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Osteoarthritis of The Knee

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Presentation on theme: "Osteoarthritis of The Knee"— Presentation transcript:

1 Osteoarthritis of The Knee

2 Osteoarthritis of The Knee
Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

3 Overview: Epidemiology
Knee OA most common cause of disability in adults Decreased work productivity, frequent sick days Highest medical expenses of all arthritis conditions Symptomatic Knee OA More than 11% of persons > 64yo

4 Arthritis vs. Arthrosis
Overview: Definition Arthritis vs. Arthrosis Gradual loss of articular cartilage in the knee joint 3 articulations: Lateral condyles of the femur and tibia Medial condyles of the femur and tibia Patellofemoral joint Damage caused by a complex interplay of joint integrity, biochemical processes, genetics, and mechanical forces

5 Anatomy of The Knee

6 Anatomy of The Knee

7 Overview: Risk Factors
Age Female Obesity ( most important modifiable) Previous knee injury Lower extremity malalignment Repetitive knee bending High impact activities Muscle weakness Weight loss is most important modifiable risk factor OA association with activities, muscle weakness not as strong

8 Osteoarthritis of The Knee
Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

9 Evaluation History: Site/Severity: Onset: Character: Radiation:
Alleviation: Time: Exacerbation: Sx associated:

10 Evaluation History: Site/Severity: medial / lateral – pain score
Onset: gradual, no acute trauma Character: ache, joint soreness Radiation: present / absent Alleviation: rest, medication Time: how many yrs/ recent episode Exacerbation: eg. walking ½ mile, inclines Sx associated: swelling / instability

11 Evaluation Physical Exam Height, weight,BMI joint line tenderness
ROM of knees: L and R Lachmann’s/valgus/varus stress testS Patellar mobility Genu varus (bowlegged) valgus alignment Type of gait (antalgic)

12 Clinical Approach to Knee Pain
Valgus Test (MCL) Varus Test (LCL) Lachman Test (ACL) Lachman more sensitive than ant drawer McMurray: positive test if pain or click with motion McMurray Maneuver (menisci) Duck Waddle (stability)

13 Clinical Approach to Knee Pain
Tests FBC, ESR, RF Arthrocentesis X-rays (3 views) Weight-bearing AP Lateral Tangential Patellar (Sunrise) MRI Weight-bearing/standing AP views important to assess for loss of jt space

14 Osteoarthritis of The Knee
Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

15 Differential Diagnosis of Knee Pain
Medial Pain OA MCL Meniscus Bursitis Diffuse Pain Infectious arthritis Gout, pseudogout RA Lateral Pain OA LCL Meniscus Iliotibial band syndrome Anterior Pain Patellofemoral syndrome Prepateller bursitis Quadriceps mechanism Medial: -Medial Knee OA 70% of cases -Anserine bursitis (most common bursitis, often B)dx: TTP quarter-sized area tibial plateau inches below jt line, pain at motion/rest/night) -Bursa adjacent to MCL Lateral: -IT band (TTP over lateral femoral condyle) Anterior: -PF syndrome (most common cause of knee pain < 45yo, female, often B, compress patella to femur) Diffuse -inflammatory (limited ROM, knee kept slightly flexed) -50% of Nongonococcal bacterial arthritis cases involve the knee

16 Osteoarthritis of The Knee
Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

17 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 yo Morning stiffness < 30 min Crepitus Bony tenderness Bony enlargement No palpable warmth 5 4 of these are exam findings

18 Diagnosis of Knee OA Classification Tree Clinical symptoms
Synovial fluid WBC<2000/mm3 Clear color High Viscosity X-rays Osteophytes Loss of joint space Subchondral sclerosis Subchondral cysts No OA Improved specificity with x-rays, fluid sample Confirmed by arthroscopy (gold standard) Sensitivity 94 %; Specificity 88 %

19 Diagnosis of Knee OA X-ray on right: Top arrow – subcondral cyst
Middle arrow – osteophytes Bottom arrow – subchondral sclerosis

20 Osteoarthritis of The Knee
Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

21 Management: Lifestyle
Weight loss Nutrition referral Exercise Program PT referral Quadriceps strengthening ROM exercises Low impact activities e.g. swimming, biking 7 Ambulatory assist devices Cane Walker Insoles Unloader knee braces Weight loss Exercise program If unclear about insoles vs braces, early referral to podiatry or orthopedics or sports medicine

22 Management: Lifestyle
Varus (bowlegged) vs Valgus (knock-kneed) What comes first? Snowball effect Depicts correction of R knee varus deformity. Unloads medial compartment. Unloader braces can correct up to 3 degrees Unloader Brace

23 Management: Medical Glucosamine/Chondroitin Acetaminophen NSAIDs
Cox-2 inhibitors Opioids Intraarticular injections Glucocorticoids Hyaluronans

24 Management: Medical Glucosamine/Chondroitin
1500 mg/1200 mg daily (Rs /month) Glucosamine: building block for glycosaminoglycans Chondroitin: glycosaminoglycan in articular cartilage What does studies show (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 8 Patient satisfaction

25 Management: Medical Acetaminophen NSAIDs
Indication: mild-moderate pain 1000 mg Q6h PRN Better than placebo but less efficacious than NSAIDs 9 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 NSAIDS > Tylenol > placebo: 2004 meta-analysis of 10 randomized trials. NSAIDs: caution in CHF, HTN (fluid retention)

26 Management: Medical NSAIDs 10 NSAIDS Doses
Motrin, Naproxen are inexpensive If toxic or ineffective, it’s worth trying another NSAID

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? APC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID Increased risk at higher doses CLASS Trial: 8,000 pts compared Celecoxib vs Ibuprofen Similar risk to Ibuprofen Safety in PUD may be overstated Rofecoxib (Vioxx) is safer for GI but more dangerous for CV than naproxen APC trial: 700 patients each assigned to 3 groups: placebo, celebrex 200 bid, celebrex 400 bid. After 33 months 7, 16, 23 CV events respectively. APC trial d/c’d. CLASS trial 8,000 patients studied taking motrin vs celebrex for OA. After 12 mos, no difference in rate of MI, CVA, angina. Motrin 800 TID vs Celebrex 400 BID Ironically cox-2 inhibitors plus ASA may offset the increased risk of CV events. However, this also increases GI toxicity and may offset cox-2 selectivity. Consider anti-ulcer meds.

28 Management: Medical Opioid Analgesics Indication: Moderate-severe pain
Acute exacerbations NSAIDs/Cox-2 inhibitors failed or contraindicated Oxycodone synergistic w/ NSAIDs 13 Tramadol/acetaminophen vs codeine/acetaminophen Similar pain relief 14 Avoid long-term use Caution in elderly Confusion, sedation, constipation

29 Management: Medical 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 15 Lidocaine tells you if in the joint Can extend injection duration if inevitably going towards total knee replacement

30 Management: Medical Intraarticular Injections
Hyaluronans (e.g. Synvisc) Indication: pain persists despite other agents Synthetic joint fluid Pain relief similar to steroid injections 2 mL injection Qwk x 3, $ /series Medicare reimburses 80%, Medi-cal $455.90 60-70% patients respond, relief up to 6 months Patient satisfaction 16, 17

31 Management: Medical Intraarticular Injections Technique
23 gauge 1.5 inch needle Approach accuracy: Lateral mid-patellar 93% 18 Patient supine Leg straight Manipulate patella Angle needle slightly posteriorly Inject after drop in resistance or fluid aspirated Anterolateral approach 71%, anteromedial 75% Doug Jackson studied accuracy of injections by orthopods by any approach, <50% on first try.

32 Management: Algorithm
Lifestyle Modifications Acetaminophen NSAIDs Celecoxib Steroid Injections Opioids Hyaluronan Injections Surgical Referral

33 Management: Surgical When to Refer Types of Procedures
Knee pain or functional status has failed to improve with non-operative management Types of Procedures Arthroscopic Irrigation Arthroscopic Debridement High Tibial Osteotomy Partial Knee Arthroplasty Total Knee Arthroplasty

34 Management: Surgical High Tibial Osteotomy Indication:
Unicompartmental arthritis Genu varus or valgus Realign mechanical axis Age < 60yo < 15 degrees deformity19

35 Management: Surgical Implant cost – Rs 200000
Partial Knee Arthroplasty Indication: Unicompartmental arthritis Ligaments spared Increased ROM Faster recovery Prosthesis 10-yr survival: 84% Implant cost – Rs Lower survival rate b/c these patients tend to be younger and more active, causing damage to prosthesis

36 Management: Surgical Implant cost – Rs 200000 Total Knee Arthroplasty
Indication: Diffuse arthritis Severe pain Functional impairment Pain relief > functional gain ACL sacrificed PCL also may be sacrificed Prosthesis 10-yr survival: 90% Implant cost – Rs

37 Clinical Pearls Assess functional loss Knee exam: palpation, ROM,
Nutrition referral Exercise program/PT referral Orthotics Lateral mid-patellar or superolateral approach Educate patients about glucosamine/chondroitin, Cox-2 inhibitors, injections


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