Upload
drabdulsuhail
View
187
Download
3
Embed Size (px)
Citation preview
Non Arthroplasty Management of Osteoarthritis Knee
Dr.Abdul G.SuhailMBBS, D.Ortho, MS(Ortho), Fellowship(Arthroplasty)
•Physical Modalities•Braces•Medications• Intra articular injections•Surgical Options
Weight Reduction
• TENS • Acupuncture • Heat/Ice thermotherapy• Quadriceps strengthening
Orthotics
Walking Stick
Lateral Wedge Insoles
• Medial or lateral unloading
Off loader Braces
Pharmacological
• Paracetamol, max 3-4 gm/day analgesic of choice 1st line and long term
• Topical NSAIDs• NSAIDs— For Pts not responding to
Pmol and for exacerbations• Tramadol• Codeine • SYSADOA - No role Glusosamine SO4 Chondroitin SO4 Diacerin
Oral Therapy
•Steroids•Hyaluronic acid•PRP
Intra articular Injection
Intra-articular Corticosteroids
• Beneficial in KNEE
• Short-duration benefits: 2-4 weeks• Every 3 months ,not effective at 2
years
• Delayed effect (4 weeks)• Long duration (6 months)• 1-5 weekly injections
Not recommended J Bone Joint Surg Am, 2013 Oct
Intra-Articular Hyaluronic Acid (IAHA)“viscosupplement”
IAHA: Mechanism of Action
• Increased synovial fluid HA conc.• Increased cartilage
lubrication/elasticity• Chondrocyte proliferation• Decreased inflammatory mediators
Devine, Shaffer. Use of viscosupplementation for knee osteoarthritis: an update. Curr Sports Med Rep 2011
Platelet-Rich Plasma in Knee OA
• Kon et al 2010 and Filardo et al 2011 , series n=115• Three 5ml PRP; improved at 6 and 12 months
• Sampson et al 2010 series n=14• PRP at 0/4/8 wks; pain reduction out to 52 weeks in majority
• Wang-Saegusa et al 2011 series n=261• PRP at 0/2/4 wks; improved pain/fxn/QOL to 6 mos w/o AdvEfx
• Sanchez et al. 2008 case/cont• PGRF vs Hyaluronic acid (HA), weekly x3• At 5 weeks, 33% decrease pain w/ PRGF, 10% w/ HA
• Spakova et al 2012 case/cont, n=120• PRP vs HA, weekly x3; At 3 & 6 mo, PRP better WOMAC/VAS
• Kon & Mendelbaum et al 2011 case/cont n=150• LMW HA vs HMW-HA vs PRP at weekly x3• PRP better than HA at 6 mo• Age > 50 and severe OA: PRP = LMW-HA• Age<50 with cartilage lesions, and mild OA: PRP best
• Li & Zhang et al, 2011 RCT n=30• PRP vs HA at 0/3/6 weeks; PRP more effective at 6 mo
Arthroscopy
Arthroscopic Debridement ??
• “In a controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic débridement were no better than those after a placebo procedure”.
Moseley, RB et al., Arthroscopic Surgery for Osteoarthritis of the Knee?. NEJM 2002 359: 1169-1170
Kirkley A et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM Sep 2008;359:1097
Osteotomy
Dr. Mark Coventry of the Mayo Clinic who first described osteotomy for degenerative arthritis. The original paper published in 1965 continues to be clinically relevant.
Coventry, M. Osteotomy of the Upper Portion of the Tibia For Degenerative Arthritis of the knee: A PRELIMINARY REPORT. J. Bone and Joint Surgery 1965 47:984-990
HTO-Indications
• Active lifestyle • ≤ 60 yrs• Uni compartment disease • ≤ 10° Fixed flexion deformity• ≥ 90° flexion
Types of OsteotomyCoventry Closing Wedge 1960s
HTO
Disadvantages of Closing Wedge Osteotomy
• Removes bone from metaphysis• Requires fibular osteotomy• Peroneal neuropathy 15%• Lateral tibiofemoral instability 15%• Patella Baja• Increases difficulty of later TKA
Opening Wedge Osteotomy1990s
Noyes FR, Goebel SX, West J: Opening wedge tibial osteotomy: The 3-triangle method to correct axial alignment and tibial slope. Am J Sports Med 33:378-387, 2005.)
Advantages of Opening Wedge Osteotomy
• Adds bone to tibial metaphysis• No lateral knee instability• Rare peroneal neuropathy• Later TKA no more difficult than
usual
J Bone Joint Surg Am, 2013 Oct 16;95(20):1885-1886
AAOS 2013 Recommendations
Strongly Recommended• Strengthening• low-impact aerobic exercises• Regular physical activity • Topical or oral
NSAIDs (nonsteroidal anti-inflammatory drugs) or Tramadol
AAOS 2013 Recommendations
Moderately Recommended • Weight loss in patients with body
mass index > = 25 • Proximal tibial osteotomy for
medial compartment osteoarthritis
AAOS 2013 Recommendations
Cannot Recommend the Following (Strong Rating)
• Glucosamine and chondroitin• Viscosupplimentation- Hyaluronic
acid• Acupuncture• Arthroscopy with lavage or
debridement
AAOS 2013 Recommendations
Cannot Recommend (Moderate Rating)• Needle lavage• Lateral wedge insoles in patients
with medial compartment osteoarthritis
AAOS 2013 Recommendations
Inconclusive Evidence to Support for or Against
• Use of a (PRP)• medial compartment unloader brace• Arthroscopic partial meniscectomy in patients
with knee osteoarthritis and torn meniscus• Intraarticular corticosteroids
Differences between 2008 and 2013
Recommendations
• With viscosupplementation and injection of hyaluronic acid.
• In 2008 guidelines – rating:
inconclusive. • In 2013 with a "strong" rating
against based on new evidences.
Medial OA
Kinespring
When patient presents late Arthroplasty is the only option to improve quality of life.
Thank You