Emory Osteoarthritis

Clinical PathwayBrandon Mines, MD

Emory Sports Medicine Center

Nothing to disclose

Osteoarthritis Overview

“The Graying of America”

Manek NJ, et al. Am Fam Physician. 2000;61:1795-1804. Centers for Disease Control and Prevention.

MMWR. 2004;53:388-389.

Year

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5

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1980 1990 2000 2010 2020 2030 2040 2050

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OA Prevalence Most common form of joint disease worldwide

Radiographic evidence

>50% at 65 years of age

≈80% at 75 years of age and older

Symptomatic OA of knee

11% of people >64 years of age

Manek NJ, et al. Am Fam Physician. 2000;61:1795-1804.

OA Pathophysiology Erosion of cartilage

Decrease in concentration and viscosity of synovial fluid

Decreased lubricating and cushioning properties of the joint

Secondary inflammation

Subchondral damage

Microfractures

Cyst formation

Clinical Pathway

A work in progress

Broad spectrum of physicians, interests, experiences

and opinions

We see different types of patients

Different patients have different expectations

Clinical Pathway That being said…

First, do no harm

Least Most invasive

Educate

Don’t give false hope, but be optimistic

Be brutally honest...in a nice way

Social network is important

Friends

Family

Support groups/system

If one feels defeated, then one is defeated

Case

45 yo male, recreational athlete

Enjoys running, tennis,

mountain biking and cross fit

Intermittent knee pain

No reported injuries

Overall, feels limited on how

much he can do and how long

he can do it

Case Finally, patient visits Emory

Sports Medicine Center

History, exam & x-rays

Mild knee osteoarthritis

Devastating news

Lifestyle changes

Lots of questions

“What do I do now, doc?”

Osteoarthritis

www.physio-pedia.com

Osteoarthritis Pathway

Currently a work in progress for us

Reviewing data & best clinical practices

Evidence based medicine vs. consensus statement

What I have always done versus what the evidence

says I should do

What does our patient need to hear 1st?...

Education:

Takes time, but needs to understand what he is up against

Needs to be in terms he can digest & accept

Don’t forget learner types See it, read it, hear it

Needs to absorb/accept diagnosis

Education This gets glossed over very

often

At Emory:

Anatomical models

Tablet videos

Pictures

Website recommendations

www.arthritis.org

www.emoryhealthcare.org

Takes time, but time well spent!

Rehabilitation “I already have a trainer at the gym”

“I’ll just get some exercises off the internet”

At Emory:

Vitally important to discuss the role of rehabilitation

Explain differences

personal trainer

google-derived exercises

physical therapy

Several studies have shown beneficial outcomes in regards to

rehabilitation and self-management programs

Rehabilitation

Coleman et al, 2012

Patients in a 6 week self-management program

Statistically significant

Improved WOMAC score

Less stiffness

Improved function

Rehabilitation

Deyle et al, 2000

Physical therapy and Osteoarthritis

Statistically significant:

Improvement in WOMAC scores with PT and knee

exercises

What fits your schedule better? Exercising 1 hour per day or

being dead 24 hours a day?

Case “Ok, Ok, I hear ya doc, but

what exercise CAN I do?”

Exercise:

At Emory: Keep moving!

Watch out for impact

activities

Prefer bike, elliptical,

walking, etc.

Water sports/aerobics

Everything in moderation

We assume patient KNOWS they need to lose

weight....

Makes an out of you & me

Patient says, “you think that would make a real

difference?”

Case: Weight Loss

How much is suggested?

At Emory:

Goal is getting to ideal body weight

Surgical standpoint:

Under 30-35 BMI at least

Weight Loss Toivanen et al

22 year follow up

Risk of knee OA was 7 times greater for BMI > 30

compared to BMI < 25

Case “Doc, how am I suppose to lose weight and stay active

if my knee hurts so bad right now?”

NSAIDs:

At Emory:

Start with OTCs

Less $

Easier access

Educate on how to take them

NSAIDS

Many studies have looked at this

Selective NSAIDs (i.e. Celebrex)

Non-selective NSAIDs (i.e. Ibuprofen)

Statistically significant improvements in pain

Compared to placebo

Case: NSAIDs

May need to try prescription NSAIDs

Topicals may be better tolerated

Diclofenac – less cardiac, GI, renal side effects

Tylenol has been shown to not be better than placebo

We recommend avoiding Tylenol at this time

Not helping pain

People tend to take too much

Case “I’m going to need something that starts making me feel

better faster than that!”

Corticosteroid injections:

Widely done and widely accepted as OK to do

Chao et al, 2010

Compared to saline

WOMAC scores statistically better at 4 weeks

Case: Corticosteroid Technique may make a difference

Ultrasound guidance, when needed/able

Patient comfort for knee aspiration

Quick point-of-care hip joint injection

No need to re-schedule for fluoro-guided injection

If time allows, can do right there in office

Mild OA responds better than severe OA

Case “that’s great doc, but do you have something that may

give relief longer than cortisone?”

Viscosupplementation:

Hyaluronic acid

Rooster comb; recombinant DNA/bacteria

Lubricate joint

Controversial product

Does it really work?

Case American Academy of Orthopaedic Surgeons (AAOS) does not

recommend but American Medical Society for Sports Medicine (AMSSM) does recommend

Based on method of reviewing the data

Complicated but related to how you interpret patient pain scores

In either case, it is still covered by insurance plans

In my hands…

70% - 75% of mild/moderate knee OA patients are happy they did it

Severe OA success drops to 20% - 30% of patients get relief

Generally getting 6-9 months of some type of relief (mild/moderate OA)

Typically, start with CSI, then add on visco when needed

Viscosupplementation Several preparations

One injection

3 injections

5 injections

No clinical difference seen in any of them

Some are more biologically “clean”

Less inflammatory reactions

Case “But what can I do myself. I’m not that excited about

injections!”

Unloader knee braces:

Medial > lateral

Custom fit

Bulky to low-profile

Literature is +/- with utility of these braces

Will offer, for the willing patient, who may be adverse to

injections

Knee braces Brouwer et al, 2006

Multi-center RCT; medial knee OA

Showed small effects in improving pain scores

Kirkley et al 1999

RCT; medial knee OA

Significant benefit from using medial unloader

Knee braces

Anecdotally, seems to work minority of the time

Doesn’t fit well with the more obese leg

Insurance covered expense, but tends to still be

expensive for patient

As a general rule, we aren’t that excited about it, but we

don’t steer people away from it

“I heard supplements are good to take?!”

Glucosamine/chondroitin:

Studies are 50/50 on if it helps or not

Hard to know what to take from that

Glucosamine tends to be the more important ingredient

We consider risk/benefit with this

$$, allergies, mild increase in diabetic blood sugar

Not invasive, patient is “doing” something, placebo affect?

Definitely not something we tend to outright recommend, but if all else fails, tend to be OK with people trying it

Case “I still don’t want joint replacement. What about those

platelet injections, or stem cells?”

PRP or Stem cell injections:

Controversial

Studies are hit and miss regarding efficacy

Seems to be better for knee than hip

Orthobiologics May be helpful in mild/moderate knee osteoarthritis

Insurance not covering these injections

Offer it as an option but with caveats

Still under heavy research/scrutiny

Won’t hurt you, but not sure if it will help as much as you want

You are not “re-growing” cartilage

You still have osteoarthritis & we don’t know how to stop it from progressing

Surgery “I’m ready to get this problem fixed”

Total joint replacement

When patient is fed up with pain

Pros outweigh cons

Thank you!Brandon Mines

bmines@emory.edu