Dr. NEERAJ AGGARWAL MBBS –SMS Medical College, 1999 MS – SMS Medical College, 2003 Senior Residency KEM Mumbai 2004 Fellowship in Joint Replacement Depuy Fellow, Mumbai 2005 Fellowship Joint Replacement Surgery Germany, Ranawat Adult Reconstruction Fellow, New York

1. Management of Arthritis:
Recent Trends
Dr. Neeraj Aggarwal MS, FJRS(Mumbai, Germany)
Consultant Orthopaedic & Joint Replacement surgeonConsultant Orthopaedic & Joint Replacement surgeon
Narayana Hrudayalaya Hospital
Pratap Nagar, Jaipur.

2. Objectives of today’s discussion
• Discuss the prevalence of degenerative Knee
Osteoarthritis (OA)
• Understand and discuss different approaches to treat
Knee OA
• Discuss the Indications, Priority and Clinical outcomes
of Knee Replacement

3.
• The knee joint is protected
in front by the patella
• Meniscus - acts as a shock
absorber
• Articular cartilage allows
the surfaces of the knee
to glide over each other
without damaging the
surface
Anatomy of Knee

5. Prevalence of Knee Pain
(Croft et al, 1998)
7,500• Knee pain, some disability & X-ray OA
12,500• Knee pain with some disability
25,000• 4 weeks of knee pain in past year
• Knee pain, severe disability & X-ray OA
2,000
100,000• Subjects aged 55 years+
2%

6. • About 7 crore Indians are suffering from knee related
problems
• Evidence suggests that women have a higher incidence
of OA than men, and overall have an incidence of 2.95
per 1000 population, compared with 1.71 per 1000
population in men
Prevalence of Knee OA

7. Why is this problem more prevalent in
India
• Squatting / Ground sitting habits
• Climbing stairs
• Indian Toilets
• Obesity
• Complicated patients
• Heredity
Can we prevent Osteoarthritis

8. Symptoms
• Pain in and around the Knee joint
• Morning Stiffness (worse on standing &
attempting to walk)
• Swelling of Joint
• Occasional night pain
Characteristics of Knee OA
The symptoms of OA may interfere with normal
activities, such as walking, dressing and sleep

9. Characteristics of Knee OA
Signs
• Crepitus on motion
• Buckling or instability
• Tenderness on pressure
• Joint effusion
• Malalignment / Joint deformity

10. Treatment Approaches
• Education
• Behavioural and Environmental changes
• Physical and Mechanical Interventions
• Pharmacological Management
• Surgical Interventions

11. Practical Approach to Knee OA
patient
• Patient A
• 45 year, Female, Home maker
• Knee pain 1 month
• Mild to Moderate
• Rarely Analgesics
• NO Night pain
• Knee ROM full
• No Crepitus
Always ask for weight bearing films

12. Education
• Education of Patients
– helps in reducing impact of condition on their
day-to-day lives
• Advice about lifestyle
• Impact vs. Non impact activities

13. WEIGHTWEIGHT

14. Physical and Mechanical Interventions
• Heat and Cold applications
– to reduce inflammation
• Walking aids
– reduce the loading on the knee while walking
• Shoe alterations
– help the patient get their footwear right
– Knee braces

15. PRECAUTIONSPRECAUTIONS
• Take rest in between if it is needed
• No squatting on floor
• No cross legged sitting (Alathi – Palathi)
on floor
• Reduce climbing stairs
• Cycling is good
• Swimming Mother of all exercises

16. • Patient B
• 54 year, Female, Part
time job
• Knee pain 1 year
• Mild to moderate,
occasionally severe
• Analgesics 2-3 times a
week
• Knee swelling
• Knee terminally painful
• Anterior Knee pain

17. Pharmacological Management
• Systemic
 Paracetamol, NSAIDs
 Cox-2 Inhibitors
• Topical
• Intra-articular
 Steroids
 Hyaluronic Acid

18. My analgesic of choice…
• Paracetamol+Low dose Tramadol
• Synergistic combination
• Block both pathways
• Dose titration (2-8 tab a day)
• GI safety

19. D.M.A.R.D.
Do we have
D.M.A.OAOA.D.
? ? ?? ? ?

20. D.M.A.OAOA.D. ? ? ?
Texanamic acid – Anti plasmin activator
CMT – Chemically Modified Tetracyclin
– Inhibit MMP, Nitric oxygenase formation, prevent cartilage wear in animals
Poly sulfated Glucosamino-glycan.
– GOOD animal studies. Limited experiencd in human beings.
– Fear of “mad cow disease “, anaphylaxis
Diacerin
– Again efficacy not established
Glucosamine
– In selected cases
NONE like DMARD yet !NONE like DMARD yet !

21. Physiotherapy
• Physiotherapy aims to restore function to
the maximum degree possible – through
exercises
– helps reduce pain
– increases joint range of movement
– improves muscles strength
– addresses specific restrictions in activities
• Exercises:
- Static Quadriceps Exercises
- Quadriceps Building Exercises
- Hamstring Building Exercises
- Isokinetic Exercises for knee joint
- Progressive resistance Exercises

22. Intra-articular
Steroids
• Indicated when knee is inflamed
• Confirm intra-articular placement by draining
effusion, then injection
• Wide variation in responses

23. Viscosupplementation
• Replaces pathologic
synovial fluid
• Supplements elasticity and
viscosity
• Reduces pain and
improves mobility

24. • Patient C
• 65 Years, Female,
Retired
• Knee pain 7 years,
severe pain, Night pain
• Analgesics daily
• Knee Crepitus
• Limp and deformity
• Has taken conservative
treatment : no benefit

25. How do we know that the
patient needs surgery ?
• Regular pain needing medication
• Deformity of the knee, crepitus in knee
• Night pain, getting up pain
• Altered social or family life due to pain

26. OSTEO ARTHRITIS
INDICATION – PENALTY POINTS ( 75 PLUS)
Progression + Disability
Pain Deformity ROM Instability
40 20 20
REPLACEMENT SURGERY
20

27. • FIVE LAKH IS THE NUMBER OF KNEE
REPLACEMENT SURGRIES DONE IN USA IN
2008
• IN INDIA THE CORRESPONDING NUMBER IS
35000 IN 2008
• WITH ALL OUR MANFORCE WE ARE ABLE
TO TACKLE ONLY 3% OF TOTAL ARTHRITIS
PATIENTS
• WHERE ARE WE ???????

28. Normal kneeNormal knee Arthritic Knee

30. Total Knee Replacement
• The ultimate solution for OA of knee is to replace the
worn-out parts of the knee with an artificial joint
• The prosthesis that is used is made up of plastic and
metal and is placed on the joint surface of each bone
• This surgery has been widely used for many years with
excellent results especially for knees

31. Third Generation Knee
How the Artificial knee
fits on the bones ?

37. Where to undergo
Surgery…

38. Post-Op TKR
AP Lateral

39. Common Post-Operative (TKR) Course
• Day 1 Standing, bending and sitting out in a chair
May take a few steps with help
• Day 2 Walking (with aids)
• Day 4/5 Stair climbing
• Day 5-7 Home (with 2 walking sticks)
• Week 6 Walking unaided (or 1 stick)
Driving
• Week 10-12 Full recovery

40. Benefits of TKR
• TKR can relieve pain that doesn't respond to other
treatment options
• Pain reduction in 90 to 95% of the patients
• Reduced stiffness and improved joint movement
• Increased walking ability
• Improved alignment of deformed joints

41. Myths
• Hip replacement works but knee replacement doesn’t
• Knee replacements are still experimental
• Knee replacements only last 8-10 years may be 15 years
maximum
• I am too fat - my implants might break

42. • TKR surgery is too costly
• TKR is not successful
• After TKR, I have to be bedridden for 3 months
• A total knee replacement implies that everything about the
joint is being replaced
Myths

43. Question about ?
• Team
• Availability
• Approachability
• Economy: we offer cost effective
packages for joint replacement surgery

44. Summary
• Knee OA, which has not responded to conservative treatment
can be effectively treated by various surgical interventions
• Effective grading of patients, counceling and management
serves as a tool to combat osteoarthritis
• Knee replacement surgery is a highly successful
(90-95%) and safe procedure
• Prioritising and effective screening by GPs and Physicians who
can identify those individuals that are likely to benefit from TKR

45. Future ………
• Robotics with navigation
• Custom Implants and Instruments
• Stem cell therapy
Appreciate yourAppreciate your
attentionattention