9. • Paracetamol, max 3-4 gm/day
analgesic of choice 1st line and long term
• Topical NSAIDs
• NSAIDs— For Pts not responding to
Pmol and for exacerbations
• Tramadol
• Codeine
• SYSADOA - No role
Glusosamine SO4
Chondroitin SO4
Diacerin
Oral Therapy
12. • Delayed effect (4 weeks)
• Long duration (6 months)
• 1-5 weekly injections
Not recommended
J Bone Joint Surg Am, 2013 Oct
Intra-Articular Hyaluronic Acid
(IAHA)
“viscosupplement”
13. IAHA: Mechanism of Action
• Increased synovial fluid HA conc.
• Increased cartilage
lubrication/elasticity
• Chondrocyte proliferation
• Decreased inflammatory mediators
Devine, Shaffer. Use of viscosupplementation
for knee osteoarthritis: an update. Curr Sports Med Rep 2011
14. Platelet-Rich Plasma in Knee
OA
• Kon et al 2010 and Filardo et al 2011 , series n=115
• Three 5ml PRP; improved at 6 and 12 months
• Sampson et al 2010 series n=14
• PRP at 0/4/8 wks; pain reduction out to 52 weeks in majority
• Wang-Saegusa et al 2011 series n=261
• PRP at 0/2/4 wks; improved pain/fxn/QOL to 6 mos w/o AdvEfx
• Sanchez et al. 2008 case/cont
• PGRF vs Hyaluronic acid (HA), weekly x3
• At 5 weeks, 33% decrease pain w/ PRGF, 10% w/ HA
• Spakova et al 2012 case/cont, n=120
• PRP vs HA, weekly x3; At 3 & 6 mo, PRP better WOMAC/VAS
• Kon & Mendelbaum et al 2011 case/cont n=150
• LMW HA vs HMW-HA vs PRP at weekly x3
• PRP better than HA at 6 mo
• Age > 50 and severe OA: PRP = LMW-HA
• Age<50 with cartilage lesions, and mild OA: PRP best
• Li & Zhang et al, 2011 RCT n=30
• PRP vs HA at 0/3/6 weeks; PRP more effective at 6 mo
16. Arthroscopic Debridement ??
• “In a controlled trial involving patients with
osteoarthritis of the knee, the outcomes after
arthroscopic lavage or arthroscopic débridement
were no better than those after a placebo
procedure”.
Moseley, RB et al., Arthroscopic Surgery for Osteoarthritis of the Knee?. NEJM 2002 359:
1169-1170
Kirkley A et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee.
NEJM Sep 2008;359:1097
20. Dr. Mark Coventry of the Mayo Clinic who first described osteotomy
for degenerative arthritis. The original paper published in 1965
continues to be clinically relevant.
Coventry, M. Osteotomy of the Upper Portion of the Tibia
For Degenerative Arthritis of the knee: A PRELIMINARY
REPORT. J. Bone and Joint Surgery 1965 47:984-990
24. Disadvantages of Closing
Wedge Osteotomy
• Removes bone from metaphysis
• Requires fibular osteotomy
• Peroneal neuropathy 15%
• Lateral tibiofemoral instability 15%
• Patella Baja
• Increases difficulty of later TKA
25. Opening Wedge Osteotomy
1990s
Noyes FR, Goebel SX, West J: Opening wedge tibial osteotomy:
The 3-triangle method to correct axial alignment and tibial slope. Am J Sports Med 33:378-387, 2005.)
26. Advantages of Opening Wedge
Osteotomy
• Adds bone to tibial metaphysis
• No lateral knee instability
• Rare peroneal neuropathy
• Later TKA no more difficult than usual
27. J Bone Joint Surg Am, 2013 Oct 16;95(20):1885-1886
33. AAOS 2013
Recommendations
Inconclusive Evidence to Support for or
Against
• Use of a (PRP)
• medial compartment unloader brace
• Arthroscopic partial meniscectomy in patients with
knee osteoarthritis and torn meniscus
• Intraarticular corticosteroids
34. Differences between 2008 and
2013 Recommendations
• With viscosupplementation and
injection of hyaluronic acid.
• In 2008 guidelines –
rating: inconclusive.
• In 2013 with a "strong" rating against
based on new evidences.
