osteoarthritis of the knee - fisiokinesiterapia · • b genu varus (bowlegged) • b mild medial...

Osteoarthritis Osteoarthritis of of

The KneeThe Knee

Case PresentationCase Presentation

G.D. is a 48 G.D. is a 48 yoyo male chef and male chef and restauranteurrestauranteur

who presents to the UCSF Sports Medicine Clinic who presents to the UCSF Sports Medicine Clinic

c/o 8c/o 8--10 yrs of B knee pain. He is a devout 10 yrs of B knee pain. He is a devout

outdoorsman whose active lifestyle is severely outdoorsman whose active lifestyle is severely

compromised by his knee pain.compromised by his knee pain.

Case PresentationCase PresentationHistory:History:

••Site/Severity:Site/Severity:••Onset:Onset:••Character:Character:••Radiation:Radiation:••Alleviation:Alleviation:••Time:Time:••Exacerbation:Exacerbation:••SxSx associated:associated:

Case PresentationCase PresentationHistory:History:

••Site/Severity: Site/Severity: medial knee L > R, 8/10 painmedial knee L > R, 8/10 pain••Onset: Onset: gradual, no acute traumagradual, no acute trauma••Character: Character: ache, joint soreness ache, joint soreness ••Radiation: Radiation: nonenone••Alleviation: Alleviation: rest, aspirinrest, aspirin••Time: Time: 88--10 yrs, lasts 1010 yrs, lasts 10--15 min15 min••Exacerbation: Exacerbation: walking walking ½½ mile, inclinesmile, inclines••SxSx associated: associated: occocc. swelling, no instability. swelling, no instability

Case PresentationCase PresentationHistory ContinuedHistory Continued……....

••Unknown L knee injury 20 yrs agoUnknown L knee injury 20 yrs ago

••L partial L partial meniscectomymeniscectomy 5 yrs ago5 yrs ago

••Hikes 8 hrs/wkHikes 8 hrs/wk

••Yoga 6 hrs/wkYoga 6 hrs/wk

••Bikes 5 hrs/wkBikes 5 hrs/wk

••Received B steroid injections w/o reliefReceived B steroid injections w/o relief

Case PresentationCase PresentationPhysical ExamPhysical Exam•• 55’’77””, 165 lbs, BMI 25.8, 165 lbs, BMI 25.8•• + mild medial joint line tenderness on L+ mild medial joint line tenderness on L•• ROM of knees: L 0ROM of knees: L 0--130130°°, R 0, R 0--140140°°•• LachmannLachmann’’s/valgus/varuss/valgus/varus stress test stress test negneg BB•• Patellar mobility w/in normal limitsPatellar mobility w/in normal limits•• GenuGenu varusvarus (bowlegged) alignment B(bowlegged) alignment B•• Minimally Minimally antalgicantalgic gaitgait

Case PresentationCase Presentation

Case PresentationCase PresentationAssessmentAssessment•• s/ps/p L meniscus injuryL meniscus injury•• B B genugenu varusvarus (bowlegged)(bowlegged)•• B mild medial compartment OA, greater on LB mild medial compartment OA, greater on L

ManagementManagement•• Use G2 Use G2 unloaderunloader brace L knee w/ exercisebrace L knee w/ exercise•• 11stst of 3 rounds of of 3 rounds of SynviscSynvisc injections B knee jointsinjections B knee joints

Case PresentationCase PresentationFollowFollow--up: 1 week laterup: 1 week later•• Swelling L knee x 3 days after 1Swelling L knee x 3 days after 1stst injection injection •• 6/10 pain6/10 pain•• 22ndnd round of round of SynviscSynvisc injections B kneesinjections B knees

FollowFollow--up: 2 weeks laterup: 2 weeks later•• Conducted exercise routine w/o swellingConducted exercise routine w/o swelling•• 2/10 pain2/10 pain•• 33rdrd round of round of SynviscSynvisc injections B kneeinjections B knee•• RTC 6 monthsRTC 6 months

Osteoarthritis of The KneeOsteoarthritis of The KneeI.I. Overview Overview

Epidemiology Epidemiology DefinitionDefinitionRisk FactorsRisk Factors

II.II. Clinical Approach to Knee Pain Clinical Approach to Knee Pain III.III. Differential Diagnosis Differential Diagnosis IV.IV. Diagnosis of Knee OADiagnosis of Knee OAV.V. ManagementManagement

LifestyleLifestyleMedical Medical SurgicalSurgical

Overview: EpidemiologyOverview: Epidemiology

•• Knee OA most common cause of disability in adultsKnee OA most common cause of disability in adults

•• Decreased work productivity, frequent sick days Decreased work productivity, frequent sick days

•• Highest medical expenses of all arthritis conditionsHighest medical expenses of all arthritis conditions

•• Symptomatic Knee OASymptomatic Knee OA

–– More than 10 million Americans More than 10 million Americans 11

–– More than 11% of persons > 64yo More than 11% of persons > 64yo 22

Overview: DefinitionOverview: DefinitionArthritis vs. Arthritis vs. ArthrosisArthrosis

Gradual loss of Gradual loss of articulararticular cartilage in the knee jointcartilage in the knee joint•• 3 articulations:3 articulations:

1)1) Lateral Lateral condylescondyles of the femur and tibiaof the femur and tibia2)2) Medial Medial condylescondyles of the femur and tibiaof the femur and tibia3)3) PatellofemoralPatellofemoral jointjoint

Damage caused by a complex interplay of joint Damage caused by a complex interplay of joint integrity, biochemical processes, genetics, and integrity, biochemical processes, genetics, and mechanical forcesmechanical forces

Anatomy of The KneeAnatomy of The Knee

Overview: Risk FactorsOverview: Risk Factors•• Age Age 33

•• FemaleFemale

•• ObesityObesity

•• Previous knee injuryPrevious knee injury

•• Lower extremity Lower extremity malalignmentmalalignment

•• Repetitive knee bendingRepetitive knee bending

•• High impact activitiesHigh impact activities

•• Muscle weakness Muscle weakness 44


EpidemiologyEpidemiologyDefinitionDefinitionRisk FactorsRisk Factors

II.II. Clinical Approach to Knee Pain Clinical Approach to Knee Pain III.III. Differential DiagnosisDifferential DiagnosisIV.IV. Making The DiagnosisMaking The DiagnosisV.V. ManagementManagement


Clinical Approach to Knee PainClinical Approach to Knee Pain““Hey Doc, my kneeHey Doc, my knee’’s been hurting!s been hurting!””

HistoryHistory

•• SOCRATES pain questionsSOCRATES pain questions

•• Inflammatory Inflammatory sxsx e.g. fever, hot jointe.g. fever, hot joint

•• History of trauma or surgeryHistory of trauma or surgery

•• InstabilityInstability

•• Functional lossFunctional loss

•• Prior treatmentPrior treatment

Clinical Approach to Knee PainClinical Approach to Knee PainPhysical ExamPhysical Exam

•• Vitals, BMIVitals, BMI

•• Palpation: isolate tenderness, effusion, Palpation: isolate tenderness, effusion, crepituscrepitus

•• ROM: measure degree of flexionROM: measure degree of flexion

•• Stability: ligaments, menisciStability: ligaments, menisci

•• Alignment: Alignment: genugenu varusvarus or or valgusvalgus

•• Function: gait, duck waddleFunction: gait, duck waddle

Clinical Approach to Knee PainClinical Approach to Knee Pain

VarusVarus Test (LCL)Test (LCL)ValgusValgus Test (MCL)Test (MCL)

McMurray ManeuverMcMurray Maneuver(menisci)(menisci)

LachmanLachman Test (ACL)Test (ACL)

Duck Waddle Duck Waddle (stability)(stability)

Clinical Approach to Knee PainClinical Approach to Knee PainTestsTests

•• CBC, ESR, RFCBC, ESR, RF

•• ArthrocentesisArthrocentesis

•• XX--rays (3 views)rays (3 views)–– WeightWeight--bearing AP bearing AP –– LateralLateral–– Tangential Patellar (Sunrise)Tangential Patellar (Sunrise)

•• MRIMRI



II.II. Clinical Approach to Knee Pain Clinical Approach to Knee Pain III.III. Differential DiagnosisDifferential DiagnosisIV.IV. Diagnosis of Knee OADiagnosis of Knee OAV.V. Management Management


Differential Diagnosis of Knee PainDifferential Diagnosis of Knee PainMedial PainMedial Pain•• OAOA•• MCLMCL•• MeniscusMeniscus•• BursitisBursitis

Diffuse PainDiffuse Pain•• OAOA•• Infectious arthritisInfectious arthritis•• Gout, Gout, pseudogoutpseudogout•• RARA

Lateral PainLateral Pain•• OAOA•• LCLLCL•• MeniscusMeniscus•• IliotibialIliotibial band syndromeband syndrome

Anterior PainAnterior Pain•• OAOA•• PatellofemoralPatellofemoral syndromesyndrome•• PrepatellerPrepateller bursitisbursitis•• Quadriceps mechanismQuadriceps mechanism

Diagnosis of Knee OADiagnosis of Knee OAClassic Clinical CriteriaClassic Clinical Criteria

–– established by ACR, 1981established by ACR, 1981–– sensitivity 95%, specificity 69%sensitivity 95%, specificity 69%

knee painknee pain plus at least 3 of 6 characteristics:plus at least 3 of 6 characteristics:•• > 50 > 50 yoyo•• Morning stiffness < 30 minMorning stiffness < 30 min•• CrepitusCrepitus•• Bony tendernessBony tenderness•• Bony enlargementBony enlargement•• No palpable warmth No palpable warmth 55

Diagnosis of Knee OADiagnosis of Knee OAClassification TreeClassification Tree•• Clinical symptomsClinical symptoms•• SynovialSynovial fluidfluid

1.1. WBC<2000/mmWBC<2000/mm33

2.2. Clear colorClear color3.3. High ViscosityHigh Viscosity

•• XX--raysrays1.1. OsteophytesOsteophytes2.2. Loss of joint spaceLoss of joint space3.3. SubchondralSubchondral sclerosissclerosis4.4. SubchondralSubchondral cystscysts

Confirmed by arthroscopyConfirmed by arthroscopy(gold standard) (gold standard) 66

No OANo OA

Sensitivity 94 %; Specificity 88 %

Diagnosis of Knee OADiagnosis of Knee OA

Management: LifestyleManagement: Lifestyle•• Weight lossWeight loss

–– Nutrition referralNutrition referral•• Exercise ProgramExercise Program

–– PT referral PT referral –– Quadriceps strengthening Quadriceps strengthening –– ROM exercisesROM exercises–– Low impact activities e.g. swimming, biking Low impact activities e.g. swimming, biking 77

•• Ambulatory assist devicesAmbulatory assist devices–– CaneCane–– Walker Walker

•• InsolesInsoles•• UnloaderUnloader knee bracesknee braces

Management: LifestyleManagement: LifestyleVarusVarus (bowlegged) (bowlegged) vsvs ValgusValgus (knock(knock--kneed)kneed)

G2 G2 UnloaderUnloader BraceBrace

Management: MedicalManagement: Medical

•• Glucosamine/ChondroitinGlucosamine/Chondroitin•• AcetaminophenAcetaminophen•• NSAIDsNSAIDs•• CoxCox--2 inhibitors2 inhibitors•• OpioidsOpioids•• IntraarticularIntraarticular injectionsinjections

–– GlucocorticoidsGlucocorticoids–– HyaluronansHyaluronans

Management: MedicalManagement: Medical

•• Glucosamine/ChondroitinGlucosamine/Chondroitin–– 1500 mg/1200 mg daily ($401500 mg/1200 mg daily ($40--50/month)50/month)–– GlucosamineGlucosamine: building block for : building block for glycosaminoglycansglycosaminoglycans–– ChondroitinChondroitin: : glycosaminoglycanglycosaminoglycan in in articulararticular cartilagecartilage–– GAIT study, NEJM, Feb 23, 2006GAIT study, NEJM, Feb 23, 2006

•• MulticenterMulticenter, double blind, placebo, double blind, placebo--controlled, 24 wks, N=1583controlled, 24 wks, N=1583•• Symptomatic mild or moderateSymptomatic mild or moderate--severe knee OAsevere knee OA•• Infrequent mild side effects e.g. bloatingInfrequent mild side effects e.g. bloating•• For mild OA, not better than placeboFor mild OA, not better than placebo•• For moderateFor moderate--severe OA, combination showed benefit severe OA, combination showed benefit 88

–– Patient satisfactionPatient satisfaction

Management: MedicalManagement: Medical•• AcetaminophenAcetaminophen

–– Indication: mildIndication: mild--moderate painmoderate pain–– 1000 mg Q6h PRN1000 mg Q6h PRN–– Better than placebo but less efficacious than Better than placebo but less efficacious than NSAIDsNSAIDs 99

–– Caution in advanced hepatic diseaseCaution in advanced hepatic disease

•• NSAIDsNSAIDs–– Indication: moderateIndication: moderate--severe pain, failed acetaminophensevere pain, failed acetaminophen–– GI/renal/hepatic toxicity, fluid retentionGI/renal/hepatic toxicity, fluid retention–– If risk of GIB, use antiIf risk of GIB, use anti--ulcer agents concurrentlyulcer agents concurrently–– Agents have highly variable efficacy and toxicityAgents have highly variable efficacy and toxicity

Management: MedicalManagement: Medical•• NSAIDsNSAIDs

1010

Management: MedicalManagement: Medical•• CoxCox--2 inhibitors2 inhibitors

–– Indication: modIndication: mod--severe pain, failed NSAID, risk of GIBsevere pain, failed NSAID, risk of GIB–– OA pain relief similar to OA pain relief similar to NSAIDsNSAIDs–– Fewer GI events e.g. symptomatic ulcers, GIBFewer GI events e.g. symptomatic ulcers, GIB–– CelecoxibCelecoxib 200 mg daily200 mg daily–– GI/renal toxicity, fluid retentionGI/renal toxicity, fluid retention–– Increased risk of CV events? Increased risk of CV events?

•• APC Trial: 700 pts each assigned to placebo, 200 BID, 400 BIDAPC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID–– Increased risk at higher doses Increased risk at higher doses 1111

•• CLASS Trial: 8,000 pts compared CLASS Trial: 8,000 pts compared CelecoxibCelecoxib vsvs IbuprofenIbuprofen–– Similar risk to Ibuprofen Similar risk to Ibuprofen 1212

Management: MedicalManagement: Medical•• OpioidOpioid AnalgesicsAnalgesics

–– Indication: Indication: •• ModerateModerate--severe painsevere pain•• Acute exacerbationsAcute exacerbations•• NSAIDs/CoxNSAIDs/Cox--2 inhibitors failed or contraindicated2 inhibitors failed or contraindicated

–– OxycodoneOxycodone synergistic w/ synergistic w/ NSAIDsNSAIDs 1313

–– TramadolTramadol/acetaminophen /acetaminophen vsvs codeine/acetaminophencodeine/acetaminophen•• Similar pain relief Similar pain relief 1414

–– Avoid longAvoid long--term useterm use–– Caution in elderlyCaution in elderly

•• Confusion, sedation, constipationConfusion, sedation, constipation

Management: MedicalManagement: MedicalIntraarticularIntraarticular InjectionsInjections•• GlucocorticoidsGlucocorticoids

–– Indication: pain persists despite oral analgesicsIndication: pain persists despite oral analgesics

–– 40 mg/40 mg/mLmL triamcinolonetriamcinolone (kenalog(kenalog--40)40)

–– Solution: 5 Solution: 5 mLmL ((lidocainelidocaine 4 4 mLmL + + kenalogkenalog 1 1 mLmL))

–– Limit to Q3months, up to 2 yrsLimit to Q3months, up to 2 yrs

–– Effective for shortEffective for short--term pain relief < 12 wksterm pain relief < 12 wks

–– Acute flare w/in 48 hrs postAcute flare w/in 48 hrs post--injection injection 1515

Management: MedicalManagement: MedicalIntraarticularIntraarticular InjectionsInjections•• HyaluronansHyaluronans (e.g. (e.g. SynviscSynvisc))

–– Indication: pain persists despite other agentsIndication: pain persists despite other agents–– Synthetic joint fluidSynthetic joint fluid–– Pain relief similar to steroid injectionsPain relief similar to steroid injections–– 2 2 mLmL injection injection QwkQwk x 3, $560x 3, $560--760/series760/series–– Medicare reimburses 80%, Medicare reimburses 80%, MediMedi--cal $455.90cal $455.90–– 6060--70% patients respond, relief up to 6 months70% patients respond, relief up to 6 months–– Patient satisfaction Patient satisfaction 16, 1716, 17

Management: MedicalManagement: MedicalIntraarticularIntraarticular InjectionsInjections•• TechniqueTechnique

–– 22 gauge 1.5 inch needle22 gauge 1.5 inch needle–– Approach accuracy:Approach accuracy:

•• Lateral midLateral mid--patellar 93% patellar 93% 1818

–– Patient supinePatient supine–– Leg straight Leg straight –– Manipulate patella Manipulate patella –– Angle needle slightly Angle needle slightly posteriorlyposteriorly–– Inject after drop in resistance or fluid aspiratedInject after drop in resistance or fluid aspirated

Management: AlgorithmManagement: AlgorithmLifestyle ModificationsLifestyle Modifications Acetaminophen PRNAcetaminophen PRN

NSAIDsNSAIDs PRNPRN

OpioidsOpioids PRNPRN

CelecoxibCelecoxib

Steroid InjectionsSteroid Injections

HyaluronanHyaluronan InjectionsInjections

Surgical ReferralSurgical Referral

Management: SurgicalManagement: SurgicalWhen to ReferWhen to Refer•• Knee pain or functional status Knee pain or functional status

has failed to improve with has failed to improve with nonnon--operative managementoperative management

Types of ProceduresTypes of Procedures•• Arthroscopic IrrigationArthroscopic Irrigation•• Arthroscopic Arthroscopic DebridementDebridement•• High High TibialTibial OsteotomyOsteotomy•• Partial Knee Partial Knee ArthroplastyArthroplasty•• Total Knee Total Knee ArthroplastyArthroplasty

Management: SurgicalManagement: Surgical

High High TibialTibial OsteotomyOsteotomy

•• Indication:Indication:–– UnicompartmentalUnicompartmental arthritisarthritis–– GenuGenu varusvarus or or valgusvalgus

•• Realign mechanical axisRealign mechanical axis

•• Age < 60yoAge < 60yo

•• < 15 degrees deformity< 15 degrees deformity1919


Partial Knee Partial Knee ArthroplastyArthroplasty•• Indication:Indication:

–– UnicompartmentalUnicompartmental arthritisarthritis

•• Ligaments sparedLigaments spared

•• Increased ROMIncreased ROM

•• Faster recoveryFaster recovery

•• Prosthesis 10Prosthesis 10--yr survival: 84% yr survival: 84% 2020


Total Knee Total Knee ArthroplastyArthroplasty•• Indication:Indication:

–– Diffuse arthritisDiffuse arthritis–– Severe painSevere pain–– Functional impairmentFunctional impairment

•• Pain relief > functional gainPain relief > functional gain•• ACL sacrificedACL sacrificed•• PCL also may be sacrificedPCL also may be sacrificed•• Prosthesis 10Prosthesis 10--yr survival: 90% yr survival: 90% 2121

Clinical PearlsClinical Pearls•• Assess functional lossAssess functional loss

•• Knee exam: palpation, ROM, duck waddleKnee exam: palpation, ROM, duck waddle

•• Nutrition referralNutrition referral

•• Exercise program/PT referralExercise program/PT referral

•• OrthoticsOrthotics

•• Lateral midLateral mid--patellar or patellar or superolateralsuperolateral approachapproach•• Educate patients about Educate patients about glucosamine/chondroitinglucosamine/chondroitin, ,

CoxCox--2 inhibitors, injections2 inhibitors, injections

BibliographyBibliography1.1. Lawrence RC, Lawrence RC, HelmickHelmick CG, Arnett FC, et al. CG, Arnett FC, et al. ““Estimates of The Prevalence of Arthritis And Estimates of The Prevalence of Arthritis And Selected Musculoskeletal Disorders in The United States.Selected Musculoskeletal Disorders in The United States.”” Arthritis And Rheumatism Arthritis And Rheumatism 1998;43:7781998;43:778--799.799.2.2. FelsonFelson DT, Zhang Y. DT, Zhang Y. ““An Update on The Epidemiology of Knee And Hip Osteoarthritis witAn Update on The Epidemiology of Knee And Hip Osteoarthritis with h A View to Prevention.A View to Prevention.”” Arthritis And Rheumatism 1998;41:1343Arthritis And Rheumatism 1998;41:1343--55.55.3. 3. Brandt, K. Brandt, K. ““Osteoarthritis: Clinical Patterns And Pathology. In: Textbook ofOsteoarthritis: Clinical Patterns And Pathology. In: Textbook of Rheumatology, Rheumatology, 5th edition.5th edition.”” Kelley WN, Harris Kelley WN, Harris JrJr ED, Ruddy S, Sledge CE (ED, Ruddy S, Sledge CE (EdsEds), W.B. Saunders, Philadelphia, ), W.B. Saunders, Philadelphia, 1997, p.1383.1997, p.1383.4.4. BuckwalterBuckwalter JA. JA. ““Osteoarthritis And Osteoarthritis And ArticularArticular Cartilage Use, Disuse, And Abuse: Cartilage Use, Disuse, And Abuse: Experimental Studies.Experimental Studies.”” Journal of Journal of RheumatologicalRheumatological SupplSuppl 1995; 43:13.1995; 43:13.5. 5. Altman R, Altman R, AschAsch E, Bloch D, et al. E, Bloch D, et al. ““Development of Criteria for The Classification And Development of Criteria for The Classification And Reporting of Osteoarthritis, Classification of Osteoarthritis ofReporting of Osteoarthritis, Classification of Osteoarthritis of The Knee.The Knee.”” Arthritis And Arthritis And Rheumatism 1986; 29:1039. Rheumatism 1986; 29:1039. 6.6. KlashmanKlashman D, D, SeegerSeeger L, Singh R, et al. L, Singh R, et al. ““Validation of Validation of NonradiographicNonradiographic ACR Osteoarthritis ACR Osteoarthritis Criteria Using ACR Arthroscopy Damage Index as Comparison StandaCriteria Using ACR Arthroscopy Damage Index as Comparison Standard.rd.”” Arthritis And Arthritis And Rheumatism 1996; 39:172. Rheumatism 1996; 39:172. 7.7. Thomas KS, Muir KR, Doherty M, Jones AC, OThomas KS, Muir KR, Doherty M, Jones AC, O’’Reilly SC, Reilly SC, BasseyBassey EJ. EJ. ““Home Based Exercise Home Based Exercise ProgrammeProgramme for Knee Pain And Knee Osteoarthritis: for Knee Pain And Knee Osteoarthritis: RandomisedRandomised Controlled Trial.Controlled Trial.”” British British Medical Journal 2002. Oct 5; 325(7367):752.Medical Journal 2002. Oct 5; 325(7367):752.8.8. Clegg DO, Clegg DO, RedaReda DJ, Harris CL, et al. DJ, Harris CL, et al. ““GluosamineGluosamine, , ChondroitinChondroitin Sulfate, and the Two in Sulfate, and the Two in Combination for Painful Knee Arthritis.Combination for Painful Knee Arthritis.”” NEJM 2006, Volume 354 No. 8:795NEJM 2006, Volume 354 No. 8:795--808.808.9.9. Zhang W, Jones A, Doherty M. Zhang W, Jones A, Doherty M. ““Does Does ParacetamolParacetamol (Acetaminophen) Reduce The Pain of (Acetaminophen) Reduce The Pain of Osteoarthritis? A MetaOsteoarthritis? A Meta--analysis of analysis of RandomisedRandomised Controlled Trials.Controlled Trials.”” Annals of The Rheumatic Annals of The Rheumatic Diseases 2004; 63:901. Diseases 2004; 63:901. 10.10. KalunianKalunian KC, KC, ConcoffConcoff AL, AL, BrionBrion PH. PH. ““Pharmacologic and Surgical Therapy of Pharmacologic and Surgical Therapy of OsteoarthritisOsteoarthritis”” in in UpToDateUpToDate 2006 [online journal]. 2006 [online journal]. VolVol 13.2, March, 2005.13.2, March, 2005.11.11. Solomon SD, McMurray JJ, Solomon SD, McMurray JJ, PfefferPfeffer MA, et al. MA, et al. ““Cardiovascular risk associated with Cardiovascular risk associated with celecoxibcelecoxibin a clinical trial for colorectal adenoma prevention.in a clinical trial for colorectal adenoma prevention.”” NEJM 2005; 352:1071.NEJM 2005; 352:1071.

BibliographyBibliography12.12. Silverstein FE, Silverstein FE, FaichFaich G, Goldstein JL, et al. G, Goldstein JL, et al. ““Gastrointestinal Toxicity with Gastrointestinal Toxicity with CelecoxibCelecoxib Vs. Vs. NonsteroidalNonsteroidal AntiAnti--inflammatory Drugs for Osteoarthritis And Rheumatoid Arthritis. inflammatory Drugs for Osteoarthritis And Rheumatoid Arthritis. The CLASS The CLASS Study: A Randomized Controlled Trial.Study: A Randomized Controlled Trial.”” JAMA 2000; 284:1247.JAMA 2000; 284:1247.13.13. Caldwell JR, Hale ME, Boyd RE, et al. Caldwell JR, Hale ME, Boyd RE, et al. ““Treatment of Osteoarthritis Pain with Controlled Treatment of Osteoarthritis Pain with Controlled Release Release OxycodoneOxycodone or Fixed Combination or Fixed Combination OxycodoneOxycodone Plus Acetaminophen Added to Plus Acetaminophen Added to NonsteroidalNonsteroidal AntiinflammatoryAntiinflammatory Drugs: A Double Blind, Randomized, Drugs: A Double Blind, Randomized, MulticenterMulticenter, Placebo , Placebo Controlled Trial.Controlled Trial.”” Journal of Rheumatology 1999; 26:862.Journal of Rheumatology 1999; 26:862.14.14. MullicanMullican WS, Lacy JR. WS, Lacy JR. ““TramadolTramadol/Acetaminophen Combination Tablets And /Acetaminophen Combination Tablets And Codeine/Acetaminophen Combination Capsules for The Management ofCodeine/Acetaminophen Combination Capsules for The Management of Chronic Pain: A Chronic Pain: A Comparative Trial.Comparative Trial.”” Clinical Therapeutics 2001; 23:1429.Clinical Therapeutics 2001; 23:1429.15.15. ArrollArroll B, GoodyearB, Goodyear--Smith F. Smith F. ““Corticosteroid Injections for Osteoarthritis of The Knee: MetaCorticosteroid Injections for Osteoarthritis of The Knee: Meta--analysis.analysis.”” British Medical Journal 2004; 328:869.British Medical Journal 2004; 328:869.16.16. Moreland LW, Arnold WJ, Moreland LW, Arnold WJ, SawaySaway A, et al. A, et al. ““Efficacy And Safety of IntraEfficacy And Safety of Intra--articulararticular HylanHylan GG--F F 20 (20 (SynviscSynvisc), A ), A ViscoelasticViscoelastic Derivative of Derivative of HyaluronanHyaluronan in Patients with Osteoarthritis of The in Patients with Osteoarthritis of The Knee.Knee.”” Arthritis Rheum 1993; 36:S165.Arthritis Rheum 1993; 36:S165.17.17. Lo GH, Lo GH, LaValleyLaValley M, M, McAlindonMcAlindon T, T, FelsonFelson DT. DT. ““IntraIntra--articulararticular HyaluronicHyaluronic Acid in Acid in Treatment of Knee Osteoarthritis: MetaTreatment of Knee Osteoarthritis: Meta--analysis.analysis.”” JAMA 2003; 290:3115.JAMA 2003; 290:3115.18.18. Jackson DW, Evans NA, Jackson DW, Evans NA, ThoomasThoomas BM, BM, ““Accuracy of Needle Placement Into The IntraAccuracy of Needle Placement Into The Intra--articulararticular Space of The Knee.Space of The Knee.”” The Journal of Bone and Joint Surgery (American) 2002; 84:1522The Journal of Bone and Joint Surgery (American) 2002; 84:1522--1527.1527.19. 19. KalunianKalunian KC, KC, ConcoffConcoff AL, AL, BrionBrion PH. PH. ““Pharmacologic And Surgical Therapy of Pharmacologic And Surgical Therapy of OsteoarthritisOsteoarthritis”” in in UpToDateUpToDate 2006 [online journal]. 2006 [online journal]. VolVol 13.2, March, 2005.13.2, March, 2005.20. 20. Ibid.Ibid.21.21. Ibid.Ibid.

osteoarthritis of the knee - fisiokinesiterapia · • b genu varus (bowlegged) • b mild medial...

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