SEMINARON

OSTEOARTHRITIS KNEE

DEPTT. OF ORTHOPAEDICSM.L.B.Medical College,Jhansi

OSTEOARTHRITIS KNEEMODERATOR:• Prof. Dr. D.K. Gupta M.S• Prof. Dr. R.P. Tripathi M.S.• Dr.Saurabh Agarwal M.S.• Dr. Mayank Bansal M.S.• Dr. Amit Sehgal M.S.• Dr. Paras Gupta M.S. SPEAKER: PRIYANK GUPTA

PAIN,DEFORMITY & DEPRESSION

NORMAL ANATOMY:KNEE JOINT

• Knee is a complex synovial joint formed between femoral condyles,tibial condyles & patella.

• Stabilised by variety of ligaments.

• Active movement at the knee are flexion,extension,medial rotation & lateral rotation.

OA-Risk Factors

• Age Strongest risk factor OA can start in young adulthood

Risk increases with age• Female Gender Affects more women than men In men commonly before age 45, women after age 45• Joint Alignment Abnormal alignment or motion predisposes joint to OA• Bow legs, dislocations

RISK FACTORS Contd… • Hereditary gene tendency Joint injury/Overuse from

physical labor or sports• Trauma to any joint

increases risk of OA • Ligament or meniscus tears• Repeated movements in

certain jobs increase risk • Obesity• Joint overload is among

strongest risks for knee OA• Indian habits : cross-legging

& squatting

IF RISK FACTORS CONTINUES……….

So Osteoarthritis is………

• Osteoarthritis is a degenerative , noninflammatory joint disease characterised by destruction of articular cartilage and formation of none at the joint surfaces & margins .

CLINICAL FEATURES

- Pain : Steady/intermittent in a joint -Stiffness : follows periods of inactivity, such as sleep or sitting

-Swelling/tenderness : in one or more joints

-Crepitus : Crunching feeling or sound of bone rubbing on bone

-Locking -Limitation of movements -Deformity : valgus/varus

Sequence of pathological events Disease process usually

begins in anteromedial compartment of knee

Fibrillation d/t loss of water of wt. bearing articular cartilage

This puts pressure on underlying bone which causes sclerosis

Cysts& microfracture New bone & osteophyte

formation

Function of Articular Cartilage

• Reduce friction at the joint

• Act as a cushion to absorb the shock associated with joint use

• Transmit weight loads to the underlying bone.

Development of O.A.

• imbalance between the destructive and reparative or synthetic processes of the articular cartilage

Mechanical axis of knee

Mechanical explanation of O.A. knee

• The mechanical axis of the knee is a line extending from the center of the hip joint to the middle of the ankle joint. This line is practically perpendicular to the ground.

• In a healthy, well aligned knee joint, the mechanical axis passes through the middle of the knee.

• Only when the mechanical axis passes through the center of the knee joint, the stresses on the knee joint surfaces are uniform in all areas of the joint and well balanced.

• In many knee joint diseases, the mechanical axis is disturbed and does not pass through the center of the joint. This disturbance results in the overload of distinct areas of the knee joint leading to their damage. The patella lies not symmetrically in its groove.

• Views

– Standing anteroposterior (weight bearing)

– Lateral– Notch patellar views (Sunrise view)

• Posteroanterior intracondylar (PAIC)

• Tangential patellar

• Findings

– Joint space narrowing• Medial tibiofemoral joint space

narrowing• Patellofemoral joint space

narrowing• Lateral joint space narrowing to

lesser extent– New subchondral bone formation– Tibia lateral subluxation– Osteophyte formation

• Medial osteophytes are most prominent initially

RADIOLOGICAL EXAMINATION

STAGES OF OSTEOARTHRITIS

• The best way to see if osteoarthritis is present and see the severity is by looking at x-rays of the knee. Osteoarthritis is classified into 5 stages or "Grades":

• Grade 0: · Normal knee joint · No loss of cartilage and no deformationGrade 1: · Some loss of articular cartilage · If severe loss of cartilage, joint space narrows · Osteophytes may be seenGrade 2: · More activity in the bone under the cartilage · Increased activity can lead to bone hardening (sclerosis) and cysts · Change in bone density (whitening of bone on x-ray)Grade 3: · Some deformations on edge of bone · Rough edges · Increased joint narrowingGrade 4: · Complete loss of joint space · Definite deformity of bone ends · Changes in joint shape mean the bone contour has been altered

O.A. STAGES

O.A. STAGES contd.

OTHER INVESTIGATIONS

COLORISED X-RAY OF O.A. KNEE

MRI

• MRI is very sensitive to bony and soft tissue changes.

• MRI can also demonstrate reactive bone edema or soft tissue swelling as well as small cartilage or bone fragments in the joint. .

CT Scanning

• CT is excellent for demonstrating the degree of osteophytes (bone spur) formation and its relationship to the adjacent soft tissues. -CT is also useful to provide guidance for therapeutic and diagnostic procedures.

ULTRASONOGRAPHY

• Ultrasound is extremely sensitive for identifying synovial cysts and outpouches that can form in association with osteoarthritis.

• Ultrasound can also be used to image articular cartilage in patients who cannot tolerate an MRI examination.

• Can also be used to guide for diagnostic and therapeutic procedures.

RADIONUCLIDE BONE SCAN

• Radionuclide Bone Scans are very sensitive in detecting reactive bone edema association with osteoarthritis.

• For multiple sites of arthritic involvement.

Arthroscopic examinationDiagnosis : Normal Articular Cartilage Osteoarthritic cartilage with

exposed subchondral bone

TREATMENT

• Treatment directed at symptoms and slowing progress of the condition

• Goals: 4 R’sRelieve pain Restore functionReduce disabilityRehabilitation

• URICE (Ultrasound, Rest, Ice, Compression and Elevate)

TREATMENT STAGES EARLY Tt. PHYSIOTHERAPY LOAD REDUCTION ANALGESICS INTERMEDIATE Tt. JOINT DEBRIDEMENT AUTOLOGOUS CHONDROCYTE GRAFTING REALIGNMENT OSTEOTOMY LATE Tt. ARTHROPLASTY ARTHRODESIS

PHYSIOTHERAPY

• Aim is to maintain joint mobility & improving muscle strength

• Includes:ExercisesMassageApplication of warmth

Load reduction

LIFE STYLE CHANGES:o Western commodeo Shock absorbing shoeso Walking stickso Weight reduction in obese DIETo Omega-3 fatty acids o vitamin Co Vitamin Do Vitamin E

Pain Management

Analgesics : NSAID ‘s Corticosteroid Injection Reduce inflammation around joints

More rapid effect than NSAIDs Visco- supplement– Intraarticular hyaluronan therapy– Increase viscosity & elasticity of fluid

Role of diacerein & glucosamine

• Diacerein is IL-1 inhibitor • Disease modifying effect on O.A.• Prophylactic use of diacerein leads to lower

degree of articular stiffness when compared to glucosamine

• prophylactic chondroprotective effects of diacerein and glucosamine are histologicaly similar

SURGERY

• INDICATIONS:Pain refractory to conservative measures.History of frequent locking episodes Haemarthroses d/t loose bodies or

osteochondral fractures.Deformity usually genu varum Joint disability Progressive limitation of knee motion

SURGICAL METHODS Arthroscopic debridement Proximal tibial osteotomy Distal femoral osteotomy Chondral resurfacing procedure

a. Autologous chondrocyte grafting b. Mosaicplasty

TKR Arthrodesis Patellectomy UKA

Arthoscopic techniques

• Simple lavage

• Debridement

• Abrasion chondroplasty

Arthroscopic debridement

PATIENT SELECTION:• Active , older adults

with mild to moderate osteoarthritis knee after conservative Tt has been exausted.

• Based on history, physical examination, radiographic finding

OSTEOCHONDRAL & AUTOLOGOUS CHONDROCYTE TRANSPLANTATON

• Healthy chondrocytes are harvested from an uninvolved area of injured knee

• Grown in tissue culture• Injected into knee cartilage defect• Sealed over with a periosteal flap from

proximal medial tibiaStill experimental

PROXIMAL TIBIAL OSTEOTOMY

• PRINCIPLE:• In Pt with

unicompartmental O.A. of knee it causes “unloading” of involved jnt compartment by correcting malalingnment & redistributing the stresses on the jnt.

• INDICATIONS:1. Pain & disability interfering high demand

employment2. Radiographic evidence of involvment of 1

compartment 3. Valgus/varus deformity4. Ability of the Pt. to use crutches after operation5. Good vascular status

• CONTRAINDICATIONS:Narrowing of lateral compartment.Lateral tibial subluxation of more than 1cm.Medial compartment bone loss of> 2-3 cm.Flexion contracture of >15°Knee flexion of < 90 ° More than 20 ° of correction neededRheumatoid arthritis

Types of osteotomy

• Medial opening wedge • Lateral closing wedge

• Dome

• Medial opening hemicallotasis

LATERAL CLOSING WEDGE OSTEOTOMY

Calculation of size of bone wedge

HTO with use of osteotomy jigIncision Positioning transverse osteotomy

guide

Placement of oblique osteotomy guide & performing osteotomy Application of compression clamp & L-

plate

• Fixation of bone after osteotomy can be done by :

• Staples• Plate• Screws• tomofix

TomoFix

• With the principle of the Locking Compression Plate (LCP) system with angular stable screws locked within the new TomoFix™ plate, anatomically designed for the medial high tibial valgus correction, stable fixation of the osteotomy without bone grafts or bone substitutes may be achieved.

• the plate functions like a bridging internal fixator

MEDIAL OPEN WEDGE TIBIAL OSTEOTOMY

• Recommended if extremity shortening is 2mm. Or more

OPENING WEDGE HEMICALLOTAXIS

Positioning of fixator Medial & lateral fixator pins

OSTEOTOMY GUIDE ATTACHED & OSTEOTOMY DONE

DISTRACTION OF OSTEOTOMY

DISTAL FEMORAL OSTEOTOMY

COVENTARY TECHNIQUE

SUPRACONDYLAR V- OSTEOTOMY

ARTHROPLASTY U.K.A.

• ADVANTAGES OVER OSTEOTOMY:

• Preservation of bone stalk • Immedite wt. bearing• Shorter recovery time• Easier revision to TKR• DISADVANTAGES:• Technical difficulty• Prosthesis loosening & failure

TKR

• When entire knee jnt is involved that cause incapacitating pain & disability .

ARTHRODESIS• Indicated for severe

disability esp. in young & active Pt. whose activity desire might severly limit the longevity of TKR Techniques of Arthrodesis:

• - External Fixation: - Intramedullary Nailing Arthrodesis: - Plate Fixation:

Patellofemoral joint osteoarthritis • Roughening of contiguous articular surfaces of patella & femur.• Aching pain behind patella

• TREATMENT:o conservativeo Surgical options:

1. Lateral release 2. Chondroplasty3. Maquet osteotomy4. Patellar osteotomy5. Patellar resurfacing6. Patellectomy7. Patellofemoral joint replacement

PAINFREE,MOBILE & HAPPY LIFE

THANK YOU