Official Osteoarthritis Treatment Guidelines
Osteoarthritis (OA) is a chronic disease process affecting synovial joints, particularly large weight-bearing joints. OA is particularly common in older patients but can occur in younger patients either through a genetic mechanism or, more commonly, because of previous joint trauma.
Rehabilitation for patients with OA can be provided in various forms, including the following:
1) Medication
2) Physical therapy
3) Occupational therapy
4) Intra-articular injections
5) Surgery
1) Medication for Osteoarthritis
The American College of Rheumatology issued the following pharmacologic guidelines for the treatment of osteoarthritis of the hip and knee[10] :
• Up to 4 g/d of acetaminophen ( which is the same thing as tylenol ) can be administered; this is the preferred initial treatment for patients with OA. It is cheap, effective, doesn't require doctors visits, cuts down pain, and slows progression of the arthritis.
• Topical anti-inflammatory medications or capsaicin can be administered only for knee OA. My favorite topical ( rub on ) anti-inflammatory is a drug called diclofenac. This is sold by the trade name Voltaren over the counter, but I prefer to use much higher prescription strengths, and it works great. Capsaicin is related to pepper spray, but also has a wonderful pain killing property if you know how to use it properly !
• Low-dose nonsteroidal anti-inflammatory drugs(NSAIDs) (ie, analgesic doses) or nonacetylated salicylates may be indicated. Some of these, such as ibuprofen and naproxen, can also be over the counter. Best of all, they are in a different drug group that acetominophen, so you can combine them and get additive beneficial effects without getting additive side effects. ( they all kill pain, but to much ibuprofen is bad for your stomach, whereas too much tylenol is bad for your liver. )
• Administer full-dose NSAIDs with misoprostol if risk factors for upper gastrointestinal bleeding are present
• Arthrocentesis with corticosteroid injection can be used only for knee OA if effusion is present
• Narcotic analgesic use may be indicated in cases of severe pain
Other medications have been investigated in OA (eg, tramadol, cyclooxygenase (COX)-2 inhibitors, dietary supplements). Many medications have been tried and are in use, but research on their effectiveness is lacking.
Glucosamine and chondroitin sulfate, currently being studied by National Institutes of Health (NIH) in double-blind trials, have been used in Europe for many years. S-adenosylmethionine (SAM-e [pronounced "sammy"]) is a European supplement receiving considerable attention in the United States.
In a randomized, controlled study by Petersen et al of patients with knee OA, neither ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), nor glucosamine administration, improved muscle mass gain during a 12-week strength-training program. However, both did improve maximal muscle strength gain in comparison with the placebo treatment, but the benefits were not significant enough to advocate taking NSAIDs or glucosamine.[11]
Chondroprotective drugs (ie, matrix metalloproteinase [MMP] inhibitors, growth factors) are being tested as disease-modifying drugs in the management of OA. Although a number of agents are currently under study, no agent has been shown to have a disease-modifying effect in humans.[10]
In a randomized, double-blind, multicenter study, etodolac plus acetaminophen was significantly more effective than etodolac alone for osteoarthritic flare-ups. Measurements of reduced pain intensity, achievement of pain relief, and symptom resolution (eg, decreased morning stiffness, inflammation) showed significantly greater improvement with the combination compared with etodolac alone.[12]
2) Physical Therapy for Osteoarthritis
Lifestyle modification, particularly exercise and weight reduction, is a core component of the management of osteoarthritis (OA).[1, 2, 3] A program of physical therapy should emphasize the importance of strengthening all muscles that cross the given joint affected by OA.
Most research focuses on quadriceps strengthening in knee OA. Also important are stretching exercises, which increase range of motion. The importance of aerobic conditioning, particularly low-impact exercises (if OA affects weight-bearing joints), should be stressed. Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful. Certain studies also indicate that a home exercise program for patients with OA of the knee provides an important benefit.
In a study of patients with knee osteoarthritis, Jan et al found that, in most respects, non–weight-bearing exercise was as therapeutically effective as weight-bearing exercise.[4] After an 8-week program, weight-bearing and non–weight-bearing exercise produced equally significant improvements in function, walking speed, and muscle torque. However, patients in the weight-bearing group demonstrated greater improvement in position sense, which may help with complex walking tasks, such as walking on a spongy surface.
In terms of reducing osteoarthritis-related knee pain, Chaipinyo and Karoonsupcharoen found no significant difference between home-based strength training and home-based balance training.[5]However, more improvement in knee-related quality of life was noted in the strength-training group than in the balance-training group.
In a review of patient adherence to exercise, Marks and Allegrante concluded that interventions to enhance self-efficacy, social support, and skills in the long-term monitoring of progress are necessary to foster exercise adherence in people with OA.[6]
Results from a study by Wang et al suggested that tai chi is a potentially effective treatment for pain associated with osteoarthritis of the knee.[7] In a prospective, single-blind, randomized, controlled trial, 40 patients with symptomatic tibiofemoral osteoarthritis who performed 60 minutes of tai chi twice weekly for 12 weeks experienced significantly greater pain reduction than did control subjects who underwent 12 weeks of wellness education and stretching.
The tai chi cohort also had significantly better Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function scores, patient and physician global visual analog scale scores, chair stand time, Center for Epidemiologic Studies Depression Scale scores, self-efficacy scores, and Short Form 36 physical component summaries.
The use of assistive devices for ambulation and for activities of daily living may be indicated. Braces and appropriate footwear may also be of some use, although a 12-month study of 200 people aged 50 years and older with medial knee OA reported that no symptomatic or structural difference was found for those who wore lateral wedge insoles compared with flat control insoles inside their footwear.[8] A cane can be used in the opposite hand for OA of the hip, and a cane in the hand of comfort may be helpful for OA of the knee. The patient can be taught joint-protection and energy-conservation techniques. Other physical therapy modalities include electrotherapy and thermotherapy.
In a study of 91 patients with hip osteoarthritis, Wright et al sought to identify a set of prognostic factors that maximize the accuracy of identifying patients likely to have a favorable response to physical therapy. Five baseline variables (unilateral hip pain, age 58 years or younger, pain greater or equal to 6 out of 10 on a numeric pain rating scale, 40-meter self-paced walk test time less than 25.9 s, and duration of symptoms less than or equal to 1 year) were in the final model. Failure to show 1 of the 5 variables decreased the posttest probability of responding favorably to physical therapy from 32% to < 1%; having at least 2 variables increased the physical therapy success from 32% to 65%; and having 3 or more variables increased the success to 99% or higher.[9] This study is the first step in developing baseline variables; further validation studies are needed before this can be used in practice.
3) Occupational Therapy for Osteoarthritis
Evaluation of how well the patient performs his/her activities of daily living, as well as retraining of the patient, can be assisted by the occupational therapist. Emphasize joint-protection techniques. Hand splinting, especially of the first carpometacarpal joint, may be indicated.
4) Intra-Articular Injections
Steroid injections
Intra-articular steroid injections may provide pain relief and have an anti-inflammatory effect on the affected joint in OA. Such injections generally result in a clinically and statistically significant reduction in osteoarthritic knee pain beginning as soon as 1 week after injection. The effect may last, on average, anywhere from 4-6 weeks per injection, but this benefit is unlikely to continue beyond that time frame.[13] One randomized, placebo-controlled study confirmed the effectiveness of corticosteroid injection in the treatment of hip OA, with benefits often lasting up to 3 months.[14]
Some controversial evidence exists regarding frequent steroid injections and subsequent damage to cartilage (chondrodegeneration). Therefore, usually no more than 3 injections are recommended per year in any 1 osteoarthritic joint.
Viscosupplementation
Intra-articular injection of sodium hyaluronate (ie, hyaluronic acid [HA], hyaluronan), also referred to as viscosupplementation, has been shown to be safe and effective for the symptomatic relief of knee OA. This topic has been reviewed in depth elsewhere.[15] The largest meta-analysis of intra-articular HA injection, using 76 controlled clinical studies (and subsequently updated by the Cochrane Collaboration), concluded that this therapy is safe and effective in patients with knee OA.[16]
To date, the US Food and Drug Administration (FDA) has approved 5 intra-articular HAs for the treatment of pain associated with knee OA. These include naturally extracted, non–cross-linked sodium hyaluronate products (Hyalgan,[17] Supartz, Orthovisc, Euflexxa) and 1 cross-linked sodium hyaluronate product known as hylan G-F 20 (Synvisc). Euflexxa is the only product derived from a fermentation process (Streptococcus), while the source material for the other 4 products is chicken combs. At present, no distinct advantage or disadvantage has been associated with either source of HA production.
Some differences between the viscosupplements do exist in the FDA-approved prescribing information. For example, Hyalgan and Synvisc have labeling that establishes their safety for repeat treatment, while other products have the precautionary statement that "the safety and efficacy of repeat treatment has not been established."
The HA class in general has demonstrated a very favorable safety profile for the chronic pain management of knee OA. The most common adverse event is injection-site pain.
While any intra-articular injection (all HA products and steroids) may elicit an inflammatory response and possible effusion, a clinically distinct acute inflammatory side effect (ie, severe acute inflammatory reaction [SAIR] or HA-associated intra-articular pseudosepsis) has been described. However, preclinical and clinical data provide compelling evidence that this reaction is limited to the cross-linked hylan G-F 20 product and may have an immunologic mechanism of action.
Molecular weight per se has not been found to correlate with efficacy (eg, higher or lower viscosity does not equate with better or worse clinical outcomes).
Interestingly, the duration of residence of an intra-articular injection (days) cannot explain the prolonged clinical benefit (months), and accordingly, subsequent biological mechanisms have also been proposed that may play an important role in the clinical benefit. The combination of quadriceps strengthening and HAs may have a synergistic effect on pain.[18]
In the United States, HAs are classified as medical devices rather than as drugs. Although the exact mechanisms of action through which they provide symptomatic relief are unknown, several possibilities exist, including direct binding to receptors (CD44 in particular) in the synovium and cartilage that can lead to several biologic activation pathways.
These mechanisms of action can include the increased endogenous production of hyaluronate and aggrecan by the joint, a mechanical barrier to the activation of nociceptors, the inhibition of pain mediators (eg, PGE, bradykinin), an anti-inflammatory effect (eg, inhibition of proinflammatory cytokine activity, inhibition of inflammatory cell function), a beneficial effect on immune cells, an antioxidant effect, and the restoration of the synovial fluid's physical characteristics (viscoelasticity). Viscosity can help to facilitate the cushioning and lubricating characteristics of the joint during slow movements, while elasticity blunts deforming forces (compression and resistance to shear forces) during rapid motions.
A study Waddell and colleagues hypothesized that hyaluronan inhibits interleukin-1beta–induced metalloproteinase production from osteoarthritic synovial tissue.[19]
As reviewed by Goldberg and Buckwalter, preclinical support is available for most of the HAs, as well as clinical evidence (particularly for Hyalgan) using arthroscopy, microscopy, and blinded morphologic assessments and weight-bearing radiographs for assessing joint space narrowing.[20] Intra-articular HAs may also possibly be chondroprotective early in the development of OA.
However, additional studies would seem to be warranted to further explore the ability of HAs to intervene in the disease processes associated with OA. Certainly, a single product with symptomatic and disease-modifying characteristics, even if only in some patient populations, would be a valuable option in the management of knee OA.
Other Treatments
Pulsed electromagnetic field stimulation
A pulsed electromagnetic field stimulation device (Bionicare) has been FDA-approved for use in patients with knee OA. Pulsed electromagnetic field stimulation is believed to act at the level of hyaline cartilage by maintaining proteoglycan composition of chondrocytes via down-regulation of its turnover.[21] One published multicenter, double-blind, randomized, placebo controlled, 4-week trial in 78 patients with knee OA found improved pain and function in patients who were treated with the device.[22]
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation (TENS) may be another treatment option for pain relief. To date, however, there is limited evidence suggesting that this method would be beneficial for some patients.[23]
Acupuncture
Acupuncture is becoming a more frequently utilized option in treating pain and physical dysfunction associated with osteoarthritis. There is some support in the literature for its use. For example, a review article of randomized, controlled trials found a significant decrease in pain after acupuncture in comparison with the amount of pain persisting after control treatments.[24]
Surgical Intervention
Surgical intervention for osteoarthritis (OA) may be indicated. Types of procedures vary according to the site and the degree of involvement.
Surgical interventions for OA of the knee include the following:
• Arthroscopic lavage - Using a saline lavage to wash out the joint
• Joint realignment (realignment osteotomy)
• Joint fusion (arthrodesis) - Surgically fusing the joint to eliminate motion
• Joint replacement (arthroplasty)
Surgical interventions for OA of the hip include the following:
• Joint realignment (realignment osteotomy)
• Joint fusion (arthrodesis) - Surgically fusing the joint to eliminate motion
• Joint replacement (arthroplasty)
Hip replacements generally are classified as either hemiarthroplasty (ie, replacement of the femoral side of the hip joint, while leaving the patient's acetabulum intact) or total hip arthroplasty (replacement of the femoral side of the hip joint and the acetabulum).
Further classification often involves specification of the specific hardware used (eg, unipolar prosthesis, bipolar prosthesis) and whether or not cement is used to hold the hardware in place.
The prognosis is good for patients with osteoarthritis who have undergone joint replacement. The prosthesis may need revision 10-15 years after its installation, depending on the patient's activity level.
Deterrence and Prevention
The prevention of osteoarthritis (OA) is a controversial topic; however, it is believed that maintaining ideal body weight lessens the probability of developing OA. This appears to be particularly true for weight-bearing joints (ie, hips, knees) in women. A cross-sectional retrospective analysis concluded that those with a higher risk for worse knee OA symptoms included women and persons with a higher body mass index.[25]
Some also believe that an adequate intake of vitamins C and D can help to lessen the probability of developing OA.
A small study from England suggested that a course of NSAIDs taken after a traumatic event seems to reduce the incidence of posttraumatic OA.
Treating Osteoarthritis With Antidepressants?
Leslie Citrome, MD, MPH
Posted: 02/21/2012
Duloxetine Added to Oral Nonsteroidal Anti-inflammatory Drugs for Treatment of Knee Pain Due to Osteoarthritis: Results of a Randomized, Double-Blind, Placebo-Controlled Trial
Frakes EP, Risser RC, Ball TD, Hochberg MC, Wohlreich MM Curr Med Res Opin. 2011;27:2361-2372
Study Summary
In a randomized, double-blind, flexible-dose study of duloxetine 60/120 mg/day that enrolled 524 adult outpatients (mean age, 61 years) who had persistent moderate pain due to osteoarthritis of the knee, despite optimized therapy with oral nonsteroidal anti-inflammatory drugs, duloxetine-treated patients had significantly greater pain reduction than placebo recipients. Moreover, at week 8, duloxetine-treated patients had significant improvements in physical function and Patient Global Impression of Improvement scores. Finally, significantly more duloxetine recipients than placebo recipients reported nausea, dry mouth, constipation, fatigue, and decreased appetite, and discontinuation due to adverse events occurred more commonly in the duloxetine group than the placebo group.
Viewpoint
Antidepressant treatments have long been used to manage pain syndromes. Duloxetine is approved by the US Food and Drug Administration for chronic musculoskeletal pain, including osteoarthritis. The mechanism of action is thought to be related to the amelioration of central pain pathway dysfunction.
It is common for patients to receive a combination of medications for osteoarthritic pain. In this study, 40 of 264 patients (15.2%) receiving adjunctive duloxetine vs 23 of 260 patients (8.8%) receiving adjunctive placebo discontinued therapy because of an adverse event, for a number needed to harm of 16 (95% CI, 9-130). However, moderate improvement in pain (defined by ≥ 30% improvement in the diary-based measure of pain severity) was observed in 139 of 259 patients (53.7%) in the duloxetine group and 86 of 255 patients (33.7%) in the placebo group, for a number needed to treat of 6 (95% CI, 4-9). Although the study was short, it provides a signal that adjunctive duloxetine (and perhaps other antidepressants with similar mechanisms of action on serotonin and norepinephrine receptors) may be useful to consider when treating osteoarthritic pain.
Abstract
Medscape Psychiatry © 2012 WebMD, LLC
What is the Effect of Physical Activity on the Knee Joint?
A Systematic Review
Donna M. Urquhart; Jephtah F. L. Tobing; Fahad S. Hanna; Patricia Berry; Anita E. Wluka; Changhai Ding; Flavia M. Cicuttini
Abstract and Introduction
Abstract
Purpose: Although several studies have examined the relationship between physical activity and knee osteoarthritis, the effect of physical activity on knee joint health is unclear. The aim of this systematic review was to examine the relationships between physical activity and individual joint structures at the knee. Methods: Computer-aided searches were conducted up until November 2008, and the reference lists of key articles were examined. The methodological quality of selected studies was assessed based on established criteria, and a best-evidence synthesis was used to summarize the results. Results: We found that the relationships between physical activity and individual joint structures at the knee differ. There was strong evidence for a positive association between physical activity and tibiofemoral osteophytes. However, we also found strong evidence for the absence of a relationship between physical activity and joint space narrowing, a surrogate method of assessing cartilage. Moreover, there was limited evidence from magnetic resonance imaging studies for a positive relationship between physical activity and cartilage volume and strong evidence for an inverse relationship between physical activity and cartilage defects. Conclusions: This systematic review found that knee structures are affected differently by physical activity. Although physical activity is associated with an increase in radiographic osteophytes, there was no related increase in joint space narrowing, rather emerging evidence of an associated increase in cartilage volume and decrease in cartilage defects on magnetic resonance imaging. Given that optimizing cartilage health is important in preventing osteoarthritis, these findings indicate that physical activity is beneficial, rather than detrimental, to joint health.
Introduction
The promotion of physical activity is a major public health initiative in western countries worldwide. It is well recognized that physical activity is beneficial in the management of numerous major health problems, including cardiovascular disease, mental illness, and obesity.[31,43] However, the influence of physical activity on the development and progression of osteoarthritis (OA), particularly on weight-bearing joints such as the knee, is unclear. Given the prevalence of OA is predicted to increase in the coming decades and physical activity is being highly promoted,[48] it is important that we understand the effect of physical activity on the health of the knee joint.
Although a large number of epidemiological studies have examined the relationship between physical activity and knee OA, the results are conflicting. Not only is there evidence to suggest that physical activity is detrimental to the knee joint[12,40] but studies have also reported physical activity to have no effect[17,27] and even be beneficial to joint health.[13,36] A previous systematic review by Vignon et al.[45] concluded that sport and recreational activities are risk factors for knee OA and that the risk correlates with the intensity and duration of exposure. Although this systematic review investigated a broad range of different types of activity, including daily life, exercises, sports, and occupational activities, only the results of six studies that examined sports activity were retained in the review after evaluation.
Moreover, although the knee joint is a complex, synovial joint consisting of a variety of different structures, and epidemiological studies have assessed the effect of physical activity on osteophytes,[26,33] joint space width (as a surrogate measure of cartilage thickness),[27,41,42] and subchrondral bone,[46] no systematic review has summarized the effect of physical activity on individual joint structures. Given that previous studies have reported the development of osteophytes with physical activity, but no effect on joint space narrowing,[40] it may be hypothesized that physical activity may have different effects on structures within the knee joint. The aim of this systematic review was to examine the effect of physical activity on the health of specific joint structures within the knee joint.
Best-evidence Synthesis
If all studies in the review were collectively examined, we would conclude that there is conflicting evidence for the relationship between physical activity and knee OA. However, if we consider the relationship between physical activity and individual joint structures, we conclude that:
• there is strong evidence (from multiple high-quality cohort studies) that there is a positive relationship between osteophytes and physical activity;
• there is strong evidence (from multiple high-quality cohort studies) that there is no relationship between joint space narrowing, as a surrogate for cartilage thickness, and physical activity;
• there is limited evidence (from a cohort study and two cross-sectional studies) that there is a positive relationship between cartilage volume and physical activity; and
there is strong evidence (from multiple high-quality cohort studies) that there is an inverse relationship between cartilage defects and physical activity.
In summary, this review found that the relationship between physical activity and specific knee structures differed, with strong evidence for a positive relationship between physical activity and tibiofemoral osteophytes, absence of an association between physical activity and joint space narrowing, and strong evidence for an inverse relationship between physical activity and cartilage defects. These findings highlight the need to examine the effect of physical activity on individual structures of the knee joint rather than the joint as a whole. Moreover, these findings suggest that physical activity may not have a detrimental effect on the knee joint but may be beneficial to joint health.
Identification of a Central Role for Complement in Osteoarthritis
Wang Q, Rozelle AL, Lepus CM, et al Nat Med. 2011;17:1674-1679
Osteoarthritis
Traditionally, osteoarthritis (OA) was believed to be a noninflammatory or minimally inflammatory disease; however, growing data suggest that inflammation may play a key role in the pathogenesis of OA.[1] Wang and colleagues explored the role of complement in the pathogenesis of OA in both human and murine disease.
Study Summary
Using synovial fluid and tissue samples from human knees and several analytic methodologies, these investigators found that complement proteins and complement factors were expressed aberrantly in patients with OA (including early disease) compared with healthy controls. Subsequently, in experiments in murine models of OA, they demonstrated that complement is a critical component of OA development and progression and that complement deficiency leads to reduced histologic evidence of OA as well as improved functional outcomes (measured by gait analyses). They further demonstrated that one of the mechanisms by which complement mediates damage in OA is through the effect of terminal complement components C5-9 that form the membrane attack complex (MAC), with MAC leading directly to chondrocyte damage and upregulation of other inflammatory pathways in the joint. Wang and colleagues concluded that the complement cascade is a crucial element in the pathogenesis of OA and that targeting the complement system may lead to disease-modifying therapy for OA
Inexpensive Footwear Reduces Joint Loading in Women With Knee Osteoarthritis
NEW YORK (Reuters Health) Dec 28 - An inexpensive pair of shoes reduces joint loading during stair descent, compared with heeled shoes, in women with knee osteoarthritis, researchers from Brazil report.
Reduction in knee loading is one of the most important therapeutic objectives in treating osteoarthritis, as overloading increases the risk that the joint disease will worsen, the researchers noted online November 10 in Arthritis Care & Research.
Dr. Isabel C. N. Sacco and colleagues from University of Sao Paolo analyzed the effect of inexpensive Moleca brand footwear on knee adduction moment (KAM) during stair descent in 34 elderly women with and without knee osteoarthritis. The shoes resemble ballet flats, but with rubber soles.
The authors say they had "no professional relationships with the manufacturer of the footwear...and no conflict of interest."
During the forward continuance phase of the descent, when the control group wore the Moleca flats, the KAM was 48.1% lower than with heeled shoes and 39.1% lower compared to being barefoot. During the propulsion phase, the KAM was 18.3% lower with inexpensive shoes than with either the heeled or barefoot conditions.
In the osteoarthritis group, during the forward continuance phase, wearing the Moleca shoes brought the KAM down by 10.4% compared to wearing heels, but there was no difference in KAM when the women wore Moleca or went barefoot. Similarly, during the propulsion phase, KAM was 9.2% lower with the inexpensive shoes than with heeled shoes but no different from being barefoot.
The non-normalized knee adduction impulse, on the other hand, was significantly lower with the inexpensive shoes than with heeled shoes or barefoot in both groups.
"In addition to the mechanical advantages of the Moleca (inexpensive shoe brand) in generating lower KAM peaks than those generated by the modern heeled shoes and similar to the barefoot condition, this flexible footwear has already been produced on a large scale in Brazil since 1986, and is usually worn by a large number of elderly people, and costs about US$9," the investigators say. "This fact makes the use of these shoes not only viable but, above all, efficient for the reduction of the loading on the knee joint in elderly women both with and without osteoarthritis."
US$9 may be the price in some countries, but in the UK, the least expensive pair of Moleca shoes on Amazon.com sells for GBP12.95 (about US$20). The brand does not appear to be sold in the U.S.
"Although the results of this study showed evidence of a decrease of instantaneous loading and temporal loading in the knee, these findings were observed only as acute effects," they caution. "Based on these promising results, future studies should investigate the chronic therapeutic effects of this flexible low-cost footwear on lower limb biomechanics, structural integrity of the osteochondral tissue, clinical aspects such as pain and inflammatory recurrences, and functionality in the activities of daily living of patients with knee osteoarthritis."
Osteoarthritis 2012 Treatment Update
Objective. To update the American College of Rheumatology (ACR) 2000 recommendations for hip and knee osteoarthritis (OA) and develop new recommendations for hand OA.
Results. Both “strong” and “conditional” recommendations were made for OA management.
Conclusion. These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines, informed by available evidence, balancing the benefits and harms of both nonpharmacologic and pharmacologic modalities, and incorporating their preferences and values. It is hoped that these recommendations will be utilized by health care providers involved in the management of patients with OA.
In other words, they are boring, but completely official.
Steroid injections and total knee replacements
There is an urban myth among orthopedic surgeons that steroid injections are a cause of infections if a patient has a total knee replacement down the line.
The data suggests otherwise.
An orthopedic surgery medical journal did a study on just this question, and found no problems with the steroid injections. A hotlink is listed here to the article in the National Library of Medicine.
AbstractIntra-articular steroids have been commonly used for the treatment of arthritis. The aim of our study was to discover any relation between deep infections following total knee arthroplasty and intra-articular steroid use before the arthroplasty. We undertook a retrospective matched cohort study. In the study group there were 32 patients with confirmed deep infection following total knee replacement. The control group consisted of 32 patients with no evidence of infection in the knee. There was no significant difference between the numbers of patients who received intra-articular steroid injection between the groups (P=1). We believe that infection following total knee replacement is due to multiple factors and that the use of intra-articular steroids does not alter the incidence of deep infections following total knee arthroplasty.
Of course one should always be suspicious of one specific study, so I looked at all of them. And they all agree. For example, another study on exactly the same question came to exactly the same conclusion.
2009 Aug;16(4):262-4. Epub 2009 Jan 12.
Does intraarticular steroid infiltration increase the rate of infectionin subsequent total knee replacements?Desai A, Ramankutty S,Board T, Raut V.
SourceWrightington Hospital, Wigan, United Kingdom. desaiaravind@yahoo.co.uk
Abstract: Steroid injection into the arthritic joint is a well-known treatment. Its efficacy is well documented. An increase in the incidence of infection secondary to steroid injection has been reported in recent literature. Based on the current literature we carried out a retrospective study to evaluate the incidence of infection in primary total knee arthroplasty as a result of previous steroid infiltration into the knee joint. In our study, 440 patients underwent total knee replacement between 1997 and 2005. Only 90 patients had intraarticular steroid injection prior to surgery, of which 45 patients had injection within 1 year prior to surgery. A matched cohort of 180 patients who had total knee replacement without steroid injection was used as control group to compare the infection rate. All patients had at least 1 year follow up. Two cases of superficial infection were noted in the study group and five cases of superficial infection in the control group. No cases of deep infection were noted in either group. Statistical analysis showed no significant difference in incidence of infection in either group (P value 1.0). This study showed no increase in the incidence of infection in patients with total knee arthroplasty with prior steroid injection.
High Tibial Osteotomy and Total knee replacement.
Another urban myth among orthopedic surgeons is that doing a 'high tibial osteotomy' to try and delay the need for a total knee replacement is a bad thing to do.
The idea behind a high tibial osteotomy is to cut a wedge out of the tibia, so that the knee joint gets a chance to wear out some other part of the contact surface. Some orthopedic surgeons like this procedure, because it delays the need for a total knee replacement for many years. Others think it screws up the eventual knee replacement surgery.
And the answer is .....
The article from the orthopedic literature, cited below, shows that high tibial osteotomies can make the final knee surgery a bit more difficult to do, but are a 'good thing'. It just makes the final total knee replacement surgery a little bit more difficult for the surgeon doing the surgery. But would you really want your knees cut open by someone who wasn't up for a little challenge ????
The effect of high tibial osteotomy on the results of total knee arthroplasty: a matched case control study.van Raaij TM, Bakker W, Reijman M, Verhaar JA.
SourceDepartment of Orthopaedics, Erasmus University Medical Centre, Rotterdam, The Netherlands. t.vanraaij@erasmusmc.nl
AbstractBACKGROUND: We performed a matched case control study to assess the effect of prior high tibia valgus producing osteotomy on results and complications of total knee arthroplasty (TKA).
METHODS: From 1996 until 2003 356 patients underwent all cemented primary total knee replacement in our institution. Twelve patients with a history of 14 HTO were identified and matched to a control group of 12 patients with 14 primary TKA without previous HTO. The match was made for gender, age, date of surgery, body mass index, aetiology and type of prosthesis. Clinical and radiographic outcome were evaluated after a median duration of follow-up of 3.7 years (minimum, 2.3 years). The SPSS program was used for statistical analyses.
RESULTS: The index group had more perioperative blood loss and exposure difficulties with one tibial tuberosity osteotomy and three patients with lateral retinacular releases. No such procedures were needed in the control group. Mid-term HSS, KSS and WOMAC scores were less favourable for the index group, but these differences were not significant. The tibial slope of patients with prior HTO was significantly decreased after this procedure. The tibial posterior inclination angle was corrected during knee replacement but posterior inclination was significantly less compared to the control group. No deep infection or knee component loosening were seen in the group with prior HTO.
CONCLUSION: We conclude that TKA after HTO seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no HTO previously.
Special Shoes for Sore Knees
NEW YORK (Reuters Health) Dec 28 - An inexpensive pair of shoes reduces joint loading during stair descent, compared with heeled shoes, in women with knee osteoarthritis, researchers from Brazil report.
Reduction in knee loading is one of the most important therapeutic objectives in treating osteoarthritis, as overloading increases the risk that the joint disease will worsen, the researchers noted online November 10 in Arthritis Care & Research.
Dr. Isabel C. N. Sacco and colleagues from University of Sao Paolo analyzed the effect of inexpensive Moleca brand footwear on knee adduction moment (KAM) during stair descent in 34 elderly women with and without knee osteoarthritis. The shoes resemble ballet flats, but with rubber soles.
The authors say they had "no professional relationships with the manufacturer of the footwear...and no conflict of interest."
During the forward continuance phase of the descent, when the control group wore the Moleca flats, the KAM was 48.1% lower than with heeled shoes and 39.1% lower compared to being barefoot. During the propulsion phase, the KAM was 18.3% lower with inexpensive shoes than with either the heeled or barefoot conditions.
In the osteoarthritis group, during the forward continuance phase, wearing the Moleca shoes brought the KAM down by 10.4% compared to wearing heels, but there was no difference in KAM when the women wore Moleca or went barefoot. Similarly, during the propulsion phase, KAM was 9.2% lower with the inexpensive shoes than with heeled shoes but no different from being barefoot.
The non-normalized knee adduction impulse, on the other hand, was significantly lower with the inexpensive shoes than with heeled shoes or barefoot in both groups.
"In addition to the mechanical advantages of the Moleca (inexpensive shoe brand) in generating lower KAM peaks than those generated by the modern heeled shoes and similar to the barefoot condition, this flexible footwear has already been produced on a large scale in Brazil since 1986, and is usually worn by a large number of elderly people, and costs about US$9," the investigators say. "This fact makes the use of these shoes not only viable but, above all, efficient for the reduction of the loading on the knee joint in elderly women both with and without osteoarthritis."
US$9 may be the price in some countries, but in the UK, the least expensive pair of Moleca shoes on Amazon.com sells for GBP12.95 (about US$20). The brand does not appear to be sold in the U.S.
"Although the results of this study showed evidence of a decrease of instantaneous loading and temporal loading in the knee, these findings were observed only as acute effects," they caution. "Based on these promising results, future studies should investigate the chronic therapeutic effects of this flexible low-cost footwear on lower limb biomechanics, structural integrity of the osteochondral tissue, clinical aspects such as pain and inflammatory recurrences, and functionality in the activities of daily living of patients with knee osteoarthritis."
Dr. Patrick Nesbitt, Vancouver, Canada ............ docnesbitt@hotmail.com
Osteoarthritis (OA) is a chronic disease process affecting synovial joints, particularly large weight-bearing joints. OA is particularly common in older patients but can occur in younger patients either through a genetic mechanism or, more commonly, because of previous joint trauma.
Rehabilitation for patients with OA can be provided in various forms, including the following:
1) Medication
2) Physical therapy
3) Occupational therapy
4) Intra-articular injections
5) Surgery
1) Medication for Osteoarthritis
The American College of Rheumatology issued the following pharmacologic guidelines for the treatment of osteoarthritis of the hip and knee[10] :
• Up to 4 g/d of acetaminophen ( which is the same thing as tylenol ) can be administered; this is the preferred initial treatment for patients with OA. It is cheap, effective, doesn't require doctors visits, cuts down pain, and slows progression of the arthritis.
• Topical anti-inflammatory medications or capsaicin can be administered only for knee OA. My favorite topical ( rub on ) anti-inflammatory is a drug called diclofenac. This is sold by the trade name Voltaren over the counter, but I prefer to use much higher prescription strengths, and it works great. Capsaicin is related to pepper spray, but also has a wonderful pain killing property if you know how to use it properly !
• Low-dose nonsteroidal anti-inflammatory drugs(NSAIDs) (ie, analgesic doses) or nonacetylated salicylates may be indicated. Some of these, such as ibuprofen and naproxen, can also be over the counter. Best of all, they are in a different drug group that acetominophen, so you can combine them and get additive beneficial effects without getting additive side effects. ( they all kill pain, but to much ibuprofen is bad for your stomach, whereas too much tylenol is bad for your liver. )
• Administer full-dose NSAIDs with misoprostol if risk factors for upper gastrointestinal bleeding are present
• Arthrocentesis with corticosteroid injection can be used only for knee OA if effusion is present
• Narcotic analgesic use may be indicated in cases of severe pain
Other medications have been investigated in OA (eg, tramadol, cyclooxygenase (COX)-2 inhibitors, dietary supplements). Many medications have been tried and are in use, but research on their effectiveness is lacking.
Glucosamine and chondroitin sulfate, currently being studied by National Institutes of Health (NIH) in double-blind trials, have been used in Europe for many years. S-adenosylmethionine (SAM-e [pronounced "sammy"]) is a European supplement receiving considerable attention in the United States.
In a randomized, controlled study by Petersen et al of patients with knee OA, neither ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), nor glucosamine administration, improved muscle mass gain during a 12-week strength-training program. However, both did improve maximal muscle strength gain in comparison with the placebo treatment, but the benefits were not significant enough to advocate taking NSAIDs or glucosamine.[11]
Chondroprotective drugs (ie, matrix metalloproteinase [MMP] inhibitors, growth factors) are being tested as disease-modifying drugs in the management of OA. Although a number of agents are currently under study, no agent has been shown to have a disease-modifying effect in humans.[10]
In a randomized, double-blind, multicenter study, etodolac plus acetaminophen was significantly more effective than etodolac alone for osteoarthritic flare-ups. Measurements of reduced pain intensity, achievement of pain relief, and symptom resolution (eg, decreased morning stiffness, inflammation) showed significantly greater improvement with the combination compared with etodolac alone.[12]
2) Physical Therapy for Osteoarthritis
Lifestyle modification, particularly exercise and weight reduction, is a core component of the management of osteoarthritis (OA).[1, 2, 3] A program of physical therapy should emphasize the importance of strengthening all muscles that cross the given joint affected by OA.
Most research focuses on quadriceps strengthening in knee OA. Also important are stretching exercises, which increase range of motion. The importance of aerobic conditioning, particularly low-impact exercises (if OA affects weight-bearing joints), should be stressed. Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful. Certain studies also indicate that a home exercise program for patients with OA of the knee provides an important benefit.
In a study of patients with knee osteoarthritis, Jan et al found that, in most respects, non–weight-bearing exercise was as therapeutically effective as weight-bearing exercise.[4] After an 8-week program, weight-bearing and non–weight-bearing exercise produced equally significant improvements in function, walking speed, and muscle torque. However, patients in the weight-bearing group demonstrated greater improvement in position sense, which may help with complex walking tasks, such as walking on a spongy surface.
In terms of reducing osteoarthritis-related knee pain, Chaipinyo and Karoonsupcharoen found no significant difference between home-based strength training and home-based balance training.[5]However, more improvement in knee-related quality of life was noted in the strength-training group than in the balance-training group.
In a review of patient adherence to exercise, Marks and Allegrante concluded that interventions to enhance self-efficacy, social support, and skills in the long-term monitoring of progress are necessary to foster exercise adherence in people with OA.[6]
Results from a study by Wang et al suggested that tai chi is a potentially effective treatment for pain associated with osteoarthritis of the knee.[7] In a prospective, single-blind, randomized, controlled trial, 40 patients with symptomatic tibiofemoral osteoarthritis who performed 60 minutes of tai chi twice weekly for 12 weeks experienced significantly greater pain reduction than did control subjects who underwent 12 weeks of wellness education and stretching.
The tai chi cohort also had significantly better Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function scores, patient and physician global visual analog scale scores, chair stand time, Center for Epidemiologic Studies Depression Scale scores, self-efficacy scores, and Short Form 36 physical component summaries.
The use of assistive devices for ambulation and for activities of daily living may be indicated. Braces and appropriate footwear may also be of some use, although a 12-month study of 200 people aged 50 years and older with medial knee OA reported that no symptomatic or structural difference was found for those who wore lateral wedge insoles compared with flat control insoles inside their footwear.[8] A cane can be used in the opposite hand for OA of the hip, and a cane in the hand of comfort may be helpful for OA of the knee. The patient can be taught joint-protection and energy-conservation techniques. Other physical therapy modalities include electrotherapy and thermotherapy.
In a study of 91 patients with hip osteoarthritis, Wright et al sought to identify a set of prognostic factors that maximize the accuracy of identifying patients likely to have a favorable response to physical therapy. Five baseline variables (unilateral hip pain, age 58 years or younger, pain greater or equal to 6 out of 10 on a numeric pain rating scale, 40-meter self-paced walk test time less than 25.9 s, and duration of symptoms less than or equal to 1 year) were in the final model. Failure to show 1 of the 5 variables decreased the posttest probability of responding favorably to physical therapy from 32% to < 1%; having at least 2 variables increased the physical therapy success from 32% to 65%; and having 3 or more variables increased the success to 99% or higher.[9] This study is the first step in developing baseline variables; further validation studies are needed before this can be used in practice.
3) Occupational Therapy for Osteoarthritis
Evaluation of how well the patient performs his/her activities of daily living, as well as retraining of the patient, can be assisted by the occupational therapist. Emphasize joint-protection techniques. Hand splinting, especially of the first carpometacarpal joint, may be indicated.
4) Intra-Articular Injections
Steroid injections
Intra-articular steroid injections may provide pain relief and have an anti-inflammatory effect on the affected joint in OA. Such injections generally result in a clinically and statistically significant reduction in osteoarthritic knee pain beginning as soon as 1 week after injection. The effect may last, on average, anywhere from 4-6 weeks per injection, but this benefit is unlikely to continue beyond that time frame.[13] One randomized, placebo-controlled study confirmed the effectiveness of corticosteroid injection in the treatment of hip OA, with benefits often lasting up to 3 months.[14]
Some controversial evidence exists regarding frequent steroid injections and subsequent damage to cartilage (chondrodegeneration). Therefore, usually no more than 3 injections are recommended per year in any 1 osteoarthritic joint.
Viscosupplementation
Intra-articular injection of sodium hyaluronate (ie, hyaluronic acid [HA], hyaluronan), also referred to as viscosupplementation, has been shown to be safe and effective for the symptomatic relief of knee OA. This topic has been reviewed in depth elsewhere.[15] The largest meta-analysis of intra-articular HA injection, using 76 controlled clinical studies (and subsequently updated by the Cochrane Collaboration), concluded that this therapy is safe and effective in patients with knee OA.[16]
To date, the US Food and Drug Administration (FDA) has approved 5 intra-articular HAs for the treatment of pain associated with knee OA. These include naturally extracted, non–cross-linked sodium hyaluronate products (Hyalgan,[17] Supartz, Orthovisc, Euflexxa) and 1 cross-linked sodium hyaluronate product known as hylan G-F 20 (Synvisc). Euflexxa is the only product derived from a fermentation process (Streptococcus), while the source material for the other 4 products is chicken combs. At present, no distinct advantage or disadvantage has been associated with either source of HA production.
Some differences between the viscosupplements do exist in the FDA-approved prescribing information. For example, Hyalgan and Synvisc have labeling that establishes their safety for repeat treatment, while other products have the precautionary statement that "the safety and efficacy of repeat treatment has not been established."
The HA class in general has demonstrated a very favorable safety profile for the chronic pain management of knee OA. The most common adverse event is injection-site pain.
While any intra-articular injection (all HA products and steroids) may elicit an inflammatory response and possible effusion, a clinically distinct acute inflammatory side effect (ie, severe acute inflammatory reaction [SAIR] or HA-associated intra-articular pseudosepsis) has been described. However, preclinical and clinical data provide compelling evidence that this reaction is limited to the cross-linked hylan G-F 20 product and may have an immunologic mechanism of action.
Molecular weight per se has not been found to correlate with efficacy (eg, higher or lower viscosity does not equate with better or worse clinical outcomes).
Interestingly, the duration of residence of an intra-articular injection (days) cannot explain the prolonged clinical benefit (months), and accordingly, subsequent biological mechanisms have also been proposed that may play an important role in the clinical benefit. The combination of quadriceps strengthening and HAs may have a synergistic effect on pain.[18]
In the United States, HAs are classified as medical devices rather than as drugs. Although the exact mechanisms of action through which they provide symptomatic relief are unknown, several possibilities exist, including direct binding to receptors (CD44 in particular) in the synovium and cartilage that can lead to several biologic activation pathways.
These mechanisms of action can include the increased endogenous production of hyaluronate and aggrecan by the joint, a mechanical barrier to the activation of nociceptors, the inhibition of pain mediators (eg, PGE, bradykinin), an anti-inflammatory effect (eg, inhibition of proinflammatory cytokine activity, inhibition of inflammatory cell function), a beneficial effect on immune cells, an antioxidant effect, and the restoration of the synovial fluid's physical characteristics (viscoelasticity). Viscosity can help to facilitate the cushioning and lubricating characteristics of the joint during slow movements, while elasticity blunts deforming forces (compression and resistance to shear forces) during rapid motions.
A study Waddell and colleagues hypothesized that hyaluronan inhibits interleukin-1beta–induced metalloproteinase production from osteoarthritic synovial tissue.[19]
As reviewed by Goldberg and Buckwalter, preclinical support is available for most of the HAs, as well as clinical evidence (particularly for Hyalgan) using arthroscopy, microscopy, and blinded morphologic assessments and weight-bearing radiographs for assessing joint space narrowing.[20] Intra-articular HAs may also possibly be chondroprotective early in the development of OA.
However, additional studies would seem to be warranted to further explore the ability of HAs to intervene in the disease processes associated with OA. Certainly, a single product with symptomatic and disease-modifying characteristics, even if only in some patient populations, would be a valuable option in the management of knee OA.
Other Treatments
Pulsed electromagnetic field stimulation
A pulsed electromagnetic field stimulation device (Bionicare) has been FDA-approved for use in patients with knee OA. Pulsed electromagnetic field stimulation is believed to act at the level of hyaline cartilage by maintaining proteoglycan composition of chondrocytes via down-regulation of its turnover.[21] One published multicenter, double-blind, randomized, placebo controlled, 4-week trial in 78 patients with knee OA found improved pain and function in patients who were treated with the device.[22]
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation (TENS) may be another treatment option for pain relief. To date, however, there is limited evidence suggesting that this method would be beneficial for some patients.[23]
Acupuncture
Acupuncture is becoming a more frequently utilized option in treating pain and physical dysfunction associated with osteoarthritis. There is some support in the literature for its use. For example, a review article of randomized, controlled trials found a significant decrease in pain after acupuncture in comparison with the amount of pain persisting after control treatments.[24]
Surgical Intervention
Surgical intervention for osteoarthritis (OA) may be indicated. Types of procedures vary according to the site and the degree of involvement.
Surgical interventions for OA of the knee include the following:
• Arthroscopic lavage - Using a saline lavage to wash out the joint
• Joint realignment (realignment osteotomy)
• Joint fusion (arthrodesis) - Surgically fusing the joint to eliminate motion
• Joint replacement (arthroplasty)
Surgical interventions for OA of the hip include the following:
• Joint realignment (realignment osteotomy)
• Joint fusion (arthrodesis) - Surgically fusing the joint to eliminate motion
• Joint replacement (arthroplasty)
Hip replacements generally are classified as either hemiarthroplasty (ie, replacement of the femoral side of the hip joint, while leaving the patient's acetabulum intact) or total hip arthroplasty (replacement of the femoral side of the hip joint and the acetabulum).
Further classification often involves specification of the specific hardware used (eg, unipolar prosthesis, bipolar prosthesis) and whether or not cement is used to hold the hardware in place.
The prognosis is good for patients with osteoarthritis who have undergone joint replacement. The prosthesis may need revision 10-15 years after its installation, depending on the patient's activity level.
Deterrence and Prevention
The prevention of osteoarthritis (OA) is a controversial topic; however, it is believed that maintaining ideal body weight lessens the probability of developing OA. This appears to be particularly true for weight-bearing joints (ie, hips, knees) in women. A cross-sectional retrospective analysis concluded that those with a higher risk for worse knee OA symptoms included women and persons with a higher body mass index.[25]
Some also believe that an adequate intake of vitamins C and D can help to lessen the probability of developing OA.
A small study from England suggested that a course of NSAIDs taken after a traumatic event seems to reduce the incidence of posttraumatic OA.
Treating Osteoarthritis With Antidepressants?
Leslie Citrome, MD, MPH
Posted: 02/21/2012
Duloxetine Added to Oral Nonsteroidal Anti-inflammatory Drugs for Treatment of Knee Pain Due to Osteoarthritis: Results of a Randomized, Double-Blind, Placebo-Controlled Trial
Frakes EP, Risser RC, Ball TD, Hochberg MC, Wohlreich MM Curr Med Res Opin. 2011;27:2361-2372
Study Summary
In a randomized, double-blind, flexible-dose study of duloxetine 60/120 mg/day that enrolled 524 adult outpatients (mean age, 61 years) who had persistent moderate pain due to osteoarthritis of the knee, despite optimized therapy with oral nonsteroidal anti-inflammatory drugs, duloxetine-treated patients had significantly greater pain reduction than placebo recipients. Moreover, at week 8, duloxetine-treated patients had significant improvements in physical function and Patient Global Impression of Improvement scores. Finally, significantly more duloxetine recipients than placebo recipients reported nausea, dry mouth, constipation, fatigue, and decreased appetite, and discontinuation due to adverse events occurred more commonly in the duloxetine group than the placebo group.
Viewpoint
Antidepressant treatments have long been used to manage pain syndromes. Duloxetine is approved by the US Food and Drug Administration for chronic musculoskeletal pain, including osteoarthritis. The mechanism of action is thought to be related to the amelioration of central pain pathway dysfunction.
It is common for patients to receive a combination of medications for osteoarthritic pain. In this study, 40 of 264 patients (15.2%) receiving adjunctive duloxetine vs 23 of 260 patients (8.8%) receiving adjunctive placebo discontinued therapy because of an adverse event, for a number needed to harm of 16 (95% CI, 9-130). However, moderate improvement in pain (defined by ≥ 30% improvement in the diary-based measure of pain severity) was observed in 139 of 259 patients (53.7%) in the duloxetine group and 86 of 255 patients (33.7%) in the placebo group, for a number needed to treat of 6 (95% CI, 4-9). Although the study was short, it provides a signal that adjunctive duloxetine (and perhaps other antidepressants with similar mechanisms of action on serotonin and norepinephrine receptors) may be useful to consider when treating osteoarthritic pain.
Abstract
Medscape Psychiatry © 2012 WebMD, LLC
What is the Effect of Physical Activity on the Knee Joint?
A Systematic Review
Donna M. Urquhart; Jephtah F. L. Tobing; Fahad S. Hanna; Patricia Berry; Anita E. Wluka; Changhai Ding; Flavia M. Cicuttini
Abstract and Introduction
Abstract
Purpose: Although several studies have examined the relationship between physical activity and knee osteoarthritis, the effect of physical activity on knee joint health is unclear. The aim of this systematic review was to examine the relationships between physical activity and individual joint structures at the knee. Methods: Computer-aided searches were conducted up until November 2008, and the reference lists of key articles were examined. The methodological quality of selected studies was assessed based on established criteria, and a best-evidence synthesis was used to summarize the results. Results: We found that the relationships between physical activity and individual joint structures at the knee differ. There was strong evidence for a positive association between physical activity and tibiofemoral osteophytes. However, we also found strong evidence for the absence of a relationship between physical activity and joint space narrowing, a surrogate method of assessing cartilage. Moreover, there was limited evidence from magnetic resonance imaging studies for a positive relationship between physical activity and cartilage volume and strong evidence for an inverse relationship between physical activity and cartilage defects. Conclusions: This systematic review found that knee structures are affected differently by physical activity. Although physical activity is associated with an increase in radiographic osteophytes, there was no related increase in joint space narrowing, rather emerging evidence of an associated increase in cartilage volume and decrease in cartilage defects on magnetic resonance imaging. Given that optimizing cartilage health is important in preventing osteoarthritis, these findings indicate that physical activity is beneficial, rather than detrimental, to joint health.
Introduction
The promotion of physical activity is a major public health initiative in western countries worldwide. It is well recognized that physical activity is beneficial in the management of numerous major health problems, including cardiovascular disease, mental illness, and obesity.[31,43] However, the influence of physical activity on the development and progression of osteoarthritis (OA), particularly on weight-bearing joints such as the knee, is unclear. Given the prevalence of OA is predicted to increase in the coming decades and physical activity is being highly promoted,[48] it is important that we understand the effect of physical activity on the health of the knee joint.
Although a large number of epidemiological studies have examined the relationship between physical activity and knee OA, the results are conflicting. Not only is there evidence to suggest that physical activity is detrimental to the knee joint[12,40] but studies have also reported physical activity to have no effect[17,27] and even be beneficial to joint health.[13,36] A previous systematic review by Vignon et al.[45] concluded that sport and recreational activities are risk factors for knee OA and that the risk correlates with the intensity and duration of exposure. Although this systematic review investigated a broad range of different types of activity, including daily life, exercises, sports, and occupational activities, only the results of six studies that examined sports activity were retained in the review after evaluation.
Moreover, although the knee joint is a complex, synovial joint consisting of a variety of different structures, and epidemiological studies have assessed the effect of physical activity on osteophytes,[26,33] joint space width (as a surrogate measure of cartilage thickness),[27,41,42] and subchrondral bone,[46] no systematic review has summarized the effect of physical activity on individual joint structures. Given that previous studies have reported the development of osteophytes with physical activity, but no effect on joint space narrowing,[40] it may be hypothesized that physical activity may have different effects on structures within the knee joint. The aim of this systematic review was to examine the effect of physical activity on the health of specific joint structures within the knee joint.
Best-evidence Synthesis
If all studies in the review were collectively examined, we would conclude that there is conflicting evidence for the relationship between physical activity and knee OA. However, if we consider the relationship between physical activity and individual joint structures, we conclude that:
• there is strong evidence (from multiple high-quality cohort studies) that there is a positive relationship between osteophytes and physical activity;
• there is strong evidence (from multiple high-quality cohort studies) that there is no relationship between joint space narrowing, as a surrogate for cartilage thickness, and physical activity;
• there is limited evidence (from a cohort study and two cross-sectional studies) that there is a positive relationship between cartilage volume and physical activity; and
there is strong evidence (from multiple high-quality cohort studies) that there is an inverse relationship between cartilage defects and physical activity.
In summary, this review found that the relationship between physical activity and specific knee structures differed, with strong evidence for a positive relationship between physical activity and tibiofemoral osteophytes, absence of an association between physical activity and joint space narrowing, and strong evidence for an inverse relationship between physical activity and cartilage defects. These findings highlight the need to examine the effect of physical activity on individual structures of the knee joint rather than the joint as a whole. Moreover, these findings suggest that physical activity may not have a detrimental effect on the knee joint but may be beneficial to joint health.
Identification of a Central Role for Complement in Osteoarthritis
Wang Q, Rozelle AL, Lepus CM, et al Nat Med. 2011;17:1674-1679
Osteoarthritis
Traditionally, osteoarthritis (OA) was believed to be a noninflammatory or minimally inflammatory disease; however, growing data suggest that inflammation may play a key role in the pathogenesis of OA.[1] Wang and colleagues explored the role of complement in the pathogenesis of OA in both human and murine disease.
Study Summary
Using synovial fluid and tissue samples from human knees and several analytic methodologies, these investigators found that complement proteins and complement factors were expressed aberrantly in patients with OA (including early disease) compared with healthy controls. Subsequently, in experiments in murine models of OA, they demonstrated that complement is a critical component of OA development and progression and that complement deficiency leads to reduced histologic evidence of OA as well as improved functional outcomes (measured by gait analyses). They further demonstrated that one of the mechanisms by which complement mediates damage in OA is through the effect of terminal complement components C5-9 that form the membrane attack complex (MAC), with MAC leading directly to chondrocyte damage and upregulation of other inflammatory pathways in the joint. Wang and colleagues concluded that the complement cascade is a crucial element in the pathogenesis of OA and that targeting the complement system may lead to disease-modifying therapy for OA
Inexpensive Footwear Reduces Joint Loading in Women With Knee Osteoarthritis
NEW YORK (Reuters Health) Dec 28 - An inexpensive pair of shoes reduces joint loading during stair descent, compared with heeled shoes, in women with knee osteoarthritis, researchers from Brazil report.
Reduction in knee loading is one of the most important therapeutic objectives in treating osteoarthritis, as overloading increases the risk that the joint disease will worsen, the researchers noted online November 10 in Arthritis Care & Research.
Dr. Isabel C. N. Sacco and colleagues from University of Sao Paolo analyzed the effect of inexpensive Moleca brand footwear on knee adduction moment (KAM) during stair descent in 34 elderly women with and without knee osteoarthritis. The shoes resemble ballet flats, but with rubber soles.
The authors say they had "no professional relationships with the manufacturer of the footwear...and no conflict of interest."
During the forward continuance phase of the descent, when the control group wore the Moleca flats, the KAM was 48.1% lower than with heeled shoes and 39.1% lower compared to being barefoot. During the propulsion phase, the KAM was 18.3% lower with inexpensive shoes than with either the heeled or barefoot conditions.
In the osteoarthritis group, during the forward continuance phase, wearing the Moleca shoes brought the KAM down by 10.4% compared to wearing heels, but there was no difference in KAM when the women wore Moleca or went barefoot. Similarly, during the propulsion phase, KAM was 9.2% lower with the inexpensive shoes than with heeled shoes but no different from being barefoot.
The non-normalized knee adduction impulse, on the other hand, was significantly lower with the inexpensive shoes than with heeled shoes or barefoot in both groups.
"In addition to the mechanical advantages of the Moleca (inexpensive shoe brand) in generating lower KAM peaks than those generated by the modern heeled shoes and similar to the barefoot condition, this flexible footwear has already been produced on a large scale in Brazil since 1986, and is usually worn by a large number of elderly people, and costs about US$9," the investigators say. "This fact makes the use of these shoes not only viable but, above all, efficient for the reduction of the loading on the knee joint in elderly women both with and without osteoarthritis."
US$9 may be the price in some countries, but in the UK, the least expensive pair of Moleca shoes on Amazon.com sells for GBP12.95 (about US$20). The brand does not appear to be sold in the U.S.
"Although the results of this study showed evidence of a decrease of instantaneous loading and temporal loading in the knee, these findings were observed only as acute effects," they caution. "Based on these promising results, future studies should investigate the chronic therapeutic effects of this flexible low-cost footwear on lower limb biomechanics, structural integrity of the osteochondral tissue, clinical aspects such as pain and inflammatory recurrences, and functionality in the activities of daily living of patients with knee osteoarthritis."
Osteoarthritis 2012 Treatment Update
Objective. To update the American College of Rheumatology (ACR) 2000 recommendations for hip and knee osteoarthritis (OA) and develop new recommendations for hand OA.
Results. Both “strong” and “conditional” recommendations were made for OA management.
- Modalities conditionally recommended for the management of hand OA include instruction in joint protection techniques, provision of assistive devices, use of thermal modalities and trapeziometacarpal joint splints, and use of oral and topical nonsteroidal antiinflammatory drugs NSAIDs), tramadol, and topical capsaicin.
- Nonpharmacologic modalities strongly recommended for the management of knee OA were aerobic, aquatic, and/or resistance exercises as well as weight loss for overweight patients.
- Nonpharmacologic modalities conditionally recommended for knee OA included medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially directed patellar taping, manual therapy, walking aids, thermal agents, tai chi, self management programs, and psychosocial interventions.
- Pharmacologic modalities conditionally recommended for the initial management of patients with knee OA included acetaminophen, oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy.
- Opioid analgesics were strongly recommended in patients who were either not willing to undergo or had contraindications for total joint arthroplasty after having failed medical therapy. Recommendations for hip OA were similar to those for the management of knee OA.
Conclusion. These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines, informed by available evidence, balancing the benefits and harms of both nonpharmacologic and pharmacologic modalities, and incorporating their preferences and values. It is hoped that these recommendations will be utilized by health care providers involved in the management of patients with OA.
In other words, they are boring, but completely official.
Steroid injections and total knee replacements
There is an urban myth among orthopedic surgeons that steroid injections are a cause of infections if a patient has a total knee replacement down the line.
The data suggests otherwise.
An orthopedic surgery medical journal did a study on just this question, and found no problems with the steroid injections. A hotlink is listed here to the article in the National Library of Medicine.
AbstractIntra-articular steroids have been commonly used for the treatment of arthritis. The aim of our study was to discover any relation between deep infections following total knee arthroplasty and intra-articular steroid use before the arthroplasty. We undertook a retrospective matched cohort study. In the study group there were 32 patients with confirmed deep infection following total knee replacement. The control group consisted of 32 patients with no evidence of infection in the knee. There was no significant difference between the numbers of patients who received intra-articular steroid injection between the groups (P=1). We believe that infection following total knee replacement is due to multiple factors and that the use of intra-articular steroids does not alter the incidence of deep infections following total knee arthroplasty.
Of course one should always be suspicious of one specific study, so I looked at all of them. And they all agree. For example, another study on exactly the same question came to exactly the same conclusion.
2009 Aug;16(4):262-4. Epub 2009 Jan 12.
Does intraarticular steroid infiltration increase the rate of infectionin subsequent total knee replacements?Desai A, Ramankutty S,Board T, Raut V.
SourceWrightington Hospital, Wigan, United Kingdom. desaiaravind@yahoo.co.uk
Abstract: Steroid injection into the arthritic joint is a well-known treatment. Its efficacy is well documented. An increase in the incidence of infection secondary to steroid injection has been reported in recent literature. Based on the current literature we carried out a retrospective study to evaluate the incidence of infection in primary total knee arthroplasty as a result of previous steroid infiltration into the knee joint. In our study, 440 patients underwent total knee replacement between 1997 and 2005. Only 90 patients had intraarticular steroid injection prior to surgery, of which 45 patients had injection within 1 year prior to surgery. A matched cohort of 180 patients who had total knee replacement without steroid injection was used as control group to compare the infection rate. All patients had at least 1 year follow up. Two cases of superficial infection were noted in the study group and five cases of superficial infection in the control group. No cases of deep infection were noted in either group. Statistical analysis showed no significant difference in incidence of infection in either group (P value 1.0). This study showed no increase in the incidence of infection in patients with total knee arthroplasty with prior steroid injection.
High Tibial Osteotomy and Total knee replacement.
Another urban myth among orthopedic surgeons is that doing a 'high tibial osteotomy' to try and delay the need for a total knee replacement is a bad thing to do.
The idea behind a high tibial osteotomy is to cut a wedge out of the tibia, so that the knee joint gets a chance to wear out some other part of the contact surface. Some orthopedic surgeons like this procedure, because it delays the need for a total knee replacement for many years. Others think it screws up the eventual knee replacement surgery.
And the answer is .....
The article from the orthopedic literature, cited below, shows that high tibial osteotomies can make the final knee surgery a bit more difficult to do, but are a 'good thing'. It just makes the final total knee replacement surgery a little bit more difficult for the surgeon doing the surgery. But would you really want your knees cut open by someone who wasn't up for a little challenge ????
The effect of high tibial osteotomy on the results of total knee arthroplasty: a matched case control study.van Raaij TM, Bakker W, Reijman M, Verhaar JA.
SourceDepartment of Orthopaedics, Erasmus University Medical Centre, Rotterdam, The Netherlands. t.vanraaij@erasmusmc.nl
AbstractBACKGROUND: We performed a matched case control study to assess the effect of prior high tibia valgus producing osteotomy on results and complications of total knee arthroplasty (TKA).
METHODS: From 1996 until 2003 356 patients underwent all cemented primary total knee replacement in our institution. Twelve patients with a history of 14 HTO were identified and matched to a control group of 12 patients with 14 primary TKA without previous HTO. The match was made for gender, age, date of surgery, body mass index, aetiology and type of prosthesis. Clinical and radiographic outcome were evaluated after a median duration of follow-up of 3.7 years (minimum, 2.3 years). The SPSS program was used for statistical analyses.
RESULTS: The index group had more perioperative blood loss and exposure difficulties with one tibial tuberosity osteotomy and three patients with lateral retinacular releases. No such procedures were needed in the control group. Mid-term HSS, KSS and WOMAC scores were less favourable for the index group, but these differences were not significant. The tibial slope of patients with prior HTO was significantly decreased after this procedure. The tibial posterior inclination angle was corrected during knee replacement but posterior inclination was significantly less compared to the control group. No deep infection or knee component loosening were seen in the group with prior HTO.
CONCLUSION: We conclude that TKA after HTO seems to be technically more demanding than a primary knee arthroplasty, but clinical outcome was almost identical to a matched group that had no HTO previously.
Special Shoes for Sore Knees
NEW YORK (Reuters Health) Dec 28 - An inexpensive pair of shoes reduces joint loading during stair descent, compared with heeled shoes, in women with knee osteoarthritis, researchers from Brazil report.
Reduction in knee loading is one of the most important therapeutic objectives in treating osteoarthritis, as overloading increases the risk that the joint disease will worsen, the researchers noted online November 10 in Arthritis Care & Research.
Dr. Isabel C. N. Sacco and colleagues from University of Sao Paolo analyzed the effect of inexpensive Moleca brand footwear on knee adduction moment (KAM) during stair descent in 34 elderly women with and without knee osteoarthritis. The shoes resemble ballet flats, but with rubber soles.
The authors say they had "no professional relationships with the manufacturer of the footwear...and no conflict of interest."
During the forward continuance phase of the descent, when the control group wore the Moleca flats, the KAM was 48.1% lower than with heeled shoes and 39.1% lower compared to being barefoot. During the propulsion phase, the KAM was 18.3% lower with inexpensive shoes than with either the heeled or barefoot conditions.
In the osteoarthritis group, during the forward continuance phase, wearing the Moleca shoes brought the KAM down by 10.4% compared to wearing heels, but there was no difference in KAM when the women wore Moleca or went barefoot. Similarly, during the propulsion phase, KAM was 9.2% lower with the inexpensive shoes than with heeled shoes but no different from being barefoot.
The non-normalized knee adduction impulse, on the other hand, was significantly lower with the inexpensive shoes than with heeled shoes or barefoot in both groups.
"In addition to the mechanical advantages of the Moleca (inexpensive shoe brand) in generating lower KAM peaks than those generated by the modern heeled shoes and similar to the barefoot condition, this flexible footwear has already been produced on a large scale in Brazil since 1986, and is usually worn by a large number of elderly people, and costs about US$9," the investigators say. "This fact makes the use of these shoes not only viable but, above all, efficient for the reduction of the loading on the knee joint in elderly women both with and without osteoarthritis."
US$9 may be the price in some countries, but in the UK, the least expensive pair of Moleca shoes on Amazon.com sells for GBP12.95 (about US$20). The brand does not appear to be sold in the U.S.
"Although the results of this study showed evidence of a decrease of instantaneous loading and temporal loading in the knee, these findings were observed only as acute effects," they caution. "Based on these promising results, future studies should investigate the chronic therapeutic effects of this flexible low-cost footwear on lower limb biomechanics, structural integrity of the osteochondral tissue, clinical aspects such as pain and inflammatory recurrences, and functionality in the activities of daily living of patients with knee osteoarthritis."
Dr. Patrick Nesbitt, Vancouver, Canada ............ docnesbitt@hotmail.com