1. Evidence Based Medicine: Treatment of Osteoarthritis.
Kenneth D. Kleist, M.D.
Joint Replacement and
Knee Arthroscopy
HealthPartners Medical Group
St. Paul, MN
In this third talk I hope to give you some tools to take back to your own practices

2. Basic 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

3. Evidence Based, Patient Centered Care
Patient Education and Lifestyle Modification
Rehabilitation/Physical Therapy
Complementary Care and Alternative Therapies
Pain Relievers
Intra-articular injections
SOURCES
AAOS – 2008
ARHQ –2006
- 2007
EULAR
ACR – 2000
Cochrane Library

4. Levels of Evidence Guideline Language Grade Level of Evidence
We Recommend A I
We Suggest B
II or III
Option C
IV or V
Inconclusive
None or conflicting

5. Patient Education and Lifestyle Modification
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

6. Does Weight Loss Really 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 1992
Data from the Framingham Study

7. Rehabilitation 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)

8. Exercise Prescriptions
Kenneth D. Kleist, M.D.
Name: Baby Boomer
Hip/Knee ROM
Lower Extremity Strength-focus on Quadriceps and Pelvifemoral Strength
Proprioception/balance training

9. Complementary Care and Alternative 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

10. Pain Relievers Unless contraindications one of below (II,B)
Acetaminophen
NSAIDs
Increased GI risk: Age > 65, PUD, concurrent corticosteroids, anticoagulant usage
Topical NSAIDs
Non-selective NSAID + GI protective
Cox-2 inhibitor
Narcotics
Poor choice due to chronicity of disease

11. Intra-articular Injections
Corticosteroids for short-term relief (II,B)
Cannot Recommend for or against Hyaluronic Acids(I/II, Inconclusive)

12. Footnotes 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)

13. 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

14. Website Resources Available
American Academy of Orthopaedic Surgeons P.O. Box 1998 Des Plaines, IL –823–7186 or 800–824–BONE (2663) (free of charge) Fax: 847–823–
American Association of Hip and Knee Surgeons
6300 N. River Road, Suite 615 Rosemont, IL Telephone: (847) Fax: (847)
United States Bone and Joint Decade, NFP (USBJD)   6300 North River Road   Rosemont, IL   Phone:   Fax:   
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) National Institutes of Health 1 AMS Circle Bethesda, MD 20892–3675 Phone: 301–495–4484 or 877–22–NIAMS (226–4267) (free of charge) TTY: 301–565–2966 Fax: 301–718–
NIH Osteoporosis and Related Bone Diseases
~National Resource Center 2 AMS Circle Bethesda, MD Phone: 202–223–0344 or 800–624–BONE TTY: 202–466–4315 Fax: 202–293–2356
American College of Rheumatology Century Place, Suite 250 Atlanta, GA Phone: 404–633–3777 Fax: 404–633–1870
American Physical Therapy Association North Fairfax Street Alexandria, VA 22314–1488 Phone: 703–684–2782 or 800–999–APTA (2782) (free of charge) Fax: 703–684–7343
Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality Office of Communications and Knowledge Transfer 540 Gaither Road, Suite 2000 Rockville, MD
(301)
Arthritis Foundation
P.O. Box 7669 Atlanta, GA

15. Save Your Knees Online Portal Media Launch
saveyourknees.org
The new Save Your Knees Web Portal, saveyourknees.org, is the most comprehensive interactive site about knees on the Web. It is full of multimedia information focused on knees: keeping knees healthy, exercise, common knee problems, injury prevention, treatments, including non-surgical and surgical options and more. On the site you will find: Question of the Week, Healthy Knees at Any Age, Fun Knee Facts, Kids Korner, eMotion Pictures, Patient Stories, Public Service Announcements, and Press Releases and Press Kits. Information about the “Save your Knees” portal appeared on a strategically placed electronic billboard located on the Las Vegas strip across from the Wynn and Venetian hotels during the 2009 Annual Meeting. The 4,000 square foot outdoor billboard broadcast our video, print PSA and Web address almost 50 times.

16. Get Up! Get Out! Get Moving! Let’s Exercise Now! Facebook Application
There are currently millions of active users on Facebook worldwide. To reach this new, social audience, the Academy created an exercise application called, “Get Up! Get Out! Get Moving! Let’s Exercise!” The application has several features including setting your own fitness goals (promoting weight-bearing exercises), tracking those goals, joining teams, challenging friends on Facebook to meet and/or beat your personal or team goals, and competing to earn points with people around the globe to get healthy, strengthen your bones and get into the game of life! If you, your family, friends, peers, colleagues or patients have a Facebook account, go to to get started.

17. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
No there is no known cure and very limited situations where cartilage procedures are a viable option and that is in very young patient with focal traumatic injuries

18. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
Several studies have shown that arthroscopic debridement and lavage is not effective for treatment of OA.

19. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
There is no maximum lifetime dosage, but injection should be spaced apart about 3 to 4 months because too many injections close together can soften the remaining cartilage.

20. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
How will I know when I am ready for joint replacement?
Most people reach a point where their quality of life is diminished enough that they know it is time. Other indicators can include loss of sleep, constant pain, inability to do typical activities of daily living, or failure of pain relief options that had been previously working.

21. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
How will I know when I am ready for joint replacement?
How long is the recovery for joint replacement?
Recovery from joint replacement is highly variable among individuals. A lot depends on age, health, preoperative function. On average most 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, walking, active job by 2 months, but again this is highly variable.

22. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
How will I know when I am ready for joint replacement?
How long is the recovery for joint replacement?
What is the likelihood I will improve with joint replacement?
On average 85% of people say they would have knee or hip replacement again.

23. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
How will I know when I am ready for joint replacement?
How long is the recovery for joint replacement?
What is the likelihood I will improve with joint replacement?
How long do joint replacements last?
Knee years, Hip years conservatively. Factors such as weight, age, and activity level play a large role.

24. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
How will I know when I am ready for joint replacement?
How long is the recovery for joint replacement?
What is the likelihood I will improve with joint replacement?
How long do joint replacements last?
What types of activity can I do after joint replacement?
There is no evidence based research to show what you can safely do. I recommend low impact exercise. Avoidance of high impact activities. In general golf, swimming, biking, walking, hiking, skating, and cross country skiing appear to be safe activities.

25. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
How will I know when I am ready for joint replacement?
How long is the recovery for joint replacement?
What is the likelihood I will improve with joint replacement?
How long do joint replacements last?
What types of activity can I do after joint replacement?
Am I a candidate for minimally invasive surgery?
Minimally invasive surgery is an option for everyone, but what that is can vary from person to person. No study has confirmed any long term benefit of minimally invasive surgery functionally. The most 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 your joint replacement.

26. Top 10 Patient FAQs… and their Answers
Is there anything that can regrow cartilage or reverse arthritis?
Can’t you just clean up the knee with arthroscopy?
How Many Cortisone shots can I get and how often?
How will I know when I am ready for joint replacement?
How long is the recovery for joint replacement?
What is the likelihood I will improve with joint replacement?
How long do joint replacements last?
What types of activity can I do after joint replacement?
Am I a candidate for minimally invasive surgery?
Why did I get arthritis?
Arthritis is due to multifactorial influences. Factors that are known to contribute are weight, trauma, genetics, activity level, and diet.

27. Thank You!