Osteoarthritis of

Knee

Diagnosis and Management

Agus Adiantono, MD
Lamongan, Oktober 2010

Definition :

No universal agreement
Current working definition :
A condition of synovial joints
charaterised by cartilage loss
(chondropathy) and evident of
periarticular bone response.

Classification :
Type I :
Polyarticular degenerative arthritis
Unknown origin
Rarely occurs before 35 years

Classification :
Type II :
Monoarticular arthritis
Reaction to some condition that has
produced incongruity of joint surfaces

Pyogenic infecton
Congenital anomaly
Coxa plana
Ligamentous instability
Physeal separation
fracture

Risk factor of OA :

Generalized susceptibility

Genetic factors :

Aging :

HLA1,B8 (Heberdens node)

1 antitrypsin phenotype
Does not cause OA
Increase the risk of degeneration
Decrease ability of articular cartilage to
prevent progression

Obesity

Risk factor of OA :

Local mechanical factors :

Trauma :

Intra articular
Alter mechanical loading

Joint shape :

Perthes diseases
Slipped capital epiphysis
CDH

Abnormal load transmission across joint

Risk factor of OA :

Local mechanical factors :

Occupational and recreational activities

Repetitive impact loading and micro trauma

Wear and tear
e.g. : miners (OA knee, spine)
cotton workers (Dip joint)

Pathology

Chondropathy

Periarticular bone response

Pathology

Chondropathy

Early :
Surface irregularities (fibrilation)
Small cleft beyond the superficial zone
Slight hypercellularity
Minimum loss of proteoglycan, not
extending beyond the transitional zone

Moderately Advance :
More extensive loss of surface
Clefts extend into middle zone
Loss of proteoglycan extend to middle zone
Hypercellular

Pathology

Chondropathy

Advance :
Reduce of cartilage thickness
Reduce proteoglycan throughout entire
thickness
Complete loss of articular cartilage
(eburnated of sub chondral bone)
Focal pressure necrosis

Pathology
Periarticular bone response :
New bone formation in sub chondral
bone
New cartilage formation and
enchondral ossification

Pathogenesis

Local mechanical factors

Generalize suscepbility
Release degrading cytokines
/enzymes by chondrocyte
(Interleukin - 1.etc)

Collagen
alteration

Proteoglycan
alteration
Mineralization

Synovial
inflamation

Cartilage
alteration
Cartilage
destruction

OA

Macroscopic

OA Knee
Symptoms :

Pain

Chief complain
Mechanism of pain :

Stimulation of capsule pain fibers and

mechanorecepters by : intra articular hypertension
Imflammatary mediators stimulating pain fibers in
the synovium and capsule.
Stimulation of periostal nerve fibers by
intraosseous hypertension, osteofit formation
Subchondral micro fracture
Bursitis, muscle spasm,
Instability

Pain characteristic

On usage : mechanical
At rest
: inflamation
At night : intra osseous hypertension

Symptoms :

Joint stiffness
Functional impairment, due to :
Pain
Reduce range and control of
movement
Deformity

Signs :
Crepitus

Bony

Irregulat articular surface

enlargement :
Osteophyte
Remodelling Deformity

Instability
Restricted

movement
Muscle weakness
Massive joint effusion

Laboratory test

Non specific
Increase inflammatory mediators on
synovial fluid
Urine CTX II increasing
(C-Telopeptide fragments of type II
collagen)

Radiography

correlates with pathological changes

Pathological change
Cartilage fibrilation, erosion
Subchondral new bone formation
New cartilage formation and
endochondral ossification
Fibrous-walled pseudocysts
reulting from fluid instrusion
or myxoid degeneration
Trabecular compression
Fragmentation of osteochondral
surface; cartilage and bone
metaphasia in synovium

Radiograhic
abnormality
Decrease in interosseous
distance (localized)
Sclerosis
Osteophyte
Subchondral cyts
Bone collapse / attrition
Osseous (loose) bodies

Radiography

Radiography

Radiography
Classification Kellgren and Lawrence
(1957)
Grade 0 : normal
Grade I : minimal osteophyte
normal joint space
Grade II : definite osteophyte
possible joint space narrowing
Grade III : definite osteophyte and joint
space narrowing
Grade IV : definite osteophyte and joint
space narrowing with sclerosis
and abnormal joint contour.

Radiography
Classification Ahlbck (1968)
Grade I : joint space narrowing (joint
space < 3mm)
Grade II : joint space obliteration
Grade III : minor bone attrition (0-5mm)
Grade IV : moderate bone attrition (510mm)
Grade V : severe bone attrition (>10mm)

Arthroscopic
Appearence

Stage I : Softening

Arthroscopic
Appearence

Stage II : Fibrilation

Arthroscopic
Appearence

Stage III : Fragmentation

Arthroscopic
Appearence

Stage IV : Eburnation

Diagnosis

Based on clinical and radiological

American Collage of Rheumatology :

Traditional format :

Knee pain and radiographic osteophytes and at

least 1 of the following 3 items :
Age >40 years
Morning stiffness <30min in duration
Crepitus on motion

Modified :

Knee pain and radiographic osteophytes or

Knee pain and age >40 years and morning siffness
<30 min in duration and crepitus on motion.

Management

Not known cure of OA

Goal of OA treatment :
Control

pain and other symptoms

Maintain and / or improve joint mobility
Minimize disability / functional
impairment
Education of patient and his or her family

Management
Multi modal management of patient
with OA of the knee :
Non
Pharmacologic
Pharmacologic
therapy
therapy
Surgical treatment

Management
Non pharmacologic therapy :
-

Patient education
Weight reducing
Resting
Exercise :

Joint protection and energy conservation :

Muscle strenghtening exercise

Physical therapy range of motion exercise
Aerobic exercise program
Assistive device for ambulation
Bracing
Reduce weight

Occupational therapy

Arthritis Exercise
According to the Degree of
Inflammation

Inflamati
on

Lo
w

Hig
h

Aerobic
Isotonic
ROM &
stretchin
g

Isometri
c

Exercise
Prescription

Recreatio
nal

Management
Pharmacologic therapy

Oral :

Intra articular :

Analgesic / anti inflamatory agent

Nutritional supplement
Anti catabolic cytokines agent
Carticosteroid ?
Visco therapy (hyaluronan)

Topical :

Capsaicin
Methyl salicylate
Transdermal Glucosamine Sulphate

Management
Pharmacologic therapy

Analgesic
Acetaminophen
Cox-2-specific inhibitor :

Celecoxib, Rofecoxib, Valdecoxib

Non selectiv NSAIDS :

Naproxen, Iboprofen, Diclofenac

Non acetylated salicylate

Opioid :

Codein, Morphin, Tramadol

American Pain Society 2004

Treatment of Chronic Pain
in OA
Mild pain
Little / no
inflammation
Acetaminop
hen
Continued
pain

Moderate-tosevere pain
inflammation
COX-2
sp.inhibitor
Continued
pain

Conduct GI
risk
Factor
analysis
High risk
Low
risk
NSAID +
protective
NSAID
Continued
pain

Hyaluronic acid
injection
Glucocorticoid

Management
Pharmacologic therapy

Nutritional supplement
Glucosamine
Chodroitine sulfate

Management
Pharmacologic therapy

Anti catabolic cytokines agent :

Diacerin :

Interleukine-1 inhibitor

Intra-Articular
Viscotherapy

Hyaluronan (hyaluronic acid ):

Attempts to restore synovial fluid protective,

lubricating, shock absorbing, barrier and
rheologic affects.
The agents are :

Non immunologic
Permeabel to metabolites and macromolecules.
Qualitatively similar to human synovial fluid.
Retained longer than endogenus hyaluronic acid.

Effects on joint pain and mobility last longer than

the agent is retained in the joint (improved
endogenous production?)

Management
Surgical therapy :

Minimally invasive arthroscopic :

Lavage
Debridement
Resurfacing

Surgical debridement :
Synovectomy
Excision

of osteophytes
Removal of loose bodies
Chondroplasty of cartilage
Removal of damaged menisci

Management
Surgical therapy :

Biological resurfacing :

Marrow stimulation
Autologos transplantation

Realignment osteotomy :

High Tibial Osteotomy

Distal Femoral Osteotomy

Arthroplasty :

Uni compartemental Knee Arthroplasty

Total Knee Arthroplasty

Arthrodesis

Biological Resurfacing

Marrow
stimulation :

Biological Resurfacing

Cartilage graft :

Biological Resurfacing

Cartilage
transplantation :

Realignment Osteotomy
High tibial osteotomy

Arthroplasty

Total knee
arthroplasty

Staging System for Establishing the Severity

of OA of the Knee.(Robert W. Jackson)

Based on :
Clinical

Symptoms
X-ray findings

Correlated with :
Arthroscopy

Severity Grading of OA of
Knee
Stage I :
Minimum

Symptoms
pain-swelling
X-ray
normal, or
minimal change
Arthroscopy
Softening or fibrilation

Severity Grading of OA of
Knee
Stage II :
Mild

Symptoms
pain-swelling, decreased ROM
Respond well to NSAIDS or
analgesic
X-ray
Decreased joint space on weightbearing film
Arthroscopy
Fibrilation

Severity Grading of OA of
Knee
Stage III :
Symptoms Moderate
pain-swelling, decreased ROM
Minimally respond to NSAIDS or
analgesic
X-ray
Decreased joint space
Osteophyte formation
Arthroscopy
Fragmentation

Severity Grading of OA of
Knee
Stage IV :

Severe Symptoms
Decreased ROM
Deformity, instability
Rest pain
X-ray
Decreased / lost of joint space
Osteophytes
Sclerosis
Malalignment
Arthroscopy
Eburnated bone

Recommended
Treatment
Stage I :

Conservatif :
Non-medication
Medication

Stage II :

Minimally invasive
arthroscopic
surgery
Lavage
Debridement

Recommended
Treatment
Stage III :
Biological resurfacing
techniques
Marrow stimulation
Penetration of
subchondral bone
(abrasion, drilling,
microfracture)
arthroscopic
Autologous transplantation
Chondrocyte
transplantation

Stage IV :

Analgesic
Realignme
nt
osteotomy
Arthroplast
y

Thank you