Vol 43 # 3 September 2011 - Kma.org.kw

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176 KUWAIT MEDICAL JOURNAL September 2011 Review Article Osteoarthritis of the Knee: Review of Risk Factors and Treatment Programs with Special Reference to Evidence-Based Research Ali Al Mukaimi 1 , Ehab El Salawi 1 , Anders Lindstrand 2 1 Al Razi Orthopedic Hospital, Kuwait 2 Department of Orthopedics, Clinical Sciences, Lund University, Lund, Sweden Kuwait Medical Journal 2011; 43 (3): 176-188 ABSTRACT Osteoarthritis is a widespread disease leading to physical disability affecting quality of life. It is primarily regarded as a cartilage disease but affect all tissues of a joint. Osteoarthritis can be regarded as an organ failure. Knee osteoarthritis is common in Kuwait, especially in women. The main symptoms are pain, stiffness and weakness affecting knee function. The diagnosis is made by history and clinical examination. A weight-bearing radiograph will fully establish the diagnosis. Many of the patients are also obese, diabetic, hypertensive or affected by other organ failures. The aim is to reduce knee pain and improve knee function which is also beneficial for the other diseases. Initially, we recommend self-management by information about knee osteoarthritis, daily exercise of any type which is pleasant for the individual like walking 10-30 minutes once or twice daily in order to induce light to moderate cartilage load. Further, regular muscle training to increase especially pelvis and lower leg strength and realistic programs to reduce weight is advised. Regular support by a primary care doctor, a physiotherapist or a coach is beneficial. The program is demanding, as it means a change of life-style. Different modalities of non-operative treatment are physiotherapy, pharmacological treatment by analgesics / NSAIDs / glucosamine and injection of steroids or hyaluronic acid. The effect of the pharmacological treatment programs vary. Often the outcome, by evidence based research, is low or at best moderate. If self-management and non-operative treatment fails and the symptoms are pronounced, surgery is an option. Knee prosthesis is the main alternative. KEY WORDS: knee, osteoarthritis, review, risk factors, treatment INTRODUCTION AND RISK FACTORS Arthritis is a chronic disease which is estimated to affect about 15 % of the population and is the leading cause of functional dependency in the activities of daily living in elderly [1] (Fig. 1). There are several reviews of risk factors and pathogenesis including the repair process as well as treatment programs of knee osteoarthritis (OA) [2-5] . In essence, there are two possible pathways for initiation of OA disease, overload or injury of normal cartilage or normal load of weak cartilage. Risk factors for development of knee OA are rheumatoid arthritis and other inflammatory conditions, knee infection, knee trauma often sustained in sports [5-7] , unfavourable loading [8] , heavy physical activity [5, 9] , resting in a squatting or kneeling position [8,10] and also obesity [5,11,12] . Poor muscle function, especially in women, influences the disease progress and severity of symptoms [13-15] . Increasing age is a major risk factor for OA [16] . Female sex [17] and heredity [18,19] are other known risk factors. OA may also occur in a knee joint where the cartilage is weak, for example due to disuse atrophy, and therefore, already sensitive to activities of daily life [17] . Thus, the etiology of OA is dependant on several factors of constitutional and environmental type. Some of these factors can be affected by treatment programs which, if effective, will slow down the symptoms of the disease. In many instances today, due to better knowledge of risk factors, the cause of knee OA can be identified and fewer patients have idiopathic OA. The earlier classification of knee OA, into secondary (known etiology) and primary (unknown etiology) is no longer recommended as most knee OA can be identified by risk factors. KNEE OSTEOARTHRITIS AND FOOTBALL OA can develop as a late consequence of knee trauma resulting in cruciate ligament, collateral Address correspondence to: Anders Lindstrand, MD PhD, Department of Orthopedics, Clinical Sciences, Lund University, 221 85 Lund, Sweden. E-mail: lindstrand5@telia.com
September 2011 KUWAIT MEDICAL JOURNAL 177 ligament, meniscal or cartilage injuries. These injuries occur during high activity level, often in contact sports which include acceleration/deceleration or rotation/pivoting movements. One example of such a contact sport is football; the most common sport of the world. Especially, after anterior cruciate ligament and meniscal injuries, there is an increased risk of developing clinical and radiological signs of OA. In a review article Lohmander et al [6] identified 127 published articles from 1970 – 2007, 10 - 20 years after an anterior cruciate ligament injury. These articles were found in a Medline search by the key words “anterior cruciate ligament, injury, osteoarthritis and follow-up”. The prevalence of OA was found to be 50% even after isolated anterior cruciate ligament injuries. The Lohmander group presented, in the same report as mentioned before [6] , a review of radiologic long term follow-up of isolated meniscal injuries and found in 41 publications a prevalence of 50% OA after 10 – 20 years. In another review article, Oiestad et al [7] identified 31 anterior cruciate ligament injury articles by a search in three computer data bases (PubMed, Embase and AMED). The number of articles retrieved originally was 2000 but the authors made a quality scoring of the study designs and included only 31 articles with the highest quality score. After a mean 13.7 (10 - 27) years follow-up, 0 - 13% of isolated anterior cruciate ligament injuries had developed knee OA. In combined anterior cruciate ligament and meniscal injuries, the prevalence of OA was 21 - 48%. Even if these two review articles are not in full agreement about the prevalence of OA after isolated anterior cruciate ligament injuries, the risk of long term OA is pronounced. Definitely there is a high price for the joy of playing football. Especially as the post-traumatic OA disease starts earlier in life compared to most other types of OA which have a later onset. The innervation of the the anterior cruciate ligament injured patient is often long-term deficient as proprioception is affected after an injury. About 1/3 of the anterior cruciate ligament injured patients, independent of reconstruction, do not regain the normal muscular function of the injured limb. There are, however, occasional reports, on non-operated anterior cruciate ligament injured patients, who were treated by intensive rehabilitation and recommended a low activity level, where the long-term muscular function was normalized [20] and long-term knee OA was low [21] . Not only knee joint injury, but also knee joint overload, is a risk factor for knee OA. In top football, there is constant knee joint overload due to the character of the game. In elite football players, even without a documented knee injury, knee OA was found in 30%, 10 - 20 years after the end of the football career, while recreational football players had the same low incidence as non-football players after the same follow-up time [22] . Therefore, daily overload of the knee in elite football is a negative factor for the joint but occasional football, even in organized league on a low level, has no such drawback. In general, sports can be divided into low, moderate or high demands of the knee joint where, apart from European and American football, also basketball and handball are examples of high knee load while swimming and golf are examples of lower knee load [23] . CARTILAGE AND BONE TISSUE OA is regarded not only as mainly a cartilage disease, but also one that affects other tissues of a joint, especially the bone, by subchondral sclerosis, osteophytes and cyst formation and also the synovium by synovitis and often increased amount of joint fluid. Also, the ligaments are involved by time. The bony ends, constituting the knee joint, are covered by hyaline cartilage. This tissue has a favourable friction coefficient which is an advantage during load transmission [24] . The thickness of articular cartilage varies with the pressure. The higher the peak pressure, the thicker the cartilage and it is interesting to note that patellar articular cartilage is the thickest in the human body [25] . This cartilage tissue constitutes of cartilage cells and extracellular matrix including water, proteglycans and collagen [24,25] . There are four different zones of articular cartilage; superficial,middle,deepand calcified [26] . These layers have a different composition of collagen formation and cell morphology. During weight-bearing, water is pressed out of the extracellular matrix, while the water returns at rest. There is a continuous turnover in normal cartilage tissue constituting a balance. This is a fine-tuned mechanism which is distorted in OA when the cartilage becomes fibrillated and by time cleft formation and areas of necrosis appear. Mechanically mediated and cytokinemediated pathways of cartilage degeneration have been identified in the pathogenesis of OA [3, 24] . The possible OA healing mechanism / response has been studied [27-30] . There is no vascular supply or innervation of cartilage which affect the healing properties. In the very early stage of the OA disease, the tissue changes can not be seen by inspection (arthroscopy) or by MRI (radiography). Microscopy of a bone/cartilage biopsy would, however, show early osteoarthritic findings. By time, cartilage fibrillation and fissures will develop, which can be seen by arthroscopy or MRI. There are several systems used for grading of cartilage disease, such as the Mankin ́s criteria (microscopy) or the Outerbridge classification (inspection). The bone tissue is affected in the early and especially the late phase of OA. The micro-architecture of the bone is deteriorated in all types of OA. In cancellous bone, the form of the trabeculae are changed and the density
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Vol 43 # 3 September 2011 - Kma.org.kw

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