nullOSTEOARTHRITIS OF THE KNEEOSTEOARTHRITIS OF THE KNEEBACKGROUNDBACKGROUND Osteoarthritis :
Most common causes of functional disability and severe pain
The prevalence of arthritic symptoms among adults is more than 50% BACKGROUNDBACKGROUND Osteoarthritis:
Begining with damage and progressive degradation of articular hyaline cartilage structure and function
Cartilage thickness loss
Remodeling and attrition of subarticular bone
Growth of osteophytes
Synovitis, ligamentous laxity, and periarticular muscle weakness
Joint tilting and malalignment
nullNormal and arthritic kneenullEPIDEMIOLOGY– risk factors EPIDEMIOLOGY– risk factors Age
Obesity
Work-related bending and heavy physical workload
Recreational and physical sporting activities
Hyaluronic acid serum levels
Knee injury
Congenital conditions
Systemic metabolic diseases
Endocrine diseases
Bone dysplasias
Calcium crystal deposition diseases
CLASSIFICATIONCLASSIFICATIONPrimary (idiopathic)
articular degeneration occurs in the absence of an obvious underlying abnormality
Secondary
result from some risk factors(injury ,repetitive motion such as found in certain occupations ,congenital conditions , systemic metabolic diseases,etc.)DIAGNOSISDIAGNOSIS Diagnostic criteria for osteoarthritis of the knee (proposed by the American College of Rheumatology, ACR)
First: presenting with pain
Second:meeting at least five of the following criteria:
Patient older than 50 years of age
Less than 30 minutes of morning stiffness
Crepitus (noisy, grating sound) on active motion
Bony tenderness
Bony enlargement
No palpable warmth of synovium
Erythrocyte sedimentation rate (ESR) <40 mm/hr
Rheumatoid factor <1:40
Noninflammatory synovial fluidDIAGNOSISDIAGNOSISX-ray
MRIDIAGNOSISDIAGNOSIS Molecular biomarkers
sC2C (serum cartilage type II collagen cleavage by collagenase )
sCPII (serum cartilage type II procollagen carboxy propeptide)
sHA(serum hyaluronic acid)
uNTX (urine N-terminal crosslinking telopeptide of type I collagen )
uCTX-II (urine cartilage type II collagen C-telopeptide )
uCTX-II(urine cartilage type II collagen C-telopeptide
Relationships between biomarkers of joint metabolism
and cartilage, bone, synovial metabolism may reflect early changes in cartilage structure w/o knee pain
EVALUATION SYSTEMEVALUATION SYSTEMKnee injury and Osteoarthritis Outcome Score (KOOS)
Likert scale
SF-36
Western Ontario and McMaster osteoarthritis (WOMAC) scale
VAS scoringEVALUATION SYSTEMEVALUATION SYSTEMKellgren and Lawrence criteria (radiographic criteria)TREATMENTTREATMENT A number of therapies, including
Exercise
Weight loss
Physical therapy
Medicine
SurgeryTREATMENTTREATMENT Exercise
There is strong evidence that both strengthening and cardiovascular exercise are effective for reducing pain and improving function in the short-term in knee osteoarthritis TREATMENTTREATMENTExercise
Weight loss
Physical therapy
Medicine
SurgeryTREATMENTTREATMENT Weight loss
A 5% weight reduction will result in moderate improvement in disability in overweight patients with knee osteoarthritis TREATMENTTREATMENTExercise
Weight loss
Physical therapy
Medicine
SurgeryTREATMENTTREATMENT Thermotherapy
Local heat or cold benefits for knee osteoarthritis in terms of pain and function
Ice massage can be used to improve range of movement and that cold packs can be used to decrease swelling TREATMENTTREATMENT Bracing
Joint bracing may protects the knee , improves function and increases walking distanceTREATMENTTREATMENT Taping
Reduction in pain
Improvement of microcirculation
Alleviation of swellingtapingtapingTREATMENTTREATMENT Acupuncture
Safe and effective in pain and function in patients with knee osteoarthritis TREATMENTTREATMENTExercise
Weight loss
Physical therapy
Medicine
SurgeryTREATMENTTREATMENT Single analgesics
Paracetamol may reduce pain in the short time,but less effective than oral NSAIDsTREATMENTTREATMENT Non-steroidal anti-inflammatory drugs (NSAIDs)
Effective for short-term use(<2 weeks)
A small to moderate effect on pain, improving stiffness, physical function
Gastrointestinal or cardiac adverse effects
TREATMENTTREATMENT Opioids
Stronger effects on pain relief
Adverse effects: constipation,nausea,vomiting, drowsiness,hypotension,respiratory depression
Not recommended as first-line treatmentTREATMENTTREATMENT Glucosamine
Amino sugar , a building block for the glycosaminoglycans that are part of the structure of cartilage
Effective and safe for improving function in knee osteoarthritis and in delaying its progression TREATMENTTREATMENT Chondroitin
A highly hydrophilic, gel forming polysaccharide macromolecule. Its hydrocolloid properties convey much of the compressive resistance of cartilage
Treatment on cartilage volume loss, subchondral bone marrow lesions TREATMENTTREATMENTControversy
Some network meta-analyses reveal glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space, while some reviews telling glucosamine are more effective than NSAIDs at reducing pain
TREATMENTTREATMENT Intra-articular steroid injections
Anti-inflammation
Safe
Only provided short-term relief of pain in knee osteoarthritis up to 4 weeks post-injection TREATMENTTREATMENT Viscosupplemention
Hyaluronic acid
One of the major glycosaminoglycans in the extracellular matrix ,binding proteoglycans
Important in maintaining articular cartilage integrity nullnullTREATMENTTREATMENTHigh molecular weight and concentration hyaluronic acid:hylan G-F 20
Providing and maintaining intraarticular lubrication
Optimising the viscoelastic properties of synovial fluidnullThe treatment effect with hylan G-F 20 was statistically significantly superior to placebo for the primary endpoint, change in WOMAC A (pain) over 26 weeks TREATMENTTREATMENTExercise
Weight loss
Physical therapy
Medicine
SurgeryTREATMENTTREATMENTArthroscopic lavage and debridement
null Washing out the joint
Repairing damaged cartilage
No lasting benefit in most cases of osteoarthritis TREATMENTTREATMENT Osteotomy (high tibial osteotomy)
An important adjunct to cartilage repair rocedures that rely on a normalized biomechanical environmentpatients
Indications: patients presenting with unicompartmental disease (eg, after prior meniscectomy) who are at an age and functional level that is not ideally suited for joint arthroplasty
Advantage: allowing 70% to 85% of patients to delay arthroplasty for ≥ 5 to 10 years and 50% to 60% for ≥ 15 years
nullMethod of planning the magnitude of the opening wedge . H hip, K knee, A ankle, VA virtual ankle, FP Fujisawa pointTREATMENTTREATMENTNote:Varus or valgus deformity often has a ligamentous component as well as osseous and cartilaginous TREATMENTTREATMENT Complications
Intra-articular fracture
Compartment syndrome
Hardware failure
Correction failure
Contracture
Neuroma
Infection
Hardware pain
Delayed union
Hematoma
Anterior knee pain
Pes anserinus pain
TREATMENTTREATMENT Cartilage Repair Techniques
Bone Marrow Stimulating Techniques
Osteochondral Transplantation Techniques
Autologous Chondrocyte Implantation (ACI) nullSchematic drawing of autologous cartilage implantation (ACI). The procedure consists of the following steps: (1) cartilage harvest generally performed during arthroscopic surgery, (2) cell culture with expansion of cells in monolayer flasks, and (3) reimplantation of the cells by injecting them underneath a sutured collagen membrane TREATMENTTREATMENT Arthroplasty
Unicompartmental Knee Arthroplasty (UKA)
Total Knee Arthroplasty (TKA)
TREATMENTTREATMENTUnicompartmental Knee Arthroplasty (UKA)
Indicated in cases where OA involves only one of the three compartments of the knee: the medial tibiofemoral, lateral tibiofemoral or patellofemoral compartment nullTREATMENTTREATMENT Advantages : a less invasive surgical technique
The patella not everted and the extensor mechanism not damaged--permitting a much more rapid recovery and earlier discharge
Preservation of bone stock
More normal knee kinematics
Greater physiological function TREATMENTTREATMENT Complications
Bearing dislocation
Tibial component loosening
Femoral component loosening
Lateral translation
Impingement
Implant fractureTREATMENTTREATMENT Total Knee Arthroplasty (TKA)
The first-line procedure for end-stage knee OA
Indications:more than one compartment involved and failure of conservative treatments nullTREATMENTTREATMENT Advantages
Highly effective treatment that results in substantial improvement in patient functioning and health-related quality of life TREATMENTTREATMENTComplications:
Postoperative pain without clinical or radiological abnormalities
Femoropatellar problems
Loosening of components
Infections
Stiffness of the knee THANK YOUTHANK YOU