evidence based medicine: treatment of osteoarthritis. kenneth d. kleist, m.d. joint replacement and...

Evidence Based Medicine:Evidence Based Medicine:Treatment of Osteoarthritis.Treatment of Osteoarthritis.

Kenneth D. Kleist, M.D.Kenneth D. Kleist, M.D.Joint Replacement andJoint Replacement and

Knee ArthroscopyKnee ArthroscopyHealthPartners Medical GroupHealthPartners Medical Group

St. Paul, MNSt. Paul, MN

Basic Tenets of OA CareBasic Tenets of OA Care

• Treatment should be tailored to the patient• The relationship between the healthcare team

and the patient should be a two-way process• Patient education has a significant impact on

pain management and patient satisfaction• Treatment should be a combination of non-

pharmacological and pharmacological measures• It is likely that each individual patient will have to

try a number of management options before finding the combination which works best for them

Evidence Based, Patient Evidence Based, Patient Centered CareCentered Care

• Patient Education and Lifestyle Modification

• Rehabilitation/Physical Therapy

• Complementary Care and Alternative Therapies

• Pain Relievers• Intra-articular injections

SOURCESSOURCES• AAOS – 2008• ARHQ –2006

- 2007• EULAR - 2005• ACR – 2000• Cochrane Library

Levels of EvidenceLevels of Evidence

Guideline Language

Grade Level of Evidence

We Recommend A I

We Suggest B II or III

Option C IV or V

Inconclusive I None or conflicting

Patient Education and Lifestyle Patient Education and Lifestyle ModificationModification

• Participation in self-management programs (II,B)– Education Programs such as the arthritis foundation

• Studies suggest that education is around 20% as effective as NSAIDs, and can have a synergistic effect with other treatments

– Promote healthy activities and management• Walking instead of running

• Regular visits related to the osteoarthritis (IV,C)• Weight Management (I,A)

– BMI > 25 should be encouraged to lose 5% body weight and maintain the new weight

• I would add assistive devices here

Does Weight Loss Really Does Weight Loss Really Matter?Matter?

• For a woman of normal height, weight loss of only 5kg reduces the risk of OA by more than 50%.

• Changing BMI Category– e.g. obese to overweight, or

overweight to normal weight, could prevent 33% of OA in women and 20% in men.

Felson et al: Annals of Internal Medicine 1992Felson et al: Annals of Internal Medicine 1992

Data from the Framingham StudyData from the Framingham Study

RehabilitationRehabilitation• Participation in low impact

aerobic fitness (I,A)• ROM/Flexibility Exercise

Program (V,C)• Quadriceps Strengthening

Program (II,B)• Patellar Taping (II,B)• +/- Unloader Bracing

(V/II,inconclusive)• DO NOT use lateral heel

wedges (II,B)

Exercise PrescriptionsExercise Prescriptions

Kenneth D. Kleist, M.D.

Name: Baby Boomer

1. Hip/Knee ROM2. Lower Extremity Strength-focus on Quadriceps and Pelvifemoral Strength

3. Proprioception/balance training

Complementary Care and Complementary Care and Alternative TherapiesAlternative Therapies

• DO NOT prescribe Glucosamine and/or Chondroitin sulfate (I,A)– No scientific evidence

• +/- Acupuncture (I,inconclusive)– I would add in aromatherapy, music

therapy, massage, tai chi, Reiki, etc into this category

– No Evidence Based Data on supplements

Pain RelieversPain Relievers

• Unless contraindications one of below (II,B)– Acetaminophen– NSAIDs

• Increased GI risk: Age > 65, PUD, concurrent corticosteroids, anticoagulant usage– Acetaminophen– Topical NSAIDs– Non-selective NSAID + GI protective– Cox-2 inhibitor– Narcotics

• Poor choice due to chronicity of disease

Intra-articular InjectionsIntra-articular Injections

• Corticosteroids for short-term relief (II,B)

• Cannot Recommend for or against Hyaluronic Acids(I/II, Inconclusive)

Footnotes on SurgeryFootnotes on Surgery• Arthroscopy is NOT recommended for

debridement and lavage (I/II, A/B)• Arthroscopy may be an option for those with OA

and primary signs and symptoms of a loose body or meniscus tear(V,C)

So what do we do now?So what do we do now?

• Do a good History and Physical Examination.

• Individualize treatment to the Patient.• Encourage Patient Involvement • Non-pharmacologic therapy is the

hallmark of treatment for Osteoarthritis.• Exercise is always good…it’s the type that

needs to be carefully determined.• Medication therapy is adjunctive.• Set appropriate expectations throughout• Surgery when quality of life continues to

deteriorate despite appropriate care

Website Resources Website Resources AvailableAvailable• American Academy of Orthopaedic SurgeonsAmerican Academy of Orthopaedic Surgeons

P.O. Box 1998Des Plaines, IL 60017847–823–7186 or800–824–BONE (2663) (free of charge)Fax: 847–823–8125

www.aaos.org

• American Association of Hip and Knee SurgeonsAmerican Association of Hip and Knee Surgeons6300 N. River Road, Suite 615Rosemont, IL 60018-4237Telephone: (847)698-1200Fax: (847)698-0704Email [email protected]

www.aahks.org

• United States Bone and Joint Decade, NFP (USBJD)United States Bone and Joint Decade, NFP (USBJD) 6300 North River Road Rosemont, IL 60018 Phone: 847.384.4010 Fax: 847.823.0536 Email: [email protected]

www.usbjd.org

• National Institute of Arthritis and Musculoskeletal National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)and Skin Diseases (NIAMS) National Institutes of Health1 AMS CircleBethesda, MD 20892–3675Phone: 301–495–4484 or877–22–NIAMS (226–4267) (free of charge)TTY: 301–565–2966Fax: 301–718–6366E-mail: [email protected]

• NIH Osteoporosis and Related Bone DiseasesNIH Osteoporosis and Related Bone Diseases~National Resource Center 2 AMS CircleBethesda, MD 20892-3676Phone: 202–223–0344 or 800–624–BONETTY: 202–466–4315Fax: 202–293–2356www.niams.nih.gov/bone

• American College of RheumatologyAmerican College of Rheumatology 1800 Century Place, Suite 250Atlanta, GA 30345Phone: 404–633–3777Fax: 404–633–1870www.rheumatology.org

• American Physical Therapy AssociationAmerican Physical Therapy Association 1111 North Fairfax StreetAlexandria, VA 22314–1488Phone: 703–684–2782 or800–999–APTA (2782) (free of charge)Fax: 703–684–7343www.apta.org

• Agency for Healthcare Research and QualityAgency for Healthcare Research and QualityAgency for Healthcare Research and QualityOffice of Communications and Knowledge Transfer540 Gaither Road, Suite 2000Rockville, MD 20850.(301) 427-1364.www.ahrq.gov

• Arthritis FoundationArthritis FoundationP.O. Box 7669Atlanta, GA 30357-0669 www.arthritis.org

Save Your KneesOnline Portal Media Launch

saveyourknees.org

Get Up! Get Out! Get Moving!Let’s Exercise Now! Facebook Application

www.aaos.org/facebook

1. Is there anything that can regrow cartilage or reverse arthritis?

2.2. Can’t you just clean up the knee with arthroscopy?Can’t you just clean up the knee with arthroscopy?

Several studies have shown that Several studies have shown that arthroscopic debridement and lavage is arthroscopic debridement and lavage is not effective for treatment of OA.not effective for treatment of OA.

Top 10 Patient FAQs…Top 10 Patient FAQs…and their Answersand their Answers


2. Can’t you just clean up the knee with arthroscopy?

3.3. How Many Cortisone shots can I get and how often?How Many Cortisone shots can I get and how often?

There is no maximum lifetime dosage, but There is no maximum lifetime dosage, but injection should be spaced apart about 3 to 4 injection should be spaced apart about 3 to 4 months because too many injections close months because too many injections close together can soften the remaining cartilage.together can soften the remaining cartilage.



2. Can’t you just clean up the knee with arthroscopy?

3. How Many Cortisone shots can I get and how often?

4.4. How will I know when I am ready for joint replacement?How will I know when I am ready for joint replacement?

Most people reach a point where their quality of life is Most people reach a point where their quality of life is diminished enough that they know it is time. Other indicators diminished enough that they know it is time. Other indicators can include loss of sleep, constant pain, inability to do typical can include loss of sleep, constant pain, inability to do typical activities of daily living, or failure of pain relief options that had activities of daily living, or failure of pain relief options that had been previously working.been previously working.


1. Is there anything that can regrow cartilage or reverse arthritis?2. Can’t you just clean up the knee with arthroscopy?3. How Many Cortisone shots can I get and how often?4. How will I know when I am ready for joint replacement?5.5. How long is the recovery for joint replacement?How long is the recovery for joint replacement?

Recovery from joint replacement is highly variable among individuals. Recovery from joint replacement is highly variable among individuals. A lot depends on age, health, preoperative function. On average most A lot depends on age, health, preoperative function. On average most people will be 85% recovered by 3 months after surgery. Most people people will be 85% recovered by 3 months after surgery. Most people will return to a sitting job by 4-6 weeks maximum and a standing, will return to a sitting job by 4-6 weeks maximum and a standing, walking, active job by 2 months, but again this is highly variable.walking, active job by 2 months, but again this is highly variable.


1. Is there anything that can regrow cartilage or reverse arthritis?2. Can’t you just clean up the knee with arthroscopy?3. How Many Cortisone shots can I get and how often?4. How will I know when I am ready for joint replacement?5. How long is the recovery for joint replacement?6.6. What is the likelihood I will improve with joint replacement?What is the likelihood I will improve with joint replacement?

On average 85% of people say they would On average 85% of people say they would have knee or hip replacement again.have knee or hip replacement again.


1. Is there anything that can regrow cartilage or reverse arthritis?2. Can’t you just clean up the knee with arthroscopy?3. How Many Cortisone shots can I get and how often?4. How will I know when I am ready for joint replacement?5. How long is the recovery for joint replacement?6. What is the likelihood I will improve with joint replacement?7.7. How long do joint replacements last?How long do joint replacements last?

Knee 15-20 years, Hip 10-15 years Knee 15-20 years, Hip 10-15 years conservatively. Factors such as weight, conservatively. Factors such as weight, age, and activity level play a large role.age, and activity level play a large role.


1. Is there anything that can regrow cartilage or reverse arthritis?2. Can’t you just clean up the knee with arthroscopy?3. How Many Cortisone shots can I get and how often?4. How will I know when I am ready for joint replacement?5. How long is the recovery for joint replacement?6. What is the likelihood I will improve with joint replacement?7. How long do joint replacements last?8.8. What types of activity can I do after joint replacement?What types of activity can I do after joint replacement?

There is no evidence based research to show what you can safely There is no evidence based research to show what you can safely do. I recommend low impact exercise. Avoidance of high impact do. I recommend low impact exercise. Avoidance of high impact activities. In general golf, swimming, biking, walking, hiking, activities. In general golf, swimming, biking, walking, hiking, skating, and cross country skiing appear to be safe activities.skating, and cross country skiing appear to be safe activities.


1. Is there anything that can regrow cartilage or reverse arthritis?2. Can’t you just clean up the knee with arthroscopy?3. How Many Cortisone shots can I get and how often?4. How will I know when I am ready for joint replacement?5. How long is the recovery for joint replacement?6. What is the likelihood I will improve with joint replacement?7. How long do joint replacements last?8. What types of activity can I do after joint replacement?9.9. Am I a candidate for minimally invasive surgery?Am I a candidate for minimally invasive surgery?

Minimally invasive surgery is an option for everyone, but what that is Minimally invasive surgery is an option for everyone, but what that is can vary from person to person. No study has confirmed any long can vary from person to person. No study has confirmed any long term benefit of minimally invasive surgery functionally. The most term benefit of minimally invasive surgery functionally. The most important thing to you as a patient is to get the pieces placed in the important thing to you as a patient is to get the pieces placed in the appropriate position so you can a have good long term function of appropriate position so you can a have good long term function of your joint replacement.your joint replacement.


1. Is there anything that can regrow cartilage or reverse arthritis?2. Can’t you just clean up the knee with arthroscopy?3. How Many Cortisone shots can I get and how often?4. How will I know when I am ready for joint replacement?5. How long is the recovery for joint replacement?6. What is the likelihood I will improve with joint replacement?7. How long do joint replacements last?8. What types of activity can I do after joint replacement?9. Am I a candidate for minimally invasive surgery?10.10. Why did I get arthritis?Why did I get arthritis?

Arthritis is due to multifactorial influences. Arthritis is due to multifactorial influences. Factors that are known to contribute are weight, Factors that are known to contribute are weight, trauma, genetics, activity level, and diet.trauma, genetics, activity level, and diet.


Thank You!Thank You!

evidence based medicine: treatment of osteoarthritis. kenneth d. kleist, m.d. joint replacement and...

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