Transcript The degenerative knee - ACSP symposium

The overuse/ degenerative
knee
Dr Leesa Huguenin
MBBS M Sports Med FACSP
MP Sports Physicians
www.mpsportsphysicians.com.au
• Weight loss
Management
paradigm for
knee
osteoarthritis
• Reduced weight bearing exercise
• Glucosamine + chondroitin
• Panadol prn
• Regular Panadol/ slow release
Panadol
• Short term NSAIDs
• Long term NSAIDs
• Stronger analgesics
• Surgery
MODERN EVIDENCE SHAKING TRADITIONAL
BELIEFS
NON WEIGHT
BEARING
EXERCISE
KNEE
ARTHROSCOPY
PARACETAMOL
CORTICOSTEROID
INJECTIONS
GLUCOSAMINE
AND
CHONDROITAN
NSAIDS
And some newer ideas enter the arena
Alternative medications
including turmeric
Stem cell injections
Topical NSAIDs
Cytokine therapy (ACS)
Anti anxiety agents
Cellular therapy (PRP)
Bisphosphonates
Viscosupplementation
Non pharmacological interventions
 Weight management
 Land based exercise
 Water based exercise
 Strength training
 Education
Biomechanical changes/ orthotics
Cochrane review March 2015
No conclusive evidence that orthotics, neutral insoles or
Lateral heel wedges have any effect on pain, function or stiffness
specialist
literature
OARSI guidelines recommend orthoses/ braces as guided by treating
specialist but acknowledges inconsistencies in the
literature
Clinically these options should still be considered in a patient with
gross biomechanical alignment issues at the foot if those
biomechanical issues are likely to be creating extra load through
the degenerative compartment or patellofemoral joint
Topical treatments
Evidence is good in single joint or knee only OA
NSAID gels
Capsaicin
Nutritional supplements/ natural therapies
Some positive
evidence, anecdotal
effect, well tolerated
Reduced pain improved
function
Equal to placebo
Glucosamine reduced
non specific knee pain
No effect on disease
progression
RCT indicates reasonable effect
Well tolerated
Rosehip – no clear
findings in research to
date
Acupuncture results
indicate pain relief but
are less reliable if a
sham arm is included
Oral analgesics
Panadol osteo is mainstay of clinical recommendations
BUT BMJ 2015 meta analysis
Paracetamol provides a significant although not clinically important improvement
In pain and disability in the short term only.
AND
Pts on paracetamol are 4 x more likely to have abnormal LFT’s (clinical importance of this
is uncertain
Therefore :
• if pt reports no help from Panadol, STOP IT
• If pt is better on Panadol, monitor LFT’s ? Frequency
• If LFT’s abnormal ????
Oral NSAIDS
Cox 2 preferable
Gastroprotection not recommended unless PHx
In knee only OA, OARSI recommends IA CSI before NSAIDS
IN multi joint OA, Cox 2 NSAIDs are second line to weight loss/ exercise
Issues
Cardiac risk
Renal
Hypertension
All compounded by diabetes/ other comorbidities
Codeine/ opioid analgesia
OARSI states that oral opioid benefit is uncertain
Some studies have shown a small benefit of tramal or similar over placebo, but
withdrawal rates from these trials are high as a result of side effects.
Transdermal opioids may be used, but as mentioned in recent Australian Prescriber
magazine, should be used with caution in the eldlerly and opioid naive – falls/
confusion/ renal function
Therefore limited use for short term flares is probably best indication
Duloxetine (Cymbalta)
SNRI
Antidepressant with excellent anti anxiety and neuropathic pain relieving properties
SE’s
• dry mouth
• Nausea
• Fatigue
• decreased appetite 
• hyperhidrosis
Useful in knee only and multijoint OA, but care must be taken with comorbidities.
BISPHOSPHONATES
Initial research done in RA – theory is that bone resorption and damage in inflammatory
conditions is osteoclast mediated.
Evidence in OA – limited
- few studies and differing outcomes
- meta analysis suggests overall no change in pain
- BUT reduction in cartilage degradation markers  ? Slow progression
Anecdotal clinical evidence (mine) – can be effective for residual bone pain if joint
pain has been addressed by other measures and bone oedema is seen on MRI
Corticosteroid injection
Still recommended by OARSI for pain relief
My clinical limitation is known degradative effects of corticosteroids and all
local anaesthetics (except ropivicaine) on articular cartilage.
Therefore I hesitate in the young patient due to likely recurrent
requirement
RISKS
FOR
PATIENT
INFORMATION
SHEET
•Death of nearby bone (osteonecrosis)
•Joint infection
•Nerve damage
•Thinning of skin and soft tissue around the injection site
•Temporary flare of pain and inflammation in the joint
•Tendon weakening or rupture
•Thinning of nearby bone (osteoporosis)
•Whitening or lightening of the skin around the injection
site
Hyaluronic acid injections
Evidence presented by manufacturers indicates good outcomes in
terms of pain and function in Grade 1-2 OA knees
OARSI guidelines
Uncertain benefit in knee only OA
Maximal benefit being seen at 8 weeks in some trials, after 12 weeks in other trials
General inconsistency of conclusions in meta analyses to date
Autologous biological therapies
Platelet rich plasma/ Autologus conditioned serum
Repeatable
No risk of chondral damage
Both rely on the actions of growth factors.
PRP – platelets are activated after injection by contact with collagen.
ACS – activation is done outside the body and GF”s/ anti inflamm proteins
are injected
UNFORTUNATELY, the available evidence cannot help treatment choices –
contradictory outcomes and non uniformity of PRP recipes and protocols
PRP/ ACS CANNOT ALTER DISEASE PROGRESSION OR REGROW CARTILAGE
Some evidence emerging that they can help pain and function
Ongoing data collection in many clinica including MPSP
Knee arthroscopy
Stem cell injections
DISCLAIMER – involvement in MSCC trials on isolated expanded mesenchymal derived stem
cells for treatment of OA. Randomised, unblended, no treatment controls.
Another can of worms
Again poor consistency of methods/ applications
Animal data indicates functional improvement
Human data variable
Controversies
% stem cells in injections
positive outcomes reported when equal to placebo
financial incentives
stem cells are a buzz word – exhuberant marketing for cosmesis and neurological
conditions with limited evidence
Jo et al 2013
• Adipose derived MSCs Autologous/Isolated/Expanded
• Low (10 million cells) / Mod (50 million cells) / High (100 million cells) dosing
• Pain and functional improvement
• High dose
• Reduction in cartilage defect size 40-50%
• Cartilage Volume increase 14-22%
• Histology – type II collagen – hyaline cartilage
Coa et al – Preliminary data presentation
• Adipose derived MSCs Autologous/Isolated/Expanded
• Low (10 million cells) / Mod (20 million cells) / High (50 million cells) dose × 2
• Pain and functional improvement
• High dose
• Cartilage Volume increase in all participants by 3months
MINIMAL EXPECTATIONS OF STEM CELL PROVIDERS
 `code of ethics’
 Informed consent
 Patient education
 Alternatives
 Current research
 Theoretical risks/side effects
 Expected outcome
 Scientific
 Data collection
 Publication
 Registry
 Safety and Efficacy
 Adherence to guidelines as per ISSCR
 Phase I and II development
 Clinical Trial/Medical Innovations
 AVOID Unproven Stem Cell Therapies
SO, TO SUMMARISE OA KNEE TREATMENT;
GOOD
QUESTIONABLE
POSSIBLE
WEIGHT LOSS
GLUCOSAMINE
PRP
EXERCISE
CHONDROITAN
ACS
STRENGTH TRAINING
ROSE HIP
STEM CELLS
EDUCATION
OPIOIDS
BISPHOSPHONATES
NSAID GEL
ACUPUNCTURE/ TENS
HYALURONIC ACID
CAPSAICIN
CORTICOSTEROID INJ (YOUNG)
ORTHOSES/ BRACES
Sam E
KNEE ARTHROSCOPY
PARACETAMOL (in responders)
NSAIDS (care in comorbidities)
CORTICOSTEROID INJECTIONS
DULOXETINE
Thank you for your attention
FOR FURTHER INFORMATION/ DISCUSSION
Dr Leesa Huguenin
T: 5975 4255/ 9770 2398
E: [email protected]
W: www.mpsportsphysicians.com.au