dr (prof.) anil arora - global ortho osteoarthritis knee management dr... · dr (prof.) anil arora...
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Dr (Prof.) Anil AroraMS (Orth) DNB (Orth) Dip SIROT
FAPOA (Korea), FIGOF (Germany), FJOA (Japan)
Computer Navigated
Knee Replacement Surgeon
Hip and Knee Surgery Clinic
70, Hargobind Enclave
Commonwealth Fellow Joint Replacement
(Royal National Orthopaedic Hospital, London, UK)
Senior Knee and Hip Replacement Surgeon
Associate Director
Department of Orthopaedics and Joint Replacement
Max Superspeciality Hospital, Patparganj, Delhi (India)
E-mail : [email protected]
What is Osteoarthritis Knee ?
OA is NON - INFLAMMATORY joint disease
characterized by
Degeneration of articular cartilage
Hypertrophy of bone margins
Changes in synovial membrane
Normal
Cartilage
Cartilage
worn out
Primary Osteoarthritis : Most Common
• Thought to be result of aging
• Decreased ability of cartilage to repair
itself
• Ligaments and muscle supporting joint
weakened
Secondary Osteoarthritis
• Obesity
• Trauma
• Surgery
• Abnormal joints
• Gout
• Diabetes
• Hormone disorders
Symptoms
1. Pain at the start of activity that gets better “warms up
over time”
2. Progressive pain with activities
3. Loss of motion, muscle weakness
4. “Crunching” sensation in the knee
5. Over the time deformity can occur in the knee
Deformed Lower Limbs
Diagnosis
• Physical Examination
• X- Ray
• Blood Test to rule out other diseases
Diagnosis : Triad
Osteoarthritic knee
Decreased
joint space
OA – Management Principles
• Slow progression over many years - Cannot
be cured
• Treatment directed at symptoms and
slowing progress of the condition
• Goals:
• Decrease pain
• Maintain / Improve range of motion
• Maintain / Improve muscle strength
Treatment Options
1. Education
2. Activity modifications such as using a cane
3. Physiotherapy
4. Drugs
5. Injections
6. Braces
7. Surgery : Arthroscopy
High Tibial Osteotomy
TOTAL KNEE REPLACEMENT
Education
• About the Disease
• Weight loss (>5 kg) has significant short-
term and long-term reduction in symptom
Physiotherapy
Aims :
• to reduce pain and disability by
strengthening muscles,
• improve joint stability
• increasing the range of movement
• Physical modalities ( US / IFT / SWD )
Exercises
Medication
EULAR - The European League Against Rheumatism
SYSDOA
Symptomatic Slow Acting Drugs for OA
• Glucosamine Sulfate
• Chondroitin Sulfate
• Hyaluronic Acid
• Diacerin
Glucosamine
1. Important for maintaining the
• Elasticity
• Strength and
• Resilience of cartilage in joints
2. Enhances both the production of
hyaluronic acid and its anti-inflammatory
3. Helps to reduce damage to the joints
4. action
Stimulate production of cartilage components
and allow rebuilding of damaged cartilage.
1. Glucosamine can increase mucopolysaccharide and
collagen synthesis in fibroblast tissue.
2. Glucosamine also appears to activate core protein
synthesis in human chondrocytes
Med Hypotheses 1994; 42: 323–327
Int J Tissue React 1992; 14: 231–241
Increases thickness and
elasticity of cartilage
Improves ability to
absorb and distribute
compressive forces
chondrocyte
metabolismCollagen
Production
Proteoglycan
Production
Degradative enzymes
Elastase and hyaluronidase
J Biomech 2007;40(8): 1847–1854.
J Biomech 2009;42(3): 286–290.
Osteoarthritis Cartilage 2009;17(8): 1001–1008.
Reduced the IL-1β-induced
nuclear factor-kb (nf-κb)
translocation in chondrocytes 1
1. Basic Clin Pharmacol Toxicol. 2008 Jan;102(1):59-65
2. Osteoarthritis Cartilage. 1998 May;6 Suppl A:14-21.
decrease the phagocytosis 2
Decreases release of lysozyme 2
Chondroitin sulfate is absorbed orally
.The bioavailability of chondroitin sulfate ranges from
15% to 24% of the orally administered dose
Arzneimittelforschung. 1995;45:918-25.
Osteoarthritis Cartilage. 1998;6 Suppl A:14-21.
Drug used Es for Pain
Acetaminophen 0.21
NSAIDs 0.32
Topical NSAIDs 0.41
IA Corticosteroid 0.72
Glucosamine sulphate 0.61
Chondroitin sulphate 0.52
Diacerine 0.22
Es = 0.2 = small effect
Es = 0.5 = moderate effect
Es = 0.8 = Large effect
The Glucosamine/chondroitin Arthritis Intervention Trial
Treatment appeared to be generally safe and well tolerated
over a 2-year period.
Glucosamine-1500mg/day
Chondroitin – 1200mg/day
Celecoxib -200mg/day
International Journal Of Pharmacy & Pharmaceutical
Sciences. October 2, 2013;5(Supp 4):647-650.
Lee YH, Woo JH, Choi SJ et al. 2009
Effect of glucosamine or chondroitin sulfate on the
osteoarthritis progression: a meta-analysis
Rheumatol Int 30(3): 357–363.
Meta-analysis included 3 RCT’s,
each over a 2-year period
1. A small significant effect in reducing the rate of
decline in minimum joint space width
2. 0.13 mm over 2 years (95% confidence interval (ci),
0.06 to 0.19; p = 0.0002)
GLUCOSAMINE
1200 to 1500 mg / day in single of divided doses
CHONDROITIN
800 to 1200 mg/day is shown efficacious in many studies.
Pharmacovigilance Risk assessment Committee
Injections
• Intra articular steroids
• Hyaluronic Acid (HA) and hyaluronan
preparations(eg, Synvisc)
Viscosupplement
Viscosupplement more beneficial in early
stage of Osteoarthritis Knee
Depomedrol
Arthroscopy
• Arthroscopy include debridement and
lavage/irrigation
Mechanical Axis Pass
from centre of Knee
Mechanical Axis Pass
from Medial side of Knee
Braces
High Tibial Osteotomy
What is Total Knee Replacement
Replacing damaged surface of the bone is
called Total knee Replacement.
Thank you