Management of Arthritis: Recent Trends Dr. Neeraj Aggarwal MS, FJRS Consultant Orthopaedic & Joint Replacement surgeon Narayana 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 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 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

WEIGHT

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

PRECAUTIONS 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

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

OA D.M.A.OA.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 !

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

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 PainDeformity ROM Instability REPLACEMENT SURGERY 20

FIVE LAKH IS THE NUMBER OF KNEE REPLACEMENT SURGRIES DONE IN USA IN 2008 IN INDIA THE CORRESPONDING NUMBER IS IN 2008 WITH ALL OUR MANFORCE WE ARE ABLE TO TACKLE ONLY 3% OF TOTAL ARTHRITIS PATIENTS WHERE ARE WE ???????

Normal 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 1Standing, bending and sitting out in a chair May 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 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

Future ……… Robotics Custom Implants and Instruments Stem cell therapy Appreciate your attention