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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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Non-Arthroplasty Rx of Arthritic
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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Non-Arthroplasty Rx of Arthritic
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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