Enhanced Knee Osteoarthritis Treatment Options

1. Intra-articular (IA) Injection-Osteoarthritis of the Knee- Putri Amalia Isdianto RS OrthopaediPurwokerto

2. To help the patient understand the nature of the disease • To provide psychological support • To alleviate pain • To suppress the inflammatory reaction (in synovial membrane) • To encourage the patient to remain as physically active as possible in order to maintain joint function and prevent deformity • To correct existing deformity • To improve function • To strengthen weak muscles • To rehabilitate the individual patient Aims of Treatment Textbook of Disorders and Injuries of the Muskuloskeletal System, Third Edition, Robert B Salter, 1999.

3. Osteoarthritis is a progressive disease, You only can limit the disease progression, so there’s no turning back.. and deal with it

4. Treatment Modality

5. Corticosteroids (CS) • Local anesthetic • Hyaluronic Acid (HA) • Platelet Rich Plasma (PRP) Agents

6. Commonly used injectable corticosteroids  synthetic analogues of adrenal glucocorticoid hormone cortisol (hydrocortisone) • Important actions • Anti-inflammatory activity • Reduce the production of a wide range of pro-inflammatory mediators (ex. cytokines etc.) • Provide short term reduction of pain • Considered as an adjunct to core treatment for the relief of moderate to severe pain Corticosteroids

7. 5 injectable CS that have current FDA label for IA injections • Methylprednisolone acetate • Depo-Medrol • Triamcinolone acetate • Flamicort • Kenacort • Kenalog • Trilac 50 mg/5 mL • Betamethasone acetate and betamethasone sodium phosphate • Triamcinolone hexacetonide • Dexamethasone Corticosteroids

8. Lidocaine hydrochloride 2%  40 mg/2 mL • Rapid onset of action (within seconds) • Duration up to 30 mins • Marcain (bupivacaine) • Slow onset of action (about 30 mins) • Duration up to 8 hrs Local Anasthetics

9. Hyaluronan = hyaluronic acid (HA)  a large, linear glycosaminoglycan and a major non-structural component of both synovial and cartilage extracellular matrix • Key functions • Produce a highly viscoelastic solution • Lubrication • Maintenance of tissue hydration and protein homeostasis (as an osmotic buffer) Hyaluronans

10. Synthetic HA  viscosupplementation • Mode of action  unclear • Stimulate synthesis of “better quality” more physiologically normal endogenous HA • Reduce inflammation • Provide pain reduction in mild OA up to 24 weeks Hyaluronans

11. Injectable hyaluronan products that are approved by FDA • Sodium hyaluronate • Hylan G-F 20 • High-molecular-weight hyaluronic acid (HMWHA) Hyaluronans

12. Hyaluronans  60 mg/3 mL  20 mg/2 mL Umarone 20 mg/2 mL Ostenil Plus  40 mg/2 mL

14. Major Absolute Contraindication INFECTION

15. Steps

16. Select an approach • Anterolateral (flexed knee) • Anteromedial (flexed knee) • Superolateral/lateral suprapatellar (straight knee) • Superomedial/medial suprapatellar (straight knee) • Lateral mid-patellar • Medial mid-patellar Step 1

17. Identify the injection site Step 2

18. Prepare the injection site • Aseptic technique • Local anasthetic Step 3

19. Aspiration • For proof • For evacuation Step 4

20. Injection Step 5

21. Medicine is not only a science, it is also an art Do not treat the disease, but treat the patient