First MTP Osteoarthritis Hallux valgus with bunion.
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Transcript of First MTP Osteoarthritis Hallux valgus with bunion.
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First MTP Osteoarthritis
Hallux valgus with bunion
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OA is a Problem with the Cartilage!
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Osteoarthritis: Risk Factors• Secondary Osteoarthritis: The
degeneration is secondary to an injury to the cartilage
• Primary Osteoarthritis: No obvious cartilage injury
• Erosive (hand) OA: runs in families, autosomal dominant but more penetration in women
• Often starts 5-10 years pre to post menopause, adds more joints (DIPs, PIPs), can mimic psoriatic arthritis, burns out with bony changes
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Risks for OA
• Advanced Age• Female• Genetics• Obesity• Occupation (overuse)• Trauma
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Osteoarthritis: Laboratory
• All laboratory investigations should be normal in osteoarthritis
• Labs and Xrays are not necessary to make the diagnosis
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Osteoarthritis: Management
• Non-Pharmacologic– Exercises– Strengthening– Splinting
• Pharmacologic– Oral Medications Surgery– Topical Medications– Injectable Medications– Alternative/Complimentary Choices
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Goals of Treatment
1. Pain Reduction
2. Improved Function
3. Changes the Disease Outcome
4. Low Cost
5. Low Side Effects
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Physical & Occupational Therapy
Assistive Devices
Proper Footwear
Exercise & Weight LossEducation
Strength Training
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Topical Medications
1. Capsaicin
2. Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Pennsaid, Diclofenac
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Topical NSAIDs
Limited Use for Osteoarthritis• Small effects in clinical trials• Apply 4 times per day• Expensive• Messy
Benefits• Little systemic absorption
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Intra-Articular Corticosteroids
Pros• Cheap• Relatively Safe: 1 in 15-20,000 risk of
infection• Safe to do 4 injections in a single joint per
yearCons• Short term benefit at 4 to 8 weeks but
negative at 12 and 24 weeks• Predictors of response are unclear
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Viscosupplementation
• Joints typically contain a small amount of lubricating fluid called synovial fluid.
• Hyaluronic acid is a component of this synovial fluid
• Synovial fluid Hyaluronic acid is decreased in patients with osteoarthritis
• Viscosupplements are synthetically or biologically derived Hyaluronic Acid
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Viscosupplementation
• Given by a series of 1 to 3 injections once a week depending on the product
• Only approved for osteoarthritis of the knee• The effects are variable lasting months in some
people and not working at all in others
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Viscosupplementation
Pros• If it works, may have a significant benefit
Cons• Expensive ~ $300 per course• The effects are variable lasting months in some
people and not working at all in others• Post-injection pain, swelling• Not very good clinical trial data
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Oral Medications
1. Simple Analgesics
2. Non-Steroidal Anti-Inflammatory Medications (NSAIDs)
3. Narcotic Analgesics and non-narcotic (tramadol)
4. Complimentary Therapy (Glucosamine)
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Acetaminophen• Acetaminophen (Tylenol ) • Useful in mild to moderate osteoarthritisPros• Cheap• Safe• Proven BenefitCons• Small effect• Often need 3g/day
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Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
• Traditional NSAIDs• COX-2 Selective NSAIDs (COXIBs)
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Prostaglandin SynthesisCell Membrane Phospholipids
Arachidonic Acid
Prostaglandins Prostaglandins
COX-1 Continuously Expressed
GI TractPlateletsEndotheliumKidney
COX-2 UpregulatedSynovial LiningMacrophagesChondrocytesEndotheliumMacula Densa
COX-2COX-1NSAIDs NSAIDs
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Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Traditional NSAIDs•Block the Actions of COX-1 and COX-2•Available Over the Counter (Ibuprofen)•Several (Ibuprofen, Diclofenac, Naproxen,
etc)
COX-2 Selective NSAIDs (COXIBs)•Only Block the Action of COX-2•Only 1 available – Celecoxib (Celebrex)
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NSAIDs & COXIBs: What Works
• NSAIDs consistently outperform acetaminophen in OA treatment
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NSAIDs & COXIBs: What to look out for
• GI Risk – gastric and duodenal ulcer• Renal Risk – raise creatinine and HTN• Cardiovascular Risk - ?increased MIs• Hepatoxicity• Edema• Allergic reactions
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Clinical Risk Factors for NSAID Gastropathy
1. History of Ulcer Related Complications 13.5%• Previous ulcer, bleeding
2. Multiple NSAIDs 9.0 %3. High-dose NSAIDs 7.0 %4. Concomitant Anticoagulation 6.4%5. Age > 69 5.6%6. Age > 59 3.1%7. Concomitant Steroids 2.2%8. History of CV disease 1.8%
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More Patients are Without Appropriate Gastroprotection
Singh G, et al. Gastroenterology 2006; 130(Suppl. 2): A-82 (Abstract 564).
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
No gastroprotection
Year
100
80
60
40
20
0
Patients >65 years not receiving gastroprotectiveapproaches with their NSAIDs (%)
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NSAIDs & COXIBS: Cardiovascular
• All NSAIDs may increase the risk of MI (possibly) and some more than others
• Use the lowest possible dose for the shortest duration of time
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Narcotics
• Benefits– Codeine does have some evidence for
efficacy, however, it also has a high incidence of side-effects.
– Oxycodone, morphine, and hydromorphone may be better choices
• Side Effects– Increaed in the elderly– Sedation, confusion, constipation
• Risk for Falls and other Accidents
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Addiction
• It is EXCEEDINGLY rare for patients with OA to show addictive behaviour. In fact, a study of over 800 patients with OA treated with opioids for 3 years found only 4 (0.02%) to have addictions. (Ytterberg S, Mahowald M, Woods S. Codeine and oxycodone use in patients with chronic
rheumatic disease pain. Arthritis Rheum 1998;41:1603-12.)
• OA patients stop opioids after surgery. (Visuri T, Koskenvuo M, Honkanen R. The influence of total hip replacement on hip pain and
the use of analgesics. Pain 1985;23:19-26.)
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Glucosamine: The Theory
• Glucosamine is a component of cartilage• Glucosamine is reduced in osteoarthritic
cartilage• Replacing glucosamine may have
beneficial effects
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Glucosamine: The Evidence
• You are a believer or not– Both positive and negative trials
• Withdrawal trial and NIH trial were both essentially negative
• DONA (RottaPharm)– Only brand of glucosamine to show positive
benefit in trials– All trials sponsored by pharmaceutical
company
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Glucosamine: Practicality
• Dose: 500 mg three times daily• If no effect after 3 months stop
? Take with chondroitin
Seems very safe
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Surgery for Osteoarthritis
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Surgery: Who is appropriate
• Most people with arthritis, including older individuals, should be referred for surgical treatment when other treatment is ineffective and function is impaired.
• Surgery should not be used as a last resort
• There is no “magic age” for surgery
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Surgery: Why Consider
Consider surgery before:• Advanced muscle weakness• Joint deformities• Significant loss of function with further
deconditioning
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Treatment Conclusions
• Non-Pharmacologic Therapy– Education– Physical Therapy
• Assessment• Education• Strengthening• Range of Motion• Joint Protection & Energy Conservation
– Weight Loss & Nutrition– Cardiovascular Exercise– Shoes & Insoles– Assistive Devices
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Treatment Conclusions
• NSAIDs– Work very well in select patients– Try a few NSAIDs before find the right one for
you.– 3 week trials of at least 3 different NSAIDs.
• Injectable Corticosteroids – Work well in some patients
• Viscosupplementation– Can work well in some patients (milder disease)
• Opioids– Can provide considerable benefit
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Treatment Conclusions
Lack of Scientific Evidence for• Acupuncture• Magnet Therapy
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OA Guidelines
Other• Exercise• Brace, Taping• Weight Loss• Joint replacement
Medications• Acetaminophen• NSAIDs/Coxibs• Topical agents• Injectable agents
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Questions