C24 Osteoarthritis of the Knee: A Closer Look 2018 WAERT Student Symposium

Objectives Define osteoarthritis (OA) Identify risk factors Explore diagnostic methods Discuss treatment options Evaluate expected outcomes

Osteoarthritis of the knee is a degenerative joint disease affecting millions of people due to obesity and the aging population; however, current treatment options provide relief from a painful and often debilitating disease.

Osteoarthritis Facts Most common causes of pain and disability worldwide1 Researchers estimate by 2030, more than 67 million people living in the U.S. will have OA1 The knee is the most common site of OA1,2 Each year 4.1 million people living in the U.S. seek care for OA-related knee problems1 Due to obesity and the aging population, the prevalence of OA is increasing2 There is no cure Both non-invasive and invasive treatment options are available The knee is the most common site of OA

What is Osteoarthritis? Degenerative condition, usually progresses slowly over many years Most common form of arthritis; often associated with “wear and tear” Occurs when the cartilage becomes rough and prevents a smooth gliding motion between articulating bones Affects the medial, lateral, and patellofemoral compartments of the knee joint Causes pain, swelling, decreased range of motion (ROM), and bone reshaping Can be debilitating and lead to decreased mobility

Risk Factors Genetics Female Age 19% of the American adult population over the age of 45 and up to 40% of the population over the age of 60 are affected3 Body mass index (BMI) There is a significant correlation between being overweight or obese and the development of OA1,2,3,4 Congenital bone conditions Trauma and/or surgical intervention Repetitive motion

Diagnosis Medical history History of trauma or injury to the affected joints Past medical conditions or surgeries Unilateral joint pain Progressive onset of symptoms Factors that improve or exacerbate symptoms Hands, hips, neck, and lower back are most common

Diagnosis Physical examination Pain, swelling, tenderness, decreased ROM, palpable joint damage, and crepitation with joint flexion Location and distribution of painful joints Affects joints subjected to biomechanical abuse Asymmetrical onset of symptoms Laboratory tests Blood tests Urine sample Synovial fluid analysis

Diagnosis Diagnostic imaging X-ray The American College of Radiology states that knee radiography is an appropriate way to evaluate non-traumatic knee pain Magnetic resonance imaging (MRI) MRI may be used to help identify those at high-risk for developing OA and for diagnosing early-stage OA Note: The American College of Rheumatology suggests that a diagnosis of OA may be determined without radiologic evidence by a clinician.2 However, American College of Radiology states that knee radiography is an appropriate way to evaluate non-traumatic knee pain.1

X-ray Cost effective and quick, but may not show signs of early OA Presence of osteophytes Joint space narrowing Normal adult joint space measures 5-6mm Sclerosis Bone reshaping (two hallmark signs) The formation of bone deposits along the joint edges, which can break off and cause additional damage and pain1,2 The formation of rounded deposits on the articular surfaces1,2 Bone reshaping causes two hallmark signs on radiographic images Formation of bone deposits along the joint edges, which can break off causing additional damage and pain Formation of rounded deposits on the articular surfaces, known as “lipping” Since cartilage is radiolucent, what appears to be empty space between the femur and tibia is actually a surrogate measure of cartilage integrity Typically, this space measures 5mm to 6mm wide in a healthy adult knee

X-ray One of the most commonly used radiographic grading system for OA is the Kellgren and Lawrence Classification System, which characterizes the severity of OA on a scale of 0 to 4 (see Table 1)1,2,5 Table 1 Kellgren-Lawrence Osteoarthritis Classification System1,2,5 Grade Description No joint space narrowing or reactive changes 1 Doubtful joint space narrowing, possible osteophytic lipping 2 Definite osteophytes, possible joint space narrowing 3 Multiple osteophytes, definite joint space narrowing, sclerosis, and possible bone deformity 4 Large osteophytes, marked joint space narrowing, severe sclerosis, and definite bone deformity

X-ray Kellgren-Lawrence Osteoarthritis Classification System http://pacificortho.ca/patients/patient-education/knee/knee-arthritis/

MRI Utilizes non-ionizing radiation MRI can directly visualize articular cartilage and other soft tissues that compose the joint Osteophytes Cartilage defects Subchondral bone marrow edema and synovial cysts Meniscal and ligamentous abnormalities Joint effusions Synovitis Expensive and time-consuming Some patients may be claustrophobic

MRI Normal knee Abnormal knee https://radiopaedia.org/cases/normal-knee-mri https://www.healthline.com/health/osteoarthritis/what-does-arthritis-look-like-on-an-mri#photos

Non-Invasive Treatment Options Self-managed care Weight loss Diet and exercise promotes weight loss, which can help control or reduce pain and improve joint mobility and function1,2,4 Heat therapy Increases circulation and may relax tight joints and muscles Cold therapy Slows circulation and reduces swelling Over-the-counter (OTC) medications Acetaminophen to relieve pain Non-steroidal anti-inflammatory (NSAIDS)

Non-Invasive Treatment Options Complementary Alternative Medicine (CAM) Bee venom acupuncture The use of bee venom, with the help of glucocorticoids, may slow the progression of inflammatory arthritis Since OA is degenerative, its effectiveness will vary Chondroitin sulfate and glucosamine supplements Chondroitin is a major component of cartilage Glucosamine has anti-inflammatory properties and may promote cartilage regeneration No scientific evidence that these supplements are effective

Invasive Treatment Options Corticosteroid or cortisone injections Reduce pain and inflammation directly in and around the joint space To prevent adverse effects, such as permanent joint damage, injections should be administered every three to four months1, Hyaluronic acid replacement therapy Involves replacing lost synovial fluid via injection directly into the knee joint

Invasive Treatment Options Surgical intervention Arthroscopic debridement and lavage Minimally invasive procedure that involves smoothing the joint surfaces Does not alter the disease process and the benefits may be short-term1,2 Results may vary and outcomes are inconsistent1,2 Cartilage repair

Invasive Treatment Options Surgical intervention Osteotomies A surgical procedure to reshape the knee joint to relieve pressure Knee replacement (partial and total knee arthroplasty) Partial knee replacement involves replacing the worn section of bone with artificial hardware Total knee replacement involves the replacement of all three joint surfaces with artificial hardware

Outcomes Treatment outcomes vary depending on the severity of the patient’s OA Accurate diagnosis and appropriate treatment plans are essential for the best outcomes According to the Arthritis Foundation, 66% of people obtained pain relief when using complementary and alternative medicine (CAM)1 Nearly 90% of patients report that knee replacement surgery reduced pain and improved their mobility and overall quality of life1

Conclusion Each year 4.1 million people seek care for OA-related knee problems1 The rising obesity epidemic and aging population increases the prevalence of OA Medical history, physical examination, laboratory tests, x-ray and MRI are key components to an accurate OA diagnosis and appropriate treatment plan Osteoarthritis has no cure Treatment options can provide relief from joint pain and restore mobility Tie back to thesis statement, Name treatment options, help with symptoms

References Shagam J. Medical imaging and osteoarthritis of the knee. Radiologic Technology. 2011;83(1):37-56. November 2017 Lespasio MJ, Piuzzi NS, Husni ME, et al. Knee osteoarthritis: A primer. Permanente Journal. 2017;21:116-183. doi:10.7812/TPP/16-183. February 2018 Verbeek J, Mischke C, Robinson R, et al. Occupational exposure to knee loading and the risk of osteoarthritis of the knee: A systematic review and a dose-response meta-analysis. Safety and Health at Work. 2017;8(2):130-142. doi:10.1016/j.shaw.2017.02.00. February 2018 Silverwood V, Blagojevic-Bucknall M, Jinks C, et al. Current evidence on risk factors for knee osteoarthritis in older adults: A systematic review and meta-analysis. Osteoarthritis and Cartilage. 2015;23(4):507-515. doi:10.1016/j.joca.2014.11.019. February 2018 Kohn MD, Sasoon AA, Fernando ND. Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Clinical Orthopaedics and Related Research. 2016;474(8):1886-1893. doi:10.1007/s11999-016-4732-4. February 2018