Mark G. Kowall, M.D., M.B.A. Orthopedic Specialty Associates Templeton , California

2. Mark G. Kowall, M.D., M.B.A. Orthopedic Specialty Associates Templeton, California

3. What makes up the Knee Joint??? Bone Synovial membrane Joint space filled with Synovial Fluid “the oil” Articular cartilage “the tread”

4. Knee Joint

5. What causes the Snap, Crackle and Pop?? Crackling (“Crepitus”)  crunchy or grinding sound or sensation Irregularities or unevenness of the coating cartilage (tread) Usually comes from the Kneecap compartment Noticeable with squatting and stairs Without pain or swelling no concern Accompanied by pain or swelling can be early “wear and tear” (osteoarthritis)

6. What causes the Snap, Crackle and Pop?? Popping or snapping (“locking”) mechanical source (i.e.) meniscus tear, ligament strain. Usually associated with significant pain and associated loss of motion. Usually needs to be evaluated Giving Out (“Instability”) either related to postop or injury-related muscle (quadriceps) weakness or Ligament (ACL) disruption.

7. Most Common Source of “S-C-P”Osteoarthritis Aging (“Tread Wear”) Muscle and Ligament Weakness Decreased ability of cartilage to repair itself

8. Contributors to development of Osteoarthritis Obesity Joint Injury Surgery Gout Congenital abnormal joints

9. “Joint Wear”=“Tread Wear” Cartilage Healthy Knee Osteoarthritic Knee “tread wear”

10. The Knee

11. Inside the Knee Joint Cartilage Femur Cartilage Tibia meniscus Advanced Arthritis Healthy Knee

12. How is Snap, Crackle and Pop Diagnosed?? • History (accident, overuse, location, pain, swelling) • Physical Exam • Blood Tests (rarely done) • X-rays (weight bearing, kneecap view) • MRI (on occasion, if above inconclusive)

13. Knee X-Ray “Bald Tire” Healthy knee Osteoarthritic knee

14. Knee MRI

15. Self-Treatment • No pain or swelling Observation • Gradual or acute onset of pain or swelling (without significant trauma or loss of motion)  Activity modification (rest), Ice, NSAID’s  Reintroduction of “knee friendly” exercise (importance of strengthening after injury) • If pain and/or swelling persists Evaluation • Significant trauma and/or loss of motion Evaluation

16. Treatment varies with severity “Ladder Approach to Treatment”

17. 1st Rung of LadderMedication

18. Medication- NSAIDs NSAIDs are nonsteroidal anti-inflammatory drugs Ibuprofen (Motrin, Advil) Naproxen (Aleve) Prescription Meds

19. Vitamins & Nutritional Supplements Glucosamine / Chondroitin Sulfate Some positive results for moderate to advance arthritis Recently, the American Academy of Orthopedic Surgeons recommended againstits use for patients with osteoarthritis of the knee (Dec, 2008) Fish Oil (Omega-3 Fatty Acids) Diet rich in Fruits and Vegetables

20. Effect of Weight Loss“Take home point” • For each pound of weight loss  4 pound reduction in the forces hitting the knee while walking. • “Less weight, Less load on the knee” Arthritis and Rheumatism, July 2005

21. Braces Sleeves • neoprene • improve balance? • local warmth • control swelling • high compliance • inexpensive

22. Braces Unloaders • “unload” or take pressure of the arthritic side of knee • decrease pain • improve walking tolerance • poor compliance • expensive

23. Knee Exercises “Friendly” vs. “Unfriendly”

24. Knee Exercises • Lower impact (cycling, swimming) • Isometric (muscle contraction without joint motion) • Terminal Extension

25. Limiting the amount of joint flexionLimiting “Joint Reactive Force” Keep Flexion to less than 90 degrees

26. Knee “Friendly”

27. Knee “Friendly” Aqua Jogging Seat High Kick Board

28. Knee “Un-Friendly”

29. Next Rung of the Ladder Injections Cortisone (steroid) Visco-Supplementation (Synvisc One,Orthovisc, Hyalgan, Supartz, Euflexxa)

30. When all else fails to improve pain………..

31. Surgery“Top of the Ladder”

32. Surgical Options-Arthroscopy Mini incisions Outpatient

33. Arthroscopy – Debridement(Shaving of articular Cartilage (“tread”) • A means of “smoothing” the coating cartilage • In conjunction to treating meniscus tears • Not designed for treatment of arthritis alone

34. Arthroscopy – Microfracture • small awl used to make holes in bone • promote re-growth of cartilage Defect in “Tread” Small holes in bone will bleed

35. Arthroscopy – “OATS” Procedure • Transfer of healthy “tread” to “bald” area

36. Arthroscopy- Meniscus Repair vs. Menisectomy Tear Repair Resection

37. Surgical Options: Joint Replacement Uni-compartment Knee Replacement Total Knee Replacement

38. Total Knee Replacement Side view

39. New Technologies

40. Laboratory • Recombinant Gene Therapy (synthesize the growth factors which produce new cartilage) • Specific Growth Factors promote cartilage (tread) maintenance and repair • May limit the progression of arthritis • Platelet Rich Plasma (PRP)

41. Recent discovery of a natural occurring molecule in the body that can counter the progression of arthritis Genes and Development

42. Consumer Beware Bozic K J, et al. Impact of direct to consumer advertising on physician attitudes and behavior in orthopedic surgery American Academy of Orthopedic Surgeons **Poll of 737 hip and knee surgeons **Over 75% of surgeons reported that direct-to-consumer (DTC) advertising negatively impacted their practice and the relationship with patients. **Ads presented a skewed view of procedures and devices by exaggerating the benefits and down playing risks. **(Patients) were not more educated about the risks and benefits, not more educated about the alternatives, not more educated about the costs and that they were less open to alternatives after reading or viewing direct-to-consumer advertisements

43. Closing RecommendationListen to your Knee!!!

44. Resources • www.ShoulderKneeSpecialists.com • Surgical Procedure Animations • Health Library • Important Links

45. Questions????