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Osteoarthritis Evaluation update

Suraj Achar MD Professor UCSD school of Medicine

Team Physician San Diego Sockers, UCSD athletics, US Olympic Training Center

Disclosures

u  Nothing to disclose.

Part 1: Evaluation: Probing the puzzle of OA

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Epidemiology of OA

u  Most common form of arthritis worldwide

u  OA affects about 12% of the US population; the incidence ↑ with age

u  Big time underestimate!

MSK Cost Back pain, Injuries, OA

u  950 billion (7.4% of US GDP) u  Annual direct & indirect costs for bone and joint health

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All cause and disease specific mortality in patients with and without walking disability. •  Etiology

•  low grade systemic inflammation

•  long term use of NSAIDS

•  lack of physical activity

Eveline Nüesch et al. BMJ 2011;342:bmj.d1165

©2011 by British Medical Journal Publishing Group

Pathophysiology: OA

Biomechanical Forces &

Cytokines (IL-1, TNF-b) Growth Factors

(TGF-1, IGF) >

Destructive forces > rebuilding forces

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Role of Trauma?

u  Does knee & hip trauma in youth lead to OA later?

u  What is the research revealing?

u  Last Decade u  Due to an elbow injury suffered

during his playing career, he had only very limited use of his right hand

u  Bl knee replacements

Female soccer players with ACL tears, radiographic findings and symptoms 12 years after injury. - Roos & Ostenberg

u  Swedish study:

u  Subjects

u  106 female soccer players with an ACL injury

u  Mean age =19y

u  ACL reconstructive surgery - 62%

Results: Swedish study

u  What percentage had OA on x-ray? u  Answer: 34%:

u  Grade I or II joint space narrowing with osteophytes

u  What % could no longer play soccer? u  pain u  function limitations

u  sports & recreational activities

u  lower quality of life

u  Answer 11% u  Did surgery reduce OA?

u  Prevalence of radiographic OA ACL reconstructed vs non-reconstructed subjects

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Implications: Swedish studyà injury leads to OA at young age

u  ACL repair may have limited effect on development of arthritis?

Does exercise lead to OA?

u  Long distance running and OA u  Lars Konradsen et al, The American J of Sports Med. 1990 u  Retrospective, case controlled

u  30 long distance runners and 27 nonrunners

u  Median period of running = 40 years!

u  Results u  No difference in pain, ROM

u  No X-ray difference

Sports and OA: Uncontrolled cross-sectional studies u  Wrestling and MMA

u  cervical spine, knees, and elbows

u  Boxing

u  carpometacarpal joints

u  Pitching in baseball

u  shoulders and elbows

u  Cycling

u  patellofemoral joints?

u  Gymnastics

u  shoulders, wrists, and elbows

u  Ballet dancing

u  talar joints

u  Soccer

u  hips, knees, ankles, cervical spine, and talar joints

u  Football

u  Everything!

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Risk vs Exercise

Neuroanatomically normal joints u  ↑risk in the absence of adequate

exercise.

u  ↑risk upon exposure to repetitive, high-impact exerciseà football

Neuroanatomically abnormal joints u  ↑risk with repetitive, low impact,

recreational exercise

The role of Knee alignment in OA

u  Sharma et al. JAMA 2001

u  Prospective longitudinal cohort study

u  237 pts, 18 month study

u  Varus alignment at baseline

u  OR 4.09 (95% CI 2.2-7.62)

u  Valgus alignment

u  OR 4.89 (95% CI 2.13-11.2)

Clinical Features of OA

u  Symptoms u  Joint pain

u  Morning stiffness lasting <30minutes

u  Joint instability or buckling

u  Loss of function

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Clinical Features of OA

u  Signs

u  ↓ ROM

u  TTPàjoint line

u  Crepitus à Not specific (PFPS)

u  Pain with motion

u  Bony enlargement at affected joints/Deformity

u  Instability?

Pattern of involvement

u  Axial:

u Cervical and lumbar spine

u  Peripheral:

u DIP, PIP, IPJ, 1st CMC, knees, hips, ankles, feet

n  Rare joints 1.  shoulder, 2.  elbow, 3.  wrist 4.  MCP joints

OA of Hands

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Symptomatic joints?

u  The Knees, Hips, ankles, are the most symptomatic.

u  1st CMC, 1st MTP

u  AC joint, DIP and PIP are rarely significantly symptomatic!

Bates, Guide to PE. 1995

Clinical features of OA thumbà 1st

CMC u  Difficulty pinching and

grasping

u  ~50% also have CTS

u  PE

u  Painful grind test

u  Swelling and crepitus

Location?

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Weight Bearing Rosenberg Merchant

Value of Tunnel View in OA!

AP view

u  Sclerosis

u  Cysts

u  Osteophytes

Tunnel view

u  Joint space loss in lat tibial-femoral OA

Tunnel (Notch) View

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Alpha Angle

Advanced Imaging?

Is MRI helpful?

u  Other pathology

u  Meniscus

u  Ligaments

u  OCD

u  synovium

u  Earlier dx

u  Bone marrow edema for full thickness cartilage defects

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Osteoarthritis with CPPD?

Erosive OA? u  Uncommon

u  Pain, TTP, warmth, soft tissue swelling more pronounced

u  Lateral instability of Interphalangeal joints

Diff Dx?: Gout

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Diff Dx: Hemochromatosis

RA vs OA

u  Pattern

u  Radiographs

u  Stiffness

u  AM vs PM

u  Transient vs long

u  Swelling Joints

u  OA: hard and bony

u  RA: soft, warm, boggy, and tender

Low back pain and Spine OA: Are they related? u  What is OA

u  disc space narrowing together with vertebral osteophyte formation

u  facet joint DJD

u  only synovial joint in the spine that has a similar pathological degenerative process to appendicular joints

u  LBP: 80%

u  OA spine:

u  prevalence ranging from 40–85 %

u  Rubin DI: Epidemiology and risk factors for spine pain. Neurol Clin. 2007 May; 25(2):353-71.

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Summary OA: Clinical Manifestations and Dx

Associated symptoms

weakness, weight loss à hemachromatosis Redness and warmth à gout

LBP vs X-ray Trauma, Urinary system, history of cancer, osteoporosis, neurofindings

Remember C sign

and Rosenberg View

Remember C sign

and Rosenberg View

Key joints Spine, 1st cmc, knee and hips

OA is not only common but

associated with à

decreased exercise and ↑ mortality

Osteoarthritis Rx Evidenced-based approach

to OA

Suraj Achar MD

Professor UCSD school of Medicine

Team Physician San Diego Sockers, UCSD athletics, US Olympic Training Center

Part 2: What is the best first line RX for knee OA

Exercise

1

Weight loss

2

NSAIDS

3

Topical nsaids

4

Insoles

5

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Should all patients with knee OA be counseled on exercise

u  Yes/No

u  All patients with knee OA should be counseled on exercise irrespective of age, radiographic disease severity, pain intensity, functional levels, and comorbidities

Cochrane review of 54 trials

u  19 studies/low risk of bias

u  High quality evidence suggesting that land-based exercise improves knee pain and function with moderate effect size immediately

u  No strong evidence on modality and dosage

u  Magnitude effect = nsaids

u  Often use PT to optimize program

u  Walking, cycling, rowing, and deep-water running

u  Lower extremity strengthening

Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med 2015; 49:1554.

What about running or jumping exercises?

u  Consider avoiding, although evidence for joint damage is scarce.

u  Meta-analysis suggested a protective effect of running against surgery due to OA: pooled odds ratio 0.46 (95% CI, 0.30-0.71)

Timmins KA, Leech RD, Batt ME, Edwards KL. Running and Knee Osteoarthritis: A Systematic Review and Meta-analysis. Am J Sports Med 2017; 45:1447.

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What% of pts with knee OA receive opioids?

u 40%

Should we use opioids to Rx

pain before knee

replacement

•  Prospective cohort of 158 pts

•  Brigham and Women’sà scheduled for knee replacement

•  Questionnaires including WOMAC, and opioid use

•  23% had at least 1 opioid within 2 years prior to surgery

•  Most common oxycodone, hydrocodone, tramadol

•  After surgery 150pts were given at least one opioid, 94% multiple

Results

u  Womac pain reduction scores

u  opioids before TKA had a mean 6-month WOMAC

u  27.0 points (95% CI = 22.7 to 31.3) vs

u  Non Opioid group

u  33.6 points (95% CI = 31.4 to 35.9) for the non–opioid-use group.

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Mild vs Mod/Severe Knee

OA? u  Mild

u  low levels of or intermittent knee pain

u  relatively well-preserved joint function and quality of life.

u  Moderate knee osteoarthritis

u  persistent pain

u  significantly impairs functionality, activity participation, and quality of life

Rx concepts based on level

u  Mild

u  Non-pharmacologic

u  Exercise

u  Weight loss

u  Topical therapies prn

u  Mod/Severe

u  1st line: non pharmacologic

u  Aquatic exercises

u  2nd line

u  Short Rx NSAIDS

u  Pts with risk for PUD u  Celecoxib

u  Non selective nsaids with PPI

u  IA CSI/HA/PRP

u  Capsaicin

u  braces

u  Surgery

u  Duloxetine (extra-articular factors)

u  Mood issues

u  Pain catastrophizing

u  Sleep problems

Tai Chi

u  Limited # of large trials

u  Effective after 12 weeks

u  Knee pain

u  Physical function

u  Reduction in analgesic use

u  Improved depression scores

u  Improvedà less falls

u  Yan et al. Efficacy of Tai Chi on pain, stiffness and function in patients with osteoarthritis: a meta-analysis. PLoS One 2013; 8:e61672.

u  Wang, et al. Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis: A Randomized Trial. Ann Intern Med 2016; 165:77.

u  Mat et al. Physical therapies for improving balance and reducing falls risk in osteoarthritis of the knee: a systematic review. Age Ageing 2015; 44:16.

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Weight loss!

u  IDEA trial

u  454 overweight/obese pts with knee OA

u  D + E, D, E

u  D +E (11.4% weight loss)

u  18 months

u  < pain 50%

u  38% no pain!

Topical NSAIDS

u  Cochrane review

u  60% of pts > 50%

u  Comparable to oral NSAIDS

u  Low risk of GI/CVD

u  Reduced systemic absorption (5-17 fold for diclofenac)

u  Mild skin rash (tolerable)

u  QID

u  Diclofenac & ketoprofen

u  Why not OTC? (60$?)

Topical Capsaicin (old data?)

u  Hot chili peppers (0.025%) u  Down regulate TRPV-1 receptor on nociceptive

sensory neurons? u  Few randomized trials u  12 week RCT

u  QID u  33% reduction in symptoms u  Local burning sensation >50% mild to

moderate and improves u  Not good when comes into eyes or

abraided skin areas!

u  Deal et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther 1991; 13:383.

u  Altman et al. Capsaicin cream 0.025% as Monotherapy for Osteoarthritis: A double-blind study. Semin Arthritis Rheum 1994; 23 (Suppl 3):25.

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Duloxetine u  Studied in pts already taking nsaids

u  meta-analysis of three trials (~1000pts) u  RR of pain 30%-50% improvement ~ 1.5-1.7 (95% CI 1.31–

1.70)

u  No serious harms, (mild AE and discontinuation RR 2.15)

u  Wang et al. Efficacy and Safety of Duloxetine on Osteoarthritis Knee Pain: A Meta-Analysis of Randomized Controlled Trials. Pain Med 2015; 16:1373.

Insoles (mixed data)

u  Medial wedged for patients with lateral tibiofemoral OA (one study+)

u  Lateral (no better than neutral soles)

u  Don’t recommend à OK if helps? u  Duivenvoorden et al. Braces and orthoses for treating

osteoarthritis of the knee. Cochrane Database Syst Rev 2015; :CD004020.

u  Parkes et al. Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta-analysis. JAMA 2013; 310:722.

Hyaluronans

u  Controversy u  AMSSMà Yes

u  AAOSà No! (strongly against!)

u  Costly u  Flares u  No ultrasound study u  New agents coming on the market may be

better! u  Hunter DJ. Viscosupplementation for

osteoarthritis of the knee. N Engl J Med 2015; 372:1040.

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PRP

u  New à Rapidly increasing evidence

u  Data at 12 months

u  Better than HS or placebo

u  Who should we do this on?

u  Severe or less severe?

u  Real cost?

u  Meheux et al. Efficacy of Intra-articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review. Arthroscopy 2016; 32:495.

Acetaminophen (paracetamol)

u  Meta-analysis (10 trials, 3541 pts)

u  Small, non clinical benefits

u  Not superior to placebo!

u  Risks of intentional overdose

u  Risks in therapeutic level

u  GI bleeding

u  Liver toxicity

u  Renal failure

u  CVD

u  Machado et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomized placebo controlled trials. BMJ 2015;

u  Roberts et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis 2016;

Glucosamine

u  Don’t encourage or discourage

u  Most major guidelines don’t recommend

u  Mixed data!

u  Strong placebo effect

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Mixed data

u  Nutritional supplements

u  Avocado soybean (ASU) u  +Industry sponsored trials

u  Vitamin D-no benefit

u  Fish Oil u  Dose dose > high dose?

u  GI upset

u  Clinical benefits unclear

u  TENS

u  Poor data, placebo effectu

Comparison of intra-articular glucocorticoids for OA, based on joint size

DailyMed Web site. US National Library of Medicine, National Institutes of Health, Health & Human Services. Available at: www.dailymed.nlm.nih.gov/dailymed.  Accessed January 25, 2014.

Duration of Effect or IA glucocorticoids?

u  RA: longer duration of effect (up to 22 months in wrist)

u  OA: shorter benefit

u  All studies prior to ultrasound guidance

u  6 weeks or less

u  Aspiration prolongs effect >6months

u  Frequent dosing > 4-6 weeks may have deleterious effects on bone and skin

u  Cartilage loss?

u  McAlindon et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA 2017; 317:1967.

u  Jüni et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev 2015;

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Adjustable Valgus bracing: Non op Rx of Med Compartment OA

Evidence? u  Meta-analysis

u  Brace> no brace

u  Valgus slightly > neutral sleeve

u  25% slipping or poor fit

u  Low compliance 45%

u  Small benefits noted with PF brace or tape if > 7.4 hrs/day

u  Moyer RF, Birmingham TB, Bryant DM, et al. Valgus bracing for knee osteoarthritis: a meta-analysis of randomized trials. Arthritis Care Res (Hoboken) 2015; 67:493.

Walking aids

u  Opposite side

u  RCT small improvements

u  Jones A, Silva PG, Silva AC, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial. Ann Rheum Dis 2012; 71:172.

Psychological interventions

u  Do they help?

u  Yes

u  CBT and even internet based education helps!

u  Keefe et al. Psychosocial interventions for managing pain in older adults: outcomes and clinical implications. Br J Anaesth 2013; 111:89.

u  Bennell et al. Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain: A Randomized Trial. Ann Intern Med 2017; 166:453.

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Adjunctive pharmacologic options for OA management

Agent Proposed,benefit

Risk, Evidence

Glucosamine/chondroitin1supplements

Potential1pain1improvement

Generally1safe1and1well1tolerated1

GAIT,1a1multicenter1RCT11sponsored1by1NIH,1found1glucosamine1alone1did1not1reduce1pain1in1patients1with1OA;1patients1with1moderateDtoDsevere1OA1may1experience1some1improvement1with1combination1glucosamine/chondroitin1as1an1adjunct1therapy39,40

SDAdenosylmethionine1(SAMe)1supplements

Symptomatic1improvement1in1pain1and1functionality

Tolerability1similar1to1placebo1and1better1than1NSAIDs

MetaDanalysis1of1111RCTs1found1SAMe1improved1OA1pain1and1increased1function1at1a1rate1comparable1to1NSAIDs,1with1fewer1side1effects41,42

Colchicine Decreased1frequency1and1intensity1of1OA1attacks

Gastrointestinal1upset/bleeding,1gout

In1RCTs,1patients1receiving1adjunctive1colchicine1twice1daily1had1greater1symptomatic1benefit1at1121and1201weeks,1compared1with1placebo1group43,44

Dextrose1prolotherapy Symptomatic1improvement1in1pain,1functionality,1and1stiffness

Pain1at1injection1site,1risk1of1bleeding1and1infection1appear1similar1to1corticosteroid1injections

Statistical1improvement1in1pain,1function,1and1stiffness1compared1with1saline1injection1at1261and1521weeks;1more1data1needed1to1assess1efficacy45,46

PlateletDrich1plasma1(PRP)1injections

Augmentation1of1tissue1healing,1symptomatic1improvement1in1pain1and1function

Pain1at1injection1site,1risk1of1bleeding1and1infection1appear1similar1to1corticosteroid1injections

Newer1modality1with1limited1clinical1evidence;121RCTs1showed1better1clinical1outcomes1241weeks1after1injection1compared1with1hyaluronic1acid1(HA);1metaDanalysis1of1161studies1showed1PRP1more1effective1than1HA1at1121months47,48

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Value of Ultrasound Guidance u  Improved

u  Accuracy

u  Outcomes

u  Discomfort of the procedures

IA Thumb

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Co-morbidities

2/3 pts

Htn COPD CVD HIV

Excess mortality in patients with

OA

OA of knee on imaging >17%

excess mortality

DM

Avoid NSAIDS • Especially in those

with CVD or renal disease

Glucosamine may be safe • Potentially lower

glucose levels

IA CSI •  Isolated 1-2 day

increase in glucose

Pts with OA and walking disability

u  Increased death from CVD

u  Rx

u  PT

u  Canes/braces

u  Walkers

u  Exercise programs

u  Cardiovascular rehab programs + effect on OA and CVD!

u  Use topical nsaids, Intra-articular CSI

u  Acetaminophen no longer preferredà >risk

u  Avoid long term opioid therapyà increase MI >40%

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PUD

u  Avoid NSAIDS

u  If using combine with PPI

u  COX 2 may be safer but still have risk!

Older patients

Acetaminophen metabolism variable

• Reduce daily max to 2-3 grms

NSAIDS?

Opioid risks (avoid!) • Cognitive impairment

• Delirium • Injuries

• CVD events • Pneumonia

• Hospitalizations • Mortality!

Surgery u  Arthroscopyà no benefit, may make it

worse

u  Isolated OA--Moseley, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347:81.

u  Osteoarthritis with Meniscal Tearà Khan et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014; 186:1057.

u  Osteotomy à young patients

u  Joint replacement

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Specialized surgery

u  Not helpful

u  ARTHROSCOPIC ABRASION ARTHROPLASTY

u  ARTHROSCOPIC SYNOVECTOMY, partial meniscectomy, debridement

u  Helpful Sometimes

u  AUTOLOGOUS CHONDROCYTE IMPLANTATION

u  focal cartilage defect involving only one side of the joint

u  Unicompartmental Arthroplasty

ACI

u  3 stage procedure

u  ~50% complications

u  arthrofibrosis and joint adhesions

u  graft overgrowth

u  chondromalacia or chondrosis

u  cartilage injury

u  meniscal lesion

u  graft delamination

u  osteoarthritis

1st CMC Surgery

u  Joint fusion (arthrodesis).

u  Osteotomy.

u  The bones in the affected joint are repositioned to help correct deformities.

u  Trapeziectomy.

u  trapezium is removed.

u  Joint replacement (arthroplasty).

u  All or part of the affected joint is removed and replaced with a graft from one of your tendons.

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Practice recommendations

1.  Weight loss and exercise are by far the best Rx for OA and can cure the symptoms!

2.  Topical therapies are 1st line pharmacological Rx

3.  Think about joint replacement before it is too late!

Questions

u  sachar@ucsd.edu