summary Knee osteoarthritis is degenerative disease of the knee joint that causes progressive loss of articular cartilage. Diagnosis can be made with plain radiographs of the knee. Treatment is observation, NSAIDs, tramadol and corticosteroids for minimally symptomatic patients. Knee arthroplasty is indicated for progressive symptoms with severe degenerative disease. Epidemiology Incidence hip OA (symptomatic) 88 per 100,000 per year knee OA (symptomatic) 240 per 100,000 per year Risk factors modifiable articular trauma occupation, repetitive knee bending muscle weakness large body mass metabolic syndrome central (abdominal) obesity, dyslipidemia (high triglycerides and low-density lipoproteins), high blood pressure, and elevated fasting glucose levels. non-modifiable gender females >males increased age genetics race African American males are the least likely to receive total joint replacement when compared to whites and Hispanics Etiology Pathophysiology pathoanatomy articular cartilage increased water content alterations in proteoglycans eventual decrease in amount of proteoglycans collagen abnormalities organization and orientation are lost binding of proteoglycans to hyaluronic acid synovium and capsule early phase of OA mild inflammatory changes in synovium middle phase of OA moderate inflammatory changes of synovium synovium becomes hypervascular late phases of OA synovium becomes increasingly thick and vascular bone subchondral bone attempts to remodel forming lytic lesion with sclerotic edges (different than bone cysts in RA) bone cysts form in late stages osteophytes form through the pathologic activation of endochondral ossification mediated by the Indian hedgehog (Ihh) signaling molecule Cell biology proteolytic enzymes matrix metalloproteases (MMPs) responsible for cartilage matrix digestion examples stromelysin plasmin aggrecanase-1 (ADAMTS-4) tissue inhibitors of MMPS (TIMPs) control MMP activity preventing excessive degradation imbalance between MMPs and TIMPs has been demonstrated in OA tissues inflammatory cytokines secreted by synoviocytes and increase MMP synthesis examples IL-1 IL-6 TNF-alpha Genetics inheritance non-mendilian genes potentially linked to OA vitamin D receptor estrogen receptor 1 inflammatory cytokines IL-1 leads to catabolic effect IL-4 matrilin-3 BMP-2, BMP-5 Classification Kellgren & Lawrence (based on AP weightbearing XRs) Grade 0 No joint space narrowing (JSN) or reactive changes Grade 1 Possible osteophytic lipping + doubtful JSN Grade 2 Definite osteophytes + possible JSN Grade 3 Moderate osteophytes + definite JSN + some sclerosis + possible bone end deformity Grade 4 Large osteophytes + marked JSN + severe sclerosis + definite bone end deformity Presentation History identify age, functional activity, pattern of arthritic involvement, overall health and duration of symptoms Symptoms function-limiting knee pain effect on walking distances pain at night or rest activity induced swelling knee stiffness mechanical instability, locking, catching sensation Physical exam inspection body habitus gait often an increased adductor moment to the limb during gait antalgic gait associated with knee arthritis knee is maintained in flexion shortened stride length compensatory toe walking limb alignment effusion skin (e.g. scars) range of motion lack of full extension (>5 degrees flexion contracture) lack of full flexion (flexion <110 degrees) ligament integrity Imaging Radiographs recommended views weight-bearing views of affected joint optional views knee sunrise view PA view in 30 degrees of flexion findings pattern of arthritic involvement medial and/or lateral tibiofemoral, and/or patellofemoral characteristics joint space narrowing osteophytes eburnation of bone subchondral sclerosis subchondral cysts Studies Histology loss of superficial chondrocytes replication and breakdown of the tidemark fissuring cartilage destruction with eburnation of subchondral bone Treatment Nonoperative non-steroidal anti-inflammatory drugs indications first line treatment for all patients with symptomatic arthritis technique Non-steroidal anti-inflammatory drugs (first choice) topical and oral NSAIDS recommended selection should be based on physician preference, patient acceptability and cost duration of treatment based on effectiveness, side-effects and past medical history outcomes AAOS guidelines: strong evidence for tramadol indications treatment option for patients with symptomatic arthritis technique weak opioid mu receptor agonist good evidence for mid term (8-13 weeks) improvement in pain and stiffness over placebo outcomes Prior AAOS guidelines recommended its use, but newer guidelines do NOT recommend its routine use rehabilitation, education and wellness activity indications first line treatment for all patients with symptomatic arthritis technique self-management and education programs combination of supervised exercises and home program have shown the best results these benefits lost after 6 months if exercises are stopped outcomes AAOS guidelines strong evidence for weight loss programs indications patients with symptomatic arthritis and BMI > 25 technique diet and low-impact aerobic exercise outcomes AAOS guidelines: moderate evidence for bracing medial unloader for isolated medial compartment OA AAOS guidelines: moderate evidence for controversial treatments acupuncture AAOS guidelines: strong evidence against viscoelastic joint injections AAOS guidelines: strong evidence against glucosamine and chondroitin AAOS guidelines: strong evidence against needle lavage AAOS guidelines: moderate evidence against lateral wedge insoles AAOS guidelines: moderate evidence against Operative high-tibial osteotomy indications younger patients with medial unicompartmental OA technique valgus producing proximal tibial oseotomy outcomes AAOS guidelines: limited evidence for unicompartmental arthroplasty (knee) indications isolated unicompartmental disease outcomes TKA have lower revision rates than UKA in the setting of unicompartmental OA total knee arthroplasty indications symptomatic knee osteoarthritis failed non-operative treatments techniques cruciate retaining vs. crucitate sacrificing implants show no difference in outcomes patellar resurfacing no difference in pain or function with or without patella resurfacing lower reoperation rates with resurfacing drains are not recommended controversial treatments arthroscopic debridement or lavage AAOS guidelines: strong evidence against arthroscopic meniscal debridement AAOS guidelines: inconclusive evidence
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA Revision Orthobullets Team Recon - TKA Stiffness Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Parapatellar Approach Derek T. Bernstein Stephen Incavo Recon - TKA Stiffness Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. High Tibial Osteotomy Orthobullets Team Recon - High Tibial Osteotomy Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique Derek T. Bernstein Stephen Incavo Recon - TKA Heterotopic Ossification
QUESTIONS 1 of 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ16HK.9) Which of the following received a strong recommendation against it by the American Academy of Orthopaedic Surgeons (AAOS) in the most recently released (2nd) edition of the Clinical Practice Guideline on the Treatment of Osteoarthritis of the Knee? QID: 211207 Type & Select Correct Answer 1 Arthroscopic debridement in patients with a primary diagnosis of osteoarthritis of the knee 53% (995/1892) 2 Arthroscopic partial meniscectomy in patients with a primary diagnosis of osteoarthritis of the knee with a torn meniscus 4% (84/1892) 3 Valgus-producing high tibial osteotomy in patients with symptomatic medial compartment osteoarthritis of the knee 4% (80/1892) 4 Free-floating interpositional devices in patients with symptomatic medial compartment osteoarthritis of the knee 15% (280/1892) 5 None were issued as strong recommendations due to a lack of high strength evidence for or against 23% (441/1892) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.31) Which of the following statements is true about racial disparities in total joint arthroplasty? QID: 4666 Type & Select Correct Answer 1 The rate of surgical intervention for African American males is lower than white or Hispanic males 87% (4313/4933) 2 The rate of surgical intervention for Hispanics is higher than that for whites 1% (72/4933) 3 The rate of surgical intervention for white males is lower than for African American males 4% (186/4933) 4 There is no difference in the rate of surgical intervention between whites, Hispanics, or African Americans 5% (268/4933) 5 The rate of surgical intervention is equal for Hispanic and white males 1% (66/4933) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.205.1) According to the 2013 American Academy of Orthopaedic Surgeons' Guidelines for the treatment of symptomatic osteoarthritis of the knee, which of the following treatments was recommended and strongly supported? QID: 211069 Type & Select Correct Answer 1 Acupuncture 0% (11/2513) 2 Hyaluronic acid injections 1% (37/2513) 3 NSAIDs or tramadol 96% (2413/2513) 4 Glucosamine and/or chondroitin 1% (25/2513) 5 Arthroscopic lavage and/or debridement 0% (12/2513) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.229) Which of the following is an example of an antalgic gait pattern not typically seen in clinical practice? QID: 3652 Type & Select Correct Answer 1 Patient's knee is maintained in slight flexion throughout the stance period for ipsilateral knee arthritis 6% (119/1988) 2 Patient's contralateral step length is shortened with ipsilateral ankle arthritis 11% (213/1988) 3 Patient leans their trunk laterally over the painful leg during stance phase with ipsilateral hip arthritis 18% (363/1988) 4 Patient ambulates on their toes with an ipsilateral calcaneal stress fracture 4% (84/1988) 5 Patient ambulates predominately through the heel for ipsilateral knee arthritis 60% (1192/1988) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ09.181) According to the latest recommendations made by the AAOS in their clinical guidelines for the treatment of osteoarthritis (OA) of the knee, which of the following nonoperative treatment modalities has the weakest supporting evidence for the treatment for knee osteoarthritis? QID: 2994 Type & Select Correct Answer 1 Weight loss 1% (30/3926) 2 Activity modifications 1% (30/3926) 3 Quadriceps strengthening 4% (153/3926) 4 Intra-articular hyaluronic acid injections 89% (3483/3926) 5 Intra-articular corticosteroid injections 6% (220/3926) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic
All Videos (10) Podcasts (1) Login to View Community Videos Login to View Community Videos 2022 California Orthopaedic Association Annual Meeting Pros and Cons on the Use of PRP for OA: Future Formulations May be Better - Constance Chu, MD Constance R. Chu Recon - Knee Osteoarthritis 8/10/2022 191 views 4.7 (3) Login to View Community Videos Login to View Community Videos Knee Injection (Viscosupplement) Kemal Gokkus Recon - Knee Osteoarthritis C 6/22/2021 329 views 5.0 (1) Login to View Community Videos Login to View Community Videos 2019 Orthopaedic Summit Evolving Techniques Rebuttal: Debate: Same Day Total Knee Arthroplasty Has Arrived Even In The Big Cities - Michael P Ast, MD, Martin Roche, MD Michael P. Ast Recon - Knee Osteoarthritis C 11/14/2020 51 views 4.0 (1) Recon⎜Knee Osteoarthritis Team Orthobullets 4 Recon - Knee Osteoarthritis Listen Now 10:56 min 10/21/2019 827 plays 5.0 (3) See More See Less
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