Long Case 1 Osteoarthritis of Knee


Long Case 1
Osteoarthritis of Knee
Introduction
Exposure
General Examination
Apparently Healthing looking ,
Conscious
Well oriented to time place and person
Co-operative
Not in distrees due to pain
………
Moderately built up

Jaundice Pallor Lymph Node Cyanosis  Clubbing Oedema Dyspnoea
Vitals                           BP                    P                      T                      RR
Skin     Hair Distribution                      HEENT
Systemic Examination
Chest
CVS
P/A
Musculoskeletal Examination
Upper Extremity
Spine – C – spine and L-spine
            Head at centre
            Shoulder and Pelvis Leveled
            Normal overlying skin without any dimpling/swelling on the back
            Normal Movement of C-spine ,

Ask patient to stand up
            Thoracic and lumbar spine movements tested

Lower Extremity –
Gait     - Varus / Valgus thrust or walks slowly on a plodding manner loading knees on lateral compartment
Squating – Painful  , One side heel higher than the other
Alignment
           
Pelvis Leveled
            Both patella facing forward ,
Genu Valgum deformity on Right side
            Upper Extremity overlying Greater Trochanter
No flexion contracture at knee
Archs at feet normal
Posterior
( Measure Genu Valgum once you see this and continue downward ..)

Attitude not any partcular on lower extremities






Sitting again


Local Examination of Knee
Look               Skin
                        Swelling
                        Discharge
           
Feel                 Temperature
                        Tenderness
                        Osteophytes
Movements     Flexion / Extension
                        Crepitations
Stability
                        Varus / Valgus
                        Anterior Drawer,Posterior Drawer,Lachman’s ,End points
                        Mc Murray’s

Distal Circulation
Distal Sensation
Examination – Hip / Ankle / Foot

Neurology – Sensation / power / Tone / Reflexes


Discussion
Inverstigations
X-ray – Weight Bearing AP / Lateral Film of Knee –
            OA changes – Joint Space narrowing
                                    Osteophytes
                                    Subchondral Cysts
                                    Subchondral Sclerosis
            Malalignment – Varus/ Valgus

Optional Views
Sunrise view
            PA view with 30 degrees knee flexion – shows early OA changes .













Knee OA and Aging Differences

Aging
OA
Water Content
decrease
Increase
Collagen
.
disorganized
Proteoglycan
decrease
decrease
Chondrocyte size
increase
.
Chondrocyte number
decrease
.
Modulus of Elasticity
increase
decrease


Risk factors for OA
Modifiable
            1)trauma
            2)occupation
            3)muscle weakness
            4)obesity
            5)metabolic
            6)metabolic syndrome (dyslipidaemia)

Non-modifiable
            1)Gender
            2)Older Age
            3PGenetics
            4)Race
Pathoanatomy
Articular Cartilage – Increase water content , Collagen disorganized ,
Synovium – inflammatory changes
Bone – Lytic Lesions , bone cysts, sclerotic edges
Examine main ligaments
Posterior Sag – See tangentially anterior knee ,
PCL Deficiency – Quadriceps Active test

If PCL injured , what else to examine ?
            Dial test at 30 and 90 degrees
Management Plan ?
            After  Patellectomy and PCL deficiecy ?
            Posterior Stabilized TKR

What do you examine a patient with ACL and MCL injury ?
            Medial joint line
            O’Donoghue’s triad













Alternatives
                        Acupuncture
                        Glucosamine compounds
                        Needle Lavage
                        Lateral Wedge Insoles
Surgery
High tibial Osteotomy
                        Unicompartmental Osteoarthritis

Unicompartmental Arthroplasty – Higher revision rates than TKR



TKR – Symtomatic Arthritis
            Failed Non operative measures
Cruciate retaining versus Sacrificing TKR – No difference
Patellar Resurfacing – no difference in function , pain









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