DEPTT. OF ORTHOPAEDICS M.L.B.Medical College,Jhansi SEMINAR ON OSTEOARTHRITIS KNEE
OSTEOARTHRITIS KNEE MODERATOR: • 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 : fol ows 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 usual y begins in anteromedial compartment of knee Fibril ation 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.
• Findings – Joint space narrowing • Medial tibiofemoral joint space narrowing • Patel ofemoral joint space narrowing • Lateral joint space narrowing to lesser extent – New subchondral bone formation – Tibia lateral subluxation – Osteophyte formation • Medial osteophytes are most prominent initial y
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 deformation Grade 1: · Some loss of articular cartilage · If severe loss of cartilage, joint space narrows · Osteophytes may be seen Grade 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 narrowing Grade 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 contd.
OTHER INVESTIGATIONS COLORISED X-RAY OF O.A. KNEE
MRI • MRI i s very sensitive to bony and soft tissue changes. • MRI can also demonstrate reactive bone edema or soft tissue swel ing as wel 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 examination Diagnosis : Normal Articular Cartilage Osteoarthritic cartilage with exposed subchondral bone
TREATMENT • Treatment directed at symptoms and slowing progress of the condition • Goals: 4 R’s Relieve pain Restore function Reduce disability Rehabilitation • URICE (Ultrasound, Rest, Ice, Compression and Elevate)
PHYSIOTHERAPY • Aim is to maintain joint mobility & improving muscle strength • Includes: Exercises Massage Application of warmth
Load reduction LIFE STYLE CHANGES: o Western commode o Shock absorbing shoes o Walking sticks o Weight reduction in obese DIET o Omega-3 fatty acids o vitamin C o Vitamin D o 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 usual y genu varum Joint disability Progressive limitation of knee motion
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 tibia Still 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 employment 2. Radiographic evidence of involvment of 1 compartment 3. Valgus/varus deformity 4. Ability of the Pt. to use crutches after operation 5. 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 needed Rheumatoid 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 jig Incision 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, anatomical y 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
DISTRACTION OF OSTEOTOMY OSTEOTOMY GUIDE ATTACHED & OSTEOTOMY DONE
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 patel a & femur. • Aching pain behind patel a • TREATMENT: o conservative o Surgical options: 1. Lateral release 2. Chondroplasty 3. Maquet osteotomy 4. Patellar osteotomy 5. Patellar resurfacing 6. Patellectomy 7. Patellofemoral joint replacement