Non arthroplasty options of OA knee

1. Osteoarthritis
Mohamed Abulsoud (M.D)
Lecturer of orthopedic surgery
Al-Azhar university
Cairo- Egypt
AOTRAUMA International faculty member

2. • Definition of arthritis
• Risk factors
• Pathology
• Diagnosis
• Treatment and guidelines
Learning outcomes

3. Definition
Osteoarthritis (OA) is a degenerative joint disease
characterized by articular cartilage degeneration,
subchondral bone sclerosis, and osteophyte
formation with major clinical symptoms.

4. Epidemiology
• OA is the most common form of arthritis
• Leading cause of impaired mobility in the elderly
• by the year 2020, 25% of the adult population, or
50 million people in the United States, will be
affected by OA

5. Risk Factors
• Age
• Female
• Obesity ( most important modifiable)
• Previous injury
• Mal alignment
• Repetitive loading
• High impact activities
• Muscle weakness

6. OA
Primary
OA
Secondary
OA
Types

7. Causes of secondary OA
• Trauma
• Congenital: dysplasia
• Infection: Septic arthritis, Brucella, Tb
• Inflammatory: RA, AS
• Metabolic: Gout
• Hematologic: Hemophilia
• Endocrine: DM, Hypothyroidism
Types

8. All structures of the joint undergo
pathologic changes including
articular surface ,synovium,
ligaments, and subchondral bone.
Pathology

9. Pathology

10. • The earliest changes in OA usually appear in the hyaline
articular cartilage.
• Chondrocytes produce inflammatory cytokines (IL1-β) (TNF-α)
and other inflammatory mediators, such as IL-6, IL-8, PGE2,
NO, and BMP-2)
• Decrease collagen synthesis and increase degradative
proteases (matrix metalloproteinases)
Pathology

11. Inflammatory process results in:
• Increased tissue swelling
• Change in color
• Cartilage fibrillation
• Cartilage erosion down to
subchondral bone
Pathology

12. • Synovium: inflammation, vascular hypertrophy
• Ligaments: tighten on concave side of deformity
• Bone: sclerosis, osteophytes, and subchondral cysts
• Muscles: atrophy
Pathology

13. Arthritis Vs Aging

14. Symptoms
• OA usually occurs slowly
• It may be many years before the
damage to the joint becomes
Symptomatic
• Only a third of people whose X-rays
show OA report pain or other
symptoms
Clinical evaluation

15. – Steady or intermittent pain in a joint (Start up pain)
– Stiffness that tends to follow periods of inactivity, such as sleep or
sitting
– Swelling in one or more joints
– Crunching feeling or sound of bone rubbing on bone (called crepitus)
when the joint is used
– Deformity is late due to bone erosion
Clinical evaluation

16. Signs
• Swelling, Effusion
• Deformity
• Skin (scar, Sinus,Psoriasis)
• Tenderness
• Crepitus
• ROM
• Other side
• The back of the joint
Clinical evaluation

17. • Asymmetrical joint space narrowing
• Periarticular sclerosis
• Osteophytes
• Sub-chrondral bone cysts (geodes)
Radiological evaluation

18. Classification

19. RA Vs OA

20. Treatment
Conservative
Activity
modification
Medical
Treatment
Injection
Operative
Arthroscopy Arthrodesis Osteotomy Arthroplasty
Treatment

21. Functional treatment goals:
•Limit pain
•Increase range of motion
•Increase muscle strength
•slowing the progress of the condition
Treatment

22. • Weight loss
– Nutrition referral
• Exercise Program
– PT referral
– muscles strengthening
– ROM exercises
– Low impact activities
e.g. swimming, biking
• Ambulatory assist devices
– Cane
– Walker
• Insoles
• Unloader braces
Lifestyle modification

23. • NSAIDs
• Acetaminophen
• Cox-2 inhibitors
• Opioids
• Glucosamine/Chondroitin
• IL1 inhibitors
Medical treatment

24. Intraarticular Injections
Glucocorticoids
Indication: pain persists despite oral analgesics
40 mg/mL triamcinolone Solution
Hyaluronic Acid
Synthetic joint fluid
Pain relief similar to steroid injections
2 mL injection / wk x 3
60-70% patients respond, relief up to 6 months

25. Biological injection
• PRP
• BMA
growth factors released from platelets
• PDGF
• TGF-B
• VEGF
• FGF-2
Intraarticular Injections

26. • 50% to 75% of patients have an initial benefit following
arthroscopic debridement.
• 15% progress to (TKA) within 1 year following Surgery
• 44% have a clinically significant reduction in pain.
Arthroscopic management

27. Arthroscopic management

28. Arthroscopic management

29. Arthrodesis
• The most common indication is the
nonreconstructable failed TKA
• Usually due to infection and loss of the
extensor mechanism.
• septic arthritis, osteomyelitis,
posttraumatic arthritis in a young
manual laborer, painful ankylosis,
neuropathic knee (Charcot joint), and
paralytic deformity

30. Position of fusion
• If the limb-length discrepancy (LLD) is less than 2 cm, in 5° to 7°
of valgus and 15° of flexion.
• If the LLD is 2 to 4 cm, in extension to enable ground clearance.
• If the LLD is greater than 4 cm, bone grafting or a prosthetic
spacer to limit gait abnormalities can be considered.
Arthrodesis

31. Osteotomy
• Realigment osteotomy
• Reconstructive osteotomy
• Early arthritis
• Proper selection of patient
• Planning

32. Osteotomy

33. Osteotomy

34. HTO
Patient selection
Good prognostic factors
• Constitutional metaphyseal Varus of >3 °.
• Symptomatic medial compartment OA
• Minor PF complaints.
• Intact lateral compartment.
• <10° flexion contracture
34
Lobenhoffer, P. (2017). indication for Unicompartmental Knee Replacement versus Osteotomy around the
Knee. Knee, 30 (08), 769-773.

35. HTO
Patient selection
Negative prognostic factors
• Smoking
• Valgus alignment of ≤5° at 5 wks post op
• Postoperative flexion <120°
• Improper surgical technique (hinge fracture)
35
Bonasia, Davide Edoardo, et al. "Medial opening wedge high tibial osteotomy for medial compartment
overload/arthritis in the varus knee: prognostic factors." AJSM (2014)
Schröter, S., et al Smoking and Unstable Hinge Fractures Cause Delayed Gap Filling Irrespective of Early Weight
Bearing After Open Wedge Osteotomy. Arthroscopy (2015).

36. HTO
Patient selection
• Age is not a major risk factor
Lobenhoffer, P. 2017
Goshima, Kenichi, et al. 2017
• Obesity is not a contra indication of HTO
Floerkemeier S, et al 2013
• In unicompartmental arthritis with kissing lesions
in young patients, HTO gives comparable results
to UKA
Ryu et al. 2018
36

37. HTO Vs UKA
• No difference between UKA or HTO in outcomes and
complications in patients with medial compartment knee
osteoarthritis.
37
SURGICAL MANAGEMENT OF OSTEOARTHRITIS OF THE KNEE
EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE
2015

38. HTO
Locking plates or non locking plates ?
• The locking plates are superior to the non-locking
plates as regards correction maintenance,
correction loss angle, and clinical outcome.
• Kfuri, Mauricio, and Philipp Lobenhoffer. "High tibial osteotomy for the correction of varus
knee deformity." The journal of knee surgery (2017)
• Han, Jae Hwi, et al. "Locking plate versus non-locking plate in open-wedge high tibial
osteotomy: a meta-analysis." Knee Surgery, Sports Traumatology, (2017)
38

39. Opening wedge HTO Vs closing wedge HTO
• 324 opening-wedge Vs 318 closing-wedge
• No difference in clinical outcome or incidence of
complications .
• Opening wedge HTO increases the risk of a greater
posterior slope angle ,patella baja and reduced HKA
angle in early post-operative period.
• Smith, T. O., Sexton, D., Mitchell, P., & Hing, C. B. (2011). Opening- or closing-wedged high tibial osteotomy: A meta-
analysis of clinical and radiological outcomes. The Knee, 18(6), 361–368.39

40. Opening wedge HTO Vs closing wedge HTO
• 27 studies,
• Posterior tibial slope increased
2.02° in OWHTO, decreased 2.35°
in CWHTO
• Non significant difference
40
• Nha, K.-W., et al. Change in Posterior Tibial Slope After Open-Wedge and Closed-Wedge High Tibial Osteotomy: A Meta-
analysis. AJSM (2016)

41. Opening wedge HTO Vs closing wedge HTO
• 23 studies
• patellar height decreased 7% after
OWHTO(except when assessed by
ISI)
• No change in patellar height in
CWHTO
• Femoral referenced parameter
(FPHI), no change in OWHTO
C. Ihle et al. The Knee (2017)
41
• Bin, Seong-Il, et al. "Changes in patellar height after opening wedge and closing wedge high tibial osteotomy: a meta-
analysis." Arthroscopy: (2016)

42. Complications
1. Compartment syndrome
2. Peroneal nerve palsy (more common in high tibial osteotomy)
3. Nonunion or malunion
4. Undercorrection or overcorrection
5. Patella baja
Osteotomy

43. The ideal candidate for a UKA:
• Is older than 55 years
• Has no osseous deformity
• Has intact ligaments (i.e., ACL, MCL)
• Has a deformity which reduces
completely in 20° of flexion
• Has an intact lateral compartment
• Has an almost normal range of
motion
• Has no inflammatory disease
• Should preferably have a BMI ≤ 30
Arthroplasty

44. Treatment
Feeley, et al J Am Acad Orthop Surg 2010

45. David S. Jevsevar, J Am Acad Orthop Surg September 2013, Vol 21, No 9
AAOS guidelines for treatment of knee OA

46. • patients with symptomatic OA of the knee participate in self-
management programs, strengthening, low-impact aerobic
exercises, and neuromuscular education.
• Strength of recommendation: Strong.
AAOS guidelines for treatment of knee OA

47. • weight loss for patients with symptomatic OA of the knee and
a body mass index ≥25.
• Strength of recommendation: Moderate.
AAOS guidelines for treatment of knee OA

48. • We recommend NSAIDs (oral or topical) for patients with
symptomatic OA of the knee.
• Strength of recommendation: Strong.
AAOS guidelines for treatment of knee OA

49. • We are unable to recommend for or against the use of
acetaminophen, opioids, or pain patches for patients with
symptomatic OA of the knee.
• Strength of recommendation: Inconclusive.
AAOS guidelines for treatment of knee OA

50. • We cannot recommend using glucosamine and chondroitin for
patients with symptomatic OA of the knee.
• Strength of recommendation: Strong
AAOS guidelines for treatment of knee OA

51. • We cannot recommend using HA for patients with
symptomatic OA of the knee.
• Strength of recommendation: Strong
AAOS guidelines for treatment of knee OA

52. • We are unable to recommend for or against the use of intra-
articular corticosteroids for patients with symptomatic OA of
the knee.
• Strength of recommendation: Inconclusive
AAOS guidelines for treatment of knee OA

53. • We are unable to recommend for or against growth factor
injections and/or platelet rich plasma for patients with
symptomatic OA of the knee.
• Strength of recommendation: Inconclusive.
AAOS guidelines for treatment of knee OA

54. • We cannot recommend using acupuncture in patients with
symptomatic OA of the knee.
• Strength of recommendation: Strong.
• We are unable to recommend for or against the use of physical
agents (including electrotherapeutic modalities) in patients with
symptomatic OA of the knee.
• Strength of recommendation: Inconclusive.
• We are unable to recommend for or against manual therapy in
patients with symptomatic OA of the knee
• Strength of recommendation: Inconclusive.
AAOS guidelines for treatment of knee OA

55. • We are unable to recommend for or against the use of a
valgus-directing force brace (medial compartment unloader)
for patients with symptomatic OA of the knee.
• Strength of recommendation: Inconclusive.
• We cannot suggest that lateral wedge insoles be used for
patients with symptomatic medial compartment OA of the
knee.
• Strength of recommendation: Moderate.
AAOS guidelines for treatment of knee OA

56. • We cannot recommend performing arthroscopy with lavage
and/or debridement in patients with a primary diagnosis of
symptomatic OA of the knee.
• Strength of recommendation: Strong
• We are unable to recommend for or against arthroscopic
partial meniscectomy in patients with OA of the knee with a
torn meniscus.
• Strength of recommendation: Inconclusive.
AAOS guidelines for treatment of knee OA

57. • The practitioner might perform a valgus-producing proximal
tibial osteotomy in patients with symptomatic medial
compartment OA of the knee.
• Strength of Recommendation: Limited.
AAOS guidelines for treatment of knee OA

58. • Osteoarthritis is a leading cause of impaired mobility in the
elderly.
• All components of the joint is affected
• Clinical and radiological assessment for cases is important to
decide the appropriate ttt
• Treatment depends on patient factors, stage of arthritis and
expected outcome should be realistic and meets patient’s
needs
Take home message