Knee Osteoarthritis

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Original Editors - Hamelryck Sascha

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Search Strategy

Databases used: Pubmed, Web of knowledge, American college of rheumatology.

Keywords used: osteoarthritis, knee, treatment, definition, exercises, surgery, condition (or a combination of these words).

Definition/Description

Knee osteoarthritis is the occurrence of osteoarthritis (OA) in the knee joint. The OA can be diagnosed in 3 places within the knee:
a. Medial compartment
b. Lateral compartment
c. Patellofemoral compartment

Clinically Relevant Anatomy

  As mentioned above OA in the knee occurs in the patellofemoral joint as well as in the tibiofemoral joint. (Figure1.)

File:OsteoarthritisKnee2.jpgFile:OsteoarthritisKnee1.jpg

Figure1 damage to:
the patellofemoral joint (left)
the tibiofemoral joint (right).

Other important factors are:
 - Quadriceps strenght
 - Alignment of the femur and tibia ( valgus/varus)
 - (age and weight)

Epidemiology /Etiology

Osteoarthritis can be catalogued in 2 types:

Type I: this type of OA is mostly related to aging, there is no other disease or trauma causing the condition.
With age the water level in the articulate cartilage rises and makes the cartilage less solid. The production of proteins that are used in the maintenance of the cartilage also decreases, making the cartilage more vulnerable to ruptures.

Type II: In this type of OA there is another condition or disease causing the OA
for example: obesity, diabetes, surgery to joint structures, repeated trauma...

In the early stage in an osteoarthritis affected knee joint the cartilage will start show signs of wear, tiny crevasses or ruptures. If no effort is made to slow down or stop this process the cartilage will then further degenerate and pieces of the cartilage “cushion” between the bones of the affected joint will be gone. This will affect the functioning of the underlying bone, making them deform, form bone spurs and such endangering the function of the joint.

Also the synovial membrane can be agitated and cause periodic inflammation.

Characteristics/Clinical Presentation

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Differential Diagnosis

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Diagnostic Procedures

Symptoms:
Primary:
- Pain
- (morning) stiffness
- Decrease in the abilities of daily functioning
Secondary:
- Loss of mobility in the affected joint
- Decrease in muscle power
- Instabillity of the joint
- Crepitations

Recently The European league against rheumatism developed diagnostic criteria for diagnosing knee osteoarthritis. The most important factors are stated in Figure 2.

Risc factors.jpg

EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis, W Zhang, M Doherty, G Peat, et al., Ann Rheum Dis 2010;69:483–489. doi:10.1136/ard.2009.113100

X-ray: The basic X-ray is used to research breakdown of cartilage, narrowing of joint space , forming of bone spurs and to exclude other causes of pain in the affected joint.

Arthrocentesis: This is a procedure which can be performed at the doctor’s office. A sterile needle is used to take samples of joint fluid which can then be examined for cartilage fragments , infection or gout.

Arthroscopy: is a surgical technique where a camera is inserted in the affected joint to visually obtain information about the damage caused to the joint by the osteoarthritis.

Outcome Measures

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Examination

If a patient is referred to you by a Doctor, it is most likely he performed a medical examination. It is imperative to look at his/her findings when examinating the patient.
- Inspection:
mind the position of the joints when in rest, and how the patient moves. This can be accomplished by making the patient perform simulations of daily activities like: getting up from and down on a chair, stair climbing, ...

- Palpation:
mind: swelling, temperature differences, muscle tonus. Also be weary of possible bone spurs (osteocyts) that have formed on the edge of the joint. These osteocyts are a serious indication towards osteoarthritis.

- Examination of basic functions:
Testing of muscle power, coordination, mobility, balance and also stability of the joint. These factors can be tested by active test like standing on one leg, and passive manual tests. When testing stability of the joint muscle strength and proprioception are of significant importance.

Medical Management

- Anti-inflammatory medication to counter periodic inflammation
- Surgical replacement of knee joint when damage to natural structures is to grave.

Physical Therapy Management

- Exercise	Has proved to be effective as pain management and improving of physical functioning on short term. However these exercises have to take place under supervision of for example a physiotherapist. When properly instructed these exercises can be performed at home. However research has show that a group exercise combined with home exercise is more effective than home exercise alone. ,
- Hydrotherapy	Is recommended in international guidelines. Despite contradictory evidence hydrotherapy can be useful in cases where pain is too grave to exercise on dry land. It can be a good preparation of exercise on dry land. Osteoarthritis usually affects the weight-bearing joints. Some of the above symptoms like muscle weakness will be present in most patients. The strength of muscles around the affected joints can be built up by graduated exercises making uses of buoyancy and floats (in the later stage of the treatment). Range of motion can also be maintained and increased using the freedom of movement offered by the water with the support given by the buoyancy. Functional difficulties of osteoarthritis patients are generally concerned with walking and climbing stairs, and much can be done to re-educate such patients in the pool. Many patients are more mobile in water than on land and this gives them greater confidence and a sense of achievement. Other studies show that aquatic exercise has some short-term beneficial effects. They established that there is a positive effect on both mixed knee and hip Osteoarthritis and on knee Osteoarthritis alone at the end of an aquatic training program. Also no long-term effects have been found. Aquatic exercise may therefore be considered as the first part of an exercise therapy program tot get particularly disabled patients introduced to training.
- Manual actions: Achieving a passive motion in the joint	Has proven effective to locate and eliminate factors like pain and joint immobility, however it is only effective when combined with active exercise. This progress can enable further or advanced exercises.
- Massage	Is not effective in the case of osteoarthritis.
- Thermotherapy	Can be used to warm up of tissue (for example very stiff joints) before exercise.
- Electrotherapy	For example electro stimulation in improving quadriceps muscle strength is not proven effective.
- Ultrasound	Is not advised in the treatment of knee osteoarthritis.
- External support devices	Braces: - total knee braces when being diagnosed with total knee   osteoarthritis - lateral elevated orthopedic sole when being diagnosed with   medial compartment knee osteoarthritis. Taping: Has proven slightly effective in decreasing pain in patients with patellofemoral osteoarthritis.
- Post-operative exercise	Is very much recommended. Exercises to improve the function of the new joint and muscle strengthening are most effective.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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