OA KNEE

1. TREATMENT OF
OSTEOARTHROSIS OF
KNEE
Done by Dr.Prashant Patel (3rd year resident in
orthopaedics)
Shri M P Shah govt medical college & GG Hospital
Jamnagar
Underguidance of Dr.Apoorva Dodia (MS
Ortho)

2.  Treatment directed at symptoms and
slowing progress of the condition
 Goals: 4 R’s
 Relieve pain
 Restore function
 Reduce disability
 Rehabilitation

3.  EARLY Treatment
 PHYSIOTHERAPY
 LOAD REDUCTION
 ANALGESICS
 INTERMEDIATE Treatment
 JOINT DEBRIDEMENT
 AUTOLOGOUS CHONDROCYTE
GRAFTING
 REALIGNMENT OSTEOTOMY
 LATE Treatment
 ARTHROPLASTY
 ARTHRODESIS

4. PHYSIOTHERAPY
 Aim is to maintain joint mobility & improving
muscle strength
 Includes:
 Exercises
 Massage
 Application of warmth

5. LOAD REDUCTION
LIFE STYLE CHANGES:
o Shock absorbing shoes
o Walking sticks
o Weight reduction in obese

6.  Analgesics : NSAID ‘s
 Corticosteroid Injection
Reduce inflammation around the joint
More rapid effect than NSAIDs
 Visco- supplement
🞑 Intraarticular hyaluronic acid and chondroitin
sulphate therapy
🞑 Increase viscosity & elasticity of fluid

7.  Diacerein is IL-1 inhibitor
 Disease modifying effect on O.A.
 Prophylactic use of diacerein leads to lower
degree of articular stiffness when compared to
glucosamine
 prophylactic chondroprotective effects of
diacerein and glucosamine are histologicaly
similar

8. SURGERY
 INDICATIONS:
 Pain refractory to conservative measures.
 Functional disability of the patient to carry out
routine day to day activities.
 Loose bodies or osteochondral fractures.
 Deformity usually genu varum
 Progressive limitation of knee motion

9. SURGICAL METHODS
 Arthroscopic joint debridement
 Chondrocyte transplantation
 Proximal tibial osteotomy
 Distal femoral osteotomy
 Total knee arthroplasty
 Arthrodesis

10. ARTHROSCOPIC
DEBRIDEMENT
 Simple lavage
 Debridement
 Abrasion chondroplasty

11.  Pain relief is due to removal of cartilaginous
debris and inflammatory factors
 Poor symptom relief in those patients with
radiographic malalignment, severe arthritis
and significant joint space reduction
 Does not alter natural progression of disease

12. CHONDROCYTE
TRANSPLANTATION
 Useful in young
,active patients with
severe articular
cartilage
degeneration
 Healthy
chondrocytes are
harvested from an
uninvolved area of
injured knee
 Grown in tissue
culture
 Injected into knee
cartilage defect

13. PROXIMAL TIBIAL
OSTEOTOMY
 Treatment for unicompartmental osteoarthrosis of
knee
 Varus or valgus deformity are common and
causes abnormal distribution of weight bearing
stresses within the joint
 Biomechanics of osteotomy is unloading of
involved joint compartment by correcting
malalignment and redistribution of the stress
uniformly on the knee joint

14.  Four basic types
1) Lateral closing wedge osteotomy
2) Medial opening wedge osteotomy
3) Dome osteotomy
4) Medial opening hemicallotaxis

15. LATERAL CLOSING WEDGE
OSTEOTOMY
 Described by COVENTRY
 Advantages
 Complication
 Measure the amount of correction needed to
achieve normal angle then additional 3 to 5
degree of overcorrection is added
 Calculating the size of wedge removed as
roughly 1 degree of correction for 1mm length
at the base of the wedge (if the width of the
tibial plateau is 57 mm).

16. If tibia is 57 mm wide, length of wedge=degrees of correction
OR
Length = Diameter of tibia X 0.02 X Angle

17. INCISION Positioning transverse osteotomy g

18. Placement of oblique osteotomAypplication of compression
guide & performing osteotomyclamp & L- plate

19.  Completion of osteotomy requires disruption of
proximal tibio fibular joint or removal of infero
medial portion of fibular head.
 After osteotomy fragment is fixed with plate
and screws.
 Passive ROM started immediately after
surgery
 Partial weight bearing on 2nd day
 Full weight bearing after 6 weeks

20. MEDIAL OPENING WEDGE
OSTEOTOMY
 Described by
HERNIGOU
 Tricortical illiac crest
bone graft with
supplemental cancellous
bone graft used
 Indicated when involved
extremity is 2cm or more
shorter and/or when

21.  A tourniquet is used
 The skin incision was placed vertically, on the
medial side of the tibia curve to the proximal
and dorsal side.
 The periosteum was cut and partially stripped
 K-wire was drilled under direct fluoroscopic
control in an oblique manner and at an angle
to the tibial axis aiming for the upper part of
the fibular head.
 When satisfactorily placed, the osteotomy was
performed using an oscillating saw for the first
part and finished using a chisel under

22.  Great care was taken not to damage the lateral cortex
 The tibia was manually wedged to the point of desired
correction, and the osteotomy plate was positioned
and fixed.
 The osteotomy gap was then filled with tricortical illiac
crest bone graft with supplemental cancellous bone
graft
 A drain was placed subcutaneously and the wound
was closed.

23. DOME OSTEOTOMY
 Described by MAQUET
 Determine the angle of correction
 Midline vertical incision
 Curved line is marked on bone with its dome
just above tibial tuberosity
 Multiple small drill holes made over this line

25.  Two k-wires inserted parallel to each other on
either side of osteotomy
 Complete the osteotomy using osteotome
 Distal fragment is rotated untill desired angle
subtend by wire
 Fix the osteotomy using staples or plate.

26. OPENING WEDGE
HEMICALLOTASIS
 Described by TURI
 Medial opening wedge osteotomy with application
of dynamic external fixator
 At 7th Post operative day, the fixator is distracted
0.25mm four times a day until desired correction
is obtained.
 It is a slow distraction at the osteotomy site and
hence obviates the need of bone grafting.
 complications

27.  Position the fixator
over the leg to check
the position of the pin
clamps,osteotomy site
and hinge
 Osteotomy site is
below the tibial
tuberosity
 Make longitudinal
incision just medial to
tibial tuberosity up tp
3-4 cm
 Position of the fixator
over the lateral tibial
cortex at the level of

28. Fixator secured with k-wires Proximal fixator pin inserted

29. Medial and lateral
proximal fixator pins
Distal fixator pin placed

30. Osteotomy guide attachedSeries of holes drilled at osteotomy s

31. Holes connected with osteotome Distraction of osteotomy

32.  Passive motion has been started immediately
after surgery
 Ambulation is begun on 2nd day,allowing
weight bearing to tolerance with crutches
 Seven day after surgery,instruct the patient to
distract the fixator 1 mm/day
 After appropriate correction is achieved,fixator
is locked
 The fixator is removed after solid union is
achieved

33. COMPLICATIONS OF HTO
 Recurrence of deformity
 Peroneal nerve palsy
 Knee stiffness
 Patella baja
 Intra articular fracture
 Non union
 Infection
 Osteonecrosis of proximal fragment

34. DISTAL FEMORAL
OSTEOTOMY
 Indicated in active
patients younger than 65
years with valgus
angulation <15 degree
 Indicated when distal
femoral malunion which
leads to
unicompartmental
arthritic changes
 Determine the size of
wedge to be removed
 Establish the angle of
plate insertion
 Osteotomy done and
plate is fixed by screw

35. KNEE ARTHROPLASTY
 Unicompartmental knee arthroplasty
 Total knee arthroplasty

36.  Classification
of implants
 Unconstrained
 Cruciate retaining
 Cruciate
substistuting

37.  Constrained

38.  TKR consists of
following:
 Cobalt chrome alloy
femoral component
 Cobalt chrome alloy or
titanium tibial tray
 UHMWPE tibial bearing
component
 UHMWPE patella
component

39.  Candidate for TKR
 Quality of life severely affected
 Daily pain
 Restriction of ordinary activities
 Evidence of significant radiographic changes of
the knee

40.  Goal of TKR
 Pain relief
 Restoration of normal limb alignment
 Restoration of a functional range of motion

41. • The Incision:
• An incision is made in the
midline and anterior aspect
of the knee with the knee
positioned in flexion.
• Another approach is a
medial parapatellar
approach.
• The medial side of the knee
is then exposed by removing
the anteromedial knee
capsule and deep medial

42. • The leg is then extended and the patella is
everted
• The knee is once again flexed and the anterior
horn of medial and lateral menisci and anterior
cruciate ligament are removed.
• Posterior horns of menisci excised after the
femoral and tibial cuts have been made
• Subluxate and externally rotate the tibia
• Expose the lateral tibial plateau by partial
excision of infra patellar fat pad

43.  The medial/lateral
adjustment screw that
is placed at the ankle is
used to align the
resection guide parallel
with the tibia.
 To check alignment to
the ankle an alignment
rod is used.
 There is 3 degrees of
posterior slope into the
polyethylene insert

44.  The amount of tibial resection depends on which
side of the joint is used for reference
 If unaffected side is taken as a reference,usually
8 mm cut is taken which is close to the size of
the implant
 If affected side is taken as a reference,the
amount of resection usually is 2mm or less
 Proximal tibial cut is taken perpendicular to its
mechanical axis

45. • A drill bit is used to
create an opening in
the femoral canal.
• The valgus alignment
guide is then used
and attached to the
IM reamer. It then
rests and is secured
on the distal femoral
condyle.
• Make a distal femoral
cut at 5 to 7 degree of

46. • Then extension gap is measured
• The anterior and posterior femoral cuts
determine the rotation of the femoral
component and shape of the flexion gap
• Make a cut in 3 degrees of external rotation
• Then flexion gap is measured
• Box cut is taken to accommodate post cam
mechanism of PCL substituiting design

47.  The flexion and extension gaps must be
roughly equal
 If the extension gap is smaller then remove
more bone from distal femoral cut surface
 If the flexion gap is smaller then remove more
bone from posterior femoral condyles
 If the flexion and extension gaps are equal,but
not enough space for prosthesis,remove more
bone from proximal tibia

48.  First the patella is laterally
retracted with the articular
surface facing in the upward
position
 Calipers are then used to
determine the size of the patella
along with the amount of bone
that will be removed.
 The patella cutting guide is then
placed to ensure the proper cut
of the patellar apex.
 The appropriate size saw is then
used to make the patellar cut.
 The patellar peg holding guide is
then placed on the resected
patella and the peg holes are
then drilled.

49.  With the knee flexed, appropriate femoral trial
is placed on the distal femur.
 The tibial trial inserted
 The knee is then put through a series of
motions to confirm normal movement and
alignment.
 The trial components are then removed after
the correct fit is confirmed.
 The joint is then irrigated with a pulse lavage.
 The cement is then injected on the cut bone
surfaces and the prostheses are then placed.

50. 🞑The femoral impactor is used to insert the
femoral implant
🞑 The tibial base impactor is used to insert the
metal tibial base.
🞑The patellar implant is secured with bone
cement and held in place using the parallel
patellar recessing clamp.
🞑The tibial polyethylene insert is seated and
locked into place on the metal tibial base.
🞑 The cement is hardened with the leg placed in
35 degrees of flexion.

51.  The wound is thoroughly irrigated.
 The tourniquet is then removed and the
bleeding is stopped using electrocautery.
 The surgeons preference is used to then
determine if a closed-suction drainage device
will be needed.
 The wound is then closed in layers and a
compressive dressing is placed on the knee.

52.  COMPLICATIONS OF TKA
 Thromboembolism
 Infection
 Patellofemoral complications
 Neurovascular complications
 Periprosthetic fractures

53. ARTHRODESIS
 Indicated for severe
disability esp. in young
& active Patient whose
activity desire might
severly limit the
longevity of
TKR,infected TKR and
neuropathic joint
 Techniques of
Arthrodesis:
 - External Fixation
- Intramedullary
Nailing

54. THANK YOU