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Evidenced Based Management Knee Osteoarthritis Dr Jonathan Mulford myorthopod.com.au.
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Transcript of Evidenced Based Management Knee Osteoarthritis Dr Jonathan Mulford myorthopod.com.au.
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Evidenced Based Management Knee Osteoarthritis
Dr Jonathan Mulford myorthopod.com.au
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Knee Arthritis
• The reality - not life threatening and has low associated mortality.
• However- – substantial influence on the quality of life– heavy economic burden on the community.
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Risk factors for knee osteoarthritis
• female • aging• Overweight• joint injury, malalignment, joint laxity, • occupational and recreational use• family history• Heberden's nodes at the distal finger joints.
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Non Operative Management
• Many Controversial treatments.
• Many of this evidence Based finding are from the Cochrane Library
• Unfortunately there are many studies of poor methodology.
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Non Op Treatments Groups
• Lifestyle modification
• Rehabilitation and Physiotherapy
• Braces and Insoles
• Pharmacology
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LIFE STYLE MODIFICATION
• Avoid aggravating factors – No high Impact– Limit Stair climbing
• Weight loss
• Diet
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Weight loss and Knee OA
• moderate weight loss (weight reduction > 5.1% or > 0.24%/wk)
improves self-reported disability.
• No clear evidence that Weight loss reduces pain or improve patient global evaluation.
• A BMI greater than 30 has a 4 times increase in risk of knee arthritis – so weight loss important preventative measure!
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Diet
• A diet high in olive oil, fish and vegetables – reduced pain by 40% & morning stiffness by 10% in RA.
• ? effects for OA. Annals of the Rheumatic Diseases 2003; 62:208-14.
• Diets rich in vitamins C slow the progression of osteoarthritis.
Arthritis and Rheumatism 1996; 39:648-56. .
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REHABILITATION
• Therapeutic Excercise
• Ultrasound, TENS, Pulsed Electric Stimulation, Acupuncture
• Hydrotherapy – Aquatic Excercise– Balneotherapy
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Therapeutic Exercise in Knee OA
• Small short term benefit for knee pain and physical function.
• No evidence long term benefit.
• Is useful pre-operatively.
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Aquatic-exercise and Knee OA
• some beneficial short-term effects for patients with hip and/or knee OA.
• no long-term effects have been documented.
• Can be useful for pre-operative conditioning.
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Balneotherapy (or spa therapy, mineral baths)
• The scientific evidence is weak.
• Cochrane review - Seven trials (498 patients) – mineral baths compared to no treatment – Dead Sea + sulphur versus no treatment, – Dead Sea baths versus no treatment – sulphur baths versus no treatment
• mineral baths may be benificial (small effect).
• Of all other balneological treatments no clear effects were found.
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Therapeutic ultrasound
• no benefit over placebo
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Transcutaneous electrical nerve stimulation (TENS)
• small improvements in pain control over placebo.
• Methodology of the studies is poor.
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Pulsed Electric Stimulation
• Electrical stimulation therapy had a small to moderate effect on outcomes for knee OA.
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Acupuncture• randomised controlled trial”, Foster et al. (BMJ 2007;335;436),
• acupuncture no benefit as an adjunct to a course of individualised, exercise based physiotherapy.
• Other papers looking at acupuncture - some benefit • however have had major methodological flaws .• Annals of Internal Medicine 2004; 141(12):901-10.
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Thermotherapy and knee OA
• Ice massage beneficial effect on ROM, swelling, function and knee strength.
• Ice packs did not affect pain significantly.
• Hot packs had no beneficial effect on edema compared with placebo or cold application.
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Brace and Orthosis (insole).
• Brace (neoprene sleeve) and a lateral wedge insole have small beneficial effect.
• However, long-term adherence to brace and insole treatment is low.
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Pharmacology
• Painkillers• Anti-inflammatory• Chondrotin and Glucosamine• Alternative medications• Injections
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Paracetamol versus Placebo and versus NSAIDs
• significant reduction in pain compared to placebo
• BUT• Small improvements in pain.
• less effective overall than NSAIDs in terms of pain reduction, global assessments and in terms of improvements in functional status.
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NSAIDS• NSAIDs are effective in relieving short-term pain in OA.
• NSAIDs at the lowest effective dose should be considered in patients who respond inadequately to simple analgesia.
• longer-term use is potential for serious side effects.(gastropathy, including peptic ulcer disease, and care if hypertension, cardiovascular and renal disease)
• Concurrent use of more than one NSAID and other medications, increasing age and duration of treatment substantially increase the risk of side effects.
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Topical NSAIDS
• Topical NSAIDs were effective and safe in short-term treatment of OA.
• lack of any trial data to support their long-term use
• Effects wane after 2 weeks. • Larger and longer trials are necessary
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COX-2
• CLASS study demonstrated that coxibs reduce clinical upper GI events by approximately 55%
• Consider COX-2 if high risk of peptic ulcer disease.
• Caution should be used due to their association with cardiovascular, renal and other adverse effects.
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Opioid Analgesia• alternative when paracetamol and NSAID drugs
are contraindicated, ineffective, or poorly tolerated.
• A once-a-day formulation of tramadol helps pain,• fewer interruptions in sleep and improved
compliance.
• effective alternative treatment for acute flares of OA pain.
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CODEINE
• Codeine in combination with simple analgesia or NSAID might be appropriate for the occasional pain relief or for patients in whom only simple analgesia is not effective.
• However, repeated use increases the occurrence of side effects.
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Chondroitin
• 22 RCTs (n = 4056)
• Conclusion: Based on evidence from higher-quality trials of patients with knee or hip osteoarthritis, chondroitin does not reduce pain more than placebo or no treatment.
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Glucosamine• 25 studies with 4963 patients.
• If Analysis restricted to studies with adequate allocation concealment – No benefit for pain, function and stiffness subscales.
• Collectively, the 25 RCTs • 22% (improvement in pain and a 11% improvement in function
• Non-Rotta preparation or adequate allocation concealment failed to show benefit in pain and WOMAC function
• Rotta preparation showed that glucosamine was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA.
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Alternative Herbal Medicine • Cochrane review found 5 studies.
• The evidence for avocado-soybean unsaponifiables in the treatment of osteoarthritis is convincing .
• Single studies of other interventions, a willow bark preparation (Reumalex), topical capsaicin and tipi tea, were inconclusive.
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Corticosteroid Injections
• Effective pain reliever however often only for short period (4 weeks)
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Viscosupplements
• at one to four weeks post injection CSI and HA same.
• Between five and 13 weeks post injection, HA products were more effective than corticosteroids
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Surgical Treatment
• Arthroscopy• Osteotomy• Uni• Patellofemoral Arthroplasty• Total knee Arthroplasty• Fusion
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Arthroscopic Surgery
• There is 'gold' level evidence that AD has no benefit for undiscriminated OA
• Can help acute mechanical pain due to meniscal tear, chondral flap or loose body.
• The acute pain is helped, however can have residual pain from the OA.
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High Tibial Osteotomy
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High Tibial Osteotomy
Indications• Isolated Compartment OA• Less than 12 degrees deformity• Stable knee• Young and activeBenefits • Avoid arthroplasty• No limits on activity
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Problem • Inconsistent results – 50% still effective at 7-
10 years – At 5 years 75% good or excellent.– At 8 years 60% good or excellent.– (Arch Orthop Trauma Surg 124:258-261, 2004)
• Arthroplasty after osteotomy may not be as successful.
• Certainly more challenging surgery.
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Uniarthroplasty
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Uni
Indications • isolated compartment Osteoarthritis.Benefits • Smaller incision, Quicker recovery, better
feeling knee, cost implications.Problems • progression, revision.
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How Long do they Last?
• Swedish Register – about 90% at 10 years
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Age and Uni RevisionAustralian Joint Register
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Patellofemoral Arthroplasty
• Indications – Isolated• Benefits• Problems
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Total Knee Arthroplasty
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When to Operate• When pain is bad enough to limit lifestyle and
function.• Don’t wait too long - – surgery performed later in the natural history of
functional decline results in worse postoperative functional status.
• However, • those with the poorest preoperative scores
gained most from the operation. • patients operated on later were more satisfied
with their outcomes.
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Total knee Replacement
• 91-96% prosthesis survival rate at 14-15 years of follow-up.
• We now know that approximately 85 percent of the knee implants will last 20 years.
• Thus most implants will last a life time.
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• Improvements in surgical technique, prosthetic designs, bearing surfaces, and fixation methods might increase the survival rate of these implants even longer.
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Swedish Knee Registry
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Australian Joint Registry
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Revision Summary Australian Joint Register
• At 7 years cumulative % revision• Primary total 4.3%• Uni 12.1%• PFJ 13.8%
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Unispacer and Partial Resurfacing