Osteoarthritis knee,, pain management

Osteoarthritis kneeDr Ravi Shankar Sharma

Fellow (Daradia)

Anatomy of knee joint

Anatomy

• Type – Hinge type synovial joint

• Femoropatellar and femorotibial joint

• The articular capsule has a synovial and a fibrous membrane separated by fatty deposits.

• Synovial membrane have multiple extensions which includes suprapatellar bursa.

LigamentsIntracapsular and extracapsular

• Intracapsularo Anterior cruciate ligament (ACL)

o Posterior cruciate ligament (PCL)

o Transverse ligament

o Anterior and posterior meniscofemoral ligament

o Coronary ligament

Extracapsular

• Petallar ligament

• Medial collateral ligament

• Lateral collateral ligament

• Oblique popliteal ligament

• Arcuate popliteal ligament

Meniscus

• Medial meniscus

• Lateral meniscus

Structure

• Fibrous cartilate

• Outer 1/3rd blood supply

Function

Nerve supply

• Femoral-through its branches in vasti medialis

• Sciatic(through genicular branches)

• Obturator nerve-through its posterior division

Blood supply:

Osteoarthritis

• Degenerative joint disease affecting joint cartilage and subchondral bone,leading to the formation of bony spurs and subchondral cyst.

• Age above 60 years

• Female more after menopause

Degenerative changes of Knee

Overview: Risk Factors

• Age

• Female

• Obesity ( most important modifiable)

• Previous knee injury

• Lower extremity malalignment

• Repetitive knee bending

• Hereditory and nodal OA

• Low level of vitamin C and D

• Muscle weakness( quardiceps)

Pathophysiology

Biomechanical stress affecting the articularcartilage and subchondralbone leading to wear and tear

WHY PAIN ?

• PERIPHERAL SENSITIZATION :

• mediator induced inflammation of articular nociceptors

• Secondary to synovitis

• Stretching of joint capsule and ligaments

• Periosteal irritation due to osteophytes

• Trabeculae microfractures

• Intraosseous hypertension

• Muscle spasm

CENTRAL SENSITIZATION

Signs and symptoms

• Pain

• Morning stiffness

• Swelling

• Decreased range of motion

• Swelling

• Sounds- crepitation

Clinical examination

• Gait

• Swelling

• Deformity

• Tenderness over joint line

• Active and passive ROM painful

• Hard end feel

• Bony crepitations

Diagnosis of Knee OA

Classic Clinical Criteria

• established by ACR, 1981

• sensitivity 95%, specificity 69%

knee pain plus at least 3 of 6 characteristics:

• > 50 yrs

• Morning stiffness < 30 min

• Crepitus

• Bony tenderness

• Bony enlargement

• No palpable warmth 5

Kellgren and Lawrence classification

Grade 0 No radiographic features of osteoarthritis

Grade 1 Possible joint space narrowing and osteophyte formation

Grade 2 Definite osteophyte formation with possible joint

space narrowing

Grade 3 Multiple osteophytes, definite joint space narrowing, sclerosis

and possible bony deformity

Grade 4 Large osteophytes, marked joint space narrowing,

severe sclerosis and definite bony deformity

Diagnosis of Knee OA

Treatment

• Non pharmacological

• Pharmacological-pcm, NSAIDS,disease modifying agents like collagenase inhibitor, elastase inhibitors,and narcotics

• Intervention

• Surgery

Intraarticular injections

• Corticosteroids- max. 3-4 times in a year

• Hyaluronic acid in major co-morbid conditions

Prolotherapy

• Proliferation therapy or regenerative injection therapy involves injecting an otherwise non-pharmacological or non-active irritant solution into knee joint

• Dextose

• Prolozone

• Platelet rich plasma

Platelet Rich Plasma (PRP)

• Platelet derived growth factor

• Transforming growth factor B

• Fibroblast growth factor

• Insulin like growth factor 1&2

• Vascular endothelial growth factor

• Epidermal growth factor

• Keratinocyte growth factor

• Connective tissue growth factor

All these promote cartilage repair

Genicular nerve block & RF neurotomy

Indications

• Chronic knee pain secondary to OA

• Patients with failed knee replacement

• Patients unfit for knee replacement

• Patients who want to avoid surgery

Surgery

• Arthoscopy debridement

• Osteotomy - malalignment

• Knee replacement