Management of Arthritis:Recent Trends

Dr. Neeraj Aggarwal MS, FJRS

Consultant Orthopaedic & Joint Replacement surgeonConsultant Orthopaedic & Joint Replacement surgeonNarayana Hrudayalaya Hospital

Pratap Nagar, Jaipur.

Objectives of today’s discussion

• Discuss the prevalence of degenerative Knee Osteoarthritis (OA)

• Understand and discuss different approaches to treat Knee OA

• Discuss the Indications, Priority and Clinical outcomes of Knee Replacement

 

                                                                                                                          

• The knee joint is protected in front by the patella

• Meniscus - acts as a shock absorber

• Articular cartilage allows the surfaces of the knee to glide over each other without damaging the surface

Anatomy of Knee

Prevalence of Knee Pain

(Croft et al, 1998)

7,500• Knee pain, some disability & X-ray OA

12,500• Knee pain with some disability

25,000• 4 weeks of knee pain in past year

• Knee pain, severe disability & X-ray OA

2,000

100,000• Subjects aged 55 years+

2%

• About 7 crore Indians are suffering from knee related problems

• Evidence suggests that women have a higher incidence of OA than men, and overall have an incidence of 2.95 per 1000 population, compared with 1.71 per 1000 population in men

Prevalence of Knee OA

Why is this problem more prevalent in India

• Squatting / Ground sitting habits• Climbing stairs• Indian Toilets• Obesity• Complicated patients• Heredity

Can we prevent Osteoarthritis

Symptoms

• Pain in and around the Knee joint• Morning Stiffness (worse on standing

& attempting to walk)• Swelling of Joint• Occasional night pain

Characteristics of Knee OA

The symptoms of OA may interfere with normal activities, such as walking, dressing and sleep

Characteristics of Knee OA

Signs

• Crepitus on motion • Buckling or instability• Tenderness on pressure • Joint effusion • Malalignment / Joint deformity

REDUCTION IN CARTILAGEREDUCTION IN CARTILAGE

Always ask for weight bearing X-rays

Grade 1

Grade 3

Grade 2

All Grade 4

Treatment Approaches

• Education

• Behavioural and Environmental changes

• Physical and Mechanical Interventions

• Pharmacological Management

• Surgical Interventions

Education

• Education of Patients – helps in reducing impact of

condition on their day-to-day lives

• Advice about lifestyle • Impact vs. Non impact

activities

WEIGHTWEIGHT

Physical and Mechanical Interventions

• Heat and Cold applications– to reduce inflammation

• Walking aids– reduce the loading on the knee while

walking

• Shoe alterations– help the patient get their footwear right

– Knee braces

Physiotherapy

• Physiotherapy aims to restore function to the maximum degree possible – through exercises– helps reduce pain– increases joint range of movement– improves muscles strength– addresses specific restrictions in

activities

• Exercises:

- Static Quadriceps Exercises - Quadriceps Building Exercises - Hamstring Building Exercises - Isokinetic Exercises for knee joint - Progressive resistance Exercises

PRECAUTIONSPRECAUTIONS

• Take rest in between if it is needed

• No squatting on floor

• No cross legged sitting (Alathi – Palathi) on floor

• Reduce climbing stairs

• Cycling is good

• Swimming Mother of all exercises

Pharmacological Management

• Systemic

Paracetamol, NSAIDs

Cox-2 Inhibitors

• Topical

• Intra-articular

Steroids

Hyaluronic Acid

My analgesic of choice…

• Paracetamol+Low dose Tramadol

• Synergistic combination

• Block both pathways

• Dose titration (2-8 tab a day)

• GI safety

D.M.A.R.D.Do we have

D.M.A.OAOA.D.

? ? ?? ? ?

D.M.A.OAOA.D. ? ? ? Texanamic acid – Anti plasmin activator

CMT – Chemically Modified Tetracyclin– Inhibit MMP, Nitric oxygenase formation, prevent cartilage wear in animals

Poly sulfated Glucosamino-glycan.– GOOD animal studies. Limited experiencd in human beings.– Fear of “mad cow disease “, anaphylaxis

Diacerin– Again efficacy not established

Glucosamine– In selected cases

NONE like DMARD yet !NONE like DMARD yet !

Intra-articular

Steroids

• Indicated when knee is inflamed

• Confirm intra-articular placement by draining effusion, then injection

• Wide variation in responses

Viscosupplementation

• Replaces pathologic synovial fluid

• Supplements elasticity and viscosity

• Reduces pain and improves mobility

‘Ideal’ Patient

• Pain on weight-bearing motion.

• Simple analgesics do not always alleviate pain

• Active, mobile, lifestyle

• Cartilage degeneration not complete

• No acute, severe inflammation in the knee

• Prior correction of significant valgus/varus deformities,

ligamentous laxity or meniscal instability.

Patient Selection: (hylan G-F 20) Results Across Radiologic Grades

P < 0.05; (2)

Radiographic grade

Grade I Grade II Grade III Grade IV

% patients judged as

“better” or “much better”

91 80 66 58

From a retrospective chart survey of 336 patients treated with SYNVISC (1537 total injections)1

1. Lussier A et al. J Rheumatol. 1996;23:1579-1585.

Please see full Prescribing Information.

Hylan G-F 20

How do we know that the patient needs surgery ?

• Regular pain needing medication

• Deformity of the knee, crepitus in knee

• Night pain, getting up pain

• Altered social or family life due to pain

OSTEO ARTHRITIS

INDICATION – PENALTY POINTS ( 75 PLUS)

Progression + Disability

Pain Deformity ROM Instability

40 20 20

REPLACEMENT SURGERY

20

• FIVE LAKH IS THE NUMBER OF KNEE REPLACEMENT SURGRIES DONE IN USA IN 2008

• IN INDIA THE CORRESPONDING NUMBER IS 35000 IN 2008

• WITH ALL OUR MANFORCE WE ARE ABLE TO TACKLE ONLY 3% OF TOTAL ARTHRITIS PATIENTS

• WHERE ARE WE ???????

Normal kneeNormal knee Arthritic Knee

Total Knee Replacement

• The ultimate solution for OA of knee is to replace the worn-out parts of the knee with an artificial joint

• The prosthesis that is used is made up of plastic and metal and is placed on the joint surface of each bone

• This surgery has been widely used for many years with excellent results especially for knees

Third Generation Knee

How the Artificial knee fits on the bones ?

Modern Knee

Where to undergo Surgery…

Post-Op TKR

AP Lateral

Common Post-Operative (TKR) Course

• Day 1 Standing, bending and sitting out in a chairMay take a few steps with help

• Day 2 Walking (with aids)

• Day 4/5 Stair climbing

• Day 5-7 Home (with 2 walking sticks)

• Week 6 Walking unaided (or 1 stick) Driving

• Week 10-12 Full recovery

Benefits of TKR

• TKR can relieve pain that doesn't respond

to other treatment options

• Pain reduction in 90 to 95% of the patients

• Reduced stiffness and improved joint

movement

• Increased walking ability

• Improved alignment of deformed joints

Myths

• Hip replacement works but knee replacement doesn’t

• Knee replacements are still experimental

• Knee replacements only last 8-10 years may be 15 years maximum

• I am too fat - my implants might break

• TKR surgery is too costly

• TKR is not successful

• After TKR, I have to be bedridden for 3 months

• A total knee replacement implies that everything about the joint is being replaced

Myths

Question about ?

• Team

• Availability

• Approachability

• Economy

Summary

• Knee OA, which has not responded to conservative treatment can be effectively treated by various surgical interventions

• Effective grading of patients, counceling and management serves as a tool to combat osteoarthritis

• Knee replacement surgery is a highly successful (90-95%) and safe procedure

• Prioritising and effective screening by GPs can identify those individuals that are likely to benefit from TKR

Total Hip Replacement

• Many indications, one Solution

Avascular Necrosis

Future ………

• Robotics

• Custom Implants and Instruments

• Stem cell therapy

Appreciate your attentionAppreciate your attention