Evidenced Based Management Knee Osteoarthritis

Dr Jonathan Mulford myorthopod.com.au

Knee Arthritis

• The reality - not life threatening and has low associated mortality.

• However- – substantial influence on the quality of life– heavy economic burden on the community.

Risk factors for knee osteoarthritis

• female • aging• Overweight• joint injury, malalignment, joint laxity, • occupational and recreational use• family history• Heberden's nodes at the distal finger joints.

Non Operative Management

• Many Controversial treatments.

• Many of this evidence Based finding are from the Cochrane Library

• Unfortunately there are many studies of poor methodology.

Non Op Treatments Groups

• Lifestyle modification

• Rehabilitation and Physiotherapy

• Braces and Insoles

• Pharmacology

LIFE STYLE MODIFICATION

• Avoid aggravating factors – No high Impact– Limit Stair climbing

• Weight loss

• Diet

Weight loss and Knee OA

• moderate weight loss (weight reduction > 5.1% or > 0.24%/wk)

improves self-reported disability.

• No clear evidence that Weight loss reduces pain or improve patient global evaluation.

• A BMI greater than 30 has a 4 times increase in risk of knee arthritis – so weight loss important preventative measure!

Diet

• A diet high in olive oil, fish and vegetables – reduced pain by 40% & morning stiffness by 10% in RA.

• ? effects for OA. Annals of the Rheumatic Diseases 2003; 62:208-14.

• Diets rich in vitamins C slow the progression of osteoarthritis.

Arthritis and Rheumatism 1996; 39:648-56. .

REHABILITATION

• Therapeutic Excercise

• Ultrasound, TENS, Pulsed Electric Stimulation, Acupuncture

• Hydrotherapy – Aquatic Excercise– Balneotherapy

Therapeutic Exercise in Knee OA

• Small short term benefit for knee pain and physical function.

• No evidence long term benefit.

• Is useful pre-operatively.

Aquatic-exercise and Knee OA

• some beneficial short-term effects for patients with hip and/or knee OA.

• no long-term effects have been documented.

• Can be useful for pre-operative conditioning.

Balneotherapy (or spa therapy, mineral baths)

• The scientific evidence is weak.

• Cochrane review - Seven trials (498 patients) – mineral baths compared to no treatment – Dead Sea + sulphur versus no treatment, – Dead Sea baths versus no treatment – sulphur baths versus no treatment

• mineral baths may be benificial (small effect).

• Of all other balneological treatments no clear effects were found.

Therapeutic ultrasound

• no benefit over placebo

Transcutaneous electrical nerve stimulation (TENS)

• small improvements in pain control over placebo.

• Methodology of the studies is poor.

Pulsed Electric Stimulation

• Electrical stimulation therapy had a small to moderate effect on outcomes for knee OA.

Acupuncture• randomised controlled trial”, Foster et al. (BMJ 2007;335;436),

• acupuncture no benefit as an adjunct to a course of individualised, exercise based physiotherapy.

• Other papers looking at acupuncture - some benefit • however have had major methodological flaws .• Annals of Internal Medicine 2004; 141(12):901-10.

Thermotherapy and knee OA

• Ice massage beneficial effect on ROM, swelling, function and knee strength.

• Ice packs did not affect pain significantly.

• Hot packs had no beneficial effect on edema compared with placebo or cold application.

Brace and Orthosis (insole).

• Brace (neoprene sleeve) and a lateral wedge insole have small beneficial effect.

• However, long-term adherence to brace and insole treatment is low.

Pharmacology

• Painkillers• Anti-inflammatory• Chondrotin and Glucosamine• Alternative medications• Injections

Paracetamol versus Placebo and versus NSAIDs

• significant reduction in pain compared to placebo

• BUT• Small improvements in pain.

• less effective overall than NSAIDs in terms of pain reduction, global assessments and in terms of improvements in functional status.

NSAIDS• NSAIDs are effective in relieving short-term pain in OA.

• NSAIDs at the lowest effective dose should be considered in patients who respond inadequately to simple analgesia.

• longer-term use is potential for serious side effects.(gastropathy, including peptic ulcer disease, and care if hypertension, cardiovascular and renal disease)

• Concurrent use of more than one NSAID and other medications, increasing age and duration of treatment substantially increase the risk of side effects.

Topical NSAIDS

• Topical NSAIDs were effective and safe in short-term treatment of OA.

• lack of any trial data to support their long-term use

• Effects wane after 2 weeks. • Larger and longer trials are necessary

COX-2

• CLASS study demonstrated that coxibs reduce clinical upper GI events by approximately 55%

• Consider COX-2 if high risk of peptic ulcer disease.

• Caution should be used due to their association with cardiovascular, renal and other adverse effects.

Opioid Analgesia• alternative when paracetamol and NSAID drugs

are contraindicated, ineffective, or poorly tolerated.

• A once-a-day formulation of tramadol helps pain,• fewer interruptions in sleep and improved

compliance.

• effective alternative treatment for acute flares of OA pain.

CODEINE

• Codeine in combination with simple analgesia or NSAID might be appropriate for the occasional pain relief or for patients in whom only simple analgesia is not effective.

• However, repeated use increases the occurrence of side effects.

Chondroitin

• 22 RCTs (n = 4056)

• Conclusion: Based on evidence from higher-quality trials of patients with knee or hip osteoarthritis, chondroitin does not reduce pain more than placebo or no treatment.

Glucosamine• 25 studies with 4963 patients.

• If Analysis restricted to studies with adequate allocation concealment – No benefit for pain, function and stiffness subscales.

• Collectively, the 25 RCTs • 22% (improvement in pain and a 11% improvement in function

• Non-Rotta preparation or adequate allocation concealment failed to show benefit in pain and WOMAC function

• Rotta preparation showed that glucosamine was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA.

Alternative Herbal Medicine • Cochrane review found 5 studies.

• The evidence for avocado-soybean unsaponifiables in the treatment of osteoarthritis is convincing .

• Single studies of other interventions, a willow bark preparation (Reumalex), topical capsaicin and tipi tea, were inconclusive.

Corticosteroid Injections

• Effective pain reliever however often only for short period (4 weeks)

Viscosupplements

• at one to four weeks post injection CSI and HA same.

• Between five and 13 weeks post injection, HA products were more effective than corticosteroids

Surgical Treatment

• Arthroscopy• Osteotomy• Uni• Patellofemoral Arthroplasty• Total knee Arthroplasty• Fusion

Arthroscopic Surgery

• There is 'gold' level evidence that AD has no benefit for undiscriminated OA

• Can help acute mechanical pain due to meniscal tear, chondral flap or loose body.

• The acute pain is helped, however can have residual pain from the OA.

High Tibial Osteotomy

High Tibial Osteotomy

Indications• Isolated Compartment OA• Less than 12 degrees deformity• Stable knee• Young and activeBenefits • Avoid arthroplasty• No limits on activity

Problem • Inconsistent results – 50% still effective at 7-

10 years – At 5 years 75% good or excellent.– At 8 years 60% good or excellent.– (Arch Orthop Trauma Surg 124:258-261, 2004)

• Arthroplasty after osteotomy may not be as successful.

• Certainly more challenging surgery.

Uniarthroplasty

Uni

Indications • isolated compartment Osteoarthritis.Benefits • Smaller incision, Quicker recovery, better

feeling knee, cost implications.Problems • progression, revision.

How Long do they Last?

• Swedish Register – about 90% at 10 years

Age and Uni RevisionAustralian Joint Register

Patellofemoral Arthroplasty

• Indications – Isolated• Benefits• Problems

Total Knee Arthroplasty

When to Operate• When pain is bad enough to limit lifestyle and

function.• Don’t wait too long - – surgery performed later in the natural history of

functional decline results in worse postoperative functional status.

• However, • those with the poorest preoperative scores

gained most from the operation. • patients operated on later were more satisfied

with their outcomes.

Total knee Replacement

• 91-96% prosthesis survival rate at 14-15 years of follow-up.

• We now know that approximately 85 percent of the knee implants will last 20 years.

• Thus most implants will last a life time.

• Improvements in surgical technique, prosthetic designs, bearing surfaces, and fixation methods might increase the survival rate of these implants even longer.

Swedish Knee Registry

Australian Joint Registry

Revision Summary Australian Joint Register

• At 7 years cumulative % revision• Primary total 4.3%• Uni 12.1%• PFJ 13.8%

Unispacer and Partial Resurfacing