Transcript Evidenced Based Management Knee Osteoarthritis

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
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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)
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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
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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 .
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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
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Painkillers
Anti-inflammatory
Chondrotin and Glucosamine
Alternative medications
Injections
Paracetamol versus Placebo and versus
NSAIDs
• significant reduction in pain compared to
placebo
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• 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 longterm 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 higherquality 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
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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 active
Benefits
• Avoid arthroplasty
• No limits on activity
Problem
• Inconsistent results – 50% still effective at 710 years
– At 5 years 75% good or excellent.
– At 8 years 60% good or excellent.
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(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 Revision
Australian 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.
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• 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
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At 7 years cumulative % revision
Primary total 4.3%
Uni 12.1%
PFJ 13.8%
Unispacer and Partial Resurfacing