OSTEOARTHRITIS OF THE KNEE (KNEE OA)

Case Examination:

A 65-year-old female came to orthopaedic consultation with chief complaint of the right knee pain and stiffness since 5 years especially after walking. She consumed NSAIDs routinely based on general practitioner’s recommendation since 6 months ago but no improvement. She denied infection, trauma, past surgery, family and malignancy history. Physical examination on the right knee showed a bit swelling of the right knee and valgus deformity of right lower extremity (Fig. 4). Feeling examination of the right knee revealed tenderness on the margin of the knee joint, crepitus on patella and swelling. Range of the right knee motion was limited actively compared the left knee.

This presentation is really incomplete information for clinical diagnosis of the patient.

Learning Objectives Evaluation in Examination

The Examiner should be able to assess the Candidate ability:

1.      To recognize the history taking, physical examination and investigation of knee joint degeneration

2.      To decide acute and long-term problem of the knee joint degeneration

3.      To develop the management and its algorithm of the knee joint degeneration

4.      To understand surgery intervention of the knee joint degeneration

5.      To predict the complications of the knee joint degeneration.

Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection

First step, the examiner must start the question: “Is there any information and physical examination data you should present completely?” or “Are there any important key data you should inform in the history taking, physical examination and investigation for clinical diagnosis?” or “What’s the next important information on the history taking, physical examination and investigation?” or other question form for the Candidate and the questions depend on the examiner’s experience to achieve objective and transparent, valid and reliable marking. 

Learning Objectives Evaluation in Examination

The Examiner should be able to evaluate the Candidate ability to collect key data or information from:

·         History taking

The Candidate ability to determine patient’s identity and complaint of knee joint, history of the knee illness and risk factors such as: diet, obesity, repetitive high impact activity, gender, race, body weight of the degeneration of the knee joint after excluding trauma to cartilage, a torn menisci, ligaments instability in history taking. The Candidate should also be able to determine past history or comorbidities history or organ function and medical history of the knee OA in elderly patient. The Candidate presents a family and social, culture and occupation history of OA patient.

·         Physical examination

The Candidate ability to collect physical examination data such as: general condition, valgus deformity of the right knee and atrophy of the right thigh, tenderness around the knee margin with limited ROM the right knee actively and passively. Valgus stress test positive or laxity of CML is positive and crepitation on patella during flexion.

·         Investigation

The Candidate ability to describe the classical PA radiography view of the knee OA in standing position such as lateral side narrowing of the knee space, osteophytes on the medial and lateral side of the knee, sclerosis and cyst subchondral (fig. 5) and sunrise view of the patella-femoral (deformity or mal-alignment and osteophytes). The Candidate ability to analyze all key data of the history taking, physical examination and radiographic finding for achieving accurate diagnosis of the knee OA. The Candidate should be able to order other investigation for example laboratory data to exclude the rheumatoid arthritis (rheumatoid factor) and infection of the knee joint (CBC & WBC, inflammations maker are sedimentation rate/ESR and C-reactive protein/CRP). Occasionally, small intra-articular effusions may be obvious and the diagnosis is still in question, so a joint aspiration may be determine for excluding infection or gout/pseudogout. Synovial fluid analysis may show clear to yellow color, few WBCs less 300/µL or <25% neutrophyls, culture is negative and fluid glucose is roughly equal to serum.

 

Fig. 5: Radiographs AP and lateral projections of the femoro-tibial joint in standing position and patella-femoral (skyline x-rays/sunrise view). According to KL classification is grade 3-4

The next step is to support knee OA diagnosis by x-rays and laboratory examination. The Candidate should describe the femoro-tibial radiographs in detail based on Kellgren and Lowrence grading system (table 18)

Table 18: Kellgren and Lowrence grading system

GRADE	RADIOGRAPHIC FINDING
1	Possible osteophytes; no joint space narrowing
2	Definite osteophytes; possible narrowing of joint space
3	Moderate multiple osteophytes; definite joint space narrowing, some sclerosis and possible deformity of bone ends
4	Large osteophytes; mark joint space narrowing, severe sclerosis and definite deformity of bone ends

The Candidate may explain these abnormalities are the clinical characteristic of osteoarthritis disease and second most common diagnosis made in elderly patient who consulted to physician. More than 10% knee pain with moderate disability of the patient of over the age of 55. Prevalence of 25% for knee pain in older people (Bristol and Nottingham) and Tameside and Greater Manchester survey found a prevalence knee pain was 21% -35% in men and women aged 45% or over. The prevalence of knee pain increases universally with age, though age trends are clearer in women than men. About one quarter of people over the age of 55 will report a knee pain and half of these report associated disability (limited motion and function).

·         The Candidate ability to determine accurate diagnosis based on history taking and clinical data from physical examination and investigation findings. The Examiner invites the Candidate to decide the possibilities of the right knee abnormalities in a question “What are the possibility abnormalities of the right knee?”  According to key data: pain on the right knee in elderly woman patient especially after activity, a bit swelling, limited motion and difficult climb stars so the most common of diagnosis is osteoarthritis of the right knee (knee OA). These abnormalities in the elderly patient come to consultation to physician without forget the Charcot joint (primarily foot and ankle predilection, diabetic neuropathy, chondrocalcinosis (crystal in the joint fluid in investigation), inflammatory arthritis (positive rheumatoid factor in laboratory investigation), epiphyseal dysplasia (patient generally is short status), hemochromatosis (abnormal liver function test) and hemophilia (bleeding tendency) as differential diagnosis. 

The Candidate should be able to conclude based on the information and data above, the accurate diagnosis is osteoarthritis of the right knee joint. Liver and renal function test, glucose blood concentration, examination function eye, ear and balance are importance to elderly patient for comorbidity determination.

The Candidate should be able to explain the pathogenesis: Knee OA pathology is unclear and develops slowly. Some cases where the precipitating can be determined, OA can take 10-30 years before the OA diagnosis can be made with the aid of radiology investigation. OA can develop in a normal joint subjected to excessive stress or weakened joint caused by normal loading. Normal cartilage can maintain a state of equilibrium, which is a prerequisite for its function. If cartilage is in excessively high or low joint load; the metabolic equilibrium changes and an imbalance between resorption and repair occur. The Candidate can explain the cells develop to repair it-self but is not able to regenerate a functional matrix and the shock-absorbing function is lost.

If the Candidate makes a mistake or an omission (forgetfulness) during the discussion of the clinical diagnosis and investigation for accurate diagnosis; the examiner can give the stimulation question.

o   Correct and complete interpretation and integrated data discussion the marking is 10.

o   Correct response to the stimulation question the marking is 6, but

o   No response or incorrect response, the marking is 0 (see below).

Table 19: List of part A evaluation

Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination	10 Com-plete presen-tation & correct statement	6 Incom-plete presenta-tion or Correct response to stimula-tion question	0 Inco-rrect response or no response	Marks
a.       Ability to gather information of the history taking of knee OA includes: ·      Identity and patient’s complaint, history of the illness and risk factors,   ·      Past medical history or comorbidities (when, how and who makes the diagnosis), allergy, severity of the abnormalities, ·      The information of the family, social, culture and occupation history, and  pregnancy history (if relevant to the present illness), management and progress or organ function evaluation
b.      Ability to collect the physical examination of knee OA such as: ·         the data of the  general condition, ambulatory or gait evaluation(crutch/cane/wheel-chair using), and body mass index, ·         local examination (look, feel, move and ·         muscle power & neurovascular, the special  clinical test or maneuver evaluation and the investigations
c.     Investigation reasoning Interpret, analyzing key data for some possibilities or diagnosis of knee OA determination
Total Marks of Ppart A

MARKS OF PART A:

§  Mark 10: Candidate presents: (a) the history taking or (b) physical examination or (c) investigation and analyze key data of knee OA diagnosis determination in discussion completely and correctly

§  Mark 6: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting (a) history taking or (b) physical examination and (c) investigation needed or a mistake analyzing data of knee OA diagnosis determination in discussion correctly.

§  Mark 0: Candidate’s response is  not correct or he/she does not respond to the examiner’s stimulation question of (a) history taking, (b) physical examination, (c) investigation and analyzing of the key data of knee OA diagnosis determination in discussion

§  Maximal marks of part A is 30

OTHER ALTERNATIVE EVALUATION LIST (Table 20)

Part A. The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis

Learning Objectives Evaluation in Examination

The Examiner should be able to assess

The Candidate ability to recognize the degeneration joint disease of the knee OA joint scenario

1.      Discussion between the Examiner and the Candidate is how the Candidate make the most likely diagnosis of the knee OA based on the key data in the scenario (history taking, physical examination and investigation finding) to support diagnosis and how he/she integrates and of analyze all data  and last is problem issues of the knee OA patient. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

Table 20: List of the evaluation marks of part A 

CONTENTS OF EVALUATION	Marks
Part A: The objectives examination evaluation of the history taking, physical examination and investigation data collection for some possibilities or accurate diagnosis determination	30 Complete & correct presentation	20 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to collect the key data of the history taking, physical examination and investigation data collection for some possibilities or the knee OA diagnosis determination in discussion

MARKS:

§  Marks 30: Candidate presents the history taking, physical examination and investigation and analyze key data for some possibilities or the knee OA diagnosis determination completely and correctly

§  Marks 20: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting history taking or physical examination, investigation needed and analyzing data for some possibilities or the knee OA diagnosis determination correctly.

§  Marks 0: Candidate’s response is not correct or he/she does not respond to the examiner’s stimulation question of history taking, physical examination, investigation and analyzing of the key data for some possibilities or the knee OA diagnosis determination.

Part B:  The objectives examination evaluation the patient’s problem, management and complications  

Learning Objectives Evaluation in Examination

The Examiner should be able to evaluate:

1.    The Candidate capability to decide acute and long-term problem of the knee OA

The Candidate should explain about acute patient problem that include knee pain, stiffness (limited knee motion less than 30 minutes), bony enlargement, crepitus and valgus deformity of the right knee. Long-term problem is a loss of function or disability and with associated reduction in quality of life (alteration life style). Disability reporting is 20% of adult over 50 and 40% over 80 years from knee pain secondary to osteoarthritis. The Candidate should be able to explain the reason of these problems, based on the patient’s management. 

2.    The Candidate ability to plan the knee OA management

The Candidate must invite the knee OA patients to discuss and join together for the decision making process. Patient will be informed about all therapy options, including surgery procedure, and clear description of risk and benefit of each treatment. The Candidate will discuss based on the aim of knee OA management including:

a)       Patient understands about degeneration joint disease.

b)      Alleviate pain.

c)       Return to normal alignment or normal biomechanics for recovering muscle balance and improving ROM.

d)      Prevent or delay progression of cartilage damage, bone, ligament structures and muscle changes, and

e)      Optimize function and quality of life for achieving patient active and reduce the number working days loss.

a.       Conservative strategy of non-pharmacology management.

1)      Patient education and lifestyle

The Examiners discuss about conservative management that includes patient participation in self-management education strategy and incorporate activity modification (walking instead of running, treadmill, running in water, dancing, cycling/stationary bike, step machine and low impact) into lifestyle of knee OA patient. The Candidate should be able to explain too little loading, where total compression is the end point, leading to erosion of cartilage with reduced ability to absorb shock, but much loading for example professional football player leads to an increased risk of knee OA. Fitness activities appear rather to protect against the development of knee OA. The Candidate should also explain the appropriate information regarding the condition, to advise and encourage activity and exercise and educate the patient about the pathogenesis of OA that it is a chronic joint disease. According to AAOS clinical guideline on treatment is level II or grade recommendation B. Regular contact to promote self-care is level IV/grade recommendation C and lose weight for obese patient is level I or grade recommendation A. The Candidate also explains that the knee OA patient is not always progressive and most patients will not need surgery, with their symptoms adequately controlled by non-surgical measures. Therefore, the conservative strategy is the cornerstone in the management of the knee OA patient.

2)      Rehabilitation

The Candidate ability to understand about low impact aerobic fitness exercise is level I and grade recommendation A, range of motion exercise is level V or grade recommendation C and quadriceps strengthening balance, coordination and ROM/flexibility of the knee joint (V/C) is level II or grade recommendation B according to AAOS recommendation.

3)      Mechanical intervention

The Candidate ability to explain AAOS recommendation about patellar taping for short term relief of pain and improvement in function is level II or grade recommendation B but lateral heel wedges is not suggest  for symptomatic medial compartment of knee OA (level II or grade recommendation B). AAOS clinical practice guideline is not able to brace using  with valgus directing force for medial uni-compartment knee OA because it levels is II or grade recommendation inconclusive and also brace using with varus directing force for lateral uni-compartmental knee OA. It level is V or grade recommendation inconclusive.

4)      Complementary and Alternative treatment

§  The Candidate may recommend topical analgesic or NSAIDs are available for effective pain reliever in knee OA patient. Patient should be warmed of initial treatment therefore the patient should wash his/her hands after application.

§  The Candidate may explain that the glucosamine is a precursor to glycosaminoglycan in cartilage matrix and synovial fluid and its effect on cartilage metabolism and anti-inflammatory. Glucosamine may also act through stimulation of proteoglycan biosynthesis to stabilize cell membrane, resulting in an anti-inflammatory effect.

§   Chondroitin sulfates may also act as a cartilage protector by inhibiting tissue elastase and the migration of polymorphonuclear leucocytes and by increasing the synthesis of hyaluronic acid. But studies in US have revealed a number of preparations claiming to contain certain doses of glucosamine or chondroitin which have significantly less dosage described. It is probably reasonable to use the combination pending further studies (level I/A).

§   Other alternative is intra-articular injections of glucocorticoid (40 mg or more of the triamcinolone hexacetonide). It is an effective short-term of pain reliever and increasing quadriceps power, but no more than three injections per year because it can lead to some risk of cartilage degradation. Some experts recommend intra-articular injection of hyaluronic acid (hyalgan or hylan G-F 20) because it acts as “lubricant” and as “shock absorber” but the exact mechanism of viscosupplementtation are unclear. It mechanisms includes anti-inflammatory and antinociceptive properties or stimulation of in vivo hyaluronic acid synthesis by this agent. This preparation stays within the joint space for hours to days, but clinical efficacy may last as long as 8-16 months. Hyaluronic acid is administered in a series of three to five weekly intra-articular and is generally well tolerated.

§   Other conservative management is an acupuncture treatment of knee OA. Seven trials representing 393 knee OA patients with acupuncture management is more effective for pain relieving. But for function was inconclusive evidence. Future acupuncture research should focus on optimal treatment, maintenance treatment and its role as adjunctive therapy to maximize effectiveness with minimal adverse effects.

5)      Pain relievers

The Candidate should be able to explain the pharmacological therapy for pain control e.g.: acetaminophen or simple non-narcotic analgesic (first line therapy,) and NSAIDs use if the first line does not improve or inflammation is still present (level of evidence is II/recommendation is B). The Candidate should also be able to explain the indication, contraindication, advantage or disadvantage of this procedure. The Candidate may explain a meta-analysis of trials comparing simple analgesic with NSAIDs in knee OA patient noted that knee OA treated with this drug had significantly greater improvement in rest and activities. But NSAIDs use should be cautious in patient who have a history of peptic ulcer or upper gastrointestinal bleeding or age of patient over 65 years, glucocorticoid or anticoagulants use and comorbid conditions and others, although available NSAIDs lack of gastrointestinal toxicity (COA-2 specific inhibitors offer a safer alternative to conventional NSAIDs) for example celecoxib or rofecoxib, valdecoxib.

6)      Intra-articular injection

The candidate must be able to recommend cortitco-steroid intra-knee articular injection for short-term pain relief to knee OA patient because the level of evidence is II or grade recommendation: B, but he/she is not able to recommend hyaluronic acid intra-articular injection with mild to moderate symptomatic knee OA patient. Its level of evidence is I and II or grade recommendation: inconclusive

7)      Needle lavage

The Candidate understands that needle-lavage is not used for symptomatic knee OA patient based on AAOS recommendation (level of evidence is I and II/grade recommendation: B).

b.    Surgery (Surgical intervention))

Principally, surgery intervention is indicated if the conservative procedure fails or no improvement of moderate or severe pain symptom by 3 months of non-surgical therapy. Other indications are the cartilage damage condition and patient decision. The Examiners discuss the reason about functional limitation and severe pain, age, gender, smoking and comorbidity of the patient. The Candidate should be able to explain about primary joint surgery for severe bone loss, extreme deformity, OA caused by anatomy disorganized, and prior joint fusion of knee joint patient. There are many procedures of surgery that Examiners discuss with the Candidate, for example:

o   Arthroscopy lavage and debridement should be determined in patient with clear history of mechanical symptoms eg. locking that have not responded to at least 3 months of conservative treatment, specific surgical target such as loose body, and the Candidate should have a detailed understanding of the degree of compartment damage within the knee. But arthroscopic debridement or lavage in patient with a diagnosis symptomatic primary knee OA can be planned because according to AAOS recommendation to this procedure is level of evidence I and II/recommendation: A

o   Arthroscopy partial meniscectomy or loose body removal is an option in knee OA patient who also has signs and symptoms of a torn meniscus and or loose body. Its level of evidence is IV and grade recommendation: C

o   High tibial osteotomy (HTO)  

The Examiner will discuss the aim of HTO surgery. The procedure is to realign the deformity of the lower limb and offload the knee. The procedure is effective and can provide functional outcome similar with joint replacement.  Post-operative failure-rate is around 30% and it should be considered. In the US, HTO application has been temporized by two factors: recognition of the procedure’s limitation and evolution, and also clinical success of total knee arthroplasty.

The Candidate should be able to explain the indication HTO includes:

·      Moderate to severe knee pain not adequately controlled by 3 months conservatively.

·      Varus mis-alignment in medial uni-compartmental osteoarthritis of the knee. The rational valgus-producing HTO is to unload the arthritic medial side compartment

·      Valgus mis-alignment in isolated lateral uni-compartment knee OA patient. Most experts have expressed a preference for performing a varus producing distal femoral osteotomy. Correction of the valgus angulation on the tibial side of the knee has been criticized because a varus-producing HTO can lead to obliquity of the tibio-femoral joint line, whereas a varus-producing distal femoral osteotomy does not. Some experts suggest valgus correction on femoral’s distal.

·      Diagnosis of the knee OA (Kellgren-Lowrence grade 1-3) isolated to one compartment and usually the medial side

·      Adult osteochondritis dissecans and osteonecrosis

·      Posterolateral instability and chondral resurfacing

The Candidate should be able explain the contraindication of HTO such as:

·      Lateral compartment degenerative

·      Loss of a significant portion of lateral meniscus

·      Symptomatic patella-femoral degeneration

·      Nonconcordant pain (eg, patella-femoral pain with medial compartment osteoarthritis).

·      Patient refuses to accept the anticipated cosmetic appearance of the desired amount of angular correction, and

·      Inflammatory arthritis

AAOS is recommendation level of evidence: IV or V and grade recommendation: C to symptomatic uni-compartmental of knee OA.

The Candidate should be able to describe osteotomy technique for valgus-producing HTO for example lateral closing wedge, medial opening wedge and dome osteotomy, cartilage regeneration after HTO and its complications.

o  Knee arthroplasty

The Candidate ability to describe the resurfacing of the knee joint articular surface with progressive joint destruction or replacement arthroplasty is indicated in elderly patient or if conservative management is ineffective. Procedure of resurfacing puts on metal femoral condylar component and a metal-backed polyethylene and tibial side. Generally, the aim of surgery is to achieve a normal alignment of the lower limb that line from the center of hip to center of the ankle passes through the center of the knee. If only one component we call “unicompartemental replacement” or partial knee arthroplasty and both compartments called “total knee arthroplasty/TKA” Modern techniques and anatomy alignment of knee, the result of knee arthroplasty may achieve the goals of the arthroplasty surgery.

The Candidate should be able to understand the objectives knee arthroplasty, includes:

(a) Alleviate pain.

(b) Return to normal alignment or normal biomechanics.

(c) Improvement ROM.

(d) Recovery muscle balance, and

(e) Improvement function and quality of life.

The discussion could be operative technique, outcome evaluation and complications.

3.    The Candidate ability to predict of the knee OA complications

The Candidate should be able to clarify the complication of knee-OA. If knee OA without management can lead to decrease patient activity or declines the quality of patient life. Complication of conservative management depends on the type of management using but post TKA surgery may complicate infection, bone loss, joint line disturbance, and extensor mechanism problem and knee instability. The Candidate should be able to plan TKA revision with numerous technical challenges and decision. The Candidate needs to determine what is insufficient and what is necessary to reconstruct both bone and the soft tissue deficit. The prognosis of knee OA is a chronic disease that can involve the quality of patient’s life.

Table 21: List of part B evaluation

PART B: The objectives examination evaluation of the patient’s problem, management and complications	20 complete & correct statement	15 Incomplete presentation or Correct response to stimulation question	0 Incorrect response or no response	Marks
a.       Candidate ability of determination of the knee OA problem (acute and long-term) in discussion
b.       Candidate ability of the management planning of knee OA patient and outcome in discussion
c.       Candidate ability to decide the complications of the knee OA in discussion
TOTAL MARKS of  Part B

MARKS OF PART B:

§  Mark 20: Candidate presents: (a) the determination of acute and long-term problem or (b) management planning, or (c) complications prediction of knee OA patient in discussion completely and correctly.

§  Mark 15: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of (a) the acute and long-term problem determination or (b) management planning or (c) complications prediction of knee OA patient in discussion correctly.

§  Mark 0: Candidate’s response is not correct or he/she does not respond to the examiner’s stimulation question of (a) the acute and long-term problem determination, or (b) management planning or (c) complications prediction of knee OA patient during discussion.  

§  Maximal marks of part B is 60

OTHER ALTERNATIVE EVALUATION LIST (Table 22)

Part B. The objectives examination evaluation of the accurate diagnosis determination or possibilities of the abnormalities, patient’s problem, management and complications

Learning Objectives Evaluation in Examination

The Examiner should be able to assess

1.      The Candidate capability to decide the acute and long-term problem of knee OA. The Candidate should be able to explain the problem of knee OA patient. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

2.      The Candidate ability to plan the management decision of knee OA based on evidence (treatment algorithm)

The Candidate should be able to understand that the based on treatment depends on accurate diagnosis, treatment options according to evidence of medicine, patient need and facilities. The Examiner questions are varying depends on the Examiner experience for achieving objective, valid and reliable marking.

3.      The Candidate ability to predict the common complication of the knee OA, promotion and prevention issues

The Candidate should be able to explain complication of the knee OA, management complications, promotion and prevention of knee OA patient. The Examiner stimulates a few questions for achieving objective, valid and reliable marking.

Table 22: List of the evaluation marks of part B

CONTENTS OF EVALUATION	Marks
Part B: The objectives examination evaluation of the patient’s problem, management and complications	60 Complete & correct presentation	45 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to determine acute and long-term problem, select the best option of the management  and to decide the complication of knee OA in discussion

MARKS:

• Marks 60: Candidate presents the acute and long-term problem, the management and complications prediction planning of knee OA completely and correctly
• Marks 45: Incomplete data presentation or the Candidate is able to respond the examiner’s stimulation question about a mistake or omission of the interesting of the acute and long-term problem, management planning and complications prediction determination of knee OA correctly.
• Marks 0: Candidate’s response is not correct or he/she does not respond to the examiner’s stimulation question of the acute and long-term problem determination, management planning, and complications prediction of knee OA.

Part C. The objectives examination evaluation of a good candidate attitude and professionalism. 

Learning Objectives Evaluation in Examination

The Examiner should be able to assess:

The Candidate capability to take action the good attitude in knee OA health care services includes:

·         What is the Candidate’s focus on communication with knee OA patient? Does the Candidate rarely interrupt patient’s story during history taking?

·         What is Candidate plan for the beneficence knee OA management orientation and to avoid malaficence in the health care intervention on discussion section B?

·         What is the Candidate social justice in health care services? Candidate should ask several questions to patient that he/she may show prejudice and discrimination in health care management knee OA patient. What is Candidate’s perspective in consideration to health care disparities to the patient?

·         How the candidate tries to improve communication and awareness regarding health care disparities through cultural competency education that can lead to better racial and ethnic harmony in health care to knee OA patient)

Professional Candidate should enhance the quality of medical care delivered based to on biopsychosociol-cultural knowledge for knee OA patient in discussion section.

·         Professional Candidate always decision making of the priority knee OA management among some options based on the evidence of medicine (EBM). What is the candidate management decision in health care and the reasoning of explanation mechanism, advantages and disadvantageous clearly and knowledgeable to the knee OA patient? How does the Candidate make decision of which management is the best management based on EBM of knee OA? What is the Candidate’s decision of management in health care? Does the Candidate explain the reasoning, the advantage and disadvantage to the patient clearly and knowledgeable enough?

Table 23: List of part C evaluation

PART C: The objectives examination evaluation of a good Candidate attitude and professionalism.  .	5 complete & correct statement	3 Incomplete presentation or Correct response to stimulation question	0 Incorrect response or no response	Marks
a.       Ability to show a good attitude in communication of knee OA patient and the Examiners in health care services discussion
b.      Ability to show a good professionalism in discussion of knee OA health care services
TOTAL MARKS of Part C

•      MARKS OF PART C:

•      Mark 5: Candidate ability to show a good attitude (a) and basic medical and clinical knowledge to decide management based on evidence or (b) professionalism in health care services of knee OA in discussion

•      Mark 3: Impolite attitude in discussion between Candidate and patient/Examiners but the Candidate is a good attitude (a) basic medical and clinical knowledge and management decision based on evidence in health care services of knee OA or (b) professionalism in discussion.   

•      Mark 0: Impolite attitude and Candidate is also a bad attitude (a) basic medical and clinical knowledge without evidence management decision in health care services of knee OA  or bad professionalism (b) in discussion  

•      Maximal marks of part C is 10

OTHER ALTERNATIVE EVALUATION LIST (Table 24)

Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism. 

Learning Objectives Evaluation in Examination

The Candidate must have good attitude and professionalism in solution of knee OA problem. The Examiner should be able to evaluate the Candidate attitude & professionalism based the response in the discussion above. If the Candidate responses are doubtfulness, the Examiner stimulates a few questions for achieving objective, valid and reliable marking.

MARKS:

•      Marks 10: Candidate ability to show a good attitude and basic medical and clinical knowledge to decide management based on evidence (professionalism) in health care services of knee OA

•      Marks 6: Impolite attitude in discussion between Candidate and patient/Examiners but the Candidate is a good basic medical and clinical knowledge and management decision based on evidence in health care services of knee OA.  

•      Marks 0: Impolite attitude and Candidate is also a bad basic medical and clinical knowledge without evidence management decision in health care services of knee OA  

Table 24: List of the evaluation marks of part C

CONTENTS OF EVALUATION	Marks
Part C: The objectives examination evaluation of a good Candidate’s attitude and professionalism.	10 Complete & correct presentation	6 Incomplete presentation  or correct response of stimulation question	0 (incorrect or no response)	Marks
Ability to show a good attitude and professionalism in discussion

Conclusion total marks = part A + part B + part C

·         Marks: 85-90 is superior ·         Marks: 79-84 is excellent ·         Marks: 69-78 is pass; and ·         Marks: 60-68 is fail

·         Marks: 85-90 is superior ·         Marks: 76-86 is excellent ·         Marks: 65-75 is pass; and ·         Marks: ≤ 65 is fail

REFERENCES

1.      Armis (2005). Musculoskeletal Competency: Guidelines for Medical Students, PCPs (Primary Care Physician) and Residents in Training. Unit Pelayanan Kampus. FK UGM. Jogjakarta.

2.      Arya RK and Jain V (2013). Osteoarthritis of the knee joint: An overview. JIACM; 14: 154-162

3.      Dennis DA, Berry DJ, Engh G, et al (2008). Revision Total Knee Arthroplasty. J Am Acad Orthop Surg 16: 442-454.

4.      Fahmy NRM, Williams EA and Noble J (1983). MENISCAL PATHOLOGY AND OSTEOARTHRITIS OF THE KNEE. JBJS 65B:24-28

5.      Favorite PJ, Mibalko WM and Krackow KA (2002). Total Knee Arthroplasty in Valgus Knee. J Am Acad Surg 10: 16-24

6.      Kurz B, Lemke A, Kehn M, et al (2004). Influence of Tissue Maturation and Antioxidants on the Apoptotic Response of Articular Cartilage After Injurious Compression. Arthr &Rheum 50: 123-30

7.      Leopold SS, Redd BB, Warme WJ, et al (2003). Cortico Compared with Hyaluronic Acid Injections for the Treatment of Osteoarthritis of the Knee: A Prospective, Randomized Trial. JBJS 85A: 1197-1203.

8.      Mcalindon T and Felson DT (1997). Nutrition: risk factors for osteoarthritis. Ann. Rheum. Dis 56: 397-400.

9.      Richmond J, Hunter D, Irrgang J, et al (2010). American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Osteoarthritis (OA) of the Knee. JBJS 92A: 990-993.

10.  Tallon D, Chard J and Dieppe P (2000). Exploring the Priorities of patients with Osteoarthritis of the Knee. Arthritis Care and Research 13: 312-319

11.  Toy EC, Rosenbaum AJ, Robert, TT and Dines JS (2013). Case Files: Orthopaedic Surgery. McGraw Hill Education. New York.

12.  Vrezas I, Elsner G, Bolm U, et al (2009). Case-control study of knee osteoarthritis and lifestyle factors considering their interaction with physical workload. Int Arch Occup Enviro Health. Springer-Verlag.

13.  Wen Wang J and Chen Hsu C (2005). Distal Femoral Varus Osteotomy for Osteoarthritis of the Knee. JBJS 87A:127-133.

14.  Wright JM, Crockett HC, Slawski DP, Madsen MW and Windsor RE (2005). High Tibial Osteotomy. J Am Orthop Surg 13: 279-289

15.  Wu SS and Tuan K (2005). Current Concepts in Nonoperative Management of Knee Osteoarthritis. Orthopaedics 28: 134-146.