Treatment of osteoarthritis of knee

TREATMENT OF OSTEOARTHROSIS OF KNEEDone by Dr.Prashant Patel (3rd year resident in orthopaedics)Shri M P Shah govt medical college & GG HospitalJamnagar

Underguidance of Dr.Apoorva Dodia (MS Ortho)

Treatment directed at symptoms and slowing progress of the condition

Goals: 4 R’s Relieve pain Restore function Reduce disability Rehabilitation

EARLY Treatment PHYSIOTHERAPY LOAD REDUCTION ANALGESICS INTERMEDIATE Treatment JOINT DEBRIDEMENT AUTOLOGOUS CHONDROCYTE GRAFTING REALIGNMENT OSTEOTOMY LATE Treatment ARTHROPLASTY ARTHRODESIS

PHYSIOTHERAPY

Aim is to maintain joint mobility & improving muscle strength

Includes: Exercises Massage Application of warmth

LOAD REDUCTIONLIFE STYLE CHANGES:o Shock absorbing shoeso Walking stickso Weight reduction in obese

Analgesics : NSAID ‘s Corticosteroid Injection Reduce inflammation around the joint

More rapid effect than NSAIDs Visco- supplement

Intraarticular hyaluronic acid and chondroitin sulphate therapy

Increase viscosity & elasticity of fluid

Diacerein is IL-1 inhibitor Disease modifying effect on O.A. Prophylactic use of diacerein leads to

lower degree of articular stiffness when compared to glucosamine

prophylactic chondroprotective effects of diacerein and glucosamine are histologicaly similar

SURGERY INDICATIONS: Pain refractory to conservative

measures. Functional disability of the patient to

carry out routine day to day activities. Loose bodies or osteochondral fractures. Deformity usually genu varum Progressive limitation of knee motion

SURGICAL METHODS

Arthroscopic joint debridement Chondrocyte transplantation Proximal tibial osteotomy Distal femoral osteotomy Total knee arthroplasty Arthrodesis

ARTHROSCOPIC DEBRIDEMENT

Simple lavage

Debridement

Abrasion chondroplasty

Pain relief is due to removal of cartilaginous debris and inflammatory factors

Poor symptom relief in those patients with radiographic malalignment, severe arthritis and significant joint space reduction

Does not alter natural progression of disease

CHONDROCYTE TRANSPLANTATION

Useful in young ,active patients with severe articular cartilage degeneration

Healthy chondrocytes are harvested from an uninvolved area of injured knee

Grown in tissue culture Injected into knee

cartilage defect Sealed over with a

periosteal flap

PROXIMAL TIBIAL OSTEOTOMY Treatment for unicompartmental osteoarthrosis

of knee Varus or valgus deformity are common and

causes abnormal distribution of weight bearing stresses within the joint

Biomechanics of osteotomy is unloading of involved joint compartment by correcting malalignment and redistribution of the stress uniformly on the knee joint

Contraindication of osteotomy

Four basic types1) Lateral closing wedge osteotomy2) Medial opening wedge osteotomy3) Dome osteotomy4) Medial opening hemicallotaxis

LATERAL CLOSING WEDGE OSTEOTOMY

Described by COVENTRY Advantages Complication Measure the amount of correction needed to

achieve normal angle then additional 3 to 5 degree of overcorrection is added

Calculating the size of wedge removed as roughly 1 degree of correction for 1mm length at the base of the wedge (if the width of the tibial plateau is 57 mm).

If tibia is 57 mm wide, length of wedge=degrees of correctionOR

Length = Diameter of tibia X 0.02 X Angle

INCISION Positioning transverse osteotomy guide

Placement of oblique osteotomy guide & performing osteotomy

Application of compression clamp & L- plate

Completion of osteotomy requires disruption of proximal tibio fibular joint or removal of infero medial portion of fibular head.

After osteotomy fragment is fixed with plate and screws.

Passive ROM started immediately after surgery

Partial weight bearing on 2nd day Full weight bearing after 6 weeks

MEDIAL OPENING WEDGE OSTEOTOMY

Described by HERNIGOU

Tricortical illiac crest bone graft with supplemental cancellous bone graft used

Indicated when involved extremity is 2cm or more shorter and/or when there is an associated medial collateral ligament laxity.

A tourniquet is used The skin incision was placed vertically, on the

medial side of the tibia curve to the proximal and dorsal side.

The periosteum was cut and partially stripped K-wire was drilled under direct fluoroscopic

control in an oblique manner and at an angle to the tibial axis aiming for the upper part of the fibular head.

When satisfactorily placed, the osteotomy was performed using an oscillating saw for the first part and finished using a chisel under fluoroscopic control.

Great care was taken not to damage the lateral cortex

The tibia was manually wedged to the point of desired correction, and the osteotomy plate was positioned and fixed.

The osteotomy gap was then filled with tricortical illiac crest bone graft with supplemental cancellous bone graft

A drain was placed subcutaneously and the wound was closed.

DOME OSTEOTOMY Described by MAQUET

Determine the angle of correction

Midline vertical incision

Curved line is marked on bone with its dome just above tibial tuberosity

Multiple small drill holes made over this line

Two k-wires inserted parallel to each other on either side of osteotomy

Complete the osteotomy using osteotome

Distal fragment is rotated untill desired angle subtend by wire

Fix the osteotomy using staples or plate.

OPENING WEDGE HEMICALLOTASIS

Described by TURI Medial opening wedge osteotomy with

application of dynamic external fixator At 7th Post operative day, the fixator is

distracted 0.25mm four times a day until desired correction is obtained.

It is a slow distraction at the osteotomy site and hence obviates the need of bone grafting.

complications

Position the fixator over the leg to check the position of the pin clamps,osteotomy site and hinge

Osteotomy site is below the tibial tuberosity

Make longitudinal incision just medial to tibial tuberosity up tp 3-4 cm

Position of the fixator over the lateral tibial cortex at the level of osteotomy

Fixator secured with k-wires Proximal fixator pin inserted

Medial and lateral proximal fixator pins Distal fixator pin placed

Osteotomy guide attachedSeries of holes drilled at osteotomy site

Holes connected with osteotomeDistraction of osteotomy

Passive motion has been started immediately after surgery

Ambulation is begun on 2nd day,allowing weight bearing to tolerance with crutches

Seven day after surgery,instruct the patient to distract the fixator 1 mm/day

After appropriate correction is achieved,fixator is locked

The fixator is removed after solid union is achieved

COMPLICATIONS OF HTO Recurrence of deformity Peroneal nerve palsy Knee stiffness Patella baja Intra articular fracture Non union Infection Osteonecrosis of proximal fragment

DISTAL FEMORAL OSTEOTOMY Indicated in active

patients younger than 65 years with valgus angulation <15 degree

Indicated when distal femoral malunion which leads to unicompartmental arthritic changes

Determine the size of wedge to be removed

Establish the angle of plate insertion

Osteotomy done and plate is fixed by screw

KNEE ARTHROPLASTY Unicompartmental knee arthroplasty Total knee arthroplasty

Classification of implants

Unconstrained Cruciate

retaining Cruciate

substistuting

Constrained

TKR consists of following:

Cobalt chrome alloy femoral component

Cobalt chrome alloy or titanium tibial tray

UHMWPE tibial bearing component

UHMWPE patella component

Candidate for TKR Quality of life severely affected Daily pain Restriction of ordinary activities Evidence of significant radiographic

changes of the knee

Goal of TKR Pain relief Restoration of normal limb alignment Restoration of a functional range of

motion

• The Incision:• An incision is made in the

midline and anterior aspect of the knee with the knee positioned in flexion.

• Another approach is a medial parapatellar approach.

• The medial side of the knee is then exposed by removing the anteromedial knee capsule and deep medial collateral ligament from the tibia.

• The leg is then extended and the patella is everted

• The knee is once again flexed and the anterior horn of medial and lateral menisci and anterior cruciate ligament are removed.

• Posterior horns of menisci excised after the femoral and tibial cuts have been made

• Subluxate and externally rotate the tibia

• Expose the lateral tibial plateau by partial excision of infra patellar fat pad

The medial/lateral

adjustment screw that is placed at the ankle is used to align the resection guide parallel with the tibia.

To check alignment to the ankle an alignment rod is used.

There is 3 degrees of posterior slope into the polyethylene insert

The amount of tibial resection depends on which side of the joint is used for reference

If unaffected side is taken as a reference,usually 8 mm cut is taken which is close to the size of the implant

If affected side is taken as a reference,the amount of resection usually is 2mm or less

Proximal tibial cut is taken perpendicular to its mechanical axis

• A drill bit is used to create an opening in the femoral canal.

• The valgus

alignment guide is then used and attached to the IM reamer. It then rests and is secured on the distal femoral condyle.

• Make a distal femoral cut at 5 to 7 degree of valgus

• Then extension gap is measured

• The anterior and posterior femoral cuts determine the rotation of the femoral component and shape of the flexion gap

• Make a cut in 3 degrees of external rotation

• Then flexion gap is measured

• Box cut is taken to accommodate post cam mechanism of PCL substituiting design

The flexion and extension gaps must be roughly equal

If the extension gap is smaller then remove more bone from distal femoral cut surface

If the flexion gap is smaller then remove more bone from posterior femoral condyles

If the flexion and extension gaps are equal,but not enough space for prosthesis,remove more bone from proximal tibia

First the patella is laterally retracted with the articular surface facing in the upward position

Calipers are then used to determine the size of the patella along with the amount of bone that will be removed.

The patella cutting guide is then placed to ensure the proper cut of the patellar apex.

The appropriate size saw is then used to make the patellar cut.

The patellar peg holding guide is then placed on the resected patella and the peg holes are then drilled.

With the knee flexed, appropriate femoral trial is placed on the distal femur.

The tibial trial inserted The knee is then put through a series of

motions to confirm normal movement and alignment.

The trial components are then removed after the correct fit is confirmed.

The joint is then irrigated with a pulse lavage.

The cement is then injected on the cut bone surfaces and the prostheses are then placed.

The femoral impactor is used to insert the femoral implant

The tibial base impactor is used to insert the metal tibial base.

The patellar implant is secured with bone cement and held in place using the parallel patellar recessing clamp.

The tibial polyethylene insert is seated and locked into place on the metal tibial base.

The cement is hardened with the leg placed in 35 degrees of flexion.

The wound is thoroughly irrigated.

The tourniquet is then removed and the bleeding is stopped using electrocautery.

The surgeons preference is used to then determine if a closed-suction drainage device will be needed.

The wound is then closed in layers and a compressive dressing is placed on the knee.

COMPLICATIONS OF TKA Thromboembolism Infection Patellofemoral complications Neurovascular complications Periprosthetic fractures

ARTHRODESIS Indicated for severe

disability esp. in young & active Patient whose activity desire might severly limit the longevity of TKR,infected TKR and neuropathic joint

Techniques of Arthrodesis:

 - External Fixation  - Intramedullary Nailing  - Plate Fixation

THANK YOU