1. Osteoarthritis of Knee joint Dilshan Munidasa

2. Overview  Definition and Risk Factors  Idiopathic vs. Secondary OA  Clinical Features  Diagnosis  Radiologic Features  ACR OA dx for knees, hands, hips  Goals of Treatment  Non-pharmacologic treatment  Pharmacologic treatment  Surgical Considerations

3. Osteoarthritis  Articular cartilage failure induced by a complex interplay of genetic, metabolic, biochemical, and biomechanical factors  With secondary components of inflammation  Initiating mechanism is damage to normal articular cartilage by physical forces (macrotrauma or repeated microtrauma)  Not necessarily normal consequence of aging

4. Risk Factors  Age  Female versus male sex  Obesity  Lack of osteoporosis  Occupation  Sports activities  Previous injury  Muscle weakness  Proprioceptive deficits  Genetic elements  Acromegaly  Calcium crystal deposition disease

5. Idiopathic Osteoarthritis  Localized or generalized forms  Localized OA most commonly affects the hands, feet, knee, hip, and spine  Other joints less commonly involved –shoulder, temporomandibular, sacroiliac, ankle, and wrist joints  Generalized OA –three or more joint sites

6. OA Pathology

7. Patterns of Presentation  Monoarticular in young adult  Pauciarticular, large-joint in middle age  Polyarticular generalized  Rapidly progressive  Secondary to trauma, congenital abnormality, or systemic disease

8. Clinical Diagnosis  Symptoms –Pain –Stiffness –Gelling  Physical examination –Crepitus –Bony enlargement –Decreased range of motion –Malalignment –Tenderness to palpation  The more features, the more likely the diagnosis

9. Differential Diagnosis  Rheumatoid Arthritis  Gout  CPPD (Calcium pyrophosphate crystal deposition disease)  Septic Joint  Polymyalgia Rheumatica

10. Radiographic Features  Joint space narrowing  Subchondral sclerosis  Marginal osteophytes  Subchondral cyst  Assymetrical

11. OA Radiology

12. OA Grading-Kellgren & Lawrence  grade 0 - no radiographic features  grade 1 - doubtful joint space narrowing (JSN) and possible osteophytic lipping  grade 2 - the presence of definite osteophytes radiograph.  grade 3 - multiple osteophytes, definite JSN +sclerosis+ deformity  grade 4 - large osteophytes, marked JSN, severe sclerosis and definitely bony deformity

13. OA of the Knee: Classic Criteria 1. Greater than 50 years of age 2. Morning stiffness for less than 30 minutes 3. Crepitus on active motion of the knee 4. Bony tenderness 5. Bony enlargement 6. No palpable warmth  3 of 6 criteria give sensitivity of 95% and specificity of 69%

14. OA of the Knee: Addition of X-rays  ACR Criteria of: 1. knee pain 2. radiographic evidence of osteophytes 3. one of three additional findings:  age greater than 50 years of age  morning stiffness of less than 30 minutes  crepitus –Sensitivity and specificity for OA of 91 and 86%

15. Synovial fluid analysis  Severe, acute joint pain is an uncommon manifestation of OA  Clear fluidWBC <2000/mm3  Normal viscosity

16. Diagnosis - Cont There is no blood test for the diagnosis of osteoarthritis. There is no blood test for the diagnosis of osteoarthritis. MRI MRI  Gold standard -Artroscopy

18. Typical OA work-up  History  PE  Consider following (especially if OA of knees or hips) –Erythrocyte sedimentation rate (ESR) –Rheumatoid factor titers –Evaluation of synovial fluid –Radiographic study of affected joints

19. Goals of Treatment  Control pain and swelling  Minimize disability  Improve the quality of life  Prevent progression  Education  Chronic Condition and Management

20. Non-pharmacologic Treatment  Weight Loss –Ten-pound weight loss over 10 years decreased the odds for developing knee OA by 50% –Even a modest amount of weight loss may be beneficial  Rest –Short period of time, typically 12-24 hours –Prolonged rest can lead to muscle atrophy and decreased joint mobility

21. Non-pharmacological Treatment  Physical Therapy –May be more beneficial in those with mild OA –Ultrasound therapy may have some benefit based on 2009 Cochrane Review

22. Knee Braces / Taping –Cochrane reports a “sliver of benefit” –73% taping for 3 weeks reported improvement (elastic knee sleeve

23. Tens  Safety/Tolerability: High  Efficacy: Medium  20 points more effective on scale of 100 compared to placebo  Few long term studies

24. Non-pharmacologic Treatment  Acupuncture – –Very small improvements in pain and physical function after 8 weeks and 26 weeks –A lot seems to be placebo effect due to incomplete blinding –Reasonable to offer if patient resistant to conventional treatment and wants to try alternative therapies

25. Non-pharmacological Treatment  Exercise – focus on low load exercise –Tai Chi –Yoga –Swimming –Biking –Walking –Most important aspect to counsel patients for prevention and treatment –Cochrane Review 2009 compares efficacy to NSAIDs in short-term benefits  Heat and Cold –Lack of convincing data despite being commonly used

26. Exercises

27. Quad Sets

28. Quadrceps

29. Quadriceps

30. Wall slide

31. Acetaminophen  NSAIDs are superior to acetaminophen  Treatment effect was modest  Median trial duration was only six weeks  In OA subjects with moderate-to-severe levels of pain  NSAIDs > Acetaminophen > Placebo  1000mg three to four times daily

32. NSAIDs  Tend to avoid for long-term use –Rash and hypersensitivity reactions –Abdominal pain and gastrointestinal bleeding –Impairment of renal, hepatic, and bone marrow function, and platelet aggregation –Cardivascular –Central nervous system dysfunction in the elderly  Low dose ibuprofen (less than 1600 mg/day) may have less serious GI toxicity  Nonacetylated salicylates (salsalate, choline magnesium trisalicylate), sulindac, and nabumetone appear to have less renal toxicity  Indomethacin should be avoided for long-term use in patients with hip OA –associated with accelerated joint destruction

33. Topical NSAIDs  Significant short term (one to two weeks) efficacy for pain relief and functional improvement when topical NSAIDs were compared to placebo  Effect was not apparent at three to four weeks  Topical NSAIDs were generally inferior to oral NSAIDs  However topical route was safer than oral use  Topical Diflofenac (1% gel or patch)

34. COX-2 Inhibitors  COX-2 inhibitors appear to be as effective NSAIDs  Associated with less GI toxicity  However increased risk of CV events  Use of low dose ASA may negate the GI sparing effects of COX-2 inhibitors  Those who are receiving low dose aspirin and a COX-2 selective agent may benefit from anti-ulcer prophylaxis

35. Capsaicin  Capsaicin Ointment 0.025% (qid) & 0.075% (bid) –Principle ingredient of chili peppers (substance P) –Love It! –Tolerability: Medium  50% experience burning which wanes  50% decrease in pain, 25% with placebo  Apply 2-4 times per day

36. Glocosamine  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

37. Injections  Corticosteroid –Safety: High for short-term use, data on frequency and degree of use is limited.  Study of pt’s receiving 8 injections over 2 year period showed no ill effects in comparison with pt’s receiving placebo. –Strict aseptic technique must be used –Tolerability: Medium to high –Efficacy: Low to medium. Modest benefit. 16 point reduction in pain on 100-point scale for one month.

38. Injections

39. Hyaluronic Injections of Knees  Efficacy: Low. Recent Meta-analyses and reviews small clinical effect. 75% were satisfied with treatment. Lasts 3-4 months.  Price: High. 3 injections cost Rs.15000

40. Narcotics for Refractory Pain  Safety: Medium  Tolerability: Medium –Constipation, somnolence, mental status changes  Use of opiates indicated in those who are not candidates for surgery and who continue to have moderate to severe pain despite being on NSAIDs or selective cyclooxygenase (COX)-2 inhibitors

41. Arthroscopic Interventions

42.  Minimally invasive procedure  Arthroscopic debridement with lavage – Short term benefit  Remove loose pieces of bone and cartilage  Lateral release can be done to off load patella

43. Autologus Chondrocyte Transplant

44. Prosthetic Joints  Several types: Unicondylar / Total knee  Last 15 years or more  About 10% need to be redone  Usually a treatment of “last resort”

46. TKR

47. Joint Replacement  Surgical candidate?  Often greater improvement in pain  Recovery is often rapid (2weeks to 2 months)  Infection rate 1%  Low mortality 0.6% to 0.7%  Complications include thrombo- embolic events 5%

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

49. Education and Self-Help  Understand the disease (progressive –temporary relief period)  Reduce pain but remain active  Clear Functional goals  Cope physically, emotionally, and mentally  Have greater control over the disease  Build confidence

50. THANK YOU