Dr (Prof.) Anil AroraMS (Orth) DNB (Orth) Dip SIROT

FAPOA (Korea), FIGOF (Germany), FJOA (Japan)

Computer Navigated

Knee Replacement Surgeon

Hip and Knee Surgery Clinic

70, Hargobind Enclave

Commonwealth Fellow Joint Replacement

(Royal National Orthopaedic Hospital, London, UK)

Senior Knee and Hip Replacement Surgeon

Associate Director

Department of Orthopaedics and Joint Replacement

Max Superspeciality Hospital, Patparganj, Delhi (India)

E-mail : anilarora@delhiorthojournal.com

What is Osteoarthritis Knee ?

OA is NON - INFLAMMATORY joint disease

characterized by

Degeneration of articular cartilage

Hypertrophy of bone margins

Changes in synovial membrane

Normal

Cartilage

Cartilage

worn out

Primary Osteoarthritis : Most Common

• Thought to be result of aging

• Decreased ability of cartilage to repair

itself

• Ligaments and muscle supporting joint

weakened

Secondary Osteoarthritis

• Obesity

• Trauma

• Surgery

• Abnormal joints

• Gout

• Diabetes

• Hormone disorders

Symptoms

1. Pain at the start of activity that gets better “warms up

over time”

2. Progressive pain with activities

3. Loss of motion, muscle weakness

4. “Crunching” sensation in the knee

5. Over the time deformity can occur in the knee

Deformed Lower Limbs

Diagnosis

• Physical Examination

• X- Ray

• Blood Test to rule out other diseases

Diagnosis : Triad

Osteoarthritic knee

Decreased

joint space

OA – Management Principles

• Slow progression over many years - Cannot

be cured

• Treatment directed at symptoms and

slowing progress of the condition

• Goals:

• Decrease pain

• Maintain / Improve range of motion

• Maintain / Improve muscle strength

Treatment Options

1. Education

2. Activity modifications such as using a cane

3. Physiotherapy

4. Drugs

5. Injections

6. Braces

7. Surgery : Arthroscopy

High Tibial Osteotomy

TOTAL KNEE REPLACEMENT

Education

• About the Disease

• Weight loss (>5 kg) has significant short-

term and long-term reduction in symptom

Physiotherapy

Aims :

• to reduce pain and disability by

strengthening muscles,

• improve joint stability

• increasing the range of movement

• Physical modalities ( US / IFT / SWD )

Exercises

Medication

EULAR - The European League Against Rheumatism

SYSDOA

Symptomatic Slow Acting Drugs for OA

• Glucosamine Sulfate

• Chondroitin Sulfate

• Hyaluronic Acid

• Diacerin

Glucosamine

1. Important for maintaining the

• Elasticity

• Strength and

• Resilience of cartilage in joints

2. Enhances both the production of

hyaluronic acid and its anti-inflammatory

3. Helps to reduce damage to the joints

4. action

Stimulate production of cartilage components

and allow rebuilding of damaged cartilage.

1. Glucosamine can increase mucopolysaccharide and

collagen synthesis in fibroblast tissue.

2. Glucosamine also appears to activate core protein

synthesis in human chondrocytes

Med Hypotheses 1994; 42: 323–327

Int J Tissue React 1992; 14: 231–241

Increases thickness and

elasticity of cartilage

Improves ability to

absorb and distribute

compressive forces

chondrocyte

metabolismCollagen

Production

Proteoglycan

Production

Degradative enzymes

Elastase and hyaluronidase

J Biomech 2007;40(8): 1847–1854.

J Biomech 2009;42(3): 286–290.

Osteoarthritis Cartilage 2009;17(8): 1001–1008.

Reduced the IL-1β-induced

nuclear factor-kb (nf-κb)

translocation in chondrocytes 1

1. Basic Clin Pharmacol Toxicol. 2008 Jan;102(1):59-65

2. Osteoarthritis Cartilage. 1998 May;6 Suppl A:14-21.

decrease the phagocytosis 2

Decreases release of lysozyme 2

Chondroitin sulfate is absorbed orally

.The bioavailability of chondroitin sulfate ranges from

15% to 24% of the orally administered dose

Arzneimittelforschung. 1995;45:918-25.

Osteoarthritis Cartilage. 1998;6 Suppl A:14-21.

Drug used Es for Pain

Acetaminophen 0.21

NSAIDs 0.32

Topical NSAIDs 0.41

IA Corticosteroid 0.72

Glucosamine sulphate 0.61

Chondroitin sulphate 0.52

Diacerine 0.22

Es = 0.2 = small effect

Es = 0.5 = moderate effect

Es = 0.8 = Large effect

The Glucosamine/chondroitin Arthritis Intervention Trial

Treatment appeared to be generally safe and well tolerated

over a 2-year period.

Glucosamine-1500mg/day

Chondroitin – 1200mg/day

Celecoxib -200mg/day

International Journal Of Pharmacy & Pharmaceutical

Sciences. October 2, 2013;5(Supp 4):647-650.

Lee YH, Woo JH, Choi SJ et al. 2009

Effect of glucosamine or chondroitin sulfate on the

osteoarthritis progression: a meta-analysis

Rheumatol Int 30(3): 357–363.

Meta-analysis included 3 RCT’s,

each over a 2-year period

1. A small significant effect in reducing the rate of

decline in minimum joint space width

2. 0.13 mm over 2 years (95% confidence interval (ci),

0.06 to 0.19; p = 0.0002)

GLUCOSAMINE

1200 to 1500 mg / day in single of divided doses

CHONDROITIN

800 to 1200 mg/day is shown efficacious in many studies.

Pharmacovigilance Risk assessment Committee

Injections

• Intra articular steroids

• Hyaluronic Acid (HA) and hyaluronan

preparations(eg, Synvisc)

Viscosupplement

Viscosupplement more beneficial in early

stage of Osteoarthritis Knee

Depomedrol

Arthroscopy

• Arthroscopy include debridement and

lavage/irrigation

Mechanical Axis Pass

from centre of Knee

Mechanical Axis Pass

from Medial side of Knee

Braces

High Tibial Osteotomy

What is Total Knee Replacement

Replacing damaged surface of the bone is

called Total knee Replacement.

Thank you