膝关节骨关节炎

nullOSTEOARTHRITIS OF THE KNEEOSTEOARTHRITIS OF THE KNEEBACKGROUNDBACKGROUND Osteoarthritis : Most common causes of functional disability and severe pain The prevalence of arthritic symptoms among adults is more than 50% BACKGROUNDBACKGROUND Osteoarthritis: Begining with damage and progressive degradation of articular hyaline cartilage structure and function Cartilage thickness loss Remodeling and attrition of subarticular bone Growth of osteophytes Synovitis, ligamentous laxity, and periarticular muscle weakness Joint tilting and malalignment nullNormal and arthritic kneenullEPIDEMIOLOGY– risk factors EPIDEMIOLOGY– risk factors Age Obesity Work-related bending and heavy physical workload Recreational and physical sporting activities Hyaluronic acid serum levels Knee injury Congenital conditions Systemic metabolic diseases Endocrine diseases Bone dysplasias Calcium crystal deposition diseases CLASSIFICATIONCLASSIFICATIONPrimary (idiopathic) articular degeneration occurs in the absence of an obvious underlying abnormality Secondary result from some risk factors(injury ,repetitive motion such as found in certain occupations ,congenital conditions , systemic metabolic diseases,etc.)DIAGNOSISDIAGNOSIS Diagnostic criteria for osteoarthritis of the knee (proposed by the American College of Rheumatology, ACR) First: presenting with pain Second:meeting at least five of the following criteria: Patient older than 50 years of age Less than 30 minutes of morning stiffness Crepitus (noisy, grating sound) on active motion Bony tenderness Bony enlargement No palpable warmth of synovium Erythrocyte sedimentation rate (ESR) <40 mm/hr Rheumatoid factor <1:40 Noninflammatory synovial fluidDIAGNOSISDIAGNOSISX-ray MRIDIAGNOSISDIAGNOSIS Molecular biomarkers sC2C (serum cartilage type II collagen cleavage by collagenase ) sCPII (serum cartilage type II procollagen carboxy propeptide) sHA(serum hyaluronic acid) uNTX (urine N-terminal crosslinking telopeptide of type I collagen ) uCTX-II (urine cartilage type II collagen C-telopeptide ) uCTX-II(urine cartilage type II collagen C-telopeptide Relationships between biomarkers of joint metabolism and cartilage, bone, synovial metabolism may reflect early changes in cartilage structure w/o knee pain EVALUATION SYSTEMEVALUATION SYSTEMKnee injury and Osteoarthritis Outcome Score (KOOS) Likert scale SF-36 Western Ontario and McMaster osteoarthritis (WOMAC) scale VAS scoringEVALUATION SYSTEMEVALUATION SYSTEMKellgren and Lawrence criteria (radiographic criteria)TREATMENTTREATMENT A number of therapies, including Exercise Weight loss Physical therapy Medicine SurgeryTREATMENTTREATMENT Exercise There is strong evidence that both strengthening and cardiovascular exercise are effective for reducing pain and improving function in the short-term in knee osteoarthritis TREATMENTTREATMENTExercise Weight loss Physical therapy Medicine SurgeryTREATMENTTREATMENT Weight loss A 5% weight reduction will result in moderate improvement in disability in overweight patients with knee osteoarthritis TREATMENTTREATMENTExercise Weight loss Physical therapy Medicine SurgeryTREATMENTTREATMENT Thermotherapy Local heat or cold benefits for knee osteoarthritis in terms of pain and function Ice massage can be used to improve range of movement and that cold packs can be used to decrease swelling TREATMENTTREATMENT Bracing Joint bracing may protects the knee , improves function and increases walking distanceTREATMENTTREATMENT Taping Reduction in pain Improvement of microcirculation Alleviation of swellingtapingtapingTREATMENTTREATMENT Acupuncture Safe and effective in pain and function in patients with knee osteoarthritis TREATMENTTREATMENTExercise Weight loss Physical therapy Medicine SurgeryTREATMENTTREATMENT Single analgesics Paracetamol may reduce pain in the short time,but less effective than oral NSAIDsTREATMENTTREATMENT Non-steroidal anti-inflammatory drugs (NSAIDs) Effective for short-term use(<2 weeks) A small to moderate effect on pain, improving stiffness, physical function Gastrointestinal or cardiac adverse effects TREATMENTTREATMENT Opioids Stronger effects on pain relief Adverse effects: constipation,nausea,vomiting, drowsiness,hypotension,respiratory depression Not recommended as first-line treatmentTREATMENTTREATMENT Glucosamine Amino sugar , a building block for the glycosaminoglycans that are part of the structure of cartilage Effective and safe for improving function in knee osteoarthritis and in delaying its progression TREATMENTTREATMENT Chondroitin A highly hydrophilic, gel forming polysaccharide macromolecule. Its hydrocolloid properties convey much of the compressive resistance of cartilage Treatment on cartilage volume loss, subchondral bone marrow lesions TREATMENTTREATMENTControversy Some network meta-analyses reveal glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space, while some reviews telling glucosamine are more effective than NSAIDs at reducing pain TREATMENTTREATMENT Intra-articular steroid injections Anti-inflammation Safe Only provided short-term relief of pain in knee osteoarthritis up to 4 weeks post-injection TREATMENTTREATMENT Viscosupplemention Hyaluronic acid One of the major glycosaminoglycans in the extracellular matrix ,binding proteoglycans Important in maintaining articular cartilage integrity nullnullTREATMENTTREATMENTHigh molecular weight and concentration hyaluronic acid:hylan G-F 20 Providing and maintaining intraarticular lubrication Optimising the viscoelastic properties of synovial fluidnullThe treatment effect with hylan G-F 20 was statistically significantly superior to placebo for the primary endpoint, change in WOMAC A (pain) over 26 weeks TREATMENTTREATMENTExercise Weight loss Physical therapy Medicine SurgeryTREATMENTTREATMENTArthroscopic lavage and debridement null Washing out the joint Repairing damaged cartilage No lasting benefit in most cases of osteoarthritis TREATMENTTREATMENT Osteotomy (high tibial osteotomy) An important adjunct to cartilage repair rocedures that rely on a normalized biomechanical environmentpatients Indications: patients presenting with unicompartmental disease (eg, after prior meniscectomy) who are at an age and functional level that is not ideally suited for joint arthroplasty Advantage: allowing 70% to 85% of patients to delay arthroplasty for ≥ 5 to 10 years and 50% to 60% for ≥ 15 years nullMethod of planning the magnitude of the opening wedge . H hip, K knee, A ankle, VA virtual ankle, FP Fujisawa pointTREATMENTTREATMENTNote:Varus or valgus deformity often has a ligamentous component as well as osseous and cartilaginous TREATMENTTREATMENT Complications Intra-articular fracture Compartment syndrome Hardware failure Correction failure Contracture Neuroma Infection Hardware pain Delayed union Hematoma Anterior knee pain Pes anserinus pain TREATMENTTREATMENT Cartilage Repair Techniques Bone Marrow Stimulating Techniques Osteochondral Transplantation Techniques Autologous Chondrocyte Implantation (ACI) nullSchematic drawing of autologous cartilage implantation (ACI). The procedure consists of the following steps: (1) cartilage harvest generally performed during arthroscopic surgery, (2) cell culture with expansion of cells in monolayer flasks, and (3) reimplantation of the cells by injecting them underneath a sutured collagen membrane TREATMENTTREATMENT Arthroplasty Unicompartmental Knee Arthroplasty (UKA) Total Knee Arthroplasty (TKA) TREATMENTTREATMENTUnicompartmental Knee Arthroplasty (UKA) Indicated in cases where OA involves only one of the three compartments of the knee: the medial tibiofemoral, lateral tibiofemoral or patellofemoral compartment nullTREATMENTTREATMENT Advantages : a less invasive surgical technique The patella not everted and the extensor mechanism not damaged--permitting a much more rapid recovery and earlier discharge Preservation of bone stock More normal knee kinematics Greater physiological function TREATMENTTREATMENT Complications Bearing dislocation Tibial component loosening Femoral component loosening Lateral translation Impingement Implant fractureTREATMENTTREATMENT Total Knee Arthroplasty (TKA) The first-line procedure for end-stage knee OA Indications:more than one compartment involved and failure of conservative treatments nullTREATMENTTREATMENT Advantages Highly effective treatment that results in substantial improvement in patient functioning and health-related quality of life TREATMENTTREATMENTComplications: Postoperative pain without clinical or radiological abnormalities Femoropatellar problems Loosening of components Infections Stiffness of the knee THANK YOUTHANK YOU