Transcript an algorithm for the management of knee osteoarthritis

AN ALGORITHM OF THE
MANAGEMENT OF KNEE
OSTEOARTHRITIS (OA)
Prof. Matjaž Sajovic MD. PhD
Department for Orthopedics and Sports Trauma Surgery
General Teaching Hospital Celje
General Teaching Hospital Celje, Slovenia
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
Osteoarthritis (OA) is the most common form of arthritis and a
major cause of disability.
OA has been defined as a progressive disease of synovial joints
that represent failed repair of joint damage that results from
stresses that may be initiated by an abnormality in any of the
synovial joint tissues, including articular cartilage.
The knee is the most common joint localization of
symptomatic OA, and symptomatic knee OA affects
24% of general population.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
X-rays; AP projection
Arthroscopic view
CLINICALLY OA OF THE KNEE IS CHARACTERIZED BY JOINT PAIN,
CREPITUS, STIFFNESS AFTER IMMOBILITY AND LIMITATION OF
MOVEMENT.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
Classification (etiology) of osteoarthritis
 Primary / idiopathic
 Secondary:
-
posttraumatic
instability
rheumatoid disease
malalignment
post-infectious
congenital
lifestyle factors
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
OSTEOARTHRITIS (OA) IS ONE OF THE MOST COMMON
FORMS OF MUSCULOSKELETAL DISORDERS AND INCURS
SIGNIFICANT ECONOMIC, SOCIAL AND PSYCHOLOGICAL
COSTS.
 Progresive
 Irreversibil
 Poor
quality of life
 Difficult
 Never
treatment
ending story
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
RECOMMENDATIONS FOR THE MANAGEMENT OF THE
KNEE OA HAVE BEEN ISSUED BY NATIONAL,
CONTINENTAL, OR GLOBAL SCIENTIFIC AUTHORITIES,
INCLUDING, AMONG OTHERS:
THE EUROPEAN SOCIETY FOR CLINICAL AND ECONOMIC
ASPECTS OF OSTEOPOROSIS AND OSTEOARTHRITIS
(ESCEO) DEVELOPED THE ALGORITHM TREATMENT OF
OSTEOARTHRITIS.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
The following organizations also issued guideline
document for the management of OA:
European
League Against Rheumatism (EULAR)
American
College of Rheumatology (ACR)
Osteoarthritis
Research Society International
(OARSI)
UK
National Institute for Health and Clinical
Excellence (NICE)
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
Appropriate diagnosis of knee OA is an essential
pre-requisite to treatment; in this respect, EULAR
recently published updated recommendations.
Three symptoms (persistent knee pain, limited morning
stiffness and reduced function) and three signs (crepitus,
restricted movement and bony enlargement) with use of
imaging and laboratory appeared to be the most useful
diagnostic criteria.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
BASIC PRINCIPLE AND CORE SET
COMBINATION OF TREATMENT MODALITIES, INCLUDING NONPHARMACOLOGICAL AND PHARMACOLOGICAL THERAPIES IS
STRONGLY RECOMMENDED.
The core set represent the initial measures and interventions
that every patient with knee OA should undergo:
- Information / Education
- Weight loss if overweight
- Exercise program
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
CORE SET
Information acces and education consists in providing to the
patient the necessary knowledge about the nature of the disease
and the objectives of treatment. The physican should promt
changes in the patients lifestyle toward behaviors that may have
a beneficial impact on joint protection. It is recognized that these
measures have minimal effect on AO symptoms, but they are
essential for treatment adherence.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
CORE SET
Weight loss if overweight
Weight loss should be targeted to at least 10% to achieve
significant symptom benefit. A similar degree of weight loss
has also been indicated to improve the quality and
thickness of medial femoral compartment cartilage.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
CORE SET
Exercise program
There is good evidence that water-based exercises is effective
on both pain and function. However, specific quadriceps
strengthening exercises with strength training for the lower
limb, together with aerobic training such as walking, remain the
best documented exercise approaches.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
It is a common clinical experience that core therapies are
usually isufficient to fully control symptoms after diagnosis
has been made and with disease progression.
In agreement with the basic principle of treatment
recommendation, paralel addition of sequential nonpharmacological and pharmacological therapies should be
established.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 1: BACKGROUND TREATMENT
During Step 1, which follows the core set, further background
physical remedies should be established as needed. In
parallel, and if the patient is still symptomatic, background
pharmacological therapy should be started and progressively
moved toward combination treatment as soon as the clinical
response is not satisfactory.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
Step 1-a: Non-pharmacological backgroud treatment
Physician should first evaluate whether correction for malignment is
necessary. Varus or valgus malalignment is a risk factor for knee OA and
its progression. There is reasonable evidence to suggest that knee
braces, foot orthoses or insoles actually improve biomechanical
imbalance and may improve knee OA symptoms.
In symptomatic patient physical therapy at any time:
•Thermal
agents (thermopack, ultrasound, sham procedure…)
•Manual therapy in combination with exercise
•Patellar taping
•Chinese acupuncture
•TENS may reduce the need for analgesic medications
•Balneotherapy
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
Step 1-b: Pharmacological background treatment
The aim is to establish a first chronic therapy that may improve or control symptoms
or at least provide rescue analgesia.
If symptomatic:
-Paracetamol
for rescue analgesia
OR / AND
-Chronic
SYSADOA (glucosamine sulfate or/and chondroitin sulfate
If still symptomatic ADD:
-
Topical NSAIDs
OR
- Topical capsaicin
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
Step 1-b: Pharmacological background treatment
Paracetamol:

Doses no greater than 3g/day on a regular basis

Recommended as an initial pharmacological approach

Short-term, rescue analgesia

Not for chronical us (GI adverse events and drug-induced liver
injury)

Minimal effect on pain

Significant effect on function
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
Step 1-b: Pharmacological background treatment
Chronic Symptomatic Slow-Acting Drugs for Osteoarthritis (SYSADOAs)
 Glucosamine sulfate and chondroitin sulfate are safe medications, with no difference
in adverse effects compared with placebo, which strengthen their role as chronic
background treatments

Are often used in combination as dietary supplements

In most country are not a prescription drugs

Long-term prescription has potential benefit beyond symptoms control when used
early in the management of knee OA

May delay joint structure changes
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 1: BACKGROUND TREATMENT
Varus arthrosis of the knee
5th International Conference of Orthopedic Surgeons and Rheumatology
Correction of the malalignment
with a) closed and b) open wedge
osteotomy
June 16-17, 2016 Alicante, Spain
STEP 2: ADVANCED PHARMACOLOGICAL
MANAGEMENT IN PERSISTIENT SYMPTOMATIC PATIENT
If Step 1 shows inadequate efficacy or in patients arriving to
the observation with moderate-to-severe pain, benefit may be
achieved with advanced pharmacological treatment.
However, these treatments are less manageable and prone to
more severe adverse reactions.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 2: ADVANCED PHARMACOLOGICAL MANAGEMENT IN
PERSISTIENT SYMPTOMATIC PATIENT
Intermitent or continuous (longer cycles) oral NSAIDs
NORMAL GI RISK
-
Non selective NSAID
INCREASED GI RISK
- Cox-2 selective NSAID with PPI
(with PPI)
-
Cox-2 selective NSAID
-
Avoid non-selective NSAIDs
(consider PPI)
Concomitant use of aspirin increases gastrointestinal risk !
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 2: ADVANCED PHARMACOLOGICAL MANAGEMENT IN
PERSISTIENT SYMPTOMATIC PATIENT
Intermittent or continuous (longer cycles) oral NSAIDs
INCREASED CV RISK
-
Prefer naproxen
- Avoid
high dose diclofenac and
INCREASED RENAL RISK
- Avoid NSAIDs in patients
with GF below 30cc/min
ibuprofen (if on low-dose aspirin)
-
Caution with other non-selective NSAIDs
- Avoid
Cox-2 selective NSAIDs
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 2: ADVANCED PHARMACOLOGICAL
MANAGEMENT
In case of contraindications to NSAIDs, or if the
patient is still symptomatic despite us of NSAIDs
or was severely symptomatic, intra-articular
treatment may be applied.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 2: ADVANCED PHARMACOLOGICAL MANAGEMENT IN
PERSISTIENT SYMTOMATIC PATIENT
May delay total joint replacement

Intra-articular hyaluronate

Intraarticular corticosteroids
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 3: LAST PHARMACOLOGICAL ATTEMPTS IN SEVERE
SYMPTOMATIC PATIENTS BEFORE SURGERY
•
Short-term weak opioids (tramadol)
- relieving pain and improving function but adverse events are significant
•
Antidepressants are commonly used in chronic pain syndromes
- they alter pain neurotransmitters (i. e., serotonin and norepinephrine) centrally
- central sensitization may play a role in the severity of osteoarthritis pain
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
THERE IS NO FAVORABLE EVIDENCE FOR ARTHROSCOPIC
JOINT LAVAGE/ DEBRIDEMENT.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 4: END-STAGE DISEASE MANAGEMENT AND
SURGERY
Total joint replacement is very effective in relieving severe
symptoms of knee OA and has a high benefit/risk ratio when
patients are carefully selected, well informed, anesthesia and
surgery are well performed, and rehabilitation is appropriate.
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
STEP 4: END-STAGE DISEASE MANAGEMENT AND SURGERY
Partial (Unicompartmental)
knee replacement
5th International Conference of Orthopedic Surgeons and Rheumatology
Total knee replacement
June 16-17, 2016 Alicante, Spain
STEP 4: END-STAGE DISEASE MANAGEMENT FOR SEVERELY
SYMPTOMATIC PATIENTS IF SURGERY IS CONTRAINDICATED OR IF
THEY ARE UNWILLING TO UNDERGO SURGERY
Last pharmacological treatment may be represented:
•Classical
oral or transdermal opioids
•Guidelines
should be followed as in the management of
chronic non-cancer pain
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain
THANKS FOR
YOUR ATTENTION
5th International Conference of Orthopedic Surgeons and Rheumatology
June 16-17, 2016 Alicante, Spain