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First MTP Osteoarthritis Hallux valgus with bunion.

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Presentation on theme: "First MTP Osteoarthritis Hallux valgus with bunion."— Presentation transcript:

1 First MTP Osteoarthritis Hallux valgus with bunion

2 OA is a Problem with the Cartilage!

3 Osteoarthritis: Risk Factors Secondary Osteoarthritis: The degeneration is secondary to an injury to the cartilage Primary Osteoarthritis: No obvious cartilage injury Erosive (hand) OA: runs in families, autosomal dominant but more penetration in women Often starts 5-10 years pre to post menopause, adds more joints (DIPs, PIPs), can mimic psoriatic arthritis, burns out with bony changes

4 Risks for OA Advanced Age Female Genetics Obesity Occupation (overuse) Trauma

5 Osteoarthritis: Laboratory All laboratory investigations should be normal in osteoarthritis Labs and Xrays are not necessary to make the diagnosis

6 Osteoarthritis: Management Non-Pharmacologic –Exercises –Strengthening –Splinting Pharmacologic –Oral Medications Surgery –Topical Medications –Injectable Medications –Alternative/Complimentary Choices

7 Goals of Treatment 1.Pain Reduction 2.Improved Function 3.Changes the Disease Outcome 4.Low Cost 5.Low Side Effects

8 Physical & Occupational Therapy Assistive Devices Proper Footwear Exercise & Weight Loss Education Strength Training

9 Topical Medications 1.Capsaicin 2.Topical Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Pennsaid, Diclofenac

10 Topical NSAIDs Limited Use for Osteoarthritis Small effects in clinical trials Apply 4 times per day Expensive Messy Benefits Little systemic absorption

11 Intra-Articular Corticosteroids Pros Cheap Relatively Safe: 1 in 15-20,000 risk of infection Safe to do 4 injections in a single joint per year Cons Short term benefit at 4 to 8 weeks but negative at 12 and 24 weeks Predictors of response are unclear

12 Viscosupplementation Joints typically contain a small amount of lubricating fluid called synovial fluid. Hyaluronic acid is a component of this synovial fluid Synovial fluid Hyaluronic acid is decreased in patients with osteoarthritis Viscosupplements are synthetically or biologically derived Hyaluronic Acid

13 Viscosupplementation Given by a series of 1 to 3 injections once a week depending on the product Only approved for osteoarthritis of the knee The effects are variable lasting months in some people and not working at all in others

14 Viscosupplementation Pros If it works, may have a significant benefit Cons Expensive ~ $300 per course The effects are variable lasting months in some people and not working at all in others Post-injection pain, swelling Not very good clinical trial data

15 Oral Medications 1. Simple Analgesics 2. Non-Steroidal Anti-Inflammatory Medications (NSAIDs) 3. Narcotic Analgesics and non-narcotic (tramadol) 4. Complimentary Therapy (Glucosamine)

16 Acetaminophen Acetaminophen (Tylenol  ) Useful in mild to moderate osteoarthritis Pros Cheap Safe Proven Benefit Cons Small effect Often need 3g/day

17 Non-Steroidal Anti- Inflammatory Drugs (NSAIDs) Traditional NSAIDs COX-2 Selective NSAIDs (COXIBs)

18 Prostaglandin Synthesis Cell Membrane Phospholipids Arachidonic Acid Prostaglandins COX-1 Continuously Expressed GI Tract Platelets Endothelium Kidney COX-2 Upregulated Synovial Lining Macrophages Chondrocytes Endothelium Macula Densa COX-2 COX-1 NSAIDs

19 Non-Steroidal Anti- Inflammatory Drugs (NSAIDs) Traditional NSAIDs Block the Actions of COX-1 and COX-2 Available Over the Counter (Ibuprofen) Several (Ibuprofen, Diclofenac, Naproxen, etc) COX-2 Selective NSAIDs (COXIBs) Only Block the Action of COX-2 Only 1 available – Celecoxib (Celebrex)

20 NSAIDs & COXIBs: What Works NSAIDs consistently outperform acetaminophen in OA treatment

21 NSAIDs & COXIBs: What to look out for GI Risk – gastric and duodenal ulcer Renal Risk – raise creatinine and HTN Cardiovascular Risk - ?increased MIs Hepatoxicity Edema Allergic reactions

22 Clinical Risk Factors for NSAID Gastropathy 1.History of Ulcer Related Complications13.5% Previous ulcer, bleeding 2.Multiple NSAIDs9.0 % 3.High-dose NSAIDs7.0 % 4.Concomitant Anticoagulation6.4% 5.Age > 695.6% 6.Age > 593.1% 7.Concomitant Steroids2.2% 8.History of CV disease1.8%

23 More Patients are Without Appropriate Gastroprotection Singh G, et al. Gastroenterology 2006; 130(Suppl. 2): A-82 (Abstract 564). Year Patients >65 years not receiving gastroprotective approaches with their NSAIDs (%)

24 NSAIDs & COXIBS: Cardiovascular All NSAIDs may increase the risk of MI (possibly) and some more than others Use the lowest possible dose for the shortest duration of time

25 Narcotics Benefits –Codeine does have some evidence for efficacy, however, it also has a high incidence of side-effects. –Oxycodone, morphine, and hydromorphone may be better choices Side Effects –Increaed in the elderly –Sedation, confusion, constipation Risk for Falls and other Accidents

26 Addiction It is EXCEEDINGLY rare for patients with OA to show addictive behaviour. In fact, a study of over 800 patients with OA treated with opioids for 3 years found only 4 (0.02%) to have addictions.  (Ytterberg S, Mahowald M, Woods S. Codeine and oxycodone use in patients with chronic rheumatic disease pain. Arthritis Rheum 1998;41: ) OA patients stop opioids after surgery.  (Visuri T, Koskenvuo M, Honkanen R. The influence of total hip replacement on hip pain and the use of analgesics. Pain 1985;23:19-26.)

27 Glucosamine: The Theory Glucosamine is a component of cartilage Glucosamine is reduced in osteoarthritic cartilage Replacing glucosamine may have beneficial effects

28 Glucosamine: The Evidence You are a believer or not –Both positive and negative trials Withdrawal trial and NIH trial were both essentially negative DONA (RottaPharm) –Only brand of glucosamine to show positive benefit in trials –All trials sponsored by pharmaceutical company

29 Glucosamine: Practicality Dose: 500 mg three times daily If no effect after 3 months stop ? Take with chondroitin Seems very safe

30 Surgery for Osteoarthritis

31 Surgery: Who is appropriate Most people with arthritis, including older individuals, should be referred for surgical treatment when other treatment is ineffective and function is impaired. Surgery should not be used as a last resort There is no “magic age” for surgery

32 Surgery: Why Consider Consider surgery before: Advanced muscle weakness Joint deformities Significant loss of function with further deconditioning

33 Treatment Conclusions Non-Pharmacologic Therapy –Education –Physical Therapy Assessment Education Strengthening Range of Motion Joint Protection & Energy Conservation –Weight Loss & Nutrition –Cardiovascular Exercise –Shoes & Insoles –Assistive Devices

34 Treatment Conclusions NSAIDs –Work very well in select patients –Try a few NSAIDs before find the right one for you. –3 week trials of at least 3 different NSAIDs. Injectable Corticosteroids –Work well in some patients Viscosupplementation –Can work well in some patients (milder disease) Opioids –Can provide considerable benefit

35 Treatment Conclusions Lack of Scientific Evidence for Acupuncture Magnet Therapy

36 OA Guidelines Other Exercise Brace, Taping Weight Loss Joint replacement Medications Acetaminophen NSAIDs/Coxibs Topical agents Injectable agents

37 Questions


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