1. Evidenced Based Management Knee Osteoarthritis
Dr Jonathan Mulford
myorthopod.com.au

2. 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.

3. 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.

4. 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.

5. Non Op Treatments Groups
Lifestyle modification
Rehabilitation and Physiotherapy
Braces and Insoles
Pharmacology

6. LIFE STYLE MODIFICATION
Avoid aggravating factors
No high Impact
Limit Stair climbing
Weight loss
Diet

7. 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!

8. 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:
Diets rich in vitamins C slow the progression of osteoarthritis.
Arthritis and Rheumatism 1996; 39:

9. REHABILITATION Therapeutic Excercise
Ultrasound, TENS, Pulsed Electric Stimulation, Acupuncture
Hydrotherapy
Aquatic Excercise
Balneotherapy

10. Therapeutic Exercise in Knee OA
Small short term benefit for knee pain and physical function.
No evidence long term benefit.
Is useful pre-operatively.

11. 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.

12. 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.

13. Therapeutic ultrasound
no benefit over placebo

14. Transcutaneous electrical nerve stimulation (TENS)
small improvements in pain control over placebo.
Methodology of the studies is poor.

15. Pulsed Electric Stimulation
Electrical stimulation therapy had a small to moderate effect on outcomes for knee OA.

16. 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):

17. 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.

18. 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.

19. Pharmacology Painkillers Anti-inflammatory Chondrotin and Glucosamine
Alternative medications
Injections

20. 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.

21. 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.

22. 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

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. Corticosteroid Injections
Effective pain reliever however often only for short period (4 weeks)

30. 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

31. Surgical Treatment Arthroscopy Osteotomy Uni
Patellofemoral Arthroplasty
Total knee Arthroplasty
Fusion

32. 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.

33. High Tibial Osteotomy

34. High Tibial Osteotomy Indications Isolated Compartment OA
Less than 12 degrees deformity
Stable knee
Young and active
Benefits
Avoid arthroplasty
No limits on activity

35. Inconsistent results – 50% still effective at 7-10 years
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: , 2004)
Arthroplasty after osteotomy may not be as successful.
Certainly more challenging surgery.

36. Uniarthroplasty

37. Uni Indications isolated compartment Osteoarthritis. Benefits
Smaller incision, Quicker recovery, better feeling knee, cost implications.
Problems
progression, revision.

38. How Long do they Last?
Swedish Register – about 90% at 10 years

39. Age and Uni Revision Australian Joint Register

40. Patellofemoral Arthroplasty
Indications – Isolated
Benefits
Problems

41. Total Knee Arthroplasty

42. 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.

43. Total knee Replacement
91-96% prosthesis survival rate at 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.

44. Improvements in surgical technique, prosthetic designs, bearing surfaces, and fixation methods might increase the survival rate of these implants even longer.

45. Swedish Knee Registry

46. Australian Joint Registry

47. Revision Summary Australian Joint Register
At 7 years cumulative % revision
Primary total 4.3%
Uni 12.1%
PFJ 13.8%

48. Unispacer and Partial Resurfacing