Dr. Md. Golam Sarwar

Dr. Md. Golam Sarwar M.S (Ortho), AO-Fellow (India), WHO-Fellow ( Indonesia) Consultant, Ortho- Surgery, Sadar Hospital, Bhola.

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Primary Old age Female Life style Over weight

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Secondary Post infective Post Menisectomy Post traumatic

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Symptoms & signs which are associated with defective integrity of articular cartilage, in addition to related changes in the underlying bone at the joint margins. American College of Rheumatology- 2005

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Also known as degenerative joint disease, is the most common form of arthritis, and a leading cause of disability worldwide.

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OA Knee is one of the five leading causes of physical disability in non- hospitalized elderly men & women. The risk for disability is as great as cardiovascular disease & greater than that due to any other medical condition in elderly.

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7.35% of the total population are suffering from osteoarthritis. 7% population in Indian are above the age of 60 years. Out of that 20% are suffering from OA knee & needs some kind of treatment (Physical, medical, Surgical) But only a few get treatment (Surgeries/ joint replacement). Bangladesh data are not available.

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Young patients age less than 55 presenting with uni-compartmental symptom. Older patient presenting with symptoms of bi-compartment with patello-femoral arthritis. Patient with inflammatory arthritis- any age group.

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Osteoarthritis of the knee increase in prevalence with age & is more common in women than in men.

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OA affects all structures within joint. Loss of hyaline articular cartilage. Synovial inflammation. Capsular stretching and weakness of periarticular muscles. Mal-alignmentTibia vara/Genu Varum Genu valgum or knock knee (Lateral compartment arthritis)

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Osteitis, synovial inflammation & a stretched joint capsule filled with fluid are to be sources of pain. Bursitis may add. Hyaline Articular cartilage is destroyed & sub-chondral bone is exposed leads to painful knee.

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Age & sex Obesity Previous existing deformity Knee injury Repetitive Stress injuries High impact sports Repetitive episodes of TB/gout/septic arthritis hemophilic arthritis/Psoriatic arthritis/ neuropathic arthritis

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Gradual destruction of Articular cartilage Mild thickening of synovium & inflammation Thickening of joint capsule.

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Gradual destruction of hyaline cartilage

Complete loss of medial joint cartilage with osteophytes formation

Cell stress

Cytokine IL-1, IL-6, TNF-

Cartilage destruction

Synovial destruction

OA.

Sub-chondral bone destruction

Clinical diagnosis  Laboratory diagnosis  Radiological diagnosis 

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Pain – Bone angina Restricted joint movement- stiffness Swelling ] Mild joint instability Crepitus (on movement) Effusion Joint deformity & instability

 General Examination - Vital Sign - obesity - Neurological status - DM - HTN 

Local Examination - Site of pain, tenderness, crepitus - Deformity Varus (OA) Valgus (RA) - Synovitis - Osteophytes - Instability -  ROM

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General Examination - Vital Sign - obesity - Neurological status - DM - HTN Local Examination - Site of pain, tenderness, crepitus - Deformity Varus (OA) Valgus (RA) - Synovitis - Osteophytes - Instability -  ROM - Gait (Wadding/ Trendelenberg)

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CBC - For infective/ inflammatory pathology ESR – Inflammatory condition CRP – For differentiate with infection RA Factor – RA. ANA titre – RA. Synovial Fluid examination – D/D Crystal examination – For gout / pseudo gout HLA – B27 – AS.

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X- Ray – AP standing, Lateral, stress view sky-line view (Digital X-Ray are preferred)

• CT scan • MRI • Bone scanning • Ultra sonography

If necessary

Prevention  Physical treatment  Medical treatment  Surgical treatment 

Pain control  Increase mobility  Further degeneration prevention  Enhance healing process  Improve quality of life 

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Education about the problem & fate Habit change & life style modification - Avoidance of squatting, cross leg sitting Weight reduction Physiotherapy Control of DM. Endocrine disorders.

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Physiotherapy - Quadriceps strengthening - Hamstring strengthening Local treatment - SWD - UST - knee cap. Load reduction over knee - Use of support – stick - Valgus brace - wedged insole - weight reduction - gait modification - out toeing - slow walking

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Symptom modifying drugs - NSAIDs - Analgesics- tramadol, paracetamol - Safer drug – naproxen. Nutraceuticals - Glucosamine sulfate - chondroitin sulfate Disease modifying anti- OA drugsDiacerein Calcium supplement Muscle relaxant - ?? Visco supplementation

 Arthroscopic

debridement  HTO  Unicondylar knee replacement.  Total knee replacement

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Joint space narrowing (Grade1)

Obliteration of joint space (Grade-2) HTO + Arthroscopy/UKA

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For joint debridement & lavage Abrasion arthroplasty Degenerative meniscal tears Synovectomy in RA Chondrocyte implantation Post traumatic arthrofibrosis

Marrow stimulation techniques  Abrasion chondroplasty  Microfracture techniques (Steandman JR CORR) 2001; 391 (Suppl): S 362 – S 369

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Cartilage restoration procedure - Osteo chondral auto – graft transfer (mosaic plasty) - Autogenous chondrocyte implantation (ACI) - Cartilage transplantation - Osteo chondral allograft trasplantation

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Grde 1 – 2 of medial compartment arthritis Relatively young patient < 60 yrs No or minimal deformity Non inflammatory disease pathology.

Arthroplasty Unicondylar knee arthroplasty (UKA)  Total knee arthroplasty (TKA) 

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Almost 70% of arthritic knee are confined to medial compartment (Till death) Replacing only the diseased or affected part of Tibio-Femoral joint - Available since 30 yrs - Popularized in last decade.

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Symptomatic uni-compartmental arthritis Varus/ Valgus deformity less than 150 Flexion contracture less than 100 Passive ROM more than 800 Young active patients Intact PCLs

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Bi-compartmental / tri-compartmental arthritis Rheumatoid arthritis PCL deficit More than 150 varus/valgus deformity More than 100 flexion contracture Stiff knee Obesity

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Considered to be gold standard in treatment of advanced arthritis or inflammatory arthritis (RA)

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For patient with advance disease, gross deformity, limited activity in life.

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Young patient (age<55) - Cruciate retaining - Bone consenving design - cement less TKR Older patient (age> 55) - High flexion TKR - PS/CR

Current surgical trends  

Minimally invasive surgery Use of navigation

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OA is very common clinical condition seen in out patient department Conservative management includes drugs & physiotherapy should be first line of management In selected patient uni-condylar knee replacement gives good, long-lasting results.

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Set up new isolated upgraded unit for proper clinical, laboratory & radiological examination OT set up with training manpower including OT nurse, stuffs & surgeons. Collaboration between neighboring country & exchange of views & good bilateral technical exchange. Good support & patronization by BOS & Government.