Le mouvement: ange ou démon de l arthrose de genou? Dr ès sc. Julien Favre

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1 Le mouvement: ange ou démon de l arthrose de genou? Dr ès sc. Julien Favre

2 Survey Disclaimer: This presentation contains ongoing research and further work is necessary before results can be transferred to clinical practice.

3 Knee osteoarthritis (OA) One of the 10 leading disease burdens in high-income countries (20-40% of individuals over 65 years of age) Health costs at 1-2.5% of the GNP Limited understanding of the disease - no cure Courtesy of UCSF

4 Occupation - physical activity Cross-sectional studies in mixed populations Increased risks in individuals with repetitive knee bending activities (Felson 1991, Coggon 2000) Increased risks in elite sportsmen (Kujala 1195, Spector 1996) Longitudinal studies on non-oa subjects No association with OA incidence (Manninen 2001, Fleson 2013, Barbour 2014) Association with OA incidence (McAlidon 1999, Wang 2011) Longitudinal studies in mixed populations These studies analzed how much, Protective against progression of cartilage defects (Foley 2007) but no how did the knee function No differences in new cartilage lesions between more and less active participants (Doré 2013) Increased incidence of BML and meniscal damages in more active participants especially in knee with baseline abnormalities (Doré 2013) Cross-sectional studies on non-oa / asymptomatic subjects No association with cartilage defects and association with cartilage volume (Hanna 2007, Racunica 2007) Unclear if/how focal damages can lead to OA Association with cartilage lesions (Stehling 2010) No association with cartilage metrics (Kretzschmar 2015) Association with meniscal lesions and BML (Kretzschmar 2015)

5 Which aspect of the knee function should be considered? Courtesy of Shue Li, Newcastle University Courtesy of L. Zhao, U Auckland Courtesy of ACR Courtesy of C. Hillman, UIC ablazetotalsolutions.com

6 Steps per day KAM, Nms Cumulative KAM, knms Knee loading during walking Relationship between knee adduction moment (KAM) and high tibial osteotomy (Prodromos 1985) Higher risk for radiographic knee OA progression in patients with higher KAM (Miyazaki 2002) Supports the idea that knee function is critical Healthy OA (Maly 2013)

7 Knee ambulatory function measurement Point Cluster Technique (Andriacchi 1998, Alexander 2001, Dyrby 2004)

8 Knee ambulatory function 70 Flexion angle, 20 Adduction angle, Ext. rotation angle, Flexion moment, %BW*Ht Adduction moment, %BW*Ht Ext. rotation moment, %BW*Ht Anterior displacement, cm -4 (Grood 1983, Andriacchi 2004)

9 So, ambulatory knee function, devil or angel? popsugar.com

10 Overall OA framework Structure (Andriacchi 2004, 2014)

11 Overall OA framework Structure (Andriacchi 2004, 2014)

12 Overall OA framework Structure (Andriacchi 2004, 2014)

13 KAM, %BW*Ht KAM and M/L cartilage thickness ratio # Subject # Male # knee Age BMI (years) (kg/m 2 ) 11 asymptomatic ± 5 24 ± Peak KAM Gait cycle, % (Koo 2007)

14 KAM, %BW*Ht KAM and M/L cartilage thickness ratio # Subject # Male # knee Age BMI (years) (kg/m 2 ) 11 asymptomatic ± 5 24 ± Peak KAM Gait cycle, % (Koo 2007)

15 KAM and M/L cartilage thickness ratio # Subject # Male # knee Age BMI (years) (kg/m 2 ) 11 asymptomatic ± 5 24 ± 2 (Koo 2007)

16 KAM and M/L cartilage thickness ratio (Blazek 2014)

17 KAM and M/L cartilage thickness ratio (Andriacchi 2009, Erhart unpublished)

18 Flexion angle, Flexion angle thickest cartilage pt # Knee # Male K/L Grade Age BMI (years) (kg/m 2 ) 17 asymptomatic 10 2 [1-3] 33 ± ± 2 Gait cycle, % (Koo 2011)

19 Flexion angle thickest cartilage pt (Koo 2011)

20 Flexion angle thickest cartilage pt # Patients Time past surgery # Male Age Height Weight (month) (years) (m) (kg) 29 unilateral ACLR 27 ± ± ± ± 12? (Koo 2011, Scanlan 2013)

21 Sagittal-plane knee function with aging and OA Group # Knee # Male Age Height Weight (years) (m) (kg) Younger asymptomatic ± ± ± 13 Older asymptomatic ± ± ± 11 Older moderate OA ± ± ± 15 Older severe OA ± ± ± 16 Asymptomatic subjects: no self-reported pain or serious lower-limb injury OA patients: diagnosed medial OA, knee pain, and ability to walk without aids moderate = KL grades 1 & 2 severe = KL grades 3 & 4 (Favre 2014)

22 Sagittal-plane knee function with aging and OA 70 Flexion angle, Flexion moment, %BW*Ht -5 3 Anterior displacement, cm -4 (Favre 2014)

23 Flexion angle, Sagittal-plane knee function with aging and OA Location of thickest pt, Supports a kinematic pathway to knee OA? 5 more flexed 100% ~20% Gait cycle, % Flexion angle at HS, Cartilage thickness, mm 0 3 6

24 ML direction, % Thickess cartilge pt with aging and gender Group # Knee Side Age Height Weight (years) (m) (kg) Younger men R 26 ± ± ± 11 Younger women R 27 ± ± ± 11 Older men R 58 ± ± ± 14 Older women R 58 ± ± ± 10 a) Mean thickness Younger men Older men (Favre 2014)

25 ML direction, % Thickess cartilge pt with aging and gender Group # Knee Side Age Height Weight (years) (m) (kg) Younger men R 26 ± ± ± 11 Younger women R 27 ± ± ± 11 Older men R 58 ± ± ± 14 Older women R 58 ± ± ± 10 a) Mean thickness Younger men Older men? Younger men 75 Older men Younger women 50 Older women All groups (Favre 2014)

26 Knee function 5 year D thickness (Favre unpublished)

27 Summary X? XX Older severe OA Younger asymptomatic

28 Conclusion Knee function at heel-strike of walking might play a role in idiopathic OA initiation Need a better understanding of the response, not only differences or associations Need to test/consider other variables need a system approach The disease is very complex and we can act on the knee function

29 Some options to modify the ambulatory knee function

30 Individual gait modification Audio instructions Visual feedback Visual instructions

31 Acknowledgements Prof. Thomas P. Andriacchi Dr. Eugene J. Alexander Dr. Katerina Blazek Dr. Chris O. Dyrby Dr. Jennifer Erhart-Hledik Dr. Seungbum Koo Dr. Sean F. Scanlan NIH, VA, AF, SNSF