osteoarthritis diagnosis and treatment

Knee joint OAKnee joint OADiagnosis and ManagementDiagnosis and Management

Rheumatology DivisionRheumatology DivisionDr Hasan Sadikin Hospital BandungDr Hasan Sadikin Hospital Bandung

Case PresentationCase Presentation

Aceng is a 48 yo male primary school teacher who Aceng is a 48 yo male primary school teacher who

presents to the Rheumatology Clinic c/o 8-10 yrs of presents to the Rheumatology Clinic c/o 8-10 yrs of

B knee pain. His active lifestyle is severely B knee pain. His active lifestyle is severely

compromised by his knee pain.compromised by his knee pain.

Case PresentationCase PresentationHistory:History:

•Site/Severity:Site/Severity:

•Onset:Onset:

•Character:Character:

•Radiation:Radiation:

•Alleviation:Alleviation:

•Time:Time:

•Exacerbation:Exacerbation:

•Sx associated:Sx associated:

Case PresentationCase Presentation

Osteoarthritis

• Epidemic in the US– More people over 65 than teenagers

• One baby boomer will turn 55 every seven seconds for the next 20 years

– Increased life span• 1940: 61.4 yrs/men, 65.7 yrs/women• 2008: 75.4 yrs/men, 80.0 yrs/women

• 66 million (1/3) US adults will have OA by 2030

• Estimated that only 10% of population currently seeks treatment

Osteoarthritis• 2nd only to CVD in producing

chronic disability that directly impacts the quality of life

• Causes

– Obesity, genetics, trauma

– More active lifestyles

– Work past retirement age

– Younger population

• #1 Cause of Decreased Work Performance

Osteoarthritis of The KneeOsteoarthritis of The Knee

I.I. Overview Overview Epidemiology Epidemiology DefinitionDefinition Risk FactorsRisk Factors

II.II. Clinical Approach to Knee Pain Clinical Approach to Knee Pain

III.III. Differential Diagnosis Differential Diagnosis

IV.IV. Diagnosis of Knee OADiagnosis of Knee OA

V.V. ManagementManagement LifestyleLifestyle Medical Medical SurgicalSurgical

Overview: EpidemiologyOverview: Epidemiology

• Knee OA most common cause of disability in adultsKnee OA most common cause of disability in adults

• Decreased work productivity, frequent sick days Decreased work productivity, frequent sick days

• Highest medical expenses of all arthritis conditionsHighest medical expenses of all arthritis conditions

• Symptomatic Knee OASymptomatic Knee OA

– More than 10 million Americans More than 10 million Americans 11

– More than 11% of persons > 64yo More than 11% of persons > 64yo 22

Overview: DefinitionOverview: DefinitionArthritis vs. ArthrosisArthritis vs. Arthrosis

Gradual loss of articular cartilage in the knee jointGradual loss of articular cartilage in the knee joint• 3 articulations:3 articulations:

1)1) Lateral condyles of the femur and tibiaLateral condyles of the femur and tibia

2)2) Medial condyles of the femur and tibiaMedial condyles of the femur and tibia

3)3) Patellofemoral jointPatellofemoral joint

Damage caused by a complex interplay of joint Damage caused by a complex interplay of joint

integrity, biochemical processes, genetics, and integrity, biochemical processes, genetics, and

mechanical forcesmechanical forces

Anatomy of The KneeAnatomy of The Knee

Overview: Risk FactorsOverview: Risk Factors

• Age Age 33

• FemaleFemale

• ObesityObesity

• Previous knee injuryPrevious knee injury

• Lower extremity malalignmentLower extremity malalignment

• Repetitive knee bendingRepetitive knee bending

• High impact activitiesHigh impact activities

• Muscle weakness Muscle weakness 44


I.I. Overview Overview EpidemiologyEpidemiology DefinitionDefinition Risk FactorsRisk Factors


III.III. Differential DiagnosisDifferential Diagnosis

IV.IV. Making The DiagnosisMaking The Diagnosis


Clinical Approach to Knee PainClinical Approach to Knee Pain““Hey Doc, my knee’s been hurting!”Hey Doc, my knee’s been hurting!”

HistoryHistory

• SOCRATES pain questionsSOCRATES pain questions

• Inflammatory sx e.g. fever, hot jointInflammatory sx e.g. fever, hot joint

• History of trauma or surgeryHistory of trauma or surgery

• InstabilityInstability

• Functional lossFunctional loss

• Prior treatmentPrior treatment

Clinical Approach to Knee PainClinical Approach to Knee Pain

Physical ExamPhysical Exam

• Vitals, BMIVitals, BMI

• Palpation: isolate tenderness, effusion, crepitusPalpation: isolate tenderness, effusion, crepitus

• ROM: measure degree of flexionROM: measure degree of flexion

• Stability: ligaments, menisciStability: ligaments, menisci

• Alignment: genu varus or valgusAlignment: genu varus or valgus

• Function: gait, duck waddleFunction: gait, duck waddle


Varus Test (LCL)Varus Test (LCL)Valgus Test (MCL)Valgus Test (MCL)

McMurray ManeuverMcMurray Maneuver(menisci)(menisci)

Lachman Test (ACL)Lachman Test (ACL)

Duck Waddle Duck Waddle (stability)(stability)


TestsTests

• CBC, ESR, RFCBC, ESR, RF

• ArthrocentesisArthrocentesis

• X-rays (3 views)X-rays (3 views)– Weight-bearing AP Weight-bearing AP – LateralLateral– Tangential Patellar (Sunrise)Tangential Patellar (Sunrise)

• MRIMRI




III.III. Differential DiagnosisDifferential Diagnosis


V.V. Management Management LifestyleLifestyle Medical Medical SurgicalSurgical

Differential Diagnosis of Knee PainDifferential Diagnosis of Knee Pain

Medial PainMedial Pain• OAOA

• MCLMCL

• MeniscusMeniscus

• BursitisBursitis

Diffuse PainDiffuse Pain• OAOA

• Infectious arthritisInfectious arthritis

• Gout, pseudogoutGout, pseudogout

• RARA

Lateral PainLateral Pain• OAOA

• LCLLCL

• MeniscusMeniscus

• Iliotibial band syndromeIliotibial band syndrome

Anterior PainAnterior Pain• OAOA

• Patellofemoral syndromePatellofemoral syndrome

• Prepateller bursitisPrepateller bursitis

• Quadriceps mechanismQuadriceps mechanism

Diagnosis of Knee OADiagnosis of Knee OA

Classic Clinical CriteriaClassic Clinical Criteria– established by ACR, 1981established by ACR, 1981– sensitivity 95%, specificity 69%sensitivity 95%, specificity 69%

knee painknee pain plus at least 3 of 6 characteristics: plus at least 3 of 6 characteristics:• > 50 yo> 50 yo• Morning stiffness < 30 minMorning stiffness < 30 min• CrepitusCrepitus• Bony tendernessBony tenderness• Bony enlargementBony enlargement• No palpable warmth No palpable warmth 55

Diagnosis of Knee OADiagnosis of Knee OAClassification TreeClassification Tree• Clinical symptomsClinical symptoms• Synovial fluidSynovial fluid

1.1. WBC<2000/mmWBC<2000/mm33

2.2. Clear colorClear color3.3. High ViscosityHigh Viscosity

• X-raysX-rays1.1. OsteophytesOsteophytes2.2. Loss of joint spaceLoss of joint space3.3. Subchondral sclerosisSubchondral sclerosis4.4. Subchondral cystsSubchondral cysts

Confirmed by arthroscopyConfirmed by arthroscopy (gold standard) (gold standard) 66

No OANo OA

Sensitivity 94 %; Specificity 88 %

Diagnosis of Knee OADiagnosis of Knee OA

SurgerySurgery

COX-2COX-2’’ss

High DoseHigh Dose

NSAIDS +NSAIDS +

GastroprotectantGastroprotectantCorticosteroidsCorticosteroids

simple analgesics, simple analgesics, low dose NSAIDlow dose NSAID’’ss

Exercise, Physical Therapy, Exercise, Physical Therapy, Weight Loss, Orthotics, Weight Loss, Orthotics, Nutraceuticals, BracingNutraceuticals, Bracing

MILDMILD

SEVERE OASEVERE OA

MODERATEMODERATE

Guidelines for Managing Osteoarthritis

Adapted from Recommendations for the Medical Adapted from Recommendations for the Medical Management of Osteoarthritis of the Hip and Knee, ACR, Management of Osteoarthritis of the Hip and Knee, ACR,

2000 2000

Hyaluronic Hyaluronic AcidAcid

AAOS Clinical Practice Guideline on the Treatment of OA of the Knee

• Patient Education and Lifestyle Modification• Rehabilitation• Mechanical Interventions• Complementary and Alternative Therapy• Pain Relievers• Intra-articular Injections• Needle Lavage• Surgical Intervention

Management: LifestyleManagement: Lifestyle• Weight lossWeight loss

– Nutrition referralNutrition referral

• Exercise ProgramExercise Program– PT referral PT referral – Quadriceps strengthening Quadriceps strengthening – ROM exercisesROM exercises– Low impact activities e.g. swimming, biking Low impact activities e.g. swimming, biking 77

• Ambulatory assist devicesAmbulatory assist devices– CaneCane– Walker Walker

• InsolesInsoles• Unloader knee bracesUnloader knee braces

AAOS Treatment of OA of the Knee:Patient Education, Lifestyle Modification, Rehabilitation

• Lifestyle modification

• Exercise• Physical therapy• Weight loss

http://www.fat-weightloss.com/fatweightloss.gif

AAOS Treatment of OA of the Knee:Patient Education, Lifestyle Modification, Rehabilitation

• Maintain healthy physical activity– Physical, emotional health

benefits– Reduce risks

• CVD• Weight gain• Diabetes

– Home exercise and supervised exercise class

• McCarthy et al, Health Tech Assess ‘04

Management: LifestyleManagement: Lifestyle

Varus (bowlegged) vs Valgus (knock-kneed)Varus (bowlegged) vs Valgus (knock-kneed)

G2 Unloader BraceG2 Unloader Brace

Management: MedicalManagement: Medical

• Glucosamine/ChondroitinGlucosamine/Chondroitin• AcetaminophenAcetaminophen• NSAIDsNSAIDs• Cox-2 inhibitorsCox-2 inhibitors• OpioidsOpioids• Intraarticular injectionsIntraarticular injections

– GlucocorticoidsGlucocorticoids

– HyaluronansHyaluronans


• Glucosamine/ChondroitinGlucosamine/Chondroitin– 1500 mg/1200 mg daily ($40-50/month)1500 mg/1200 mg daily ($40-50/month)

– Glucosamine: building block for glycosaminoglycansGlucosamine: building block for glycosaminoglycans

– Chondroitin: glycosaminoglycan in articular cartilageChondroitin: glycosaminoglycan in articular cartilage

– GAIT study, NEJM, Feb 23, 2006GAIT study, NEJM, Feb 23, 2006• Multicenter, double blind, placebo-controlled, 24 wks, N=1583Multicenter, double blind, placebo-controlled, 24 wks, N=1583

• Symptomatic mild or moderate-severe knee OASymptomatic mild or moderate-severe knee OA

• Infrequent mild side effects e.g. bloatingInfrequent mild side effects e.g. bloating

• For mild OA, not better than placeboFor mild OA, not better than placebo

• For moderate-severe OA, combination showed benefit For moderate-severe OA, combination showed benefit 88

– Patient satisfactionPatient satisfaction


• AcetaminophenAcetaminophen– Indication: mild-moderate painIndication: mild-moderate pain

– 1000 mg Q6h PRN1000 mg Q6h PRN

– Better than placebo but less efficacious than NSAIDs Better than placebo but less efficacious than NSAIDs 99

– Caution in advanced hepatic diseaseCaution in advanced hepatic disease

• NSAIDsNSAIDs– Indication: moderate-severe pain, failed acetaminophenIndication: moderate-severe pain, failed acetaminophen

– GI/renal/hepatic toxicity, fluid retentionGI/renal/hepatic toxicity, fluid retention

– If risk of GIB, use anti-ulcer agents concurrentlyIf risk of GIB, use anti-ulcer agents concurrently

– Agents have highly variable efficacy and toxicityAgents have highly variable efficacy and toxicity

Management: MedicalManagement: Medical• Opioid AnalgesicsOpioid Analgesics

– Indication: Indication: • Moderate-severe painModerate-severe pain• Acute exacerbationsAcute exacerbations• NSAIDs/Cox-2 inhibitors failed or contraindicatedNSAIDs/Cox-2 inhibitors failed or contraindicated

– Oxycodone synergistic w/ NSAIDs Oxycodone synergistic w/ NSAIDs 1313

– Tramadol/acetaminophen vs codeine/acetaminophenTramadol/acetaminophen vs codeine/acetaminophen• Similar pain relief Similar pain relief 1414

– Avoid long-term useAvoid long-term use

– Caution in elderlyCaution in elderly• Confusion, sedation, constipationConfusion, sedation, constipation

Management: MedicalManagement: MedicalIntraarticular InjectionsIntraarticular Injections

• GlucocorticoidsGlucocorticoids

– Indication: pain persists despite oral analgesicsIndication: pain persists despite oral analgesics

– 40 mg/mL triamcinolone (kenalog-40)40 mg/mL triamcinolone (kenalog-40)

– Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL)Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL)

– Limit to Q3months, up to 2 yrsLimit to Q3months, up to 2 yrs

– Effective for short-term pain relief < 12 wksEffective for short-term pain relief < 12 wks

– Acute flare w/in 48 hrs post-injection Acute flare w/in 48 hrs post-injection 1515

Management: MedicalManagement: MedicalIntraarticular InjectionsIntraarticular Injections

• Hyaluronans (e.g. Synvisc)Hyaluronans (e.g. Synvisc)– Indication: pain persists despite other agentsIndication: pain persists despite other agents

– Synthetic joint fluidSynthetic joint fluid

– Pain relief similar to steroid injectionsPain relief similar to steroid injections

– 2 mL injection Qwk x 3, $560-760/series2 mL injection Qwk x 3, $560-760/series

– Medicare reimburses 80%, Medi-cal $455.90Medicare reimburses 80%, Medi-cal $455.90

– 60-70% patients respond, relief up to 6 months60-70% patients respond, relief up to 6 months

– Patient satisfaction Patient satisfaction 16, 1716, 17

ContraindicationsOverlying cellulitis*Severe coagulopathyAnticoagulant therapySeptic effusionMore than three injections per year in a weight-bearing jointLack of response after two to four injectionsBacteremia*Unstable jointsInaccessible joints (i.e. facet joints of spine)Joint prosthesis*Evidence of surrounding osteoporosisRecent intra-articular joint osteoporosisHistory of allergy or anaphylaxis to injectable pharmaceuticals

*absolute contraindicationsAdapted from Pfenninger, 1991 and Cardone, 2002

Pharmacologic Agents

• Corticosteroids – Modify local inflammatory response– Increase viscosity of synovial fluid– Alter production of hyaluronic acid synthesis– Change synovial fluid leukocyte activity

Short-term benefit of intra-articular corticosteroids in treatment of knee OA well established; longer term

benefits not confirmed.

Cochrane Collaboration, 2006

Hyaluronan is usually not a first line treatment for knee osteoarthritis

• Typically, hyaluronan injections (also sometimes called viscosupplements) are recommended for patients who have not found adequate pain relief from more conservative treatment options:

• Although, hyaluronan injections are not usually recommended before trying other treatment options, the best result usually occurs if the patient is in the early stages of osteoarthritis

• Patients in the later stages of osteoarthritis, who may be waiting for knee replacement surgery, are considered good candidates for hyaluronan injections so they hopefully can get some relief while waiting.

•

http://osteoarthritis.about.com/od/osteoarthritistreatments/

http://arthritis.about.com/od/kneesurgery/

Among patients who were helped by hyaluronan injections, when pain relief occurred was variable

• The most significant pain relief occurred 8 to 12 weeks after the first injection for most patients. Studies have shown that Synvisc and Hyalgan provide pain relief from knee osteoarthritis for up to six months, with some patients getting relief for an even longer duration. Supartz was shown in studies to provide pain relief for up to 4 1/2 months after the fifth injection.

• Patients may be able to repeat the course of treatment with hyaluronan injections. For example, a patient who has experienced up to six months of pain relief from Synvisc but has had pain return may be a candidate for another course of Synvisc injections.

Available

• Hyalgan - May 28, 1997

• Synvisc - August 8, 1997

• Osflex - January 24, 2001

• Lydium – Pharos 2005

• Durolane 2006

• Synvisc-One - February 26, 2009

• Dualvisk 2010

Management: MedicalManagement: MedicalIntraarticular InjectionsIntraarticular Injections• TechniqueTechnique

– 22 gauge 1.5 inch needle22 gauge 1.5 inch needle

– Approach accuracy:Approach accuracy:• Lateral mid-patellar 93% Lateral mid-patellar 93% 1818

– Patient supinePatient supine

– Leg straight Leg straight

– Manipulate patella Manipulate patella

– Angle needle slightly posteriorly Angle needle slightly posteriorly

– Inject after drop in resistance or fluid aspiratedInject after drop in resistance or fluid aspirated

Who is a candidate for Viscosupplemenation?

• Poor responders to conservative treatments like OTC pain relievers and physical therapy

• Active patients with mild to moderate OA

• Patients that cannot tolerate oral NSAIDs

– 16,500 GI bleed-related deaths/year

• Patients too young, heavy and/or not ready for arthroplasty

To minimize potential side effects, after an injection patients should avoid strenuous activities for 48 hours

The most common side effects around the injected joint, which are usually mild, include:

• temporary injection site pain

• swelling

• redness and warmth

• itching

• bruising

There are important safety factors to consider before using hyaluronan injections

Patients wishing to try Synvisc, who are allergic to bird products (i.e., feathers, eggs or poultry), should talk to their doctor. Patients should also make their doctor aware of legs which are swollen or infected. Also, hyaluronan injections have not been tested in children, pregnant women, or nursing mothers.

What Is Synvisc-One ?

• Synvisc-One is a single injection viscosupplement approved in the United States for the treatment of knee osteoarthritis. Synvisc-One became FDA-approved on Feb. 26, 2009. It is manufactured and marketed by Genzyme Corp.

• Synvisc - the original formula - was FDA-approved in 1997. It is administered as a series of three weekly 2 milliliter injections (for a total of 6 ml). Both Synvisc and Synvisc-One contain the same material (hylan G-F 20) as well as the same total treatment volume. But, Synvisc-One delivers the 6 ml of hylan G-F 20 in a single injection.

http://arthritis.about.com/od/kneetreatments/g/viscosupplement.htm

http://osteoarthritis.about.com/od/kneeosteoarthritis

Synvisc-One as an Osteoarthritis Treatment

Synvisc-One can be used for patients with knee osteoarthritis pain who have not been sufficiently helped by conservative non-drug treatments and simple analgesics like acetaminophen. Patients being treated with Synvisc-One can achieve up to 6 months pain relief.

Warnings and Precautions for Synvisc-One

Patients with a known previous serious reaction to hyaluronan, the active ingredient in Synvisc and related products, should not be treated with Synvisc-One. Patients with infection in or around the affected knee should not be injected. Patients who are allergic to bird proteins, feathers, or egg products or those with venous or lymphatic problems in the leg should be treated cautiously. Likewise, for patients with severe inflammation in the knee.

Common adverse events associated with Synvisc-One included mild to moderate arthralgia, arthritis, injection site pain, and joint effusion. No serious adverse events were reported.

http://arthritis.about.com/od/painmanage/g/arthralgia.htm

http://arthritis.about.com/od/arthritislearnthebasics/f/jointeffusion.htm

Advice for Patients Treated With Synvisc-One

• After injection with Synvisc-One, you should avoid strenuous activity, including prolonged weightbearing activities, for about 48 hours after treatment.

Management: AlgorithmManagement: Algorithm

Lifestyle ModificationsLifestyle Modifications Acetaminophen PRNAcetaminophen PRN

NSAIDs PRNNSAIDs PRN

Opioids PRNOpioids PRN

CelecoxibCelecoxib

Steroid InjectionsSteroid Injections

Hyaluronan InjectionsHyaluronan Injections

Surgical ReferralSurgical Referral

Management: SurgicalManagement: Surgical

When to ReferWhen to Refer• Knee pain or functional status Knee pain or functional status has failed to improve with has failed to improve with non-operative managementnon-operative management

Types of ProceduresTypes of Procedures• Arthroscopic IrrigationArthroscopic Irrigation

• Arthroscopic DebridementArthroscopic Debridement

• High Tibial OsteotomyHigh Tibial Osteotomy

• Partial Knee ArthroplastyPartial Knee Arthroplasty

• Total Knee ArthroplastyTotal Knee Arthroplasty

Conclusions: AAOS Clinical Practice Guidelines on the Treatment of OA of the Knee

• OA is becoming more frequent as population is more active and lives longer– 581,000 TKR annually in US (AAOS)

• Diagnosis, indications and patient expectations are paramount to success– Improved pain relief and functionality

• Higher quality evidence is needed for treatments up to but not including arthroplasty

Clinical PearlsClinical Pearls• Assess functional lossAssess functional loss

• Knee exam: palpation, ROM, duck waddleKnee exam: palpation, ROM, duck waddle

• Nutrition referralNutrition referral

• Exercise program/ referralExercise program/ referral

• OrthoticsOrthotics

• Lateral mid-patellar or superolateral approachLateral mid-patellar or superolateral approach• Educate patients about glucosamine/chondroitin, Educate patients about glucosamine/chondroitin,

Cox-2 inhibitors, injectionsCox-2 inhibitors, injections

THANK YOU

osteoarthritis diagnosis and treatment

Health & Medicine