Management of Arthritis:

Recent Trends

Dr. Neeraj Aggarwal MS, FJRS

Consultant Orthopaedic & Joint Replacement surgeon
Narayana Hrudayalaya Hospital
Pratap Nagar, Jaipur.

Objectives of todays 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

Anatomy of Knee

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

Prevalence of Knee Pain

2%
2,000

Knee pain, severe disability & Xray OA

Knee pain, some disability & Xray OA
Knee pain with some
disability
4 weeks of knee pain in past
year
Subjects aged 55
years+

7,500
12,500
25,000
100,000
(Croft et al, 1998)

Prevalence of Knee OA

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

Why is this problem more

prevalent in India

Squatting / Ground sitting habits

Climbing stairs
Indian Toilets
Obesity
Complicated patients
Heredity

Can we prevent Osteoarthritis

Characteristics of Knee OA
Symptoms
Pain in and around the Knee joint
Morning Stiffness (worse on standing
& attempting to walk)
Swelling of Joint
Occasional night pain
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 2

Grade 1

All Grade 4
Grade 3

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

Physiotherap
y
Exercises:
- Static Quadriceps

Exercises
- Quadriceps Building
Exercises
- Hamstring Building
Exercises
Physiotherapy aims to restore
- Isokinetic Exercises for
function
knee
joint to the maximum degree
possible
through
exercises
- Progressive
resistance
helps reduce pain
Exercises
increases joint range of movement
improves muscles strength
addresses specific restrictions in
activities

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

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

D.M.A.OA.D.
OA

???

D.M.A.OA.D.
OA ?

??

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 !

Intraarticular
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
REPLACEMENT SURGERY
INDICATION PENALTY POINTS ( 75 PLUS)
Progression + Disability

Pain
40

Deformity
20

ROM
20

Instability
20

 FIVE LAKH IS THE NUMBER OF KNEE

REPLACEMENT SURGRIES DONE IN USA IN
2008
IN INDIA THE CORRESPONDING NUMBER IS
35000 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

HowtheArtificialknee
fitsonthebones?

Modern Knee

Where to undergo
Surgery

Post-Op TKR

AP

Lateral

Common Post-Operative (TKR)

Course
Day 1

Standing, 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 10-12

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 doesnt
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

Myths

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

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 attenti