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Osteoarthritis of the Knee

 - See:
     - Osteoarthritis Menu:
           - predisposing conditions
           - pathology and histology
           - clinical features 

- Discussion:
    - biomechanical considerations: (see kinematics and anatomy of knee
           - thick cartilaginous surfaces of the knee helps to spread out joint reactive load over a wide area and helps contribute to cam
                  shape of condyles which maximizes extensor lever arm;
           - in degenerative arthritis the quality of the articular cartilage is lost;
                  - early in the process, there may be discrete chondral injuries where as advanced changes include chrondal injuries on both
                            sides of the joint;
                  - as wear occurs, the patello femoral joint is reduced to a cylindrical outline;
                  - the mechanical outline is lost, but wear in the bone to bone contact area is reduced; 
           - reference: Does osteoarthrosis depend on growth of the mineralized layer of cartilage?
    - mechanical malalignment:
           - references:
                  - The role of knee alignment in disease progression and functional decline in knee osteoarthritis.
                  - The influence of alignment on risk of knee osteoarthritis progression according to baseline stage of disease.
                  - Thrust during ambulation and the progression of knee osteoarthritis.
    - synovial fluid
           - Synovial fluid features and their relations to osteoarthritis severity: new findings from sequential studies.
           - Synovial fluid crystals in osteoarthritis.
           - The high prevalence of pathologic calcium crystals in pre-operative knees.
    - meniscii
           - Increased vascular penetration and nerve growth in the meniscus: a potential source of pain in osteoarthritis
           - The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee

 - Non Operative Treatment: (see narrated slide show)
          - NSAIDS 
          - colchicine
                 - A randomized controlled trial to evaluate the slow-acting symptom modifying effects of a regimen containing colchicine in a subset of patients with osteoarthritis of the knee.
                 - A randomized controlled trial to evaluate the slow-acting symptom-modifying effects of colchicine in osteoarthritis of the knee: a preliminary report.
          - steroid injection
          - viscosupplementation: (hyaluronic acid
                 - Supartz, Hyalgan, Synvisc, Orthovisc, Euflexxa;
                 - references:
                        - Granulomatous Inflammation After Hylan G-F 20 Viscosupplementation of the Knee
                        - Increased frequency of acute local reaction to intra-articular hylan GF-20 (synvisc) in patients receiving more than one course of treatment
                        - Clinical Trials of Hyaluronic Acid Reflect Significant Publication Bias

          - reduction of cartilage impact loading: (typically this is 6 times body wt);
                 - cane (same side vs opposite side)
                 - rubber heel wedges (consider lateral wedges w/ medial compartment arthrosis); 
                         - references:
                               - Medial knee osteoarthritis treated by insoles or braces: a randomized trial
                               - Immediate Coronal Plane Kinetic Effects of Novel Lateral-offset Sole Shoes and Lateral-wedge Insole Shoes in
                 - wt loss;
                 - valgus unloading knee brace; (see Donjoy and Breg)
                         - A Mechanical Theory for the Effectiveness of Bracing for Medial Compartment Osteoarthritis of the Knee

- Operative Treatment: 
          - total knee arthroplasty 
          - unicondylar replacement
          - high tibial osteotomy 
          - alternatives to total knee replacement:  autologous hamstring resurfacing arthroplasty
          - arthroscopy of osteoarthritic knee 
          - arthodesis (limited indications in non infectious arthritis)
          - fibular osteotomy:
                  - Medial Compartment Decompression by Proximal Fibular Osteotomy: A Biomechanical Cadaver Study

Osteoarthritis Slide Show

Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee.

Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective, randomized trial.

Correlation of sonographic severity with biochemical markers of synovium and cartilage in knee osteoarthritis patients.

Cartilage Lesions - Treatment