1. RHEUM UPDATE IV— KNEE DISORDERS “The Bum Knee Revisited” Mark A. McQuillan MD FACP SFHM June 16, 2016

2. DISCLOSURES (COI) none

3. OUTLINE 2016 evidence on treatment outcomes !! Epidemiology Warning signs “Locking” “Giving way” Pathology Management Referral Prevention

4. KEY OUTCOME STUDIES Kinesio-tape March 2016—not effective Tai Chi-June 2016—not inferior, RCT, n=200, similar WOMAC scores, tai chi had improvements in depression and quality of life, compared to PT and home exercise regimen, 12 weeks, 52 week f/u Acetaminophen-May 2016, better than no Rx, sl. Less benefit compared to NSAIDs, hip and knee OA; network meta-analysis of 60,000 pts.; modest benefit compared to placebo; Vitamin D-March 2016—n=400, largest study, no benefit, Rx for two years, did not reduce pain, did not improve cartilage loss or Bone lesions by MR;

5. INCIDENTAL KNEE FINDINGS ON MR Incidental Knee MR findings in middle age and elder, Englund M, et al, Felson DT, NEJM 2008 Sept 11, 359:(11): 1108-15 Framingham MA; ages 50-90, n=991, 57% women 19% of women age 50-59 had meniscal tear 56% of men ages 70-90 Prevalence of meniscal tear of 63% for those with symptoms of pain, aching, stiffness on most days; Prevalence of 60% for those who had no symptoms

6. KEY SURGERY OUTCOMES Sihvonen, Raine Englund, Martin et al with two studies April 2016 Annals of Internal Medicine; 164, 449-455. locking or catching symptoms, no benefit from anterior partial meniscectomy NEJM Dec 2013; 369: 2515-24. Sham Meniscectomy Katz JN, et al, NEJM, 2013, 368(18): 1675-1684; Surgery vs PT for meniscal tear in OA; no significant differences in improvement at 6 mo. But 30% of pts assigned to PT alone, underwent surgery within 6 months; Carpenter J et al, adherence to surg guidelines

7. PROLOTHERAPY, PRP Platelet rich plasma Stem cell therapy ?? Evidence Web sites

8. KNEE DISORDERS  Pain Locations anterior posterior medial lateral  “Pain generator”  Correlates

10. KNEE INSTABILITY

11. INSTABILITY

12. “LOCKING”

13. “BUCKLING” OR “GIVING WAY” Importance? Next steps? Rehab? Strengthening! Referral? Arthroscopic Repair of …??

14. MENISCAL INJURY TYPES

16. CAN WE REDUCE ACL INJURIES IN WOMEN? Landing technique Posture Q angle Impact loading Weight training

17. CAN BALANCED LANDING BE COACHED?

23. COACHING YOUTHS

24. EPIDEMIOLOGY OF ELDER KNEES Arthroscopy—mainly for meniscal injuries Resection vs. repair Cartilage regrowth? Controversies Arthroplasty Demographics of aging Destination programs Demand for arthroplasty of knees and hips Anticoagulation advances

25. ACKNOWLEDGEMENTS Patients!! UMHS Orthopedics and SCO service SportsMedicine Community UM Family Medicine Rheumatologists Kelley, Bole, Mikkelsen, Robinson, Castor, Thompson, TNTC