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Osteoarthritis of The Knee

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Slide 1 :

Osteoarthritis of The Knee Patrick Chen, M.D. Department of Family Medicine San Francisco General Hospital March 3, 2006

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Case Presentation G.D. is a 48 yo male chef and restauranteur who presents to the UCSF Sports Medicine Clinic c/o 8-10 yrs of B knee pain. He is a devout outdoorsman whose active lifestyle is severely compromised by his knee pain.

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Case Presentation History: Site/Severity: Onset: Character: Radiation: Alleviation: Time: Exacerbation: Sx associated:

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Case Presentation History: Site/Severity: medial knee L > R, 8/10 pain Onset: gradual, no acute trauma Character: ache, joint soreness Radiation: none Alleviation: rest, aspirin Time: 8-10 yrs, lasts 10-15 min Exacerbation: walking ½ mile, inclines Sx associated: occ. swelling, no instability

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Case Presentation History Continued….. Unknown L knee injury 20 yrs ago L partial meniscectomy 5 yrs ago Hikes 8 hrs/wk Yoga 6 hrs/wk Bikes 5 hrs/wk Received B steroid injections w/o relief

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Case Presentation Physical Exam 5’7”, 165 lbs, BMI 25.8 + mild medial joint line tenderness on L ROM of knees: L 0-130°, R 0-140° Lachmann’s/valgus/varus stress test neg B Patellar mobility w/in normal limits Genu varus (bowlegged) alignment B Minimally antalgic gait

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Case Presentation

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Case Presentation

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Case Presentation

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Case Presentation Assessment s/p L meniscus injury B genu varus (bowlegged) B mild medial compartment OA, greater on L Management Use G2 unloader brace L knee w/ exercise 1st of 3 rounds of Synvisc injections B knee joints

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Case Presentation Follow-up: 1 week later Swelling L knee x 3 days after 1st injection 6/10 pain 2nd round of Synvisc injections B knees Follow-up: 2 weeks later Conducted exercise routine w/o swelling 2/10 pain 3rd round of Synvisc injections B knee RTC 6 months

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Osteoarthritis of The Knee Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

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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

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Overview: Definition Arthritis vs. Arthrosis Gradual loss of articular cartilage in the knee joint 3 articulations: Lateral condyles of the femur and tibia Medial condyles of the femur and tibia Patellofemoral joint Damage caused by a complex interplay of joint integrity, biochemical processes, genetics, and mechanical forces

Slide 15 :

Anatomy of The Knee

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Anatomy of The Knee

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Overview: Risk Factors Age 3 Female Obesity Previous knee injury Lower extremity malalignment Repetitive knee bending High impact activities Muscle weakness 4

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Osteoarthritis of The Knee Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Making The Diagnosis Management Lifestyle Medical Surgical

Slide 19 :

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

Slide 20 :

Clinical Approach to Knee Pain Physical 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

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Clinical Approach to Knee Pain Varus Test (LCL) Valgus Test (MCL) McMurray Maneuver (menisci) Lachman Test (ACL) Duck Waddle (stability)

Slide 22 :

Clinical Approach to Knee Pain Tests CBC, ESR, RF Arthrocentesis X-rays (3 views) Weight-bearing AP Lateral Tangential Patellar (Sunrise) MRI

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Osteoarthritis of The Knee Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

Slide 24 :

Differential Diagnosis of Knee Pain Medial Pain OA MCL Meniscus Bursitis Diffuse Pain OA Infectious arthritis Gout, pseudogout RA Lateral Pain OA LCL Meniscus Iliotibial band syndrome Anterior Pain OA Patellofemoral syndrome Prepateller bursitis Quadriceps mechanism

Slide 25 :

Osteoarthritis of The Knee Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

Slide 26 :

Diagnosis of Knee OA Classic 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

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Diagnosis of Knee OA Classification Tree Clinical symptoms Synovial fluid WBC<2000/mm3 Clear color High Viscosity X-rays Osteophytes Loss of joint space Subchondral sclerosis Subchondral cysts Confirmed by arthroscopy (gold standard) 6 No OA Sensitivity 94 %; Specificity 88 %

Slide 28 :

Diagnosis of Knee OA

Slide 29 :

Osteoarthritis of The Knee Overview Epidemiology Definition Risk Factors Clinical Approach to Knee Pain Differential Diagnosis Diagnosis of Knee OA Management Lifestyle Medical Surgical

Slide 30 :

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

Slide 31 :

Management: Lifestyle Varus (bowlegged) vs Valgus (knock-kneed) G2 Unloader Brace

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Management: Medical Glucosamine/Chondroitin Acetaminophen NSAIDs Cox-2 inhibitors Opioids Intraarticular injections Glucocorticoids Hyaluronans

Slide 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

Slide 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

Slide 35 :

Management: Medical NSAIDs 10

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Management: Medical Cox-2 inhibitors Indication: mod-severe pain, failed NSAID, risk of GIB OA pain relief similar to NSAIDs Fewer GI events e.g. symptomatic ulcers, GIB Celecoxib 200 mg daily GI/renal toxicity, fluid retention Increased risk of CV events? APC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID Increased risk at higher doses 11 CLASS Trial: 8,000 pts compared Celecoxib vs Ibuprofen Similar risk to Ibuprofen 12

Slide 37 :

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

Slide 38 :

Management: Medical Intraarticular 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

Slide 39 :

Management: Medical Intraarticular 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

Slide 40 :

Management: Medical Intraarticular 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

Slide 41 :

Management: Algorithm Lifestyle Modifications Acetaminophen PRN NSAIDs PRN Opioids PRN Celecoxib Steroid Injections Hyaluronan Injections Surgical Referral

Slide 42 :

Management: Surgical When to Refer Knee pain or functional status has failed to improve with non-operative management Types of Procedures Arthroscopic Irrigation Arthroscopic Debridement High Tibial Osteotomy Partial Knee Arthroplasty Total Knee Arthroplasty

Slide 43 :

Management: Surgical High Tibial Osteotomy Indication: Unicompartmental arthritis Genu varus or valgus Realign mechanical axis Age < 60yo < 15 degrees deformity19

Slide 44 :

Management: Surgical Partial Knee Arthroplasty Indication: Unicompartmental arthritis Ligaments spared Increased ROM Faster recovery Prosthesis 10-yr survival: 84% 20

Slide 45 :

Management: Surgical Total Knee Arthroplasty Indication: Diffuse arthritis Severe pain Functional impairment Pain relief > functional gain ACL sacrificed PCL also may be sacrificed Prosthesis 10-yr survival: 90% 21

Slide 46 :

Clinical Pearls Assess functional loss Knee exam: palpation, ROM, duck waddle Nutrition referral Exercise program/PT referral Orthotics Lateral mid-patellar or superolateral approach Educate patients about glucosamine/chondroitin, Cox-2 inhibitors, injections

Slide 47 :

Bibliography 1. Lawrence RC, Helmick CG, Arnett FC, et al. “Estimates of The Prevalence of Arthritis And Selected Musculoskeletal Disorders in The United States.” Arthritis And Rheumatism 1998;43:778-799. 2. Felson DT, Zhang Y. “An Update on The Epidemiology of Knee And Hip Osteoarthritis with A View to Prevention.” Arthritis And Rheumatism 1998;41:1343-55. 3. Brandt, K. “Osteoarthritis: Clinical Patterns And Pathology. In: Textbook of Rheumatology, 5th edition.” Kelley WN, Harris Jr ED, Ruddy S, Sledge CE (Eds), W.B. Saunders, Philadelphia, 1997, p.1383. 4. Buckwalter JA. “Osteoarthritis And Articular Cartilage Use, Disuse, And Abuse: Experimental Studies.” Journal of Rheumatological Suppl 1995; 43:13. 5. Altman R, Asch E, Bloch D, et al. “Development of Criteria for The Classification And Reporting of Osteoarthritis, Classification of Osteoarthritis of The Knee.” Arthritis And Rheumatism 1986; 29:1039. 6. Klashman D, Seeger L, Singh R, et al. “Validation of Nonradiographic ACR Osteoarthritis Criteria Using ACR Arthroscopy Damage Index as Comparison Standard.” Arthritis And Rheumatism 1996; 39:172. 7. Thomas KS, Muir KR, Doherty M, Jones AC, O’Reilly SC, Bassey EJ. “Home Based Exercise Programme for Knee Pain And Knee Osteoarthritis: Randomised Controlled Trial.” British Medical Journal 2002. Oct 5; 325(7367):752. 8. Clegg DO, Reda DJ, Harris CL, et al. “Gluosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Arthritis.” NEJM 2006, Volume 354 No. 8:795-808. 9. Zhang W, Jones A, Doherty M. “Does Paracetamol (Acetaminophen) Reduce The Pain of Osteoarthritis? A Meta-analysis of Randomised Controlled Trials.” Annals of The Rheumatic Diseases 2004; 63:901. 10. Kalunian KC, Concoff AL, Brion PH. “Pharmacologic and Surgical Therapy of Osteoarthritis” in UpToDate 2006 [online journal]. Vol 13.2, March, 2005. 11. Solomon SD, McMurray JJ, Pfeffer MA, et al. “Cardiovascular risk associated with celecoxib in a clinical trial for colorectal adenoma prevention.” NEJM 2005; 352:1071.

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Bibliography 12. Silverstein FE, Faich G, Goldstein JL, et al. “Gastrointestinal Toxicity with Celecoxib Vs. Nonsteroidal Anti-inflammatory Drugs for Osteoarthritis And Rheumatoid Arthritis. The CLASS Study: A Randomized Controlled Trial.” JAMA 2000; 284:1247. 13. Caldwell JR, Hale ME, Boyd RE, et al. “Treatment of Osteoarthritis Pain with Controlled Release Oxycodone or Fixed Combination Oxycodone Plus Acetaminophen Added to Nonsteroidal Antiinflammatory Drugs: A Double Blind, Randomized, Multicenter, Placebo Controlled Trial.” Journal of Rheumatology 1999; 26:862. 14. Mullican WS, Lacy JR. “Tramadol/Acetaminophen Combination Tablets And Codeine/Acetaminophen Combination Capsules for The Management of Chronic Pain: A Comparative Trial.” Clinical Therapeutics 2001; 23:1429. 15. Arroll B, Goodyear-Smith F. “Corticosteroid Injections for Osteoarthritis of The Knee: Meta-analysis.” British Medical Journal 2004; 328:869. 16. Moreland LW, Arnold WJ, Saway A, et al. “Efficacy And Safety of Intra-articular Hylan G-F 20 (Synvisc), A Viscoelastic Derivative of Hyaluronan in Patients with Osteoarthritis of The Knee.” Arthritis Rheum 1993; 36:S165. 17. Lo GH, LaValley M, McAlindon T, Felson DT. “Intra-articular Hyaluronic Acid in Treatment of Knee Osteoarthritis: Meta-analysis.” JAMA 2003; 290:3115. 18. Jackson DW, Evans NA, Thoomas BM, “Accuracy of Needle Placement Into The Intra-articular Space of The Knee.” The Journal of Bone and Joint Surgery (American) 2002; 84:1522-1527. 19. Kalunian KC, Concoff AL, Brion PH. “Pharmacologic And Surgical Therapy of Osteoarthritis” in UpToDate 2006 [online journal]. Vol 13.2, March, 2005. 20. Ibid. 21. Ibid.

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Pain relief > functional gain; ACL sacrificed; PCL also may be sacrificedThe Journal of Bone and Jo more Pain relief > functional gain; ACL sacrificed; PCL also may be sacrificedThe Journal of Bone and Joint Surgery (American) 2002; 84:1522-1527. ... less

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