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MODALITIES OF MANAGMENT

Department of OrthopedicsSurgical Division

MH, JRC

OSTEOARTHRITIS KNEES

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MODALITIES OF MANAGMENT

By Maj S B PandeyModerator: Lt Col Ravinder Singh

OSTEOARTHRITIS KNEES

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Osteoarthritis is a degenerative disorder that results from the biochemical breakdown of articular (hyaline) cartilage in the synovial joints.

However, the current concept holds that osteoarthritis involves not just the articular cartilage but the entire joint organ, including the subchondral bone and synovium.

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Osteoarthritis predominantly involves the weight-bearing joints, including the knees, hips, cervical and lumbosacral spine, and feet. Other commonly affected joints include the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of the hands.

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Clinical Presentation Joint soreness after inactivity or periods of overuse

of a joint.

Stiffness after rest and disappears quickly as activity begins again.

Morning stiffness lasting no longer than 30 minutes.

Joint pain which is less in the morning and stronger at the end of the day following activity.

Muscle atrophy around joints caused by inactivity can increase pain.

Pain and stiffness can affect posture, coordination and ability to walk.

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Signs of Knee Osteoarthritis may include :

pain exacerbated by moving the knee

knee locking or catching

pain when standing up from a chair

pain when going up and down stairs

weakening thigh muscles.

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Radiographic appearance

Radiographic Criteria Loss of joint space

Sub-chondral sclerosis or cyst formation

Presence of new bone formation or

osteophytes

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The goals of osteoarthritis treatmentPain alleviation and improvement of functional status

Non-pharmacologic interventions are the cornerstones of

osteoarthritis therapy

Patient education

Temperature modalities

Weight loss

Exercise

Physical therapy

Occupational therapy

Joint unloading in certain joints (e.g., knee, hip).

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Acetaminophen has clearly been demonstrated to be effective in the treatment of pain of OA when c/w placebo for 50% pain reduction when using 1000mg.

Acetaminophen has been demonstrated to be safe up to 4 gm/day.

As OA is principally non-inflammatory NSAIDs should clearly be titrated for clinical effect.

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Opioids

Tramadol is specifically identified as the initial agent of choice in patients with OA

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Do Oral Medications (Acetaminophen, NSAIDs) help or hurt ?

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Glucosamine Sulfate Glucosamine sulfate has measured its effectiveness on Osteoarthritis of the knee. However, there is some evidence that it might also help Osteoarthritis of the hip or spine.

In addition to relieving pain, glucosamine sulfate might also slow the breakdown of joints in people with osteoarthritis who take it long-term.

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Side Effects of Glucosamine Sulfate

Glucosamine appears to be safe for most people with diabetes, but blood sugar should be monitored closely.

People with asthma should be cautious about taking products that contain glucosamine.

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There is not enough reliable scientific information available to know if glucosamine sulfate is safe to take during pregnancy or while breast-feeding.

Until more is known, do not take glucosamine sulfate while pregnant or breast-feeding.

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What about the role of Steroid Injections ?

Steroid injections can be used as an adjunct therapy along with systemic therapy.

This is an effective way to knock down inflammation.

Mechanism of Action

Inhibit accumulation of inflammatory cell lines

Reduction of prostaglandin synthesis Inhibit leukocyte secretion from synovial cells Decrease interleukin secretion by the

synovium Increase viscosity of synovial fluid

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HYLURINIDASE

Hyalgan® is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy, and to simple analgesics, e.g., acetaminophen.

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NEW DRUGS

Protelosa, contain the chemical Strontium Ranelate which is thought to encourage the body to produce cartilage and is already used to treat osteoporosis.

Celecoxib : 100 to 200 mg once or twice a day.

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PHYSIOTHERAPY AND

REHABILITATION

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OPERATIVE PROCEDURES

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HIGH TIBIAL CORRECTIVE OSTEOTOMY

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Uni-Condylar/Compartmental Arthroplasty

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Minimal Incision Arthroplasty

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Total Knee Arthroplasty

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Indications for Total Knee Joint Replacement

The main indication for Total Knee Arthroplasty is for relief of pain associated with arthritis of the knee in patients who have failed non operative treatments.

(American Academy of Orthopedics)

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22 Jul 2011

(Ex- Sub) Gurmukh Singh, 65 Yrs Old case of Hypertension with Type 2 DM on medication for past 15 YrsDiagnosed with Osteoarthritis Both Knees with Varus Deformity.

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133.mp4

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Medication Strength/dose AmountFirst injection

Bupivacaine 0.5% (200-400 mg) 24 cc

Morphine sulphate 8 mg 0.8 cc

Epinephrine (1:1000) 300 μg 0.3 cc

Methylprednisolone acetate

40 mg 1 cc

Cefuroxime 750 mg 10cc (reconstituted in normal saline)

Sodium chloride 0.9% 22 cc

Second injectionBupivacaine 0.5% 20 cc

Sodium chloride 0.9% 20 cc

Ranawat Orthopedic Center (ROC) cocktail

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Navigation Assisted Knee Arthroplasty

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MAKOPLASTY

Navigation assisted resurfacing of joints using minimal incision

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MESSAGE

THANKS

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Question Hour