膝关节骨关节炎

OSTEOARTHRITIS OF THE KNEE,BACKGROUND,Osteoarthritis :Most common causes of functional disability and severe painThe prevalence of arthritic symptoms among adults is more than 50%,BACKGROUND,Osteoarthritis:Begining with damage and progressive degradation of articular hyaline cartilage structure and function Cartilage thickness loss Remodeling and attrition of subarticular boneGrowth of osteophytesSynovitis, ligamentous laxity, and periarticular muscle weakness Joint tilting and malalignment,Normal and arthritic knee,EPIDEMIOLOGY risk factors,AgeObesity Work-related bending and heavy physical workload Recreational and physical sporting activities Hyaluronic acid serum levels Knee injury Congenital conditionsSystemic metabolic diseasesEndocrine diseasesBone dysplasiasCalcium crystal deposition diseases,CLASSIFICATION,Primary (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.),DIAGNOSIS,Diagnostic criteria for osteoarthritis of the knee (proposed by the American College of Rheumatology, ACR) First: presenting with painSecond:meeting at least five of the following criteria: Patient older than 50 years of ageLess than 30 minutes of morning stiffnessCrepitus (noisy, grating sound) on active motionBony tendernessBony enlargementNo palpable warmth of synoviumErythrocyte sedimentation rate (ESR) 40 mm/hrRheumatoid factor 1:40Noninflammatory synovial fluid,DIAGNOSIS,X-rayMRI,DIAGNOSIS,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-telopeptideRelationships between biomarkers of joint metabolism and cartilage, bone, synovial metabolism may reflect early changes in cartilage structure w/o knee pain,EVALUATION SYSTEM,Knee injury and Osteoarthritis Outcome Score (KOOS) Likert scale SF-36 Western Ontario and McMaster osteoarthritis (WOMAC) scale VAS scoring,EVALUATION SYSTEM,Kellgren and Lawrence criteria (radiographic criteria),TREATMENT,A number of therapies, includingExerciseWeight lossPhysical therapyMedicineSurgery,TREATMENT,ExerciseThere is strong evidence that both strengthening and cardiovascular exercise are effective for reducing pain and improving function in the short-term in knee osteoarthritis,TREATMENT,ExerciseWeight lossPhysical therapyMedicineSurgery,TREATMENT,Weight lossA 5% weight reduction will result in moderate improvement in disability in overweight patients with knee osteoarthritis,TREATMENT,ExerciseWeight lossPhysical therapyMedicineSurgery,TREATMENT,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,TREATMENT,BracingJoint bracing may protects the knee , improves function and increases walking distance,TREATMENT,TapingReduction in painImprovement of microcirculationAlleviation of swelling,taping,TREATMENT,Acupuncture Safe and effective in pain and function in patients with knee osteoarthritis,TREATMENT,ExerciseWeight lossPhysical therapyMedicineSurgery,TREATMENT,Single analgesicsParacetamol may reduce pain in the short time,but less effective than oral NSAIDs,TREATMENT,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,TREATMENT,Opioids Stronger effects on pain reliefAdverse effects: constipation,nausea,vomiting, drowsiness,hypotension,respiratory depressionNot recommended as first-line treatment,TREATMENT,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,TREATMENT,ChondroitinA 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,TREATMENT,Controversy 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,TREATMENT,Intra-articular steroid injections Anti-inflammationSafe Only provided short-term relief of pain in knee osteoarthritis up to 4 weeks post-injection,TREATMENT,ViscosupplementionHyaluronic acidOne of the major glycosaminoglycans in the extracellular matrix ,binding proteoglycans Important in maintaining articular cartilage integrity,TREATMENT,High molecular weight and concentration hyaluronic acid:hylan G-F 20Providing and maintaining intraarticular lubrication Optimising the viscoelastic properties of synovial fluid,The 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,TREATMENT,ExerciseWeight lossPhysical therapyMedicineSurgery,TREATMENT,Arthroscopic lavage and debridement,Washing out the jointRepairing damaged cartilage No lasting benefit in most cases of osteoarthritis,TREATMENT,Osteotomy (high tibial osteotomy)An important adjunct to cartilage repair rocedures that rely on a normalized biomechanical environmentpatientsIndications: patients presenting with unicompartmental disease (eg, after prior meniscectomy) who are at an age and functional level that is not ideally suited for joint arthroplastyAdvantage: allowing 70% to 85% of patients to delay arthroplasty for 5 to 10 years and 50% to 60% for 15 years,Method of planning the magnitude of the opening wedge . H hip, K knee, A ankle, VA virtual ankle, FP Fujisawa point,TREATMENT,Note:Varus or valgus deformity often has a ligamentous component as well as osseous and cartilaginous,TREATMENT,ComplicationsIntra-articular fractureCompartment syndromeHardware failureCorrection failureContractureNeuroma,InfectionHardware painDelayed unionHematomaAnterior knee painPes anserinus pain,TREATMENT,Cartilage Repair Techniques Bone Marrow Stimulating Techniques Osteochondral Transplantation Techniques Autologous Chondrocyte Implantation (ACI),Schematic 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,TREATMENT,ArthroplastyUnicompartmental Knee Arthroplasty (UKA) Total Knee Arthroplasty (TKA),TREATMENT,Unicompartmental 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,TREATMENT,Advantages : a less invasive surgical techniqueThe patella not everted and the ext