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Osteoarthritis of The Knee. I.Overview Epidemiology Epidemiology Definition Definition Risk Factors Risk Factors II.Clinical Approach to Knee Pain III.Differential.

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Presentation on theme: "Osteoarthritis of The Knee. I.Overview Epidemiology Epidemiology Definition Definition Risk Factors Risk Factors II.Clinical Approach to Knee Pain III.Differential."— Presentation transcript:

1 Osteoarthritis of The Knee

2 I.Overview Epidemiology Epidemiology Definition Definition Risk Factors Risk Factors II.Clinical Approach to Knee Pain III.Differential Diagnosis IV.Diagnosis of Knee OA V.Management Lifestyle Lifestyle Medical Medical Surgical Surgical

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

4 Overview: Definition Arthritis vs. Arthrosis Gradual loss of articular cartilage in the knee joint 3 articulations:3 articulations: 1)Lateral condyles of the femur and tibia 2)Medial condyles of the femur and tibia 3)Patellofemoral joint Damage caused by a complex interplay of joint integrity, biochemical processes, genetics, and mechanical forces

5 Anatomy of The Knee

6

7 Overview: Risk Factors AgeAge FemaleFemale Obesity ( most important modifiable)Obesity ( most important modifiable) Previous knee injuryPrevious knee injury Lower extremity malalignmentLower extremity malalignment Repetitive knee bendingRepetitive knee bending High impact activitiesHigh impact activities Muscle weaknessMuscle weakness

8 Osteoarthritis of The Knee I.Overview Epidemiology Epidemiology Definition Definition Risk Factors Risk Factors II.Clinical Approach to Knee Pain III.Differential Diagnosis IV.Diagnosis of Knee OA V.Management Lifestyle Lifestyle Medical Medical Surgical Surgical

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

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

11 Evaluation Physical Exam Height, weight,BMIHeight, weight,BMI joint line tendernessjoint line tenderness ROM of knees: L and RROM of knees: L and R Lachmanns/valgus/varus stress testSLachmanns/valgus/varus stress testS Patellar mobilityPatellar mobility Genu varus (bowlegged) valgus alignmentGenu varus (bowlegged) valgus alignment Type of gait (antalgic)Type of gait (antalgic)

12 Clinical Approach to Knee Pain Varus Test (LCL) Valgus Test (MCL) McMurray Maneuver (menisci) Lachman Test (ACL) Duck Waddle (stability)

13 Clinical Approach to Knee Pain Tests FBC, ESR, RFFBC, ESR, RF ArthrocentesisArthrocentesis X-rays (3 views)X-rays (3 views) –Weight-bearing AP –Lateral –Tangential Patellar (Sunrise) MRIMRI

14 Osteoarthritis of The Knee I.Overview Epidemiology Epidemiology Definition Definition Risk Factors Risk Factors II.Clinical Approach to Knee Pain III.Differential Diagnosis IV.Diagnosis of Knee OA V.Management Lifestyle Lifestyle Medical Medical Surgical Surgical

15 Differential Diagnosis of Knee Pain Medial Pain OAOA MCLMCL MeniscusMeniscus BursitisBursitis Diffuse Pain OAOA Infectious arthritisInfectious arthritis Gout, pseudogoutGout, pseudogout RARA Lateral Pain OAOA LCLLCL MeniscusMeniscus Iliotibial band syndromeIliotibial band syndrome Anterior Pain OAOA Patellofemoral syndromePatellofemoral syndrome Prepateller bursitisPrepateller bursitis Quadriceps mechanismQuadriceps mechanism

16 Osteoarthritis of The Knee I.Overview Epidemiology Epidemiology Definition Definition Risk Factors Risk Factors II.Clinical Approach to Knee Pain III.Differential Diagnosis IV.Diagnosis of Knee OA V.Management Lifestyle Lifestyle Medical Medical Surgical 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: knee pain plus at least 3 of 6 characteristics: > 50 yo> 50 yo Morning stiffness < 30 minMorning stiffness < 30 min CrepitusCrepitus Bony tendernessBony tenderness Bony enlargementBony enlargement No palpable warmth 5No palpable warmth 5

18 Diagnosis of Knee OA Classification Tree Clinical symptomsClinical symptoms Synovial fluidSynovial fluid 1.WBC<2000/mm 3 2.Clear color 3.High Viscosity X-raysX-rays 1.Osteophytes 2.Loss of joint space 3.Subchondral sclerosis 4.Subchondral cysts Confirmed by arthroscopy Confirmed by arthroscopy (gold standard) (gold standard) No OA Sensitivity 94 %; Specificity 88 %

19 Diagnosis of Knee OA

20 Osteoarthritis of The Knee I.Overview Epidemiology Epidemiology Definition Definition Risk Factors Risk Factors II.Clinical Approach to Knee Pain III.Differential Diagnosis IV.Diagnosis of Knee OA V.Management Lifestyle Lifestyle Medical Medical Surgical Surgical

21 Management: Lifestyle Weight lossWeight loss –Nutrition referral Exercise ProgramExercise Program –PT referral –Quadriceps strengthening –ROM exercises –Low impact activities e.g. swimming, biking 7 Ambulatory assist devicesAmbulatory assist devices –Cane –Walker InsolesInsoles Unloader knee bracesUnloader knee braces

22 Management: Lifestyle Varus (bowlegged) vs Valgus (knock-kneed) Unloader Brace

23 Management: Medical Glucosamine/ChondroitinGlucosamine/Chondroitin AcetaminophenAcetaminophen NSAIDsNSAIDs Cox-2 inhibitorsCox-2 inhibitors OpioidsOpioids Intraarticular injectionsIntraarticular injections –Glucocorticoids –Hyaluronans

24 Management: Medical Glucosamine/ChondroitinGlucosamine/Chondroitin –1500 mg/1200 mg daily (Rs. 2500 /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=1583Multicenter, double blind, placebo-controlled, 24 wks, N=1583 Symptomatic mild or moderate-severe knee OASymptomatic mild or moderate-severe knee OA Infrequent mild side effects e.g. bloatingInfrequent mild side effects e.g. bloating For mild OA, not better than placeboFor mild OA, not better than placebo For moderate-severe OA, combination showed benefit 8For moderate-severe OA, combination showed benefit 8 –Patient satisfaction

25 Management: Medical AcetaminophenAcetaminophen –Indication: mild-moderate pain –1000 mg Q6h PRN –Better than placebo but less efficacious than NSAIDs 9 –Caution in advanced hepatic disease NSAIDsNSAIDs –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

26 Management: Medical NSAIDsNSAIDs 10 NSAIDS Doses

27 Management: Medical Cox-2 inhibitorsCox-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 BIDAPC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID –Increased risk at higher doses CLASS Trial: 8,000 pts compared Celecoxib vs IbuprofenCLASS Trial: 8,000 pts compared Celecoxib vs Ibuprofen –Similar risk to Ibuprofen

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

29 Management: Medical Intraarticular Injections GlucocorticoidsGlucocorticoids –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

30 Management: Medical Intraarticular Injections Hyaluronans (e.g. Synvisc)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, $560-760/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 TechniqueTechnique –23 gauge 1.5 inch needle –Approach accuracy: Lateral mid-patellar 93% 18Lateral mid-patellar 93% 18 –Patient supine –Leg straight –Manipulate patella –Angle needle slightly posteriorly –Inject after drop in resistance or fluid aspirated

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

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

34 Management: Surgical High Tibial Osteotomy Indication:Indication: –Unicompartmental arthritis –Genu varus or valgus Realign mechanical axisRealign mechanical axis Age < 60yoAge < 60yo < 15 degrees deformity 19< 15 degrees deformity 19

35 Management: Surgical Partial Knee Arthroplasty Indication:Indication: –Unicompartmental arthritis Ligaments sparedLigaments spared Increased ROMIncreased ROM Faster recoveryFaster recovery Prosthesis 10-yr survival: 84%Prosthesis 10-yr survival: 84% Implant cost – Rs 200000 Implant cost – Rs 200000

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

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


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