Knee Osteoarthritis - Recon - Orthobullets (2024)

• 88 per 100,000 per year

• 240 per 100,000 per year

• articular trauma

• occupation, repetitive knee bending

• muscle weakness

• large body mass

• metabolic syndrome

  • central (abdominal) obesity, dyslipidemia (high triglycerides and low-density lipoproteins), high blood pressure, and elevated fasting glucose levels.

• gender

  • females >males

• increased age

• genetics

• race

  • African American males are the least likely to receive total joint replacement when compared to whites and Hispanics

• articular cartilage

  • increased water content

  • alterations in proteoglycans

    • eventual decrease in amount of proteoglycans

  • collagen abnormalities

    • organization and orientation are lost

  • binding of proteoglycans to hyaluronic acid

    See Also

    Non-operative management of osteoarthritis of the knee jointArtrose in de knie | Diagnose en behandeling voor fysiotherapeutenA.3 Klinisch beeld en beloop - Artrose heup-knie [richtlijn]

• synovium and capsule

  • early phase of OA

    • mild inflammatory changes in synovium

  • middle phase of OA

    • moderate inflammatory changes of synovium

    • synovium becomes hypervascular

  • late phases of OA

    • synovium becomes increasingly thick and vascular

• bone

  • subchondral bone attempts to remodel

    • forming lytic lesion with sclerotic edges (different than bone cysts in RA)

  • bone cysts form in late stages

  • osteophytes form through the pathologic activation of endochondral ossification mediated by the Indian hedgehog (Ihh) signaling molecule

proteolytic enzymes

• matrix metalloproteases (MMPs)

  • responsible for cartilage matrix digestion

    • examples

      • stromelysin

      • plasmin

      • aggrecanase-1 (ADAMTS-4)

• tissue inhibitors of MMPS (TIMPs)

  • control MMP activity preventing excessive degradation

  • imbalance between MMPs and TIMPs has been demonstrated in OA tissues

• inflammatory cytokines

  • secreted by synoviocytes and increase MMP synthesis

    • examples

      • IL-1

      • IL-6

      • TNF-alpha

• non-mendilian

• vitamin D receptor

• estrogen receptor 1

• inflammatory cytokines

  • IL-1

    • leads to catabolic effect

  • IL-4

  • matrilin-3

  • BMP-2, BMP-5

• effect on walking distances

• instability, locking, catching sensation

• body habitus

• gait

  • often an increased adductor moment to the limb during gait

  • antalgic gait associated with knee arthritis

  • knee is maintained in flexion

  • shortened stride length

  • compensatory toe walking

• limb alignment

• effusion

• skin (e.g. scars)

• lack of full extension (>5 degrees flexion contracture)

• lack of full flexion (flexion <110 degrees)

• weight-bearing views of affected joint

• knee

  • sunrise view

  • PA view in 30 degrees of flexion

• pattern of arthritic involvement

  • medial and/or lateral tibiofemoral, and/or patellofemoral

• characteristics

  • joint space narrowing

  • osteophytes

  • eburnation of bone

  • subchondral sclerosis

  • subchondral cysts

• indications

  • first line treatment for all patients with symptomatic arthritis

• technique

  • Non-steroidal anti-inflammatory drugs (first choice)

    • topical and oral NSAIDS recommended

    • selection should be based on physician preference, patient acceptability and cost

    • duration of treatment based on effectiveness, side-effects and past medical history

• outcomes

  • AAOS guidelines: strong evidence for

• indications

  • treatment option for patients with symptomatic arthritis

• technique

  • weak opioid mu receptor agonist

    • good evidence for mid term (8-13 weeks) improvement in pain and stiffness over placebo

• outcomes

  • Prior AAOS guidelines recommended its use, but newer guidelines do NOT recommend its routine use

• indications

  • first line treatment for all patients with symptomatic arthritis

• technique

  • self-management and education programs

  • combination of supervised exercises and home program have shown the best results

    • these benefits lost after 6 months if exercises are stopped

• outcomes

  • AAOS guidelines strong evidence for

• indications

  • patients with symptomatic arthritis and BMI > 25

• technique

  • diet and low-impact aerobic exercise

• outcomes

  • AAOS guidelines: moderate evidence for

bracing

• medial unloader for isolated medial compartment OA

• AAOS guidelines: moderate evidence for

• acupuncture

  • AAOS guidelines: strong evidence against

• viscoelastic joint injections

  • AAOS guidelines: strong evidence against

• glucosamine and chondroitin

  • AAOS guidelines: strong evidence against

• needle lavage

  • AAOS guidelines: moderate evidence against

• lateral wedge insoles

  • AAOS guidelines: moderate evidence against

• Orthobiologics (BMAC, PRP, etc.)

  • Bone marrow aspirate concentrate has higher concentration of IL-1ra than both leukocyte poor and rich PRP

  • PRP has better outcomes than Hyaluronic Acid
    

• indications

  • younger patients with medial unicompartmental OA

• technique

  • valgus producing proximal tibial oseotomy

• outcomes

  • AAOS guidelines: limited evidence for

• indications

  • isolated unicompartmental disease

• outcomes

  • TKA have lower revision rates than UKA in the setting of unicompartmental OA

• indications

  • symptomatic knee osteoarthritis

  • failed non-operative treatments

• techniques

  • cruciate retaining vs. crucitate sacrificing implants show no difference in outcomes

  • patellar resurfacing

    • no difference in pain or function with or without patella resurfacing

    • lower reoperation rates with resurfacing

  • drains are not recommended

• arthroscopic debridement or lavage

  • AAOS guidelines: strong evidence against

• arthroscopic meniscal debridement

  • AAOS guidelines: inconclusive evidence