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Mark G. Kowall, M.D., M.B.A. Orthopedic Specialty Associates Templeton , California. What makes up the Knee Joint???. Bone. Synovial membrane. Joint space filled with Synovial Fluid “the oil”. Articular cartilage “the tread”. Knee Joint. What causes the Snap, Crackle and Pop??. - PowerPoint PPT Presentation
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Mark G. Kowall, M.D., M.B.A.
Orthopedic Specialty Associates
Templeton, California
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Bone
Joint space filled with Synovial Fluid “the oil” Articular
cartilage“the tread”
Synovial membrane
What makes up the Knee Joint???
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Knee Joint
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What causes the Snap, Crackle and Pop??
Crackling (“Crepitus”) crunchy or grinding sound or sensation
Irregularities or unevenness of the coating cartilage (tread)
Usually comes from the Kneecap compartment
Noticeable with squatting and stairs
Without pain or swelling no concern
Accompanied by pain or swelling can be early “wear and tear” (osteoarthritis)
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What causes the Snap, Crackle and Pop??
Popping or snapping (“locking”) mechanical source
(i.e.) meniscus tear, ligament strain.
Usually associated with significant pain and associated loss of motion.
Usually needs to be evaluated
Giving Out (“Instability”) either related to postop or injury-related muscle (quadriceps) weakness or Ligament (ACL) disruption.
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Most Common Source of “S-C-P”Osteoarthritis
Aging (“Tread Wear”)
Muscle and Ligament Weakness
Decreased ability of cartilage to repair itself
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ObesityJoint Injury
Surgery
Congenital abnormal joints
Gout
Contributors to development of Osteoarthritis
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Healthy Knee
Osteoarthritic Knee
“tread wear”
Cartilage
“Joint Wear”=
“Tread Wear”
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The Knee
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Inside the Knee Joint
Healthy Knee Advanced Arthritis
CartilageTibia
CartilageFemur
meniscus
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How is Snap, Crackle and Pop Diagnosed??
History (accident, overuse, location, pain, swelling)
Physical Exam
Blood Tests (rarely done)
X-rays (weight bearing, kneecap view)
MRI (on occasion, if above inconclusive)
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Knee X-Ray
Osteoarthritic kneeHealthy knee
“Bald Tire”
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Knee MRI
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Self-Treatment No pain or swelling Observation Gradual or acute onset of pain or swelling (without significant
trauma or loss of motion)
Activity modification (rest), Ice, NSAID’s
Reintroduction of “knee friendly” exercise (importance
of strengthening after injury)
If pain and/or swelling persists Evaluation
Significant trauma and/or loss of motion Evaluation
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Treatment varies with severity
“Ladder Approach to Treatment”
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1st Rung of LadderMedication
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Medication- NSAIDs
NSAIDs are nonsteroidal anti-inflammatory drugs
Ibuprofen (Motrin, Advil)
Naproxen (Aleve)
Prescription Meds
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Vitamins & Nutritional Supplements
Glucosamine / Chondroitin Sulfate
Some positive results for moderate to advance arthritisRecently, the American Academy of Orthopedic Surgeonsrecommended against its use for patients with
osteoarthritis of the knee (Dec, 2008)
Fish Oil (Omega-3 Fatty Acids)Diet rich in Fruits and Vegetables
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Effect of Weight Loss“Take home point”
For each pound of weight loss 4 pound reduction in the forces hitting the knee while walking.
“Less weight, Less load on the knee”
Arthritis and Rheumatism, July 2005
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Braces Sleeves neoprene
improve balance?
local warmth
control swelling
high compliance
inexpensive
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Braces Unloaders “unload” or take pressure of the arthritic side of knee
decrease pain
improve walking tolerance
poor compliance
expensive
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Knee Exercises
“Friendly”
vs.
“Unfriendly”
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Knee Exercises
Lower impact (cycling, swimming)
Isometric (muscle contraction without joint motion)
Terminal Extension
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Limiting the amount of joint flexionLimiting “Joint Reactive Force”
Keep Flexion to less than 90 degrees
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Knee “Friendly”
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Knee “Friendly”
Seat HighAqua Jogging
Kick Board
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Knee “Un-Friendly”
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Next Rung of the Ladder
InjectionsCortisone (steroid)
Visco-Supplementation (Synvisc One,Orthovisc, Hyalgan, Supartz, Euflexxa)
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When all else fails
to improve pain………..
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Surgery“Top of the Ladder”
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Surgical Options-Arthroscopy
Mini incisions
Outpatient
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Arthroscopy – Debridement(Shaving of articular Cartilage (“tread”)
A means of “smoothing” the coating cartilage
In conjunction to treating meniscus tears
Not designed for treatment of arthritis alone
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Arthroscopy – Microfracture
small awl used to make holes in bone
promote re-growth of cartilage
Defect in “Tread”Small holes in bone will bleed
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Arthroscopy – “OATS” Procedure
Transfer of healthy “tread” to “bald” area
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Arthroscopy- Meniscus Repair vs. Menisectomy
Repair
Resection
Tear
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Surgical Options: Joint Replacement
Total Knee Replacement
Uni-compartment Knee Replacement
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Total Knee Replacement
Side view
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New Technologies
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Laboratory
Recombinant Gene Therapy (synthesize the growth factors which produce new cartilage)
Specific Growth Factors promote cartilage (tread) maintenance and repair
May limit the progression of arthritis
Platelet Rich Plasma (PRP)
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Recent discovery of a natural occurring molecule in the body that can counter the progression of arthritis
Genes and Development
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Consumer Beware
Bozic K J, et al. Impact of direct to consumer advertising on physician attitudes and behavior in orthopedic surgery American Academy of Orthopedic Surgeons
**Poll of 737 hip and knee surgeons
**Over 75% of surgeons reported that direct-to-consumer (DTC) advertising
negatively impacted their practice and the relationship with patients. **Ads presented a skewed view of procedures and devices by
exaggerating the benefits and down playing risks.
**(Patients) were not more educated about the risks and benefits, not more educated about the alternatives, not more educated about the costs and that they were less open to alternatives after reading or viewing direct-to-consumer advertisements
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Closing RecommendationListen to your Knee!!!
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www.ShoulderKneeSpecialists.com Surgical Procedure Animations
Health Library
Important Links
Resources
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Questions????