1
Mark G. Kowall, M.D., M.B.A.
Orthopedic Specialty Associates
Templeton, California
2
What makes up the Knee Joint???
Bone
Joint space
filled with
Synovial Fluid
“the oil”
3
Synovial
membrane
Articular
cartilage
“the tread”
Knee Joint
4
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)
5
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.
6
Most Common Source of “S-C-P”
Osteoarthritis
Aging (“Tread Wear”)
Muscle and Ligament Weakness
Decreased ability of cartilage to repair
itself
7
Contributors to development of
Osteoarthritis
Obesity
Surgery
Joint Injury
Gout
Congenital abnormal joints
8
“Joint Wear”
=
“Tread Wear”
Cartilage
Healthy
Knee
9
Osteoarthritic
Knee
“tread wear”
The Knee
10
Inside the Knee Joint
Cartilage
Femur
Cartilage
Tibia
meniscus
Healthy Knee
11
Advanced Arthritis
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)
12
Knee X-Ray
“Bald Tire”
Healthy knee
13
Osteoarthritic knee
Knee MRI
14
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
15
Treatment varies with severity
“Ladder Approach to Treatment”
16
1st Rung of LadderMedication
17
Medication- NSAIDs
NSAIDs are nonsteroidal antiinflammatory drugs
 Ibuprofen (Motrin, Advil)
 Naproxen (Aleve)
 Prescription Meds
18
Vitamins &
Nutritional Supplements
Glucosamine / Chondroitin Sulfate
Some positive results for moderate to advance arthritis
Recently, the American Academy of Orthopedic Surgeons
recommended against its use for patients with
osteoarthritis of the knee (Dec, 2008)
Fish Oil (Omega-3 Fatty Acids)
Diet rich in Fruits and Vegetables
19
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
20
Braces
Sleeves
 neoprene
 improve balance?
 local warmth
 control swelling
 high compliance
 inexpensive
21
Braces
Unloaders
 “unload” or take pressure of the arthritic side of knee
 decrease pain
 improve walking tolerance
 poor compliance
 expensive
22
Knee Exercises
“Friendly”
vs.
“Unfriendly”
23
Knee Exercises
 Lower impact (cycling, swimming)
Isometric (muscle contraction without
joint motion)
Terminal Extension
24
Limiting the amount of joint flexion
Limiting “Joint Reactive Force”
Keep Flexion to less than 90 degrees
25
Knee “Friendly”
26
Knee “Friendly”
Aqua Jogging
Seat High
27
Kick Board
Knee “Un-Friendly”
28
Next Rung of the Ladder
Injections
Cortisone (steroid)
Visco-Supplementation
(Synvisc One,Orthovisc,
Hyalgan, Supartz, Euflexxa)
29
When all else fails
to improve pain………..
30
Surgery
“Top of the Ladder”
31
Surgical Options-Arthroscopy
Mini incisions
Outpatient
32
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
33
Arthroscopy – Microfracture
 small awl used to make holes in bone
 promote re-growth of cartilage
Defect in “Tread”
34
Small holes in bone will bleed
Arthroscopy – “OATS” Procedure
 Transfer of healthy “tread” to “bald” area
35
Arthroscopy- Meniscus Repair
vs. Menisectomy
Tear
Repair
Resection
36
Surgical Options:
Joint Replacement
Uni-compartment Knee Replacement
Total Knee Replacement
37
Total Knee Replacement
Side view
38
New Technologies
39
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)
40
Recent discovery of a natural
occurring molecule in the body
that can counter the progression
of arthritis
Genes and Development
41
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-toconsumer advertisements
42
Closing Recommendation
Listen to your Knee!!!
43
Resources
www.ShoulderKneeSpecialists.com
 Surgical Procedure Animations
 Health Library
44
 Important Links
Questions????
45