non-arthroplasty rx of arthritic knee

8/6/2019 Non-Arthroplasty Rx of Arthritic Knee

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Non-Arthroplasty

Rx of ArthriticKnee / Hip

Dr .ibrahim ali musa (R2)

October 3,2010


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CONTENTS

INTRODUCTION.

BASIC SC

IENC

E.

TYPES OF ARTHRITIS.

Non-Arthroplasty Rx of Arthritic

Knee/ Hip .


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INTRODUCTION


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Basic Science

CHARASTRESTICS:

smooth gristle

avascular, aneural, and alymphatic

average thickness is 1 mm to 5 mm.


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Basic Science

FUNCTIONS:

to provide a relatively frictionless,

highly lubricated surface

to distribute contact pressure tosubchondral trabecular bone


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Basic Science

STRUCTURE :

Extracellular matrix (95%)

Pericellular

Territorial

Interterritorial

.


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Basic Science

Constituents:a. Water (65-80%)

- more superficially

- nutrition and lubrication

- Shifts in and out

increases in osteoarthritis (90%)


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b. Collagen [10-20%]

Type II collagen [95%]

provides shearand tensile strength. Small amounts of types V, VI, IX, X,

and XI type IX collagen on the surface of the

fibril.

Collagen type XI is an adhesive holdingthe collagen lattice together

Collagen type X is associated withcalcification of cartilage

Collagen type VI increases significantlyin early OA.

organization and orientation areseverely disturbed in OA.


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c. Proteoglycans (10-15%)

provide compression strength produce the porous structure,

trap water

composed of glycosaminoglycans

-chondroitin sulfate

- keratin sulfate.

-CS/KS ratio is 10/1 at birth , 2/1 in

adults.

Changes with ageing and osteoarthritis:

chondroitin-4-sulfate decreases with age

keratin sulfate increases with age.

In OA :

loss of proteoglycan content and

composition [shorter chains , increased

chondroitin/keratin sulfate ratio].

unbound Proteoglycans..


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d. Chondrocytes (5% of wet

weight)

incr

produce collagen,

proteoglycans,proteins metalloproteinases

and TIMPs

Mesenchymal cells differentiate

into Chondroblasts, and later

trapped in lacunae to becomechondrocytes.

OA:loss of superficial

chondrocytes.

Collagenase activitydifferentiation of chondrocytes

MMP-13Collagen x

Calcification

of the matrixmatrix degradation products

fibronectin

collagen ll

IL1 and TNFa


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Hip biomechanics

Kinematics:

Flexion - 120 . Extension - 30.

Abduction 50. Adduction - 30.

External rotation 45 Internal rotation 45

Kinetics:

Joint reaction force (R) :

Twice during SLR.

3 times in single leg stance.

5 times in walking.

Upto 10 times while running.(R) = Body Weight + Abductor Force(R) = Body Weight + Abductor Force


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Knee biomechanics

Kinematics:

Extension - 10. Flexion 140 .

Functionally : full extension to 90 flexion .

Abduction Adduction 0 degrees . External rotation 45 Internal rotation 30

[at 90 degrees of flexion ].

Kinetics:

Knee joint surface loads :

3 times bw during level walking.

up to 4 times bw with stair walking .

loaded 50% more,due to the adduction

moment


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TYPES OF ARTHROSIS

1. Noninflammatory arthritides.

2. Inflammatory arthritides.

3. Infectious arthritides.

4. Hemorrhagic arthritides.


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Noninflammatory arthritides

Osteoarthritis

biochemical, Biomechanical failure.

Genetic predisposition .

primary or secondary .

Joint space narrowing

2. Subchondral sclerosis and cyst

formation

3. Osteophyte formation

Radiographic findingsMacroscopic findings

1. softening (chondromalacia),

fibrillation, and erosions.2. focal areas of ulceration with

exposure of sclerotic, eburnated

subchondral bone.

Histologic findings

1. surface erosion and irregularities.

2. replication and deterioration ofthe tidemark

3. fissuring,

4. eburnation of subchondral bone.


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Noninflammatory arthritides

Acute rheumatic fever

Neuropathic arthropathy

Ochronosis from

alkaptonuria

hypertrophic

osteoarthropathy

bracing

penicillin and salicylates+Symptomatic

Supportive

treatment of the underlying

condition


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Inflammatory arthritides

Rheumatoid Arthritis-Required diagnostic criteria

-cell-mediated immune response (T cell)

Radiographic characteristics

periarticular erosions

osteopenia

Protrusio acetabuli

Treatment

control synovitis and

pain

maintain joint function

and prevent

deformities

Therapeutic drugs

Physical therapy

Surgery

The pyramid approach

begins with NSAIDs

Slowly progress to antimalarials

remittent agents (methotrexate, sulfasalazine,

gold, and penicillamine)

steroids, cytotoxic drugs

and finally experimental drugs

disease-modifying antirheumatic drugs

(DMARDs)

methotrexate, azathioprine,

anakinra (an IL-1 inhibitor),

and other TNF- inhibitors, such as

infliximab and etanercept

Surgery

synovectomy

soft tissue realignments

various reconstructive procedures

TJA


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Inflammatory arthritides

SLE Drug therapy like RA

Polymyalgia rheumatica

JRA

Spondyloarthropathies

Relapsing polychondritis

steroids

Supportive, dapsone?

ASA

steroidsCrystal deposition

PT, Drug therapy


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Pyogenic arthritis

Tuberculous arthritis

Fungal arthritis

Lyme disease

Infectious arthritides


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Hemorrhagic effusions

Hemophilic arthropathy

Sickle cell disease

Pigmented villonodularsynovitis


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Non-Arthroplasty Rx of

Arthritic Knee/ Hip :

Nonsurgical Modalities.

Surgical Modalities.


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Management Objectives

1

1) control pain .

2) reduce functional limitation

and disability.

3) improve health-related quality

of life.

4) avoid over-treatment with

potentially harmful

pharmacologic agents.


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Nonsurgical Modalities

Nonpharmacological.

pharmacological.


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Nonpharmacological.

Patient Education .

Weight Loss.

Physical Therapy Interventions .

Occupational TherapyInterventions .

Orthotic Management .


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Patient Education and Lifestyle

Modification

Level of Evidence: II

Grade of Recommendation: B

-Using high stools for prolonged standing

-avoiding high-impact activities

- ensuring adequate rest

-avoide running and jumping,

-encourage low-impact or nonimpactactivities, such as swimming and bicycling.

-Limiting squatting and stair climbing -modify employment responsibilities.

Adaptations in the home.


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Weight Loss AAOS Level of Evidence: I

AAOS Grade of Recommendation: A The single most important potentially

modifiable risk factor

Those who are overweight (BMI>25),

should lose weight ,a minimum (5%).


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Physical Therapy Interventions

Benefits :

Physiological Benefits

Psychological Benefits

goals :

1) preserve or restore range of motion and flexibility

around affected joints.

2) increase muscle strength and endurance.

3) increase aerobic conditioning to improve mood and

decrease health risks associated with a sedentary

lifestyle


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Physical Therapy Interventions

Key points :

1) should be individualized

2) should include advice and education

3) group exercise and home exercise areequally effective and patient preference

should be considered.

4) adherence is the principle predictor of

long-term outcome .5) improvements in muscle strength and

proprioception may reduce arthrits

progression .


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Specific Modalities

Thermotherapy:

- enhance stretching exercises .

-provide analgesia .

- superficial :

conduction radiatioconvection


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Specific Modalities

Thermotherapy ,Deep: [Therapeutic

ultrasound ].-pulsed ultrasound had a greater effect .


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Specific Modalities

CRYOTHERAPY-beneficial in acute arthritic flares .


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SpecificModalities

Electrical stimulation galvanic stimulation [pulsed

electromagnetic field ]

transcutaneous electrical nerve

stimulation (TE

NS)


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Range of motion exercises

prevent motion loss .

Active, Active-assistive or Passive .

performed without any equipment.


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Stretching Exercises prevent abnormal force across a joint.

increases flexibility improves range of motion .

effective on a daily basis .

after heating .

Quadriceps

StretchHamstring StretchGastroc Stretch:


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Muscle Strengthening Exercises

support and protect your joints .

Strength must be built up gradually

3 or4 times a week.

20 to 30 minutes .

open chain [increase forces ] ,or closed chain .

Isometric ,isotonic,or auxotonic.

Quad setsStraight-leg raise to the frontStraight-leg raise to the outside Straight-leg raise to the insideHamstring curls Straight-leg raise to the back


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Mobility Training

Transferring

grab bars

elevated toilet seats

ambulation

straight

canes

quad canes

elevations

rampsramps


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Aerobic Conditioning Level of Evidence: I , Recommendation: A

improve the oxygen system. performed at moderate intensity for

extended periods of time .

analgesic effect .

aquatic and land-based exercises .


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Occupational Therapy

Interventions

overlap with physical therapy .

Assess the needs for independent

community living. emphasis on patient education and

functional training.

provision of assistive devices.

energy conservation techniques .


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Orthotic Management

improve function and possibly reduce

disease .

footwear alterations

subtalar strap

viscoelastic insertsantisupinator

bracing


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The Pharmacologic Treatment of

Osteoarthritis

The choice remains to be individualized.

effectiveness , limitations, and safety

profile .


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Initial approach

4 gm daily

better GI tolerability.

action: centerally acting

- (PGs) synthesis in brain [ ? COX-3 ].- Through vanilloid receptor =capsaicin receptor.

-activation of descending serotonergic pathways .

-toxicity : hepatotoxicity , (INR) ,? renal ,?CVS

Acetaminophen [Paracetamol] :


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If the patient continues to complain of

pain

anti-inflammatory, analgesic, and antipyretic .

at least 20 different

NSAIDs [ 7 classes]

Nonsteroidal Anti-Inflammatory Drugs

ACETIC ACID DERIVATIVES [Diclofenac, Indomethacin]

PROPRIONIC ACIDS [Ibuprofen, Naproxen]

CARBOXYLIC ACIDS[ASA ]

ENOLIC ACIDS[Piroxicam ]FENAMATES[Mefenamicacid]

NAPHTHYLKANONES[Nabumetone ]

COXIBS[Celecoxib ]


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evaluate the risk factors for (GI) and

renal toxicity.

Age >=65

Comorbid medical conditions

Oral glucocorticoids

History of peptic ulcer disease

History of upper gastrointestinal bleedingAnticoagulants

nonselective NSAIDs COX-2- inhibitorsgastroprotective agentsTopical agents


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-synthetic opioid agonist .

-binds to the opioid receptor.

-serotonin and norepinephrine uptake inhibitor.-up to 400 mg/day .

-cannot be given with MAO inhibitors.

-nausea ,vomiting , dysphoric reactions andseizure

who do not respond

who are not candidates for surgery

If the patient continues to complain of pain

If the benefit to risk ratio is unwarranted

Tramadol

Opioid Analgesics


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Intra-articular Therapy

inhibition of inflammatory mediators

stimulation of cartilage matrix synthesis

and inhibition degradation

direct protective action on nociceptive

nerve endings.

Adverse Reactions :

pseudogout , Pseudoseptic reactions ,

Granulomatous synovitis

Viscosupplementation (hyaluronic acid)


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Intra-articular Therapy

-When joints are painful and swollen .

-used as monotherapy or as an adjunct .

-non predictable response.

- not more than three times a year .-aspirate any fluid, and instill

-Remain at rest for 3 days AND use a walking aid for 3

weeks [TO minimizes systemic overflow effects ]

-action :

-Antilymphocytic.

-inhibit PGS synthesis and decrease collagenase .

-reduce (IL)-1, TNF-alpha, and protease enzymes .

Intra-Articular Steroids

CONTRAINDICATIONS

Infection (local or systemic)

Anticoagulant therapy

Hemorrhagic effusions

Uncontrolled diabetes mellitus

Severe joint destruction and/or deformity

Extreme overnutrition

COMPLICATIONS

Infection

Postinjection flare

Crystal-induced synovitis

Cutaneous atrophy (local)

Steroid arthropathy (rare) Charcot-like

Available Compounds

Depomethylprednisolone (DepoMedrol)

triamcinolone hexacetonide (Aristospan)


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Complementary and Alternative

Medicine

Glucosamine.

Chondroitin Sulfate .

Vitamins . C , E ,D. Herbal Supplements .

Avocado Soybean Unsaponifiables .

Ginger .

Methylsulfonyl Methane .

pharmacologic InterventionsNonpharmacologic Interventions

not to be prescribedAcupuncture

Yoga

Tai Chi


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Knee/ Hip :

Surgical Modalities. [ knee ]

When nonoperative treatment fails.

options :-arthroscopy

- osteotomy

-arthrodesis

-techniques for focal chondral defect


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Arthroscopy

arthroscopic lavage +/- debridement .

[recommend against performance]

wash out or dilute inflammatory

mediators

is controversial .

Those who present with a history of

mechanical symptoms.

symptoms of short duration .

normal alignment .

mild to moderate OA .

O t t


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Osteotomy

Varus Malalignment :

younger active patient with varus malalignment

and medial arthrosis

perform a valgus-producing high tibial osteotomy

better to perform sooner [


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Valgus Malalignment

for valgus deformity of the knee with lateral

arthritis .1-Distal femoral varus osteotomy.

lateral opening wedgemedial wedge closing osteotomy

2-Proximal tibial varus osteotomy


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Reparative Treatment Options

Marrow-Stimulating Techniques :

- abrasion arthroplasty.

- subchondral drilling, microfracture ..

R t ti (T l t ti )


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Restorative (Transplantation)

Treatment Options

Autologous ChondrocyteI

mplantation


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Osteochondral Autografts


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Knee Arthrodesis

in rare cases :

-unreconstructable bone.

-soft tissue loss.

-extensor mechanism loss.

- failed [ infected], TKR.


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Knee/ Hip :

Surgical Modalities. [Hip

]

Hip arthroscopy. gold standard of diagnosis .

for the pre-arthritic hip . labral tears,

capsular laxity,

chondral injury,

ligamentum teres

avulsions, and removal of loose

bodies


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Femoro-Acetabular

Impingement [ Ganz ]

cam impingement

PincerImpingement


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trochanteric flip osteotomy


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Arthrodesis

young patients with nonin-flammatory, monoarticularend stage arthritis.

20 to 30 of hip flexion, 5 to 7 of adduction, and 5

to 10 of external rotation .

can be later converted to THA .


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Osteotomy

1) improvement in joint congruity

2) improvement in hip biomechanics

3) rotation of intact articular cartilage into

the weight-bearing dome.

4) reduction in joint subluxation.

Indications:

young patients with symptomatic hipsecondary to DDH.

Pelvic Osteotomy


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Pelvic Osteotomy

Reconstructive OsteotomiesSalvage Pelvic Osteotomies


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Femoral Osteotomy


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Resection arthroplasty of the hip

(Gridlestone Procedure)

sepsis after a total hip

replacement.

aseptic loosening of a total hip .

primary septic arthritis . avascular necrosis .

a painful ununited femoral neck

fracture.


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non-arthroplasty rx of arthritic knee

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