Management of...

Management of Osteoarthritis of the

Hip and Knee

Mr. Lee Woo Guan

MBBS (UM)

MMed(Surgery) Sing, FRCS(Edin)

Osteoarthritis

• Most common joint disorder

• > 65 years - majority have radiographic evidenc

• > 65 years - 11% have symptomatic OA of the knee

Classification

• Primary

• Secondary - has a cause

• OA knee - primary, genetic?, > females

• OA hip - secondary (Orientals)

Dysplastic Hip

Post meniscectomy OA knee

Management

• Medical

• Surgical

Management: Medical

• Non-Pharmacological

- Patient education

- Social support

- Physiotherapy / Exercise

• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors

- Topical treatment

- Intraarticular therapy

Management: Medical


- Patient education- Social support


• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors

- Topical treatment


Weight reduction

• Effective in all stages

• 3 kg load across knee per kg weight

• 5 kg 5% reduction of risk for OA

• SF 36-measurement of

quality of life

Wt loss 6 min walk

SF-36

Diet 5.7% 2.8%

Exercise 2.6% 9.3%

Diet+exercise

4.4%% 12.2%

Highest

Patient Education

• Disease and management, wt. reduction, exercise

• 20% of cases as effective as NSAIDs in reducing pain but not in disability

• Synergestic effect with NSAIDs

Management: Medical


- Patient education

- Social support


• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors

- Topical treatment


Social Support

• Regular phone call from a healthcare worker

• Education of family members

Management: Medical


- Patient education

- Social support


• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors

- Topical treatment


Physiotherapy/Exercise

• Mainstay of treatment

• Definite improvement of pain and disability

• Traditional belief - patients concerned that joint use will “wear out” a damaged joint that is already “worn out” - NOT true for moderate intensity exercises


• Goals

- Maintain Range of Motion

- Muscle strength

- Aerobic conditioning

(general/cardiovascular health)


• Joint motion is chondroprotective

Cartilage needs compression / decompression

for nutrition and repair

• Increased osteophytes in those who stopped running?

• Improved aerobic capacity increases well-being, reduces depression and anxiety

Exercise

• Aerobic vs Strentherning

• Pain relief and functional improvement-

equally effective

Decrease depressive symptoms-only in aerobic exercise

Aerobic Exercises

• 15 minutes of aerobic activity at least three times a week, and then gradually build up to 30 minutes daily.

• The activity also should include at least 5 to 10 minutes of warm-up plus 5 to 10 minutes of cool-down.

walking, swimming, low-impact aerobic dance, skiing and biking, and may even include such daily activities as mowing the lawn, raking leaves or playing golf


• Examples:

- walking (good shoe wear)

- swimming

- stationary bicycling

- quads strengthening with weights

Walking Aids

• A cane can reduce hip loading by 20-30%

• Cane handle should reach patient’s proximal wrist crease when patient is standing with arms at the side

• Held on unaffected side of body

Weight Reduction

• Longitudinal association between obesity and OA

Management: Medical


- Patient education

- Social support


• Pharmacological

- Analgesics- NSAIDs

- COX-2 inhibitors

- Topical treatment


Analgesics

• Paracetamol - first line

safe and effective

• Tramadol

• Opioids - eg. Codeine

short periods, for exacerbations

long use - constipation and risk of

falling in elderly

Management: Medical


- Patient education

- Social support


• Pharmacological

- Analgesics

- NSAIDs- COX-2 inhibitors

- Topical treatment


NSAIDs

• Effective

• Can reduce dose when used concurrently with paracetamol

• Side effects:

peptic ulcer disease

renal toxicity

hepatic toxicity

NSAIDs: Peptic Ulcer Disease

• 20-30% of hospital admissions and deaths from peptic ulcer disease in elderly

• The medicine may be worse than the disease

• Per rectal forms not safer

• With H2 blockers only reduces duodenal ulceration

• With Omeiperazole - more protective

NSAIDs: Peptic Ulcer Disease

Caution in patients:

• > 65 yrs

• h/o peptic ulcer disease

• concomitant treatment with steroids and anticoagulants

• Smokers

• CVS disease

• Heavy alcohol drinkers

NSAIDS: Renal Toxicity

Caution in:

• > 65 years

• Hypertension

• CCF

• concomitant use of diuretics

NSAIDs: Recommendations

• Short courses

• Minimal effective dose

• Toxicity in increasing order:- ibuprofen

- diclocenac

- aspirin

- naproxen

- indomethacin

- ketoprofen

- piroxicam

Management: Medical


- Patient education

- Social support


• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors- Topical treatment


COX-2 Inhibitors

• Rofecoxib, Celecoxib

• Reduce GIT events

• Still can have dyspepsia, diarrhoea, abdominal pain

Oral Chondroprotective Agents

• Chondroitin and Glucosamine compounds

(Viatril S)

• Does not modify structure

• May have analgesic and anti-inflam. effects

• Exaggerated effects? - small trials flawed in design with small no. of patients

• Need large trials without company interference

Management: Medical


- Patient education

- Social support


• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors

- Topical treatment- Intraarticular therapy

Topical Treatment

• Topical NSAIDs / Capsaicin

• cannot tolerate systemic therapy

• inadequate pain relief with systemic therapy

• adjunctive in exacerbations

• better than placebo

Management: Medical


- Patient education

- Social support


• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors

- Topical treatment


Intraarticular Therapy: Corticosteroids

• Last several months

• Potential for accelerated cartilage damage

Intraarticular Therapy: Hyaluronic acid

• Hyalgan

• equivalent to intraarticular corticosteroids but with greater duration of action

• equivalent to oral NSAIDs

• SYNVISC is an elastic and viscous fluid that is made from a substance called hyaluronan that is found in normal joint fluid. Hyaluronan acts as a "shock absorber" and lubricant in your knee joint

Surgery

• Arthroscopic debridement

• High tibial osteotomy

• Unicompartmental knee arthroplasty

• Total knee arthroplasty

Arthroscopic Debridement

• one of the goals -delay need for TKR

• Safe

• Debridement of degenerated meniscus tear and removal of loose body

Chondral defect

Microfracture

Autologous chondrocyte transplant

• age 15 to 50 years; and

• focal articular cartilage defect on a load bearing surface size of defect is a minimum of 1 cm2; AND

• body Mass Index (BMI) of < 35; AND

• disabling pain and/or knee locking; AND

• no active inflammatory or other arthritis, clinically and by X-ray; AND

• failure of conservative therapy, and other traditional surgical interventions, such as abrasion, drilling and microfra

High Tibial Osteotomy

• Role controversial because of good results with TKR

• Survival 85% at 5 years

• Can convert to TKR

• Alternative in young with malignment

OSTEOTOMY

Medial wedge osteotomies

Opening Wedge Osteotomies

Opening Wedge Osteotomies

Unicompartmental Knee Arthroplasty

• New TREND

• Middle aged

UKR

TKR: Indications

• Pain

- significantly affecting daily life

- complications to medical therapy

- rest pain, affecting sleep

• Deformity?: progressive and threatens outcome of arthroplasty

TKR

TKR

POST OP XRAYS

TKR COMPONENTS

TKR COMPONENTS

Computer Assisted TKR

Alignment

Implant Planning

Real time implant information

TKR: Absolute Contraindications

• Recent knee sepsis

• Remote source of ongoing infection

• Extensor mechanism discontinuity

• Recurvatum deformity secondary to muscular weakness

Hip Resurfacing

Total Hip Replacement

The Future

• Tissue culture - autologous chondrocytes cultured in vitro and reintroduced into joint

• Inhibition of collagenolytic enzymes

eg. Doxycycline

• Gene therapy - cartilage strength

Summary Medical


- Patient education

- Social support


- Walking aids / Weight

• Pharmacological

- Analgesics

- NSAIDs

- COX-2 inhibitors

- Topical treatment


Surgical

• Arthroscopic debridement

• Osteotomy

• Joint replacement

Thank you

Management of...

Documents

Transcript of Management of...