <6 months), normal alignment, and only mild to moderate radiographic evidence of OA.
- 39. Osteochondral or chondrocyte transplantation • Autologous chondrocyte implantation • Biologically resurfaces the knee in the presence of focal cartilage damage. • Cartilage defect in the knee joints repaired with the patient's own healthy cartilage cells • originally harvested through an arthroscopic procedure from separate, minor load-bearing area in the knee.
- 40. High Tibial Osteotomy • Indication: • Unicompartmental arthritis • Genu varus or valgus • Realign mechanical axis • Age < 60 years • < 15 degrees deformity
- 41. Partial Knee Arthroplasty • Indication: • Unicompartmental arthritis • Ligaments spared • Increased ROM • Faster recovery • Prosthesis 10-yr survival: 84%
- 42. Total Knee Arthroplasty • Indication: • Diffuse arthritis • Severe pain • Failure of conservative measures • Limited motion • Functional impairment • Pain relief > functional gain • ACL sacrificed • PCL also may be sacrificed • Prosthesis 10-yr survival: 90%
- 43. CONTRAINDICATIONS • Severe osteoporosis • Neuropathic joint • Quadriceps insufficiency • Prior infection • Flexion deformity of more than 60 degree combined with valgus or varus • Hyperextension of more than 20 to 30 degrees
- 44. THANK YOU