Osteoarthritis 191016103144

/
KNEE OSTEOARTHRITIS : AN OVERVIEW

BY
Dr / AHMED SAFWAT MOHAMED KASEM

Assistant Lecturer Of Orthopedic Department
3 Definition

A DEGENERATIVE, NON-INFLAMMATORY JOINT
DISEASE CHARACTERIZED BY DESTRUCTION OF
ARTICULAR
CARTILAGE AND FORMATION OF NEW BONE AT
THE JOINT SURFACES AND MARGINS.
Osteoarthritis affects the synovial joints, though it can affect any
joint , it is more common in the weight bearing joints like :
_ Hip
_ Knee
_ Wrist
_ Spine ,etc
Classification of OA
OA
Primary OA Secondary OA
11 Remember the risk factors
o O –O B E S I T Y
o S–SENILITY OR OLD AGE
o T–TRAUMA
o E–EMOTIONAL STRESS
o O –O S T E O P O R O S I S
o A–ALCOHOL
o R–RIGOROUS LIFESTYLES
o T – TA X I N G PROFESSIONS
o H–HORMONAL IMBALANCES
o R–REPETITIVE INJURIES
o I–INDIAN CULTURAL HABI
TS
o T–AXING SPORTS
o I–IMPROPER POSTURAL
HABITS
Primary Osteoarthritis Of The Knee
5 (Also Called Idiopathic)
• More common than secondary OA

• Cause –Unknown
• Common-in elders where there is no previous
pathology.
• Its mainly due to wear and tear changes occuring in
old ages mainly in weight bearing joints.
• Women have a greater tendency than men do
• More than 50 percent have bilateral OA knee.

6 SECONDARY OSTEOARTHRITIS OF THE
KNEE
It Is Generally Observed That Secondary
Osteoarthritis Occurs In The Younger Age Groups And
Is More Severe Than The Primary.
7
The Causes For Secondary Osteoarthritis
•Valgus And Varus Deformities Of The Knee.

•Intra-articular Fractures Of The Knee, Etc.
•Rheumatoid Arthritis, Infection, Trauma, Tb, Etc.
• Previous infection
•Hyperparathyroidism.
•Hemophilia.
•Syringomyelia.
•Neurological Disease Like Diabetes.
•Overuse Of Intra-articular Steroid Therapy.
•Obesity.
What are the typical symptoms of osteoarthritis?
10
• PAI N
• JOINT STIFFNESS
• RESTRICTED R A NGE OF JOI NT MOVE ME NT S
• SWELLI NG OF T HE JOI NT S.
• CREPITUS
• VARUS DEFORMITY
• Wasting of Quadricepsfemoris muscle can be noticied
Pain and Tenderness
– Usually slow onset of discomfort, with gradual and intermittent increase
– Pain is more on wt. bearing due to stress on the synovial membrane &
later on due to bone surface,which rich in nerve endings coming in
contact.
-Initially relieved by rest but later on disturb sleep.
-Diffuse/ sharp and stabbing local pain
– Types of pain
• Mechanical: increases with use of the joint
• Inflammatory phases
• Rest pain later on in 50%
• Night pain in 30% later on

JOINT STIFFNESS
– stiffness after periods of inactivity, passes over within minutes (approx
15min.) of using joint again
CREPITUS
– Coarse crepitus: palpate/hear (due to flaked cartilage & eburnated

bone ends)
RANGE OF MOVEMENT
– Reduced ROM: capsular thickening and bony changes in joint,ms. Spasm

or soft tissue contracture.
Pathology
OA is a degenerative condition primarily affecting the articular
cartilage.
1. Articular cartilage
2. Bone
3. Synovial membrane
4. Capsule
5. Ligament
6. Muscle
12 MECHANISMS FOR MAINTAINING
JOINT STABILITY
o Alignment of joint components
o Shape and ﬁt of articular surfaces
o Adhesive property of synovial ﬂuid
o Integrity of capsule and ligaments
o Muscle tone and power
o Neurological control of balance

Sequence of pathological events in
13 osteoarthritis
 The disease process usually begins in
the anteromedial compartment of
the knee joint.
 Fibrillation due to loss of water of the weight

bearing articular cartilage is seen in early
stages of the disease followed by complete
loss of articularcartilage.
 This puts enormous pressure on the

underlying bone, which causes sclerosis
and later
 Cysts may develop in the subchondral area due to
microfractures that degenerate.
 New bone formation takes place and results in osteophyte formation

Kellegren and Lawrence
22 Radiological Grading
Grade I: Doubtful narrowing of joint space and possible osteophyte lipping.
Grade II: Definite osteophytes and possible narrowing of the joint space.
Grade III: Moderate multiple osteophytes, definite narrowing of joint space and some sclerosis and
possible deformity of the bone ends.
Grade IV: Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of the
bone ends.
16 How to make a diagnosis?
• Physical examination
• Symptomatology
• Radiography
• Blood tests
• CT scan and MRI.
18 Criteria and Classification of OA Knee
(American College of Rheumatology—ACR)
Clinical:
1.Knee Pain For Most Days Of Prior Month.
2.Crepitus On Active Joint Motion.

3.Morning Stiffness Equal And Not More Than 30 Minutes In Duration.
4.Age Equal To More Than 38 Years.
5.Bony Enlargement Of The Knee On Examination.

 RADIOLOGICAL

20 IS THE MOST IMPORTANT DIAGNOSTIC TOOL.
21
•. SCLEROSIS (DUE TO INCREASE CELLULARITY AND BONE DEPOSITION).
• SUBCHONDRAL CYSTS (DUE TO SYNOVIAL FLUID INTRUSION INTO. THE BONE).
• OSTEOPHYTE. (DUE TO REVASCULARIZATION OF REMAINING CARTILAGE AND CAPSULAR. TRACTION).
• B O NY COLLAPSE (DUE TO C O M PR E S S I O N OF W EAKENED BONE).
• LO O S E B OD I E S (DUE TO FRAGMENTATION OF OSTEOCHONDRAL SURFACE).
• DEFORMITY AND MALALIGNMENT. (DUE TO DESTRUCTION OF CAPSULES AND. LIGAMENTS).

24 Other Investigations
• Arthroscopic examination:
This allows direct inspection and visualization of the damaged joint surfaces.
• But arthroscopy alone for diagnostic purposes is rarely used.
•Synovial fluid analysis shows non-inflammatory picture.

• Bone scan , MRI and CT scan also helps to diagnose,
subchondral cysts, osteophytes, etc.
LABORATORY INVESTIGATIONS ARE USUALLY WITHIN NORMAL

LIMITS.
 _SEROLOGICAL TESTS AND ESR TO RULE OUT RHEUMATOID
ARTHRITIS*
 _ SERUM URIC ACID TO RULE OUT GOUT *
25
Treatment
27 Aims of Treatment of OA Knee
It can be best illustrated by 4 R’s:

•Relieve pain.
•Restore function.
•Reduce disability if any
•Rehabilitation.
28 Conservative Methods
 This Forms The Mainstay Of Management In Osteoarthritis Of The Knee.

 About 50 Percent Of Patients Respond To Conservative Treatment, Which
Consists Of The Following Measures.
Management
• Weight loss
– Nutrition referral
 Self education—Educating the patient and his relatives measures about the disease
• Exercise Program (improves cartilage nutrition, muscle strength and prevents

progression of OA and deformity)
– Physiotherapy
– Quadriceps strengthening
– ROM exercises
– Low impact activities e.g. swimming, biking
– Avoid high stress activities (eg- jumping, running etc)
Mechanical aids
29
• They reduce the load on the knee joint

and provides support to the weak
knees.
• Ambulatory assist devices

– Cane
– Walker
• Insoles and knee braces

Pharmacologic Drugs
39
•Nonopioid analgesics – E.g. Acetaminophen:
•NSAIDs: If patients fail to respond to paracetamol or other oral or topical

analgesics, then the use of an NSAID is indicated.
• Opioid analgesics: These can be tried if patients fail to

respond to paracetamol and NSAIDs
• Chondroprotective agents Glucosamine/Chondroitin/Collagen

polypeptide/Diacerin/Rosehip Powder (help in cartilage repair)
• Anti-Osteoporotic treatment( Bisphosphonates, Calcium, Vit D3)

• Anti- Oxidants ( Vit A, C, E, Se, Mn, Zn)
• Intraarticular injections
– Glucocorticoids - Hyaluronans. - PRP
• Intra-articular steroids:
o This is indicated if there is effusion and there are signs of inflammation
40
o The basic intra-articular steroid injections are designed to provide 2 to 6 weeks of pain
relief for patients with knee osteoarthritis
o Such steroids are used to decrease the inflammatory reaction associated with
osteoarthritis
 contraindicated in patients with:
• bacteremia,
• Sepsis
• periarticular or intra-articular infections
(eg, septic arthritis, periarticular cellulitis,
osteomyelitis)
• significant skin breakdown at the target site
• known hypersensitivity to the steroid injection
• intraarticular or osteochondral fracture at the target site
• severe joint destruction
• joint prosthesis, or uncontrolled coagulopathy.
• Intra-articular Hyaluronans./ PRP
43
INDICATIONS
 •Failed conservative treatment
 •If there are major risk factors for surgery
 •Failed intra-articular steroid injections
 •Advanced osteoarthritis.
 FUNCTION :
 helps in joint lubrication
 buffers load transmission
 imparts anti-inflammatory properties
to synovial fluid.
 reduction in pain, stiffness, and improved
function.
46 Surgery
Indications for surgery
•Pain refractory to conservative measures.
•History of frequent locking episodes.
•Hemarthrosis due to loose bodies or osteochondral fractures.
•Deformity, usually genu varum.
•Joint instability.
•Progressive limitation of knee motion.
1_ ARTHROSCOPY
47
• Excision of osteophytes is rarely done

alone.
• Excision of loose bodies, meniscectomy,

synovectomy, and reconstruction or joint
debridement are best done by arthroscopy.
2- OSTEOCHONDRAL AUTOLOGOUS TRANSFER
SURGERY (OATS)
• a surgical procedure to treat isolated cartilage defects which are usually no more than 10 to
20mm in size.
• The procedure involves transfer of cartilage plugs taken from non-weight bearing areas of
the joint and transferring them into the damaged area of the joint.
3- Bone marrow aspirate concentrate
4- MENISCAL TRANSPLANTATION
5- PROXIMAL TIBIAL OSTEOTOMY:
5- PROXIMAL TIBIAL OSTEOTOMY
• 5- PROXIMAL TIBIAL OSTEOTOMY:
 osteotomy changes the line of weightbearing and correct a bowlegged alignment that is putting too much
stress on the inner (medial) compartment of the knee.
Indicated for:
 unicompartmental osteoarthritis of knee with pain

 correct varus (less than 15°) or
 valgus deformity (less than 12°).
 Age < 60yo
TYPES :
- OPENING MEDIAL OSTEOTOMY
- CLOSING LATERAL OSEOTOMY
6- unicompartmental knee replacement
• Unicompartmental knee arthroplasty (UKA): This is again regaining its popularity over
tibial osteotomy in treating unicompartmental OA, as it helps in early postoperative
rehabilitation , range of movement and Faster recovery
7- TOTAL KNEE REPLACEMENT
• Total knee arthroplasty: This is indicated when both the compartments of the knee joint are destroyed or if valgus or varus
deformity is more than 15°.
– It is also indicated in failed conservative treatment ,Pain during rest is the strongest indication and Diffuse arthritis
8- ARTHRODESIS

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KNEE OSTEOARTHRITIS : AN OVERVIEW

Dr / AHMED SAFWAT MOHAMED KASEM

• More common than secondary OA

• More than 50 percent have bilateral OA knee.

•Valgus And Varus Deformities Of The Knee.

• Mechanical: increases with use of the joint

• Rest pain later on in 50%

• Night pain in 30% later on

– Coarse crepitus: palpate/hear (due to flaked cartilage & eburnated

– Reduced ROM: capsular thickening and bony changes in joint,ms. Spasm

o Shape and ﬁt of articular surfaces

o Adhesive property of synovial ﬂuid

o Integrity of capsule and ligaments

o Muscle tone and power

o Neurological control of balance

 Fibrillation due to loss of water of the weight

 This puts enormous pressure on the

 New bone formation takes place and results in osteophyte formation

1.Knee Pain For Most Days Of Prior Month.

2.Crepitus On Active Joint Motion.

4.Age Equal To More Than 38 Years.

5.Bony Enlargement Of The Knee On Examination.

•. SCLEROSIS (DUE TO INCREASE CELLULARITY AND BONE DEPOSITION).

• SUBCHONDRAL CYSTS (DUE TO SYNOVIAL FLUID INTRUSION INTO. THE BONE).

• OSTEOPHYTE. (DUE TO REVASCULARIZATION OF REMAINING CARTILAGE AND CAPSULAR. TRACTION).

• B O NY COLLAPSE (DUE TO C O M PR E S S I O N OF W EAKENED BONE).

• LO O S E B OD I E S (DUE TO FRAGMENTATION OF OSTEOCHONDRAL SURFACE).

• DEFORMITY AND MALALIGNMENT. (DUE TO DESTRUCTION OF CAPSULES AND. LIGAMENTS).

•Synovial fluid analysis shows non-inflammatory picture.

LABORATORY INVESTIGATIONS ARE USUALLY WITHIN NORMAL

It can be best illustrated by 4 R’s:

 This Forms The Mainstay Of Management In Osteoarthritis Of The Knee.

• Exercise Program (improves cartilage nutrition, muscle strength and prevents

• They reduce the load on the knee joint

• Ambulatory assist devices

• Insoles and knee braces

•Nonopioid analgesics – E.g. Acetaminophen:

•NSAIDs: If patients fail to respond to paracetamol or other oral or topical

• Opioid analgesics: These can be tried if patients fail to

• Chondroprotective agents Glucosamine/Chondroitin/Collagen

• Anti-Osteoporotic treatment( Bisphosphonates, Calcium, Vit D3)

 contraindicated in patients with:

• Excision of osteophytes is rarely done

• Excision of loose bodies, meniscectomy,

 unicompartmental osteoarthritis of knee with pain

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