Osteoarthritis knee Dr Ravi Shankar Sharma Fellow (Daradia)
Osteoarthritis kneeDr Ravi Shankar Sharma
Fellow (Daradia)
Anatomy of knee joint
Anatomy
• Type – Hinge type synovial joint
• Femoropatellar and femorotibial joint
• The articular capsule has a synovial and a fibrous membrane separated by fatty deposits.
• Synovial membrane have multiple extensions which includes suprapatellar bursa.
LigamentsIntracapsular and extracapsular
• Intracapsularo Anterior cruciate ligament (ACL)
o Posterior cruciate ligament (PCL)
o Transverse ligament
o Anterior and posterior meniscofemoral ligament
o Coronary ligament
Extracapsular
• Petallar ligament
• Medial collateral ligament
• Lateral collateral ligament
• Oblique popliteal ligament
• Arcuate popliteal ligament
Meniscus
• Medial meniscus
• Lateral meniscus
Structure
• Fibrous cartilate
• Outer 1/3rd blood supply
Function
Nerve supply
• Femoral-through its branches in vasti medialis
• Sciatic(through genicular branches)
• Obturator nerve-through its posterior division
Blood supply:
Osteoarthritis
• Degenerative joint disease affecting joint cartilage and subchondral bone,leading to the formation of bony spurs and subchondral cyst.
• Age above 60 years
• Female more after menopause
Degenerative changes of Knee
Overview: Risk Factors
• Age
• Female
• Obesity ( most important modifiable)
• Previous knee injury
• Lower extremity malalignment
• Repetitive knee bending
• Hereditory and nodal OA
• Low level of vitamin C and D
• Muscle weakness( quardiceps)
Pathophysiology
Biomechanical stress affecting the articularcartilage and subchondralbone leading to wear and tear
WHY PAIN ?
• PERIPHERAL SENSITIZATION :
• mediator induced inflammation of articular nociceptors
• Secondary to synovitis
• Stretching of joint capsule and ligaments
• Periosteal irritation due to osteophytes
• Trabeculae microfractures
• Intraosseous hypertension
• Muscle spasm
CENTRAL SENSITIZATION
Signs and symptoms
• Pain
• Morning stiffness
• Swelling
• Decreased range of motion
• Swelling
• Sounds- crepitation
Clinical examination
• Gait
• Swelling
• Deformity
• Tenderness over joint line
• Active and passive ROM painful
• Hard end feel
• Bony crepitations
Diagnosis of Knee OA
Classic Clinical Criteria
• established by ACR, 1981
• sensitivity 95%, specificity 69%
knee pain plus at least 3 of 6 characteristics:
• > 50 yrs
• Morning stiffness < 30 min
• Crepitus
• Bony tenderness
• Bony enlargement
• No palpable warmth 5
Kellgren and Lawrence classification
Grade 0 No radiographic features of osteoarthritis
Grade 1 Possible joint space narrowing and osteophyte formation
Grade 2 Definite osteophyte formation with possible joint
space narrowing
Grade 3 Multiple osteophytes, definite joint space narrowing, sclerosis
and possible bony deformity
Grade 4 Large osteophytes, marked joint space narrowing,
severe sclerosis and definite bony deformity
Diagnosis of Knee OA
Treatment
• Non pharmacological
• Pharmacological-pcm, NSAIDS,disease modifying agents like collagenase inhibitor, elastase inhibitors,and narcotics
• Intervention
• Surgery
Intraarticular injections
• Corticosteroids- max. 3-4 times in a year
• Hyaluronic acid in major co-morbid conditions
Prolotherapy
• Proliferation therapy or regenerative injection therapy involves injecting an otherwise non-pharmacological or non-active irritant solution into knee joint
• Dextose
• Prolozone
• Platelet rich plasma
Platelet Rich Plasma (PRP)
• Platelet derived growth factor
• Transforming growth factor B
• Fibroblast growth factor
• Insulin like growth factor 1&2
• Vascular endothelial growth factor
• Epidermal growth factor
• Keratinocyte growth factor
• Connective tissue growth factor
All these promote cartilage repair
Genicular nerve block & RF neurotomy
Indications
• Chronic knee pain secondary to OA
• Patients with failed knee replacement
• Patients unfit for knee replacement
• Patients who want to avoid surgery
Surgery
• Arthoscopy debridement
• Osteotomy - malalignment
• Knee replacement