Management of Osteoarthritis of the Knee last.pptx

Presenation about managment of knee osteoarthritis from conservative and total knee replacment

1. Management of Osteoarthritis of the Knee Dr Ehab Elzayyat Consultant of orthopedic Surgery

2. Persons in Our countries tend to remain physically active and participate in demanding activities well into their fifth, sixth, and even seventh decades. However, with this increase in activity comes an increased risk of developing a chondral injury that may lead to early onset of arthritis in the knee. The recent literature on osteoarthritis (OA) in patients aged 40 to 60 years indicates that successful outcomes can be gained with surgical treatment.

3. These vary from person to person. People may experience: • Pain • Stiffness • Swelling • Reduced function Weakening of the muscles presentation of Knee osteoarthritis?

4. Physical exam inspection body habitus gait often an increased adductor moment to the limb during gait antalgic gait associated with knee arthritis knee is maintained in flexion shortened stride length compensatory toe walking limb alignment Effusion skin (e.g. scars) range of motion lack of full extension (>5 degrees flexion contracture) lack of full flexion (flexion <110 degrees) ligament integrity (varus and valgus)

5. Osteoarthritis is sometimes described as degenerative joint disease Age is often the leading cause of osteoarthritis Women tend to be more affected by knee osteoarthritis than men Previous injury such as fractures or surgery Other factors that can predispose someone to knee osteoarthritis include: their occupation, genetics and excess body weight, which can contribute to the onset of joint pain. What are the causes?

6. CLASSIFICATION Kellgren & Lawrence (based on AP weightbearing XRs) Grade 0 No joint space narrowing (JSN) or reactive changes Grade 1 Possible osteophytic lipping + doubtful JSN Grade 2 Definite osteophytes + possible JSN Grade 3 Moderate osteophytes + definite JSN + some sclerosis + possible bone end deformity Grade 4 Large osteophytes + marked JSN + severe sclerosis + definite bone end deformity

7. Types of patients with knee OA Knee joint OA Knee-only OA: Symptomatic OA in one or both knees only. Multiple-joint OA*: Symptomatic OA of the knee(s) in addition to other joints (e.g., hip, hand, spine, etc Co-Morbidity No co-morbidities: The individual with OA has no pertinent co-morbid health concerns. Co-morbidities: The individual with OA has any of the following pertinent co-morbid health concerns: diabetes; hypertension; CV disease; renal failure; gastrointestinal (GI) bleeding; depression; or physical impairment limiting activity, including obesity.

8. Co-morbid Knee OA Patients Moderate Risk The individual with OA has any of the following pertinent co-morbid health concerns: diabetes; advanced age; hypertension; CV disease; renal failure; GI complications; depression; or physical impairment limiting activity, including obesity. High Risk The individual with OA has risk factors such as history of GI bleed, myocardial infarction, chronic renal failure, etc.

9. Nonsurgical Management In an effort to delay major surgery, many younger patients with early knee OA are offered a variety of nonsurgical modalities, such as exercise and weight loss programme and physical therapy, bracing, orthoses, nonsteroidal anti-inflammatory drugs (NSAIDs), and intraarticular viscosupplementation or corticosteroid injection.

10. AAOS Clinical Practice Guideline Strong Evidence from two or more “High” quality studies with consistent findings for recommending for or against the intervention. Also requires no reasons to downgrade from the EtD framework Moderate Evidence from two or more “Moderate” quality studies with consistent findings or evidence from a single “High” quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed in the EtD framework. Limited Evidence from one or more “Low” quality studies with consistent findings or evidence from a single “Moderate” quality study recommending for or against the intervention. In addition, higher strength evidence can be downgraded to limited because of major concerns addressed in the EtD framework Consensus There is no supporting evidence, or higher quality evidence was downgraded because of major concerns addressed in the EtD framework. In the absence of reliable evidence, the guideline work group is making a recommendation based on their clinical opinion

11. In general, the goals of these therapeutic options are to decrease pain and improve function. Appropriate use of specific nonsurgical modalities requires knowledge of evidencebased practice guidelines, careful patient selection, patient education, and adequate long-term follow-up

12. Exercise Several large randomized controlled trials have shown that exercise reduces pain and improves function in patients with early OA. Two recent meta-analyses also demonstrate that muscle strengthening and aerobic exercise are important in the management of OA. Muscle strengthening exercises are superior for specific impairment-related outcomes, such as pain, but aerobic exercise contributes to better long-term functional outcomes. An individualized, multimodal approach tailored to specific symptoms and patient expectations is recommended to maximize pain relief and functional outcomes.

13. Patient compliance with a regimen of exercise or physical therapy is a significant concern. The best available evidence shows that supplementation of a home exercise program with supervised exercise classes results in the largest gains in pain relief and locomotion at 12-month follow-up. Exercise must also be sustained because any beneficial effects are lost 6 months after an exercise program is terminated. Strength of recommendation : Strong Implication: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

14. Level 1

15. Level 2

16. Level 3

17. Weight loss Weight loss should be addressed as part of the management of knee OA. Strength of recommendation : Moderate . Framingham Study by Felson et al[10] demonstrated that women with an approximately 5 kg weight loss had a 50% reduction in the risk of development of symptomatic knee OA.

18. Christensen et al used a meta-regression analysis of randomized controlled trials to evaluate if there were changes in pain and function when overweight patients with knee OA achieve a weight loss. The study concluded that disability could be significantly improved when weight was reduced > 5.1% over a 20-wk period, or at the rate of 0.24% reduction per week

19. Riddle et al[12] found there to be a significant dose-response relationship between the extent of percentage change in body weight and the extent of change in WOMAC index for physical function score. Specifically those who gained ≥ 10% of body weight had worse WOMAC physical function score. It has also been associated with MRI changes as Teichtahl et al showed that obese individuals with OA who lost as little as 1% of their body weight were able to reduce the amount of medial femorotibial cartilage volume loss

20. Biomechanical interventions Knee braces and sleeves Brace treatment could be used to improve function, pain, and quality of life in patients with knee osteoarthritis. Strength of recommendation : Moderate . Implication : Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences. Cane Canes could be used to improve pain and function in patients with knee osteoarthritis. Strength of recommendation : Moderate . Implication : Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences. Lateral wedge insoles Lateral wedge insoles are not recommended for patients with knee osteoarthritis. Strength of recommendation : Strong Implication : Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is presen

21. Oral/Dietary Supplements The following supplements may be helpful in reducing pain and improving function for patients with mild- tomoderate knee osteoarthritis; however, the evidence is inconsistent/limited, and additional research clarifying the efficacy of each supplement is needed. • Turmeric • Ginger extract • Glucosamine • Chondroitin • Vitamin D Strength of recommendation : Limited . (downgrade) Implication: Practitioners should feel little constraint in following a recommendation labeled Limited, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.

22. Topical Treatments Topical nsaids should be used to improve function and quality of life for the treatment of osteoarthritis of the knee, when not contraindicated. Strength of recommendation : strong . Implication : practitioners should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present.

23. Neuromuscular training Neuromuscular training ( ie , balance, agility, and coordination) programs in combination with exercise could be used to improve performance-based function and walking speed for the treatment of knee osteoarthritis. Strength of recommendation : Moderate . (downgrade) Implication : Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.

24. Self-management Patient education programs are recommended to improve pain in patients with knee osteoarthritis. Strength of recommendation : Strong . Implication : Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. Patient Education Patient education programs are recommended to improve pain in patients with knee osteoarthritis. Strength of recommendation : Strong . Implication : Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is presen t.

25. Manual Therapy Manual therapy in addition to an exercise program may be used to improve pain and function in patients with knee osteoarthritis. Strength of recommendation : Limited Massage Massage may be used in addition to usual care to improve pain and function in patients with knee osteoarthritis. Strength of recommendation : Limited .

26. . LASER Laser Treatment FDA-approved laser treatment may be used to improve pain and function in patients with knee osteoarthritis. Strength of recommendation : Limited . (downgrade) TENS Transcutaneous Electrical Nerve Stimulation Modalities that may be used to improve pain and/or function in patients with knee osteoarthritis include a. Transcutaneous electrical nerve stimulation (pain) Strength of recommendation : Limited

27. Oral NSAIDs Oral NSAIDs are recommended to improve pain and function in the treatment of knee osteoarthritis when not contraindicated. Strength of recommendation : Strong Oral Acetaminophen Oral acetaminophen is recommended to improve pain and functions. Strength of recommendation : Strong Oral Narcotics Oral narcotics, including tramadol, result in a notable increase of adverse events and are not effective at improving pain or function for the treatment of osteoarthritis of the knee. Strength of recommendation : Strong

28. ECSW Extracorporeal shockwave therapy may be used to improve pain and function for the treatment of osteoarthritis of the knee. Strength of recommendation : Limited Hyalurinic Acid Hyaluronic acid intra-articular injection(s) is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee. Strength of recommendation : Moderate Intra-Articular steriod Intra-articular corticosteroids could provide short-term relief for patients with symptomatic osteoarthritis of the knee. Strength of recommendation : Moderate

29. Platelet-rich Plasma Platelet-rich plasma may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee. Strength of recommendation : Limited Denervation Therapy Denervation therapy may reduce pain and improve function in patients with symptomatic osteoarthritis of the knee. Strength of recommendation : Limited

30. Acupuncture Acupuncture may improve pain and function in patients with knee osteoarthritis. Strength of recommendation : Limited Dry Needling In the absence of reliable evidence, it is the opinion of the work group that the utility/efficacy of dry needling is unclear and requires additional evidence. Strength of recommendation : Consensus

31. Surgical Management Knee replacment Unicompartmental Total knee replacement Knee arthroscopy Irrigation and lavage Partial menisectomy Knee Osteotomy High tibial osteotomy Tibial tubercle osteotomy Distal femur osteotomy

32. Knee arthroscopy Usually may be indicated in mild to moderate knee arthritis Need preserved joint space. Positive MRI finding (meniscal tear or meniscal degenation ) Strength of recommendation : Limited

33. Knee osteotomy High Tibial Osteotomy (HTO) is a surgical procedure that is performed to correct angular deformities of the knee to prevent development or progression of unicompartmental osteoarthritis.  It is predominately done to correct for varus deformities in young patients but can also be done to correct valgus deformities. Contraindications include inflammatory arthritis, flexion contracture > 15 degrees, bicompartmental osteoarthritis, and ligamentous instability. 

34. Use predominately done for varus deformities less common for valgus deformities Angular deformity in the knee leads to abnormal distribution of weight bearing stresses can accelerate wear in medial or lateral compartments of the knee and lead to degeneration HTO is commonly combined with cartilage restoration procedures to provide better mechanical environment for biologic repair

35. Mechanical axis of lower extremity can be assessed by drawing straight line from center of femoral head to the center of the ankle joint line axis should pass just medial to the medial tibial spine

36. Indications young, active patient (<50 years) in whom an arthroplasty would fail due to excessive wear healthy patient with good vascular status non-obese patients pain and disability interfering with daily life only one knee compartment is affected compliant patient that will be able to follow postop protocol General contraindications inflammatory arthritis obese patient BMI>35 flexion contracture >15 degrees knee flexion <90 degrees procedure will need >20 degrees of correction patellofemoral arthritis ligament instability varus thrust during gait

37. Lateral closing wedge Medial opening wedge

38. Unicompartment Knee replacement When only one compartment of the knee is involved. For isolated medial, isolated lateral or isolated patellofemoral osteoarthritis. The most common reasons for conversion to a total knee arthroplasty are the progression of osteoarthritis and aseptic loosening. Incidence 5% of surgeries where knee arthroplasty is indicated are unicompartmental knee replacements Anatomic location medial compartment is most common Fixed-bearing historical standard of care Mobile-bearing

39. Advantages Compared to TKA faster rehabilitation and quicker recovery less blood loss less morbidity less expensive lower rates of PJI, wound complications preservation of normal kinematics Compared to HTO faster rehabilitation and quicker recovery improved cosmesis higher initial success rate fewer short-term complications lasts longer easier to convert to a TKA

40. Indications controversial and vary widely as an alternative to TKA or osteotomy for unicompartmental disease classicaly reserved for older (>60), lower-demand, and thin (<82 kg) patients 6% of patient's meet the above criteria with no contraindications Contraindications inflammatory arthritis ACL deficiency absolute contraindication for mobile-bearing UKA and lateral UKA controversial for medial fixed-bearing fixed varus deformity > 10 degrees fixed valgus deformity >5 degrees restricted motion arc of motion < 90° flexion contracture of > 5-10° previous meniscectomy in other compartment tricompartmental arthritis (diffuse or global pain) younger high activity patients and heavy laborers grade IV patellofemoral chondrosis (anterior knee pain)

41. avoid overcorrections undercorrect the mechanical axis by 2-3 degrees overcorrection places excess load on unresurfaced compartment remove osteophytes (peripheral and notch) resect minimal bone avoid extensive releases avoid edge loading prevent tibial spine impingement with proper mediolateral placement avoid making a varus tibial cut which increases the chance for loosening use caution when placing the proximal tibial guide pins to avoid stress fractures correct varus deformity to 1-5 degrees of valgus This Photo by Unknown Author is licensed under CC BY Surgical tips and tricks

42. Complications Aseptic loosening   most common cause of early failure (5 years) at somewhere between 25%-45.3%   Stress fractures   always involve tibia associated with high activity and patient weight clinically there will be a pain free interval followed by spontaneous pain with activity blood commonly found on joint aspiration risk factors   penetrating posterior tibial cortex with guide pin, placing guide pin medial in periphery, re-drilling for guide pin, and under-sized tibial component Intra-operative fractures associated with forceful impacting of implant

43. Total knee replacment

44. indications symptomatic knee osteoarthritis failed non-operative treatments   techniques cruciate retaining vs. crucitate sacrificing implants show no difference in outcomes patellar resurfacing no difference in pain or function with or without patella resurfacing lower reoperation rates with resurfacing drains are not recommended

45. Goals of total knee Restoration of mechanical alignment Maintain the joint line Achieve ligaments balance Normal patellar tracking

46. Restoration of mechanical alignment

47. Maintain the joint line

48. Ligament balancing

49. Normal patellar tracking

50. Total knee surgical approaches Medial para[ atellar Medial subvastus Midvastus

51. Bone cuts

52. This Photo by Unknown Author is licensed under CC BY-NC This Photo by Unknown Author is licensed under CC BY posterior cruciate-retaining

53. This Photo by Unknown Author is licensed under CC BY-NC posterior-stabilized

54. An overview of revision knee prostheses on the market illustrating different constraint mechanisms. (A to G) Represent bicruciate -retaining, posterior cruciate-retaining, highly congruent (anterior-stabilized), posterior-stabilized, varus–valgus constrained (condylar constrained knee), rotating hinge, and pure (rigid) hinge prostheses. The upper line indicates the polyethylene insert, and the lower line indicates the contact pattern of condylar and tibial components. Types of constrained total knee arthroplasty