Degenerative Osteoarthritis

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Degenerative osteoarthritis (OA) of the knee is caused by loss of the hyaline cartilage along the knee joint surfaces. This can occur in an isolated compartment or diffusely throughout all three compartments of the knee. OA more often develops in the medial side or medial compartment of the knee, first

Figure 30-24 24 Transverse fracture through waist of scaphoid.

(Courtesy James L. Moeller, MD.)

Figure 30-24 24 Transverse fracture through waist of scaphoid.

(Courtesy James L. Moeller, MD.)

Figure 30-25 Weight-bearing knee radiographs showing osteoarthritis.

leading to joint space narrowing and varus or bowleg deformity. Loss of articular cartilage and joint space on the lateral aspect of the knee leads to valgus or knock-knee deformity. Weight-bearing (standing flexed-knee PA) radiographs are strongly recommended to evaluate joint space narrowing and OA extent. Lateral and patella sunrise tangential views complete the study (Fig. 30-25). MR images are not routinely required and should not be ordered instead of plain x-ray films. MRI is best reserved for mechanical pathology or preoperative planning. X-ray findings include loss of the joint space, presence of osteophytes, subchondral sclerosis, and cysts.

Patients with OA typically complain of knee pain and stiffness with walking, after prolonged sitting, descending stairs, and early in the morning. Swelling of knees and worse symptoms are typical with weather changes. Physical exam findings often reveal decreased ROM (flexion contractures), knee varus or valgus deformity, joint line tenderness, and crepitus with palpation during ROM.

Treatment of OA is based on the patient's age, demand, comorbidities, and severity of osteoarthritis. Conservative treatment for knee arthritis should include a generalized conditioning program, weight loss, a knee sleeve to improve the proprioceptive control, cushioned shoes, and NSAIDs. Oral supplementation with glucosamine and chondroitin sulfate may also be considered. If these do not provide relief after 4 to 6 weeks, corticosteroid or viscosupplement injections can be administered, typically with variable pain relief and duration. Injections may be repeated depending on patient response. In resistant cases, total or partial knee replacement can provide excellent pain relief and improve function. The effect of arthroscopy in patients with degenerative arthritis remains controversial (Hunt et al., 2002; Mosely et al., 2002). However, arthroscopy in the absence of loose bodies, cartilage flaps, or meniscal pathology is unlikely to be unsuccessful.

EVIDENCE-BASED SUMMARY

• The short-term benefit of intra-articular corticosteroid in treatment of knee osteoarthritis is well established; however, longer-term benefits have not been confirmed, and the response to hyaluronic products appears to have more durability (Bellamy et al., 2005a) (SOR: A).

• Based on a single RCT, bracing for OA may provide additional benefit compared to medical treatment alone (Brouwer et al., 2001) (SOR: B).

• Land-based therapeutic exercise programs reduce pain and improve physical function for patients with OA of the knee (Brosseau et al., 2003; Fransen et al., 2001) (SOR: A).

• Viscosupplementation (injection of hyaluronate) is an effective treatment for OA of the knee, with beneficial effects on pain and function (Bellamy et al., 2005b) (SOR: A).

• Nonglucosamine preparations failed to show benefit, whereas glucosamine preparations were superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA (Towhead et al., 2009) (SOR: A).

• Arthroscopic debridement has no benefit for undiscriminated OA with mechanical or inflammatory causes (Laupattarakasem et al., 2009) (SOR: A).

• In OA patients, exercise results in a modest reduction in pain and a modest improvement in physical function (Fransen and McConnell, 2009) (SOR: B).

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