Osteoarthritis Diagnosis and Treatment


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an overview of osteoarthritis management

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  • Craig S. Radnay, M.D. 03/01/13 30-40% of population by age 65
  • Craig S. Radnay, M.D. 03/01/13 Increased # of falls, with balance issues
  • Weight loss is most important modifiable risk factor OA association with activities, muscle weakness not as strong
  • OA sx: gradual onset, pain (most common medial 70%), stiffness, gelling, alleviated by rest R/O infectious arthritis
  • Important to isolate tenderness for correct dx Duck waddle for function
  • Lachman more sensitive than ant drawer McMurray: positive test if pain or click with motion
  • Weight-bearing/standing AP views important to assess for loss of jt space
  • Medial: -Medial Knee OA 70% of cases -Anserine bursitis (most common bursitis, often B)dx: TTP quarter-sized area tibial plateau 1-1.5 inches below jt line, pain at motion/rest/night) -Bursa adjacent to MCL Lateral: -IT band (TTP over lateral femoral condyle) Anterior: -PF syndrome (most common cause of knee pain < 45yo, female, often B, compress patella to femur) Diffuse -inflammatory (limited ROM, knee kept slightly flexed) -50% of Nongonococcal bacterial arthritis cases involve the knee
  • 4 of these are exam findings
  • Improved specificity with x-rays, fluid sample
  • X-ray on right: Top arrow – subcondral cyst Middle arrow – osteophytes Bottom arrow – subchondral sclerosis
  • NSAID ’s, Cox-2’s (and the added cost of gastroprotective agents) , cortico steroid effectiveness and or potential adverse effects must be considered. What makes sense is that JFT is moved earlier on in the treatment of OA knee pain… Medicare covers SUPARTZ IF IT is administered and gets 6 months of documented pain relief after the last injection, and there is documented pain relief. This is a local treatment for a local disease and is extremely safe and does not have the potential effects of pills or corticosteroids in treating knee OA. Perhaps, we need to treat OA of the knee with a treatment that can cause more damage to the patient than the underlying disease that we are treating. To Make this clear: NSAIDS/Cox 2 ’s can cause serious and lifethreatening consequences even death – 16,500 per year SUPARTZ = LOCALIZED TREATMENT FOR A LOCALIZED DISEASE = 0 deaths… safe, effective, compliance that is absolute, Medicare covers and now I the doctor can choose the therapy and determine when my patients needs have been met. Typically I will start out with 5 injections as I want everyone to get the maximum opportunity to get pain relief and miss the TKR. Then it will be up to me and my patients to determine the next steps…. What is best for the patients… Adapted from: Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee; AMERICAN COLLEGE OF RHEUMATOLOGY SUBCOMMITTEE ON OSTEOARTHRITIS GUIDELINES; ARTHRITIS & RHEUMATISM, Vol. 43, No. 9, September 2000, pg. 1905-1915, © 2000, An alternative approach to the use of oral agents in the palliation of joint pain is the use of intraarticular therapy such as hyaluronan (hyaluronic acid) or glucocorticoids. Two preparations of intraarticular hyaluronan have been approved by the FDA for the treatment of knee OA patients who have not responded to a program of nonpharmacological therapy and acetaminophen. To date, differences in clinical efficacy between these preparations as a function of molecular weight have not been demonstrated (70). Because the duration of benefit reported for these agents exceeds their synovial half-life, their mechanisms of action are unclear; proposed mechanisms include inhibition of inflammatory mediators such as cytokines and prostaglandins, stimulation of cartilage matrix synthesis and inhibition of cartilage degradation, and a direct protective action on nociceptive nerve endings. In clinical trials of intraarticular hyaluronan preparations, pain relief among those who completed the study was significantly greater than that seen after intraarticular injection of placebo, and comparable with that seen with oral NSAIDs (71-73). In addition, pain relief among those who completed the study was comparable with or greater than that with intraarticular glucocorticoids (73). Although pain relief is achieved more slowly with hyaluronan injections than with intraarticular glucocorticoid injections, the effect may last considerably longer with hyaluronan injections (73). Intraarticular hyaluronan therapy is indicated for use in patients who have not responded to a program of nonpharmacologic therapy and simple analgesics; intraarticular hyaluronan injections may be especially advantageous in patients in whom- nonselective NSAIDs and COX-2-specific inhibitors are contraindicated, or in whom they have been associated either with a lack of efficacy or with adverse events. Limited data are available concerning the effectiveness of multiple courses of intraarticular hyaluronan therapy (74). Transient mild-to-moderate pain at the injection site may occur; occasionally, mild-to-marked increases in joint pain and swelling have been noted following hyaluronan injection. AAOS Clinical Guideline on Osteoarthritis of the Knee Support Document (2003) “ Viscosupplementation (we refer to this as Joint Fluid Therapy) ( “ C ” recommendation) may have a role in the treatment of knee pain due to osteoarthritis during the initial 12 weeks in the hands of physicians technically proficient in arthrocentesis.
  • Weight loss Exercise program If unclear about insoles vs braces, early referral to podiatry or orthopedics or sports medicine
  • Craig S. Radnay, M.D. 03/01/13
  • What comes first? Snowball effect Depicts correction of R knee varus deformity. Unloads medial compartment. Unloader braces can correct up to 3 degrees
  • NSAIDS > Tylenol > placebo: 2004 meta-analysis of 10 randomized trials. NSAIDs: caution in CHF, HTN (fluid retention)
  • Lidocaine tells you if in the joint Can extend injection duration if inevitably going towards total knee replacement
  • Anterolateral approach 71%, anteromedial 75% Doug Jackson studied accuracy of injections by orthopods by any approach, <50% on first try.
  • Young pts—how long can you keep them on NSAIDs?
  • Craig S. Radnay, M.D. 03/01/13
  • Osteoarthritis Diagnosis and Treatment

    1. 1. Knee joint OADiagnosis and Management Rheumatology Division Dr Hasan Sadikin Hospital Bandung
    2. 2. Case PresentationAceng is a 48 yo male primary school teacher whopresents to the Rheumatology Clinic c/o 8-10 yrs ofB knee pain. His active lifestyle is severelycompromised by his knee pain.
    3. 3. Case PresentationHistory:•Site/Severity:•Onset:•Character:•Radiation:•Alleviation:•Time:•Exacerbation:•Sx associated:
    4. 4. Case Presentation
    5. 5. Case Presentation
    6. 6. Osteoarthritis• Epidemic in the US – More people over 65 than teenagers • One baby boomer will turn 55 every seven seconds for the next 20 years – Increased life span • 1940: 61.4 yrs/men, 65.7 yrs/women • 2008: 75.4 yrs/men, 80.0 yrs/women• 66 million (1/3) US adults will have OA by 2030• Estimated that only 10% of population currently seeks treatment
    7. 7. Osteoarthritis• 2nd only to CVD in producing chronic disability that directly impacts the quality of life• Causes – Obesity, genetics, trauma – More active lifestyles – Work past retirement age – Younger population• #1 Cause of Decreased Work Performance
    8. 8. Osteoarthritis of The KneeI. Overview  Epidemiology  Definition  Risk FactorsI. Clinical Approach to Knee PainII. Differential DiagnosisIII. Diagnosis of Knee OAIV. Management  Lifestyle  Medical  Surgical
    9. 9. Overview: Epidemiology• Knee OA most common cause of disability in adults• Decreased work productivity, frequent sick days• Highest medical expenses of all arthritis conditions• Symptomatic Knee OA – More than 10 million Americans 1 – More than 11% of persons > 64yo 2
    10. 10. Overview: Definition Arthritis vs. ArthrosisGradual loss of articular cartilage in the knee joint • 3 articulations: 1) Lateral condyles of the femur and tibia 2) Medial condyles of the femur and tibia 3) Patellofemoral jointDamage caused by a complex interplay of jointintegrity, biochemical processes, genetics, andmechanical forces
    11. 11. Anatomy of The Knee
    12. 12. Anatomy of The Knee
    13. 13. Overview: Risk Factors• Age 3• Female• Obesity• Previous knee injury• Lower extremity malalignment• Repetitive knee bending• High impact activities• Muscle weakness 4
    14. 14. Osteoarthritis of The KneeI. Overview  Epidemiology  Definition  Risk FactorsI. Clinical Approach to Knee PainII. Differential DiagnosisIII. Making The DiagnosisIV. Management  Lifestyle  Medical  Surgical
    15. 15. Clinical Approach to Knee Pain “Hey Doc, my knee’s been hurting!”History• SOCRATES pain questions• Inflammatory sx e.g. fever, hot joint• History of trauma or surgery• Instability• Functional loss• Prior treatment
    16. 16. Clinical Approach to Knee PainPhysical Exam• Vitals, BMI• Palpation: isolate tenderness, effusion, crepitus• ROM: measure degree of flexion• Stability: ligaments, menisci• Alignment: genu varus or valgus• Function: gait, duck waddle
    17. 17. Clinical Approach to Knee PainValgus Test (MCL) Varus Test (LCL) Lachman Test (ACL) McMurray Maneuver Duck Waddle (menisci) (stability)
    18. 18. Clinical Approach to Knee PainTests• CBC, ESR, RF• Arthrocentesis• X-rays (3 views) – Weight-bearing AP – Lateral – Tangential Patellar (Sunrise)• MRI
    19. 19. Osteoarthritis of The KneeI. Overview  Epidemiology  Definition  Risk FactorsI. Clinical Approach to Knee PainII. Differential DiagnosisIII. Diagnosis of Knee OAIV. Management  Lifestyle  Medical  Surgical
    20. 20. Differential Diagnosis of Knee Pain Medial Pain Lateral Pain • OA • OA • MCL • LCL • Meniscus • Meniscus • Bursitis • Iliotibial band syndrome Diffuse Pain Anterior Pain • OA • OA • Infectious arthritis • Patellofemoral syndrome • Gout, pseudogout • Prepateller bursitis • RA • Quadriceps mechanism
    21. 21. Osteoarthritis of The KneeI. Overview  Epidemiology  Definition  Risk FactorsI. Clinical Approach to Knee PainII. Differential DiagnosisIII. Diagnosis of Knee OAIV. Management  Lifestyle  Medical  Surgical
    22. 22. Diagnosis of Knee OAClassic Clinical Criteria – established by ACR, 1981 – sensitivity 95%, specificity 69% knee pain plus at least 3 of 6 characteristics: • > 50 yo • Morning stiffness < 30 min • Crepitus • Bony tenderness • Bony enlargement • No palpable warmth 5
    23. 23. Diagnosis of Knee OAClassification Tree• Clinical symptoms• Synovial fluid 1. WBC<2000/mm3 2. Clear color 3. High Viscosity No OA• X-rays 1. Osteophytes 2. Loss of joint space 3. Subchondral sclerosis 4. Subchondral cysts Confirmed by arthroscopy Sensitivity 94 %; (gold standard) 6 Specificity 88 %
    24. 24. Diagnosis of Knee OA
    25. 25. Osteoarthritis of The KneeI. Overview  Epidemiology  Definition  Risk FactorsI. Clinical Approach to Knee PainII. Differential DiagnosisIII. Diagnosis of Knee OAIV. Management  Lifestyle  Medical  Surgical
    26. 26. Guidelines for Managing Osteoarthritis Surgery SEVERE OA COX-2’s Hyaluronic Acid High Dose NSAIDS + Corticosteroids Gastroprotectant MODERATE simple analgesics, low dose NSAID’s MILD Exercise, Physical Therapy, Weight Loss, Orthotics, Nutraceuticals, Bracing Adapted from Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee, ACR, 2000
    27. 27. AAOS Clinical Practice Guideline on the Treatment of OA of the Knee• Patient Education and Lifestyle Modification• Rehabilitation• Mechanical Interventions• Complementary and Alternative Therapy• Pain Relievers• Intra-articular Injections• Needle Lavage• Surgical Intervention
    28. 28. Management: Lifestyle• Weight loss – Nutrition referral• Exercise Program – PT referral – Quadriceps strengthening – ROM exercises – Low impact activities e.g. swimming, biking 7• Ambulatory assist devices – Cane – Walker• Insoles• Unloader knee braces
    29. 29. AAOS Treatment of OA of the Knee:Patient Education, Lifestyle Modification, Rehabilitation• Lifestyle modification• Exercise• Physical therapy• Weight loss
    30. 30. AAOS Treatment of OA of the Knee: Patient Education, Lifestyle Modification, Rehabilitation• Maintain healthy physical activity – Physical, emotional health benefits – Reduce risks • CVD • Weight gain • Diabetes – Home exercise and supervised exercise class • McCarthy et al, Health Tech Assess ‘04
    31. 31. Management: LifestyleVarus (bowlegged) vs Valgus (knock-kneed) G2 Unloader Brace
    32. 32. Management: Medical• Glucosamine/Chondroitin• Acetaminophen• NSAIDs• Cox-2 inhibitors• Opioids• Intraarticular injections – Glucocorticoids – Hyaluronans
    33. 33. Management: Medical• Glucosamine/Chondroitin – 1500 mg/1200 mg daily ($40-50/month) – Glucosamine: building block for glycosaminoglycans – Chondroitin: glycosaminoglycan in articular cartilage – GAIT study, NEJM, Feb 23, 2006 • Multicenter, double blind, placebo-controlled, 24 wks, N=1583 • Symptomatic mild or moderate-severe knee OA • Infrequent mild side effects e.g. bloating • For mild OA, not better than placebo • For moderate-severe OA, combination showed benefit 8 – Patient satisfaction
    34. 34. Management: Medical• Acetaminophen – Indication: mild-moderate pain – 1000 mg Q6h PRN – Better than placebo but less efficacious than NSAIDs 9 – Caution in advanced hepatic disease• NSAIDs – Indication: moderate-severe pain, failed acetaminophen – GI/renal/hepatic toxicity, fluid retention – If risk of GIB, use anti-ulcer agents concurrently – Agents have highly variable efficacy and toxicity
    35. 35. Management: Medical• Opioid Analgesics – Indication: • Moderate-severe pain • Acute exacerbations • NSAIDs/Cox-2 inhibitors failed or contraindicated – Oxycodone synergistic w/ NSAIDs 13 – Tramadol/acetaminophen vs codeine/acetaminophen • Similar pain relief 14 – Avoid long-term use – Caution in elderly • Confusion, sedation, constipation
    36. 36. Management: MedicalIntraarticular Injections• Glucocorticoids – Indication: pain persists despite oral analgesics – 40 mg/mL triamcinolone (kenalog-40) – Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL) – Limit to Q3months, up to 2 yrs – Effective for short-term pain relief < 12 wks – Acute flare w/in 48 hrs post-injection 15
    37. 37. Management: MedicalIntraarticular Injections• Hyaluronans (e.g. Synvisc) – Indication: pain persists despite other agents – Synthetic joint fluid – Pain relief similar to steroid injections – 2 mL injection Qwk x 3, $560-760/series – Medicare reimburses 80%, Medi-cal $455.90 – 60-70% patients respond, relief up to 6 months – Patient satisfaction 16, 17
    38. 38. Contraindications Overlying cellulitis* Severe coagulopathy Anticoagulant therapy Septic effusion More than three injections per year in a weight-bearing joint Lack of response after two to four injections Bacteremia* Unstable joints Inaccessible joints (i.e. facet joints of spine) Joint prosthesis* Evidence of surrounding osteoporosis Recent intra-articular joint osteoporosis History of allergy or anaphylaxis to injectable pharmaceuticals*absolute contraindications Adapted from Pfenninger, 1991 and Cardone, 2002
    39. 39. Pharmacologic Agents• Corticosteroids – Modify local inflammatory response – Increase viscosity of synovial fluid – Alter production of hyaluronic acid synthesis – Change synovial fluid leukocyte activity Short-term benefit of intra-articular corticosteroids in treatment of knee OA well established; longer term benefits not confirmed. Cochrane Collaboration, 2006
    40. 40. Hyaluronan is usually not a first line treatment for knee osteoarthritis• Typically, hyaluronan injections (also sometimes called viscosupplements) are recommended for patients who have not found adequate pain relief from more conservative treatment options:
    41. 41. • Although, hyaluronan injections are not usually recommended before trying other treatment options, the best result usually occurs if the patient is in the early stages of osteoarthritis• Patients in the later stages of osteoarthritis, who may be waiting for knee replacement surgery, are considered good candidates for hyaluronan injections so they hopefully can get some relief while waiting.•
    42. 42. Among patients who were helped by hyaluronaninjections, when pain relief occurred was variable• The most significant pain relief occurred 8 to 12 weeks after the first injection for most patients. Studies have shown that Synvisc and Hyalgan provide pain relief from knee osteoarthritis for up to six months, with some patients getting relief for an even longer duration. Supartz was shown in studies to provide pain relief for up to 4 1/2 months after the fifth injection.• Patients may be able to repeat the course of treatment with hyaluronan injections. For example, a patient who has experienced up to six months of pain relief from Synvisc but has had pain return may be a candidate for another course of Synvisc injections.
    43. 43. Available• Hyalgan - May 28, 1997• Synvisc - August 8, 1997• Osflex - January 24, 2001• Lydium – Pharos 2005• Durolane 2006• Synvisc-One - February 26, 2009• Dualvisk 2010
    44. 44. Management: MedicalIntraarticular Injections• Technique – 22 gauge 1.5 inch needle – Approach accuracy: • Lateral mid-patellar 93% 18 – Patient supine – Leg straight – Manipulate patella – Angle needle slightly posteriorly – Inject after drop in resistance or fluid aspirated
    45. 45. Who is a candidate for Viscosupplemenation?• Poor responders to conservative treatments like OTC pain relievers and physical therapy• Active patients with mild to moderate OA• Patients that cannot tolerate oral NSAIDs – 16,500 GI bleed-related deaths/year• Patients too young, heavy and/or not ready for arthroplasty
    46. 46. To minimize potential side effects, after an injection patients should avoid strenuous activities for 48 hoursThe most common side effects around the injected joint, which are usually mild, include:• temporary injection site pain• swelling• redness and warmth• itching• bruising
    47. 47. There are important safety factors toconsider before using hyaluronan injections Patients wishing to try Synvisc, who are allergic to bird products (i.e., feathers, eggs or poultry), should talk to their doctor. Patients should also make their doctor aware of legs which are swollen or infected. Also, hyaluronan injections have not been tested in children, pregnant women, or nursing mothers.
    48. 48. What Is Synvisc-One ?• Synvisc-One is a single injection viscosupplement approved in the United States for the treatment of knee osteoarthritis. Synvisc-One became FDA- approved on Feb. 26, 2009. It is manufactured and marketed by Genzyme Corp.• Synvisc - the original formula - was FDA-approved in 1997. It is administered as a series of three weekly 2 milliliter injections (for a total of 6 ml). Both Synvisc and Synvisc-One contain the same material (hylan G-F 20) as well as the same total treatment volume. But, Synvisc-One delivers the 6 ml of hylan G-F 20 in a single injection.
    49. 49. Synvisc-One as an Osteoarthritis TreatmentSynvisc-One can be used for patients with knee osteoarthritis pain who have not been sufficiently helped by conservative non-drug treatments and simple analgesics like acetaminophen. Patients being treated with Synvisc-One can achieve up to 6 months pain relief.
    50. 50. Warnings and Precautions for Synvisc-OnePatients with a known previous serious reaction to hyaluronan, the active ingredient in Synvisc and related products, should not be treated with Synvisc- One. Patients with infection in or around the affected knee should not be injected. Patients who are allergic to bird proteins, feathers, or egg products or those with venous or lymphatic problems in the leg should be treated cautiously. Likewise, for patients with severe inflammation in the knee.Common adverse events associated with Synvisc-One included mild to moderate arthralgia, arthritis, injection site pain, and joint effusion. No serious adverse events were reported.
    51. 51. Advice for Patients Treated With Synvisc-One• After injection with Synvisc-One, you should avoid strenuous activity, including prolonged weightbearing activities, for about 48 hours after treatment.
    52. 52. Management: AlgorithmLifestyle Modifications Acetaminophen PRN NSAIDs PRN Celecoxib Steroid Injections Opioids PRN Hyaluronan Injections Surgical Referral
    53. 53. Management: SurgicalWhen to Refer• Knee pain or functional status has failed to improve with non-operative managementTypes of Procedures• Arthroscopic Irrigation• Arthroscopic Debridement• High Tibial Osteotomy• Partial Knee Arthroplasty• Total Knee Arthroplasty
    54. 54. Conclusions: AAOS Clinical PracticeGuidelines on the Treatment of OA of the Knee• OA is becoming more frequent as population is more active and lives longer – 581,000 TKR annually in US (AAOS)• Diagnosis, indications and patient expectations are paramount to success – Improved pain relief and functionality• Higher quality evidence is needed for treatments up to but not including arthroplasty
    55. 55. Clinical Pearls• Assess functional loss• Knee exam: palpation, ROM, duck waddle• Nutrition referral• Exercise program/ referral• Orthotics• Lateral mid-patellar or superolateral approach• Educate patients about glucosamine/chondroitin, Cox-2 inhibitors, injections
    56. 56. THANK YOU