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osteoarthritis of the knee

Etiology: 1) see osteoarthritis 2) leg length inequality may be risk factor [5] 3) meniscectomy is a risk factor for early osteoarthritis of the knee [1,39] 4) obesity is the most modifiable risk factor [1] 5) weight bearing activity in persons with reduced leg muscle mass is associated with increased risk of knee osteoarthritis [115] Epidemiology: - prevalence of symptomatic osteoarthritis of the knee has increased from 1974 to 2004 [6] - 13% to 26% white females - 9% to 20% white males - 10% to 17% black females - 6% to 16% black males - overall prevalence of radiologically defined osteoarthritis has not changed [6] Clinical manifestations: 1) pain after stressful or prolonged weight-bearing 2) pain after climbing stairs 3) pain is relieved by rest 4) joint effusion after weight bearing may occur 5) loss of range of motion 6) varus or valgus angulation may occur with disease progression Diagnostic criteria: - at least 3 of the following a) age > 50 years b) stiffness lasting < 30 minutes c) crepitus d) bony tenderness e) bony enlargement f) no palpable warmth [1] Laboratory: - joint aspiration of effusion - non-inflammatory fluid; WBC < 3000/uL - small, cool effusions need not be aspirated [112] Radiology: - X-ray of the knee (bilateral) - standing views appropriate to confirm diagnsosis - demonstrate joint space narrowing better than supine views [1] - >70% of population >40 years of age with radiographic evidence of osteoarthritis - MRI detects structural abnormalities consistent with osteoarthritis of the knee in most older people without radiographic evidence for knee osteoarthritis, regardless of the presence of pain [8] Differential diagnosis: 1) anserine bursitis 2) patellofemoral pain syndrome 3) tendonitis 4) internal derangement of the knee - meniscus tear - synovial fluid: bloody effusion - osteonecrosis - plain radiograph, MRI if early [117] 5) inflammatory joint disease - rheumatoid arthritis - lupus arthritis - psoriatic arthritis [117] 6) crystalline arthropathy - gout - calcium pyrophosphate deposition (pseudogout) 7) septic arthritis [117] 8) joint instability 9) referred pain from the hip Complications: - increased risk for depression - risk increases with severity of knee osteoarthritis [69] - fatigue is strongest predictor of reduced activity [2] Management: 1) weight reduction via calorie restriction [1,12] - weight reduction via diet & exercise in obese or overweight patients results in small improvements in knee pain of uncertain clinical significance [99] - weight reduction with favorable effect of development & progression of knee osteoarthritis in obese patients [104] 2) avoidance of pain-inducing activities 3) pharmaceuticals (also see osteoarthritis) a) acetaminophen of no benefit [1] - less effective than NSAIDs [30] - no better than placebo [52] b) NSAIDs - diclofenac most effective agent on U.S. market [52] - NSAIDs associated with greater loss of medial minimum joint space width compared with other drugs [87] - avoid oral NSAIDS in patients with coronary artery disease, heart failure, chronic renal failure & peptic ulcer disease [1] c) topical diclofenac [24] - efficacy similar to oral diclofenac with adverse effect profile similar to placebo (except for application reactions) [2] - American College of Rheumatology recommends topical NSAIDs rather than oral NSAIDs for elderly (>= 75 years of age) [25] regardless of whether or not they are doing well on oral NSAIDs [1] - associated with more skin reactions [1] - considerably more expensive than oral NSAIDs [1] - placebo effect of topical application [40] d) topical salicylates - efficacy poor to moderate [2] e) topical capsaicin 0.025% applied QID - poor to modest efficacy [2] f) oral methotrexate once weekly (6-week escalation 10 to 25 mg weekly) [114] - reduction in pain & stiffness at 6 months - subcutaneous methotrexate not evaluated g) weekly semaglutide reduces pain, improves physical function in patients with obesity & knee osteoarthritis [118] h) nerve & joint injections - glucocorticoid joint injection [111] - exclude infection with joint aspiration & synovial fluid analysis if signs of inflammation [1] - predictors of response difficult to identify [37] - effusion noted as possible predictor to response [37] - injection under ultrasound guidance may improve likelihood of response [37] - triamcinolone equivalent to methylprednisolone [43] - benefit modest at best; of no benefit [62] - may hasten cartilage loss [65,98] - max once every 4 months - in patients with type-2 diabetes, extended-release triamcinolone associated with less hyperglycemia than immediate-release triamcinolone [116] - intramuscular joint injection of glucocorticoid may be as effective as intra-articular injection [109] - hyaluronic acid injections not recommended [1,10,32,54] - osteoarthritis not responding to other treatment [1] - better than intra-articular saline [30] - no better than glucocorticoid injection [54] - does not hasten cartilage loss [98] - ineffective [48,95], expensive [54] - clinicians not following recommendations [94] - glucocorticoid injections are as safe as hyaluronic acid injections & disease progression is similar [91] - intra-articular saline better than oral NSAIDs [30] - glucocorticoid joint injection prior to exercise therapy of no benefit [34] - placebo effect of injection > topical placebo > oral placebo [40] - studies on intra-articular stem cell injections of poor quality [57] - ultrasound-guided genicular nerve block - 3 injections of 5.7 mg celestone chronodose (1 ml) & 0.5% bupivacaine (3 ml) to the inferomedial, superomedial, & superolateral genicular nerves may improve osteoarthritis pain for 12 weeks [97] i) serotonin norepinephrine reuptake inhibitors (SNRI) - duloxetine, venlafaxine (low-certainty evidence) [102] - duloxetine reduces knee pain & improves physical function in mild-moderate osteoarthritis [1,112] - no significant benefit of duloxetine in end-stage osteoarthritis [93,112] j) joint effusion: spironolactone 25 mg PO QD for 2 weeks may be effective [55] k) use of beta-blockers is associated with less arthragias & less use of opioids & other analgesics for symptomatic large-joint osteoarthritis [67] l) tramadol of minimal benefit with significant adverse effects [100] m) opiates as a last resort n) glucosamine, chondroitin sulfate (see GAIT trial) - MKSAP19 says do not use [1] - some clinical trials have found benefit [18] - may reduce cartilage loss in some regions of the knee [31] - combined chondroitin sulfate & glucosamine as effective as celecoxib [49] - no better than placebo [2,60] - safety profile equivalent to placebo [18] - not recommended [1,2,10]; not useful [22,35] - pharmaceutical-grade chondroitin sulfate 800 mg/day as effective as celecoxib [64] o) only celecoxib & glucosamine sulfate of long-term benefit, albeit small benefit [73] p) colchicine 0.5 mg QD may reduce need for total knee arthoplasty [106] q) turmeric may be of some benefit in reducing knee pain [81] - long-term benefit unlikely [2] r) of no benefit - vitamin D of no benefit [9,51] - zoledronate of no benefit [76] - biologic agents of no benefit [1] - botulinum toxin of no benefit [1] - platelet-rich plasma of no benefit 4) aerobic exercise may be useful [1,4,12,16] - no specific exercise program proven superior [1] - supervised exercise 3 times a week [19] - improve aerobic capacity, quadriceps strength, or lower extremity performance [19] - walking may be beneficial in rehabilitation [2] {20-30 minutes at least once a week} - walking exercise may be useful for patients for mild or intermittent symptoms [96] - moderate intensity aerobic exercise may not be achievable in some elderly patients [2] - self-management program including low-impact aerobic exercise [10] - physical activity reduces risk of disability [26] - Low-to-moderate physical activity might be protective [77] - daily walking may delay functional limitations [28] - land-based exercise of benefit in terms of reduced knee pain & improvement in physical function [36] - benefit sustained >= 2-6 months after cessation - stepwise program may benefit less motivated patients - step 1: internet-based exercise program - step 2: non-responders at 3 months: biweekly telephone coaching to address barriers to physical activity - step 3: non-responders at 6 months: in-person physical therapy [85] - internet-base exercise therapy convenient & effective in reducing pain & increasing function [88] 5) quadriceps-strengthening activities - twice weekly [1,2,74] - high-intensity strength training no better than low-intensity strength training or an attention control in adults with knee osteoarthritis [86] - individualized self-directed strengthening & physical activity with automated text messaging encouraging adherence reduces pain & improves function [89] - strength training to increase leg muscle mass may be of benefit [115] 6) orthotics: - correction of pronation of foot can relieve knee pain - stable, supportive shoes better for pain than flat, flexible shoes [84] - lateral wedge sole inserts not effective for varus deformity of knee [11,74] 7) physical therapy 3 times per week for 4 weeks for patients not responding to therapy - physical therapy may benefit patients with substantial comorbidities [66] - physical therapy better than glucocorticoid injection [75] - physical therapy better than saline injections, but difference not significant [92] 8) weight loss, physical activity, & self-management education [68] - delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through electronic medical record in combination with telephone-based patient intervention focused on weight management, physical activity, & cognitive behavioral therapy for pain management of benefit [47] 9) Tai Chi as effective as physical therapy [1,53] 10) cognitive behavioral therapy (CBT) - beneficial for patients with osteoarthritis & insomnia [29] - (CBT) may be useful for patients intolerant of NSAIDs [80] 11) raised seating alleviates forces across the knee & hip 12) use of a cane 13) knee brace may provide symptomatic relief - valgus bracing for medial knee OA [33] - no evidence to support the use of valgus knee braces [63] 14) special biomechanical shoes - cost is considerable, overall clinical value is unclear [79] 15) acupuncture can help patients with OA of the knee [3] - effective for patients with chronic pain due to osteoarthritis [108] - can improve short & long-term physical function [107] - can provide only short-term pain relief [107] - not recommended [10] - statistically significant benefits are small & do not meet thresholds for clinical relevance [23] - long-term benefit unklikely [2] 16) cooled radiofrequency ablation on 4 genicular nerves may provide pain relief in for patients with refractory knee osteoarthritis [82] - genicular nerve block with anthesthetic/glucocorticoid may provide short-term pain relief diminishing over 12 weeks [103] 17) unproven therapies a) insufficient data to recommend electrotherapy (TENS) [10] b) omega-3 fatty acids without benefit [2] - low-dose fish oil (0.45 g EPA + DHA daily, blended with high-oleic acid sunola oil) may be of benefit [50] - krill oil (2000 mg/day) of no benefit [113] c) coenzyme Q10 without benefit [2] d) unloading shoes of no benefit [56] e) platelet-rich plasma does not improve knee pain or slow disease progression [90] f) arthroscopic lavage, debridement, closed lavage [1] g) cupping therapy 18) surgery a) arthroscopic surgery - indications: - degenerative meniscal tear - osteoarthritis with joint buckling, joint instability or locking, or symptomatic mechancal disorder [1] - in most cases not indicated [61] b) arthroplasty (knee replacement) - may improve pain, activities of daily living, & quality of life at 1 year at the cost of increased risk for venous thromboembolism (RR=4) [44] c) high tibial osteotomy (individuals too young for knee replacement) d) allograft meniscal transplantation (new technique 1998) e) knee cartilage repair (MACI) [59] f) arthroscopic lavage, debridement not indicated [1,10,61] g) reduces cardiovascular risk possibly due to increased exercise capacity & decreased NSAID use [17] h) implantable shock absorber superior to high tibial osteotomy [105] 19) no intervention favorably changes natural course of knee OA

Related

knee knee pain patellofemoral pain syndrome; chondromalacia patella (PFPS) pes anserine bursitis tendonitis (tendon injury)

General

osteoarthritis (OA)

References

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