Curriculum Vitae

Nama
: dr. Gede Chandra Purnama
Yudha, SpOT
Tempat/Tgl Lahir : Malang, 24 November 1983
Agama
: Hindu
Status Pernikahan : Menikah
Alamat
: Jl. Setiabudi No 2 Malang
HP/Email
: 081230934000 /
dechanortho@yahoo.com

 Riwayat Pendidikan
1989 1995 : SDK Mardi Wiyata Malang, SDK Santo Yusuf II Malang
1995 1998 : SMP Negeri 3 Malang
1998 2001 : SMA Negeri 3 Malang
2001 2007 : Fakultas Kedokteran Universitas Brawijaya Malang
2008 2013 : Program Pendidikan Dokter Spesialis 1 Orthopaedi dan
Traumatologi Fakultas Kedokteran Universitas Brawijaya Malang

Riwayat Pekerjaan :
2013 sekarang : Dosen tetap Fakultas Kedokteran Universitas Wijaya Kusuma
Surabaya

Keanggotaan :
Ikatan Dokter Indonesia (IDI)
Perhimpunan Dokter Spesialis Orthopedi dan Traumatologi Indonesia (PABOI)
AOSpine

NON OPERATIVE
TREATMENT
OF OSTEOARTHRITIS
Gede Chandra P. Yudha
Surabaya Orthopaedic and Traumatology Hospital
2015

OSTEOARTHRITIS
Most common joint disorder in the United
States
Symptomatic knee OA occurs in 10% men
and 13% in women aged 60 years or older
Multi-factorial etiology
Old age, female gender, overweight and
obesity, knee injury, repetitive use of joints,
muscle weakness, and joint laxity
development of joint osteoarthritis,
particularly in the weight-bearing joints
Yuqing Zhang, D.Sc1 and Joanne M. Jordan, MD, MPH. Epidemiology of
Osteoarthritis

OSTEOARTHRITIS
TREATMENT

NON OPERATIVE
OPERATI
VE

AIMS OF TREATMENT
1. Help the patient understand the
nature of the disease
2. Provide psychological support
3. Alleviate pain
4. Suppress the inflammatory reaction
5. Encourage the patient to remain as
physically active as possible in order
to maintain joint function and
prevent
deformity
Salter,
Robert B. 1999. Textbook of Disorders and Injuries of the
Musculoskeletal System. Maryland : Lipincott Williams & Wilkins

AIMS OF TREATMENT
6.
7.
8.
9.

Correct existing deformity

Improve function
Strengthen weak muscles
Rehabilitate individual patient

Salter, Robert B. 1999. Textbook of Disorders and Injuries of the

Musculoskeletal System. Maryland : Lipincott Williams & Wilkins

NON OPERATIVE OA TREATMENT

MODALITIES
NON
PHARMACOLOGICAL

Education
Weight reduction
Physical therapy
Occupational therapy
Orthoses

PHARMACOLOGICAL

Analgesics - NSAIDs
Supplement
IA Injections

Non-pharmacological
EDUCATION
Patient needs to be reassured
Aging process, wearing out of joints
Better prepared to live within the limits
imposed by the painful joints

Salter, Robert B. 1999. Textbook of Disorders and Injuries of the

Musculoskeletal System. Maryland : Lipincott Williams & Wilkins

Non-pharmacological
WEIGHT REDUCTION
Achieved by exercise and dietary changes
Being only 10 pounds overweight increases
the force on the knee by 30-60 pounds
with each step.
among women with BMI 25, weight loss
was associated with a significantly lower
risk of knee OA
weight reduction of 10% improved function
by 28%

Felson DT: Weight and osteoarthritis. J.Rheumatol. 1995;43:7-9.

Felson DT, Zhang Y, Hannan MT, et al: Risk factors for incident radiographic knee osteoarthritis in the
elderly: the Framingham Study. Arthritis Rheum. 1997;40:728-733.
R. Christensen M.Sc.yz, Prof. A. Astrup D.M.Sc., M.D.z and Prof. H. Bliddal D.M.Sc., M.D. 2005. Weight loss:
the treatment of choice for knee osteoarthritis? A randomized trial. OsteoArthritis and Cartilage (2005)

Non-pharmacological
WEIGHT REDUCTION
AAOS reccomendation

American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of

the Knee, Evidence Based Guidelines 2nd ed

Non-pharmacological
PHYSICAL THERAPY
ROM exercises
Strengthening
Pain relieving modalities

Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine &

Rehabilitation, 5th ed. Philadelphia : Lipincott Williams & Wilkins

 ROM exercises
ROM deficits are well known sequelae of
OA, d/t articular changes, capsular
fibrosis, shortening myotendineous
structure
Principles :
Gentle movement through available ROM
Stretching is added (slow, gentle, sustained)
for 20-40s, repeat
Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine &
Rehabilitation, 5th ed. Philadelphia : Lipincott Williams & Wilkins

 Strengthening
Muscle weakness is common
shortening, ROM deficits, joint
imbalance
Exercises : Isometric, isotonic, or
isokinetic
AAOS reccomendation

Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine &

Rehabilitation, 5th ed. Philadelphia : Lipincott Williams & Wilkins
American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of the
Knee, Evidence Based Guidelines 2nd ed

 Pain-relieving modalities
Modalities :

Therapeutic heat/ cold

TENS
Ultrasound
Laser

Varying degrees of support within medical

literature
AAOS reccomendation

Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine &

Rehabilitation, 5th ed. Philadelphia : Lipincott Williams & Wilkins
American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of the
Knee, Evidence Based Guidelines 2nd ed

Non-pharmacological
OCCUPATIONAL THERAPY
Joint Protection & ADL training :
Respect pain, avoid activities that hurt
affected joints
Use appropiate assitive devices
Use largest and strongest joints and muscles
Avoid staying in one position for too long
Balance activity and rest
Avoid prolonged periods of immobility
Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine &
Rehabilitation, 5th ed. Philadelphia : Lipincott Williams & Wilkins

Non-pharmacological
ORTHOSES
Knee unloading brace, Lateral wedge
insole
AAOS reccomendations :

Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine &

Rehabilitation, 5th ed. Philadelphia : Lipincott Williams & Wilkins
American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of the
Knee, Evidence Based Guidelines 2nd ed

Pharmacological
ANALGESICS
Non opioids
Opioids
AAOS reccomendations

American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of

the Knee, Evidence Based Guidelines 2nd ed

Basic Medication Algorithm for

Hip/ Knee OA

Altman R, Hochberg M, Moskowitz R, et al. Recommendations for the medical

management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum.

Pharmacological
SUPPLEMENTS
Glucosamines
Chondroitin sulphate
AAOS reccomendation

American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of the Knee,

Evidence Based Guidelines 2nd ed

Pharmacological
INTRA ARTICULAR (IA) INJECTION
Corticosteroids
Hyaluronic acid
Platelet-Rich Plasma

 IA corticosteroid injection
Corticosteroids inhibit the inflammatory and
immune cascade at several levels
Widely used
Short term reduction for OA pain (4 weeks)
Possible adverse effects
Infection
Charcot arthropathy
Egemen Ayhan, Hayrettin Kesmezacar, Isik Akgun. Intraarticular injections (corticosteroid,
hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop 2014 July
18; 5(3): 351-361 ISSN 2218-5836
Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine & Rehabilitation, 5 th

 IA corticosteroid injection
AAOS reccomendation

American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of

the Knee, Evidence Based Guidelines 2nd ed

 IA Hyaluronic acid injection

Exact mechanism of action not clear
The actual period that HA injection stays within the
joint is only hours to days, but the time of clinical
efficacy is several months (up to 26 weeks)
Possible anti-inflamatory effect, stimulation of in vivo
HA synthesis by the injection
Benefits similar to NASIDS but no side effects

Egemen Ayhan, Hayrettin Kesmezacar, Isik Akgun. Intraarticular injections (corticosteroid,

hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop 2014 July
18; 5(3): 351-361 ISSN 2218-5836
Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine & Rehabilitation, 5 th

 IA Hyaluronic acid injection

AAOS reccomendation

American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of

the Knee, Evidence Based Guidelines 2nd ed

 IA Platelet-Rich Plasma
injection
Promising treatment for knee
osteoarthritis
Studies have shown that PRP is
a safe and effective treatment
option for knee osteoarthritis.
Similar in efficacy to hyaluronic
acid, and seems to be more
effective than hyaluronic acid
in younger, active patients with
low-grade osteoarthritis.
Treatment benefits seem to
wane after 6-9 mos.
Pourcho AM1, Smith J, Wisniewski SJ, Sellon JL. Intraarticular platelet-rich plasma injection in the treatment
of knee osteoarthritis: review and recommendations. Am J Phys Med Rehabil. 2014 Nov
Y. Zhu, M. Yuan, H.Y. Meng, A.Y. Wang, Q.Y. Guo, Y. Wang, J. Peng. 2013. Basic science and clinical application
of platelet-rich plasma for cartilage defects and osteoarthritis: a review. Osteoarthritis and Cartilage 21

 IA Platelet-Rich Plasma Injection

Mechanism of action :
Poorly understood
Broad spectrum of Growth Factors
chondroprotective and promoting anabolic
response
Animal model :
Decrease chondrocyte apoptosis
Incresed proteoglycans in articular cartilage
Prevention against OA progression
Egemen Ayhan, Hayrettin Kesmezacar, Isik Akgun. Intraarticular injections (corticosteroid,
hyaluronic acid, platelet rich plasma) for the knee osteoarthritis. World J Orthop 2014 July

 IA Platelet-Rich Plasma injection

AAOS reccomendation

American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of

the Knee, Evidence Based Guidelines 2nd ed

IA KNEE INJECTION

Superolateral Approach
Patient Supine with knee extended
Palpate bony landmarks
Patella
Lateral Femur

Palpate Patella

X Marks the Spot

Palpate lateral
border of
patella and
Lateral femur
at the PF joint
The space
between these
bony structures
is your injection
site

The Injection
Reassure
patient
Relaxed quads
= more space
at PF jt
Needle
Trajectory
15-20 degrees
Toward trochlea
of femur

Needle Trajectory

Anterior Approach (bent

knee)

Anterior Approach
Palpate landmarks
Inferior pole of patella
Patella tendon
Tibial Plateau

Landmarks - Patella

Landmarks - Plateau

Landmarks

Injection Site
May inject medial
or lateral to patella
tendon
1cm above tibial
plateau or
Half the distance
from plateau to
inferior pole of
patella
Trajectory of needle
should be toward
intercondylar notch

Trajectory

TAKE HOME MESSAGE

Non operative treatment of
osteoarthritis comprises of nonpharmacological and pharmacological
treatment that vary greatly. Some are
already clear, and some others still
need further studies
To obtain the best result of non
operative treatment, multidiciplinary
approach is necessary

REFERENCE

Altman R, Hochberg M, Moskowitz R, et al. Recommendations for the medical

management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum.
2000;43(9):19051915
American Academy of Orthopaedic Surgeon. 2013. Treatment of Osteoarthritis of the
Knee, Evidence Based Guidelines 2nd ed
Egemen Ayhan, Hayrettin Kesmezacar, Isik Akgun. Intraarticular injections
(corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis.
World J Orthop 2014 July 18; 5(3): 351-361 ISSN 2218-5836
Felson DT: Weight and osteoarthritis. J.Rheumatol. 1995;43:7-9.
Felson DT, Zhang Y, Hannan MT, et al: Risk factors for incident radiographic knee
osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997;40:728733.
Pourcho AM1, Smith J, Wisniewski SJ, Sellon JL. Intraarticular platelet-rich plasma
injection in the treatment of knee osteoarthritis: review and recommendations. Am J
Phys Med Rehabil. 2014 Nov
Salter, Robert B. 1999. Textbook of Disorders and Injuries of the Musculoskeletal
System. Maryland : Lipincott Williams & Wilkins
Stitik, Todd P, et al. 2010. Osteoarthritis, in : DeLisas Physical Medicine &
Rehabilitation, 5th ed. Philadelphia : Lipincott Williams & Wilkins
Y. Zhu, M. Yuan, H.Y. Meng, A.Y. Wang, Q.Y. Guo, Y. Wang, J. Peng. 2013. Basic science
and clinical application of platelet-rich plasma for cartilage defects and osteoarthritis:
a review. Osteoarthritis and Cartilage 21 (2013) 1627-1637
Yuqing Zhang, D.Sc1 and Joanne M. Jordan, MD, MPH. Epidemiology of Osteoarthritis.

RS ORTHOPEDI & TRAUMATOLOGI

SURABAYA