Introduction Definition degenerative disease of synovial joints that causes progressive loss of articular cartilage 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 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 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) 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 AAOS guidelines: strong evidence for 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 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 againnst 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
Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Revision TKR Orthobullets Team Recon - TKA Rehabilitation Technique Guide 5/9/2017 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. TKA - Parapatellar Approach Derek Bernstein Stephen Incavo Recon - TKA Coronal Plane Balancing Technique Guide 10/4/2016 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. High Tibial Osteotomy Orthobullets Team Recon - High Tibial Osteotomy Technique Guide 7/15/2017 Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. TKA - Varus Knee with Anterior Referencing and Gap Balancing Technique Derek Bernstein Stephen Incavo Recon - TKA Stiffness
QUESTIONS 1 of 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 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 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 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? Review Topic QID: 2994 1 Weight loss 1% (21/3106) 2 Activity modifications 1% (26/3106) 3 Quadriceps strengthening 4% (134/3106) 4 Intra-articular hyaluronic acid injections 88% (2735/3106) 5 Intra-articular corticosteroid injections 6% (183/3106) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ13.241) Which of the following non-operative treatments for osteoarthritis has the best evidence to support its use? Review Topic QID: 4876 1 Combination of supervised and home exercise programs 83% (3076/3685) 2 Hyaluronic acid injections 3% (95/3685) 3 Lateral heel wedge 1% (32/3685) 4 Acetaminophen 12% (426/3685) 5 Glucosamine 1% (33/3685) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ13.31) Which of the following statements is true about racial disparities in total joint arthroplasty? Review Topic QID: 4666 1 The rate of surgical intervention for African American males is lower than white or Hispanic males 88% (3289/3757) 2 The rate of surgical intervention for Hispanics is higher than that for whites 2% (58/3757) 3 The rate of surgical intervention for white males is lower than for African American males 4% (136/3757) 4 There is no difference in the rate of surgical intervention between whites, Hispanics, or African Americans 5% (199/3757) 5 The rate of surgical intervention is equal for Hispanic and white males 1% (52/3757) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (OBQ11.201) Which of the following treatment recommendations lacks Level 1 supporting evidence (Grade A Recommendation) according to the the American Academy of Orthopaedic Surgeons (AAOS) Guidelines for Treatment of Knee Arthritis (OA)? Review Topic QID: 3624 1 Recommend patients be encouraged to participate in low-impact aerobic fitness exercises 4% (109/2651) 2 Recommend against glucosamine and/or chondroitin sulfate or hydrochloride for patients with symptomatic OA of the knee 25% (664/2651) 3 Recommend for arthroscopic partial meniscectomy as an option in patients with symptomatic OA of the knee who also have primary signs and symptoms of a torn meniscus 56% (1478/2651) 4 Recommend for weight loss in patients who are overweight (as defined by a BMI>25) 6% (155/2651) 5 Recommend against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee 9% (234/2651) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 3 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
Cortisone and Viscosupplementation: Do Injections actually Work? - Jason L. Dragoo, MD (3.15, 2018 Winter SKS) Recon - Knee Osteoarthritis - All WINTER SKS: 2018 SHOULDER, KNEE, & SPORTS MEETINGCortisone and Viscosupplementat... 8/8/2018 331 views Evolving Technique Update: 61-Year-Old with Rheumatoid Arthritis 15 Degrees of Varus - How to Succeed Steven B. Haas, MD Recon - Knee Osteoarthritis - All Evolving Technique Update: 61-Year-Old with Rheumatoid Arthritis 15 Degrees of V... 4/27/2018 202 views Knee Donor-Site Morbidity after Mosaicplasty - What Does the Literature Tell Us - João Espregueira-Mendes, MD, PhD Recon - Knee Osteoarthritis - All Knee Donor-Site Morbidity after Mosaicplasty - What Does the Literature Tell UsJ... 4/23/2018 87 views See More See Less
59M with Knee Pain and Varus/flexion Contracture (C101138) Recon - Knee Osteoarthritis HPI - 59M with 3 years of right knee pain. Due to bilateral knee pain, he uses a motorized cart to get around outside the house and a walker inside the house. He rates his pain as a constant 5/10, worse with walking, and awakens him from sleep. What type of implant would you expect to use in this patient. 11/26/2018 128 8 4 70M with Knee Pain and h/o Retrograde IM nail (C101130) Recon - Knee Osteoarthritis HPI - Remote history (30 yrs) of left “knee injury” Left distal 1/3 femur fx 6 years ago Treated with retrograde IM nail When performing a TKA in this patient, I would use a: 11/15/2018 78 2 4 Medial-sided knee pain and degenerative changes in a 50M (C2818) Recon - Knee Osteoarthritis HPI - Factory worker, 3 year history of medial-sided knee pain, previous knee arthroscopy, and debridement of MM and MFC defect which got progressively worse. What is your surgical management of this patient's knee pain? 5/18/2017 141 5 6 See More See Less