Knee Osteoarthritis

Authors: Evan Watts Mark Karadsheh

Introduction
 Definition degenerative disease of synovial joints that causes
progressive loss of articular cartilage
 Epidemiology
o incidence
 hip OA (symptomatic)
 88 per 100,000 per year
 knee OA (symptomatic)
 240 per 100,000 per year
 Risk factors
o modifiable
 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.
o non-modifiable
 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
 Pathophysiology
o pathoanatomy
 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
 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
 Cell biology
o 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
 Genetics
o inheritance
 non-mendilian
o genes potentially linked to OA
 vitamin D receptor
 estrogen receptor 1
 inflammatory cytokines
 IL-1
 leads to catabolic effect
 IL-4
 matrilin-3
  BMP-2, BMP-5

Presentation
 History
o identify age, functional activity, pattern of arthritic involvement,
overall health and duration of symptoms
 Symptoms
o function-limiting knee pain
 effect on walking distances
o pain at night or rest
o activity induced swelling
o knee stiffness
o mechanical
 instability, locking, catching sensation
 Physical exam
o inspection
 body habitus
 gait
 often an increased adductor moment to the limb
during gait
 limb alignment
 effusion
 skin (e.g. scars)
o range of motion
 lack of full extension (>5 degrees flexion contracture)
 lack of full flexion (flexion <110 degrees)
o ligament integrity

Imaging
 Radiographs
o recommended views
 weight-bearing views of affected joint
o optional views
 knee
 sunrise view
 PA view in 30 degrees of flexion
o findings
 pattern of arthritic involvement
 medial and/or lateral tibiofemoral, and/or
patellofemoral
 characteristics
 joint space narrowing
 osteophytes
 eburnation of bone
  subchondral sclerosis
 subchondral cysts

Studies
 Histology
o loss of superficial chondrocytes
o replication and breakdown of the tidemark
o fissuring
o cartilage destruction with eburnation of subchondral bone

Treatment
 Nonoperative
o non-steroidal anti-inflammatory drugs
 indications
 first line treatment for all patients with symptomatic
arthritis
 technique
 Non-steroidal anti-inflammatory drugs (first choice)
 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
o rehabilitation, education and wellness activity
 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
o weight loss programs
 indications
 patients with symptomatic arthritis and BMI > 25
 technique
 diet and low-impact aerobic exercise
 outcomes
 AAOS guidelines: moderate evidence for
o controversial treatments
 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 againnst
 lateral wedge insoles
 AAOS guidelines: moderate evidence against
 Operative
o high-tibial osteotomy
 indications
 younger patients with medial unicompartmental OA
 technique
 valgus producing proximal tibial oseotomy
 outcomes
 AAOS guidelines: limited evidence for
o unicompartmental arthroplasty (knee)
 indications
 isolated unicompartmental disease
 outcomes
 TKA have lower revision rates than UKA in the setting
of unicompartmental OA
o total knee arthroplasty
 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