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Osteoarthritis of Knee joint Dilshan Munidasa

Osteoarthritis of Knee joint Dilshan Munidasa. Overview. Definition and Risk Factors Idiopathic vs. Secondary OA Clinical Features Diagnosis Radiologic Features ACR OA dx for knees, hands, hips Goals of Treatment Non-pharmacologic treatment Pharmacologic treatment

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Osteoarthritis of Knee joint Dilshan Munidasa

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  1. Osteoarthritis of Knee joint Dilshan Munidasa

  2. Overview • Definition and Risk Factors • Idiopathic vs. Secondary OA • Clinical Features • Diagnosis • Radiologic Features • ACR OA dx for knees, hands, hips • Goals of Treatment • Non-pharmacologic treatment • Pharmacologic treatment • Surgical Considerations

  3. Osteoarthritis • Articular cartilage failure induced by a complex interplay of genetic, metabolic, biochemical, and biomechanical factors • With secondary components of inflammation • Initiating mechanism is damage to normal articular cartilage by physical forces (macrotrauma or repeated microtrauma) • Not necessarily normal consequence of aging

  4. Risk Factors • Age • Female versus male sex • Obesity • Lack of osteoporosis • Occupation • Sports activities • Previous injury • Muscle weakness • Proprioceptive deficits • Genetic elements • Acromegaly • Calcium crystal deposition disease

  5. Idiopathic Osteoarthritis • Localized or generalized forms • Localized OA most commonly affects the hands, feet, knee, hip, and spine • Other joints less commonly involved • shoulder, temporomandibular, sacroiliac, ankle, and wrist joints • Generalized OA • three or more joint sites

  6. OA Pathology

  7. Patterns of Presentation • Monoarticular in young adult • Pauciarticular, large-joint in middle age • Polyarticular generalized • Rapidly progressive • Secondary to trauma, congenital abnormality, or systemic disease

  8. Clinical Diagnosis • Symptoms • Pain • Stiffness • Gelling • Physical examination • Crepitus • Bony enlargement • Decreased range of motion • Malalignment • Tenderness to palpation • The more features, the more likely the diagnosis

  9. Differential Diagnosis • Rheumatoid Arthritis • Gout • CPPD (Calcium pyrophosphate crystal deposition disease) • Septic Joint • Polymyalgia Rheumatica

  10. Radiographic Features • Joint space narrowing • Subchondral sclerosis • Marginal osteophytes • Subchondral cyst • Assymetrical

  11. OA Radiology

  12. OA Grading-Kellgren & Lawrence grade 0 - no radiographic features grade 1 - doubtful joint space narrowing (JSN) and possible osteophyticlipping grade 2 - the presence of definite osteophytes radiograph. grade 3 - multiple osteophytes, definite JSN +sclerosis+ deformity grade 4 - large osteophytes, marked JSN, severe sclerosis and definitely bony deformity

  13. OA of the Knee: Classic Criteria 1. Greater than 50 years of age 2. Morning stiffness for less than 30 minutes 3. Crepitus on active motion of the knee 4. Bony tenderness 5. Bony enlargement 6. No palpable warmth • 3 of 6 criteria give sensitivity of 95% and specificity of 69%

  14. OA of the Knee: Addition of X-rays • ACR Criteria of: 1. knee pain 2. radiographic evidence of osteophytes 3. one of three additional findings: • age greater than 50 years of age • morning stiffness of less than 30 minutes • crepitus • Sensitivity and specificity for OA of 91 and 86%

  15. Synovial fluid analysis • Severe, acute joint pain is an uncommon manifestation of OA • Clear fluidWBC <2000/mm3 • Normal viscosity

  16. Diagnosis - Cont • There is no blood test for the diagnosis of osteoarthritis. • MRI • Gold standard -Artroscopy

  17. Typical OA work-up • History • PE • Consider following (especially if OA of knees or hips) • Erythrocyte sedimentation rate (ESR) • Rheumatoid factor titers • Evaluation of synovial fluid • Radiographic study of affected joints

  18. Goals of Treatment • Control pain and swelling • Minimize disability • Improve the quality of life • Prevent progression • Education • Chronic Condition and Management

  19. Non-pharmacologic Treatment • Weight Loss • Ten-pound weight loss over 10 years decreased the odds for developing knee OA by 50% • Even a modest amount of weight loss may be beneficial • Rest • Short period of time, typically 12-24 hours • Prolonged rest can lead to muscle atrophy and decreased joint mobility

  20. Non-pharmacological Treatment • Physical Therapy • May be more beneficial in those with mild OA • Ultrasound therapy may have some benefit based on 2009 Cochrane Review

  21. Knee Braces / Taping • Cochrane reports a “sliver of benefit” • 73% taping for 3 weeks reported improvement (elastic knee sleeve

  22. Tens • Safety/Tolerability: High • Efficacy: Medium • 20 points more effective on scale of 100 compared to placebo • Few long term studies

  23. Non-pharmacologic Treatment • Acupuncture • Very small improvements in pain and physical function after 8 weeks and 26 weeks • A lot seems to be placebo effect due to incomplete blinding • Reasonable to offer if patient resistant to conventional treatment and wants to try alternative therapies

  24. Non-pharmacological Treatment • Exercise – focus on low load exercise • Tai Chi • Yoga • Swimming • Biking • Walking • Most important aspect to counsel patients for prevention and treatment • Cochrane Review 2009 compares efficacy to NSAIDs in short-term benefits • Heat and Cold • Lack of convincing data despite being commonly used

  25. Exercises

  26. Quad Sets

  27. Quadrceps

  28. Quadriceps

  29. Wall slide

  30. Acetaminophen • NSAIDs are superior to acetaminophen • Treatment effect was modest • Median trial duration was only six weeks • In OA subjects with moderate-to-severe levels of pain • NSAIDs > Acetaminophen > Placebo • 1000mg three to four times daily

  31. NSAIDs • Tend to avoid for long-term use • Rash and hypersensitivity reactions • Abdominal pain and gastrointestinal bleeding • Impairment of renal, hepatic, and bone marrow function, and platelet aggregation • Cardivascular • Central nervous system dysfunction in the elderly • Low dose ibuprofen (less than 1600 mg/day) may have less serious GI toxicity • Nonacetylatedsalicylates (salsalate, choline magnesium trisalicylate), sulindac, and nabumetone appear to have less renal toxicity • Indomethacin should be avoided for long-term use in patients with hip OA • associated with accelerated joint destruction

  32. Topical NSAIDs • Significant short term (one to two weeks) efficacy for pain relief and functional improvement when topical NSAIDs were compared to placebo • Effect was not apparent at three to four weeks • Topical NSAIDs were generally inferior to oral NSAIDs • However topical route was safer than oral use • Topical Diflofenac (1% gel or patch)

  33. COX-2 Inhibitors • COX-2 inhibitors appear to be as effective NSAIDs • Associated with less GI toxicity • However increased risk of CV events • Use of low dose ASA may negate the GI sparing effects of COX-2 inhibitors • Those who are receiving low dose aspirin and a COX-2 selective agent may benefit from anti-ulcer prophylaxis

  34. Capsaicin • Capsaicin Ointment 0.025% (qid) & 0.075% (bid) • Principle ingredient of chili peppers (substance P) • Love It! • Tolerability: Medium • 50% experience burning which wanes • 50% decrease in pain, 25% with placebo • Apply 2-4 times per day

  35. Glocosamine • Glucosamine/Chondroitin • 1500 mg/1200 mg daily ($40-50/month) • Glucosamine: building block for glycosaminoglycans • Chondroitin: glycosaminoglycan in articular cartilage • GAIT study, NEJM, Feb 23, 2006 • Multicenter, double blind, placebo-controlled, 24 wks, N=1583 • Symptomatic mild or moderate-severe knee OA • Infrequent mild side effects e.g. bloating • For mild OA, not better than placebo • For moderate-severe OA, combination showed benefit 8 • Patient satisfaction

  36. Injections • Corticosteroid • Safety: High for short-term use, data on frequency and degree of use is limited. • Study of pt’s receiving 8 injections over 2 year period showed no ill effects in comparison with pt’s receiving placebo. • Strict aseptic technique must be used • Tolerability: Medium to high • Efficacy: Low to medium. Modest benefit. 16 point reduction in pain on 100-point scale for one month.

  37. Injections

  38. Hyaluronic Injections of Knees • Efficacy: Low. Recent Meta-analyses and reviews small clinical effect. 75% were satisfied with treatment. Lasts 3-4 months. • Price: High. 3 injections cost Rs.15000

  39. Narcotics for Refractory Pain • Safety: Medium • Tolerability: Medium • Constipation, somnolence, mental status changes • Use of opiates indicated in those who are not candidates for surgery and who continue to have moderate to severe pain despite being on NSAIDs or selective cyclooxygenase (COX)-2 inhibitors

  40. Arthroscopic Interventions

  41. Arthroscopic Interventions • Minimally invasive procedure • Arthroscopic debridement with lavage – Short term benefit • Remove loose pieces of bone and cartilage • Lateral release can be done to off load patella

  42. AutologusChondrocyte Transplant

  43. Prosthetic Joints • Several types: Unicondylar / Total knee • Last 15 years or more • About 10% need to be redone • Usually a treatment of “last resort”

  44. TKR

  45. Joint Replacement • Surgical candidate? • Often greater improvement in pain • Recovery is often rapid (2weeks to 2 months) • Infection rate 1% • Low mortality 0.6% to 0.7% • Complications include thrombo-embolic events 5%

  46. Management: Algorithm Lifestyle Modifications Acetaminophen PRN NSAIDs PRN Celecoxib Steroid Injections Opioids PRN Hyaluronan Injections ? Surgical Referral

  47. Education and Self-Help • Understand the disease (progressive –temporary relief period) • Reduce pain but remain active • Clear Functional goals • Cope physically, emotionally, and mentally • Have greater control over the disease • Build confidence

  48. THANK YOU

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