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