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

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178 Osteoarthritis of the Knee: Review of Risk Factors and Treatment Programs ... September 2011 Fig. 1: Operative photograph of the left knee To the left: OA of the medial femoral condyle (MFC) with centrally bare bone To the right: almost normal cartilage of the lateral femoral condyle (LFC) Fig. 2: Osteoarthritis on antero-posterior standing radiograph of both knees. The distance between the bony ends of femur and tibia on the medial side is abnormal. On the left side it is medial bone contact (Ahlback grade 2) and on the right side the medial cartilage is reduced (Ahlback grade 1). (bone volume) is increased. The subchondral bone plate [31] will also be affected and by time, sclerosis will be found there. Experimentally, by using alendronate to affect bone remodelling, the subchondral bone density was increased and different amount of cartilage degeneration (OA) was observed [32] . It is also shown that subchondral bone collagen metabolism is increased in OA [33] . The role of bone tissue and especially the subchondral bone in the OA process is, however, not fully known but this structure probably plays an essential role in the onset and development of OA. The concentration of certain cartilage matrix components in joint fluid, serum and urine can be measured [34-36] . The idea is to monitor the degradation and reparation of the cartilage. This technique is presently mainly used in research but in the future, if reliable, could be a better instrument than radiology, to identify and follow the OA process. SYMPTOMS AND SIGNS Three common complaints due to knee OA are pain, stiffness and weakness. In the long perspective, quality of life is affected [1] and even psychological stress symptoms can occur [3, 37] . The pain is mainly on weight bearing but by time, pain at rest disturbing sleep may also develop. Early in the disease, there is mild knee pain after long walks or other exertions. The onset is gradual and intermittent with better or worse periods. There is, by time, often joint swelling and excessive joint fluid is produced which is best palpated in the suprapatellar pouch or posteriorly as a Baker cyst. During disease progress, the pain on weight-bearing becomes more pronounced and disturbs ordinary activities of daily living (ADL). The maximum walking time becomes shorter by about 10 - 20 minutes, and often a stick or a crutch is used. There is also pain on palpation [38] . Clinical accuracy of diagnosing meniscal injuries in existing knee OA is difficult as most menisci, by time, are affected by degeneration due to the OA disease. The range of motion will be reduced especially in advanced OA. For example, in advanced knee OA (Ahlbach grade IV - V) [39] 10 degrees of extension defect and 30 degrees of reduced flexion is a common finding. The muscle power is reduced [40] leading to weakness and even giving way. Gradually a deformity will develop; varus in medial OA and valgus in lateral OA. Especially the valgus deformity is bothering, as it may lead to knock-knee which means that the knees, during walking, collide and are in the way of each other. RADIOLOGY Ten or even twenty years may elapse after the debut of knee OA before obvious radiographic OA findings are present on plain radiographs. It is often a long radiographic silent period when subjective symptoms are present on-and-off and standing radiographs are normal OA can be seen by inspection during surgery (Fig. 1). Joint space narrowing based on weight-bearing radiographs, indicating cartilage wear, is a diagnostic finding in OA (Fig. 2). A weight-bearing posteroanterior radiograph, obtained in 45 degrees flexion, can better identify early cartilage wear [41] . Joint space narrowing and, by time, bone attrition is used in the Ahlback classification in five stages [39] . However, even if joint space reduction is not present on weight-bearing radiographs, other signs of early OA like osteophytes, bone sclerosis or cyst formation may be seen on plain radiographs [42] . Structural changes are the basis for the early stage of the Kjellgren and Lawrence radiographic classification based on plain radiographs. An MRI, on
September 2011 KUWAIT MEDICAL JOURNAL 179 the other hand, will show early cartilage wear and often there is a concomitant degenerative meniscal injury. This meniscal injury is more a sign of the early OA disease and less a sign of a traditional meniscus rupture. In a long-term study, MRI predictors for a rapid OA progression were meniscus extrusion beyond the tibial margins, a major medial meniscus tear and bone edema [43] . Also, subchondral bone attrition, as found on MRI, is a sign of compartment specific mechanical load [44] . Information from MRI can be enhanced by gadolinium [45] . The future goal, by specialized MRI, related to articular cartilage is to detect abnormalities even before early morphological changes occur. The idea is to implement treatment programs early. The radiographic findings often have a slow but consistent progress. However, research has shown that some patients do not have such a radiographic progression during a long time period. There is no consensus on which radiographic classification system to use which makes comparison between studies more difficult. There is, therefore, a need for one internationally accepted, reliable and validated radiographic classification based on plain radiographs [7] in order to be able to compare the outcome of studies using different interventions (Table 1). Table 1: Radiographs in Knee OA • Weight-bearing plain radiographs will establish the OA diagnosis • Specialized radiography like MRI is usually not necessary • A degenerative meniscal injury on MRI is more a sign of the early OA disease and less a sign of a traditional meniscal rupture KNEE OSTEOARTHRITIS IN KUWAIT In Kuwait, females are more affected by symptomatic knee OA than males. This is documented in the operation statistics, as nowadays, six out of seven operated patients in this country are female [17] . This difference is higher here than in other countries, where six out of ten operated patients are female [46] . The onset of severe symptoms indicating surgery is not only earlier in life for females than males, but also earlier than females in other countries [17] . There are certain specific risk factors for the early onset of OA in Kuwait. Many individuals are obese which increase the load on the joint during walking. Overweight has been shown to have a large impact on symptoms of knee OA [43] . However, even slight weight loss is beneficial for self-reported function and pain [47] . There is also a low ambulatory activity level due to frequent use of cars [17] which will, by time, cause disuse atrophy of the cartilage and also weaker lower limb muscles. The cartilage, which needs daily regular activity in order to maintain its properties, becomes more vulnerable [25] . However, the precise amount of joint load needed in order to maintain healthy articular cartilage is not fully known [25] , but it demands a more active life-style. Also the cultural habits of sitting and kneeling in Kuwait are risk factors for knee OA [8] . Hormonal and metabolic factors are probably involved and there may also be hereditary traits, which are not fully known in the Arab population, but are reported for other populations [18,19] . NON-OPERATIVE TREATMENT Most of the patients with knee OA are treated by non-operative programs, and surgery by knee prosthesis is often not indicated at least not in the early course of the disease. The non-operative treatment is often called conservative treatment, but the nonoperative treatment should not be conservative, rather active, patient-directed non-operative treatment. The development of the symptoms of the OA disease is very individual and it is difficult to predict the outcome for a specific person. It is until now not proven, that it is possible to reverse the cartilage destruction by pharmacological means, but there are ways to affect the symptoms of knee OA. Knowledge of the natural history of the OA disease allows the patient for better confidence, as certain OA patients do not experience progress of symptoms during the years to come. The key points of the non-operative treatment are self-management by: 1. Patient education about the OA disease 2. Physical activity, which is individual regarding type and time, but often involves daily walking with (stick, crutch) or without support. Despite suffering from pain, every knee OA patient needs to walk daily, sometimes to the limit of their capacity, in order to keep up their ability to walk. 3. Muscle training of the pelvis and lower limb. Thigh strength (quadriceps) training is essential. 4. Realistic program for weight reduction by implementing certain diet plan and follow-up These active, patient-directly-involved, nonoperative treatment programs differ from, out of the patient’s perspective, passive non-operative treatments like medicine or injection therapy. This basic program needs to be implemented early by the primary care doctor and needs regular follow-up as regards any changes in life-style. Physiotherapists can be involved in a structural way, not only for physiotherapy treatment programs, but also to assist the patient in self-management. Sometimes, a personal trainer or a coach can follow and support the patient. In order to implement and follow-up such a program well and get a reasonable compliance, a national computer file program for the health care system involving all hospitals and all primary care units is an advantage. A few simple variables like length, weight and a functional tests like chair stand test [15,48] and / or a walking test [15] may be used for follow-up.
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