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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 arthritis

Recently, the American Academy of Orthopedic Surgeons

recommended 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

Injections

Cortisone (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

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Important Links

Resources

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Questions????