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Hi Grandma, why are you limping?

An evidence-based

approach to the patient with

hip or knee osteoarthritis

Larry Collins, MPAS, PA-C, ATC, DFAAPA

Assistant Professor, Physician Assistant Program

Assistant Professor, Department of Orthopaedics & Sports Medicine

USF Health, Morsani College of Medicine

Disclosures

I have no real or apparent conflicts of

interest to report

Osteoarthritis (OA)

Deshpande BR, et al. Number of Persons With Symptomatic Knee Osteoarthritis in the U.S.: Impact of Race and Ethnicity, Age, Sex and Obesity. Arthritis Care & Research. 2016. 68(12):1743-1750.The Burden of Musculoskeletal Diseases in the United States (BMUS). Prevalence, Societal, and Economic Cost, Third Edition. 2014. Available at http://www.boneandjointburden.orgArthritis-Related Statistics. https://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm. Accessed 8/12/2017.

• Most common form of arthritis and the most common joint disease

• >14 million Americans suffer from OA of the knee

• Knee OA peaks between 55-64

• Women > men

• ~ 750k knee and 500k hip replacements in 2011

OA Affects All Weight-bearing Components

• Articular cartilage

• Menisci

• Bone

Arthritis of the Knee. http://orthoinfo.aaos.org/topic.cfm?topic=a00212. Accessed 8/1/2017

Osteoarthritis (OA)

• Progressive degenerative

disorder involving diarthrodial

(synovial) joints

• Complex process involving• Biomechanical factors

• Proinflammatory mediators

• Proteases

• Characterized by breakdown

of articular cartilage and

proliferative changes of

surrounding bones

• decreased function

Osteoarthritis of the Hip. http://orthoinfo.aaos.org/topic.cfm?topic=a00213. Accessed 8/1/2017

Articular Cartilage

• Change in color

• Cartilage fibrillation

• Cartilage erosion to subchondral bone

Lacourt M, Gao C, Li A, Girard C, Beauchamp G, Henderson JE, Laverty S. Relationship between cartilage and subchondral bone lesions in repetitive impact trauma-induced equine osteoarthritis. Osteoarthritis and Cartilage. 2012. 20(6):572-583.

Characteristics

• Chronic disease of the musculoskeletal system

• Without systemic involvement

• Primarily a non-inflammatory process

• Except at the cellular level

• Joint ankylosis not typically observed until late

• May be seen in erosive OA

Classification

Primary OA Secondary OA• Genetics? • Autoimmune/inflammatory

diseases

• Congenital disorders of joints

• Diabetes

• Ehlers-Danlos Syndrome

• Hemochromatosis and

Wilson's disease

• Joint infection

• Ligament instability

• Marfan syndrome

• Obesity

• TraumaWarner SC, Valdes AM. The Genetics of Osteoarthritis: A Review. J. Funct. Morphol. Kinesiol. 2016, 1(1), 140-153; doi:10.3390/jfmk1010140

Epidemiology

• Most common joint disease

• ~70% >60yo diagnosed with OA of hip or knee

• ~ 90% have radiographic evidence of OA

Risk factors• Age

• Female >> male

• Obesity

• Lack of osteoporosis

• Occupation

• Sports activities

• Previous injury

• Muscle weakness

• Proprioceptive deficits

• Genetic elements

• Acromegaly

• Calcium crystal

deposition disease

• Articular cartilage

• Primarily acts as a smooth, low-friction surface

• Bone

• Subchondral sclerosis and osteophyte formation

• Synovium

• Hypertrophy and inflammation

• Soft tissues

• Ligaments, capsule, meniscus and muscles

Pathophysiology

Clinical Presentation

• Slowly progressive

• activity levels ( co-morbidities – obesity, diabetes, etc.)

• Antalgic gait

• Pain – deep, achy, exacerbated by use

• range of motion

• Crepitus

• Morning stiffness <30 minutes and with inactivity

Patient Characteristics and Symptoms

Zhang W, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010 Apr;18(4):476-99. doi: 10.1016/j.joca.2010.01.013. Epub 2010 Feb 11.

Physical Exam Findings

Zhang W, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010 Apr;18(4):476-99. doi: 10.1016/j.joca.2010.01.013. Epub 2010 Feb 11.

Radiologic Findings

• Underestimate the extent and severity

• Quantify end-stage changes

• Cartilage loss joint space narrowing

• Bony changes subchondral sclerosis, cysts and

osteophytes

Osteoarthritis of the Hip. http://orthoinfo.aaos.org/topic.cfm?topic=a00213. Accessed 8/1/2017Arthritis of the Knee. http://orthoinfo.aaos.org/topic.cfm?topic=a00212. Accessed 8/1/2017

Radiologic Grading

Kellgren Lawrence Classification

von Bernstorff M, Feierabend M, Jordan M, Glatzel C, Ipach I, Hofmann U. Radiographic Hip or Knee Osteoarthritis and the Ability to Drive. ORTHOPEDICS. 2017; 40: e82-e89. doi: 10.3928/01477447-20160915-05

Grade Description

0 No radiographic features of OA

1 Subtle osteophytes, no joint space narrowing

2 Definite osteophytes, +/- narrowing

3 Definite joint space narrowing, osteophytes, some

sclerosis, +/- bone deformity

4 Gross loss of joint space, large osteophytes,

deformity of bone ends

Radiologic Grade Of OA

von Bernstorff M, Feierabend M, Jordan M, Glatzel C, Ipach I, Hofmann U. Radiographic Hip or Knee Osteoarthritis and the Ability to Drive. ORTHOPEDICS. 2017; 40: e82-e89. doi: 10.3928/01477447-20160915-05

Kellgren Lawrence Classification

Hip OA

• Anterior hip/groin pain – hip joint

• Lateral – trochanteric bursitis, meralgia

paresthetica

• Posterior – SI joint, lumbar, Zoster

• Thigh – hip joint, stress Fx, lumbar, tumor, knee

Hip Physical Examination

• Inspection• Antalgic (possibly Trendelenburg) gait

• Arising from chair (arm rests)/getting onto exam table

• Palpation• Trochanteric bursa

• Pelvic obliquity – ? Leg length discrepancy

• Trendelenburg – Hip abductor weakness

• Range of motion – ? painful

• ~40-50 degrees IR/ER is normal

• Log roll – ? painful

• Strength• Straight leg raise – active

• Sensation

• Patrick (Fabere) test – localize pain


Pelvic Obliquity Trendelenburg test

• Used as screening maneuver for leg

length discrepancy

• Hands are placed on top of the iliac

crests and the level of the pelvis is

estimated

• Asymmetry is seen with leg length

discrepancy, pelvic fracture, scoliosis,

and paraspinal muscle spasm

https://www.uptodate.com/contents/image?imageKey=EM%2F80105&topicKey=SM%2F252&rank=2~48&source=see_link&search=hip%20osteoarthritis.

https://www.uptodate.com/contents/search?search=trendelenburg%20test&sp=&searchType=PLAIN_TEXT&source=USER_INPUT&searchControl=TOP_PULLDOW

N&searchOffset=1&autoComplete=true&language=&max=0&index=3~4&autoCompleteTerm=Trendelenburg. Accessed 8/10/2017


Range of Motion Log Roll

http://www.nle.nottingham.ac.uk/websites/rheumatology/chapter7.html. Accessed 8/10/2017

• ~40-50 degrees IR/ER is normal


Dr. Donald Corenman, MD - Colroado Spine Doctor. www.neckandback.com. http://www.flickr.com/photos/neckandback/6145561772/. Accessed 8/10/2017.

Hip Radiographs

Weight bearing AP pelvis Lateral Hip

http://www.wikiradiography.net/page/Pelvis+Radiographic+Anatomy. Accessed 8/10/2017.

Hip Radiographs

Case courtesy of Townsville radiology training, Radiopaedia.org, rID: 18287. Accessed 11/13/2017.

Knee OA

• Obese females >50

• Joint stiffness (<30

minutes)

• Mechanical pain

• Crepitus

• Pain with pressure

• Painful ROM

• Functional limitations

• Limited ROM in later

stages

Knee OA

• Pain• Worse with activity – relieved by rest

• Progressive

• Predictable, sharp pain brought on by insult

• More constant, affects ADLs

• Constant dull/aching, with unpredictable episodic flare-ups

• Tenderness• Joint line suggests intra-articular pathology

• Range of motion• May be painful

• Limitations typically in later stages

• ‘Bony swelling’• Remodeling of bone and cartilage with osteophyte formation

• Deformity• Later stages

• Instability• Giving way or buckling is common complaint

Knee Physical Examination

• Inspection• Gait

• Normal, limping (antalgic), shuffling, or cannot walk

• Swelling

• Effusion versus other soft tissue swelling (e.g.,

bursitis)

• Ecchymosis and other signs of injury (e.g., abrasions)

• Muscle atrophy

• Alignment

• Varus (knee bends outward) or valgus (knee bends

inward)

• Windswept – worse prognosis

• Skin changes

• Scars (surgical or traumatic), rash, lymphangitis


• Palpation• Lateral joint line

• Medial joint line

• Anterior knee

• Tibial tuberosity

• Patellar tendon

• Patella

• Quadriceps tendon

• Posterior knee

• Bursa

• Effusion

• Skin temperature – "warm-cold-warm"

https://www.medscape.com/slideshow/evaluatingkneepain-6006108#2. Accessed 11/18/2017.

Windswept Knee Deformity


• Range of motion• Usually later in disease

• Maintaining extension is important

• Strength• May be limited 2° pain

• Stability• Pseudolaxity

• Neurovascular

http://joh.co.in/joint-replacement/knee-replacement/. Accessed 11/08/2017.

Varus Thrust Gait

https://youtu.be/k8kKCPo7pcE

https://youtu.be/k8kKCPo7pcE


Rabago D, Patterson JJ, Baumgartner JJ. Prolotherapy: A CAM Therapy for Chronic Musculoskeletal Pain. https://clinicalgate.com/prolotherapy-a-cam-therapy-for-chronic-musculoskeletal-pain/. Accessed 8/1/2017.


Effusion Bursitis

Joint Pseudolaxity

Waldstein, Wenzel & Bou Monsef, Jad & Buckup, Johannes & Boettner, Friedrich. (2013). The Value of Valgus Stress Radiographs in the Workup for Medial Unicompartmental Arthritis. Clinical orthopaedics and related research. 471. . 10.1007/s11999-013-3212-3.


Management of OA

• Education• Etiology, risk factors, prognosis, expectations and treatment

options

• Self-management – complements traditional education

• Goal-setting – identify problems, set priorities, realistic long and

short term goals

• Monitoring• Periodic and regular

• Holistic evaluation• Impact on ADLs

• Restrictions

• Aspirations

• Level of distress

• Falls risk assessment

• Supports

• Comorbidities

Western Ontario and McMaster Universities

Osteoarthritis Index (WOMAC)

• Assesses pain, stiffness, and physical function in patients

with hip and / or knee osteoarthritis

• 24 items divided into 3 subscales

• Pain (5 items)• During walking, using stairs, in bed, sitting or lying, and standing

• Stiffness (2 items)• After first waking and later in the day

• Physical Function (17 items)• Stair use, rising from sitting, standing, bending, walking, getting in / out of

a car, shopping, putting on / taking off socks, rising from bed, lying in bed,

getting in / out of bath, sitting, getting on / off toilet, heavy household

duties, light household duties

Gandek B. Measurement properties of the Western Ontario and McMaster Universities Osteoarthritis Index: a systematic review. Arthritis Care Res (Hoboken). 2015;67(2):216.

http://www.womac.com

Management Goals

• Decrease pain

• Improve function

• Positively affect joint degeneration• No approved disease-modifying OA drugs

• Target modifiable risk factors

• Overall quality of OA care suboptimal

• <50% compliance with indicators of

appropriate care• Inferior to diabetes and osteoporosis

Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012; 197:100.

Nonpharmacologic Therapy

• Education

• Weight management

• Exercise

• Braces

• Assistive devices

• Loss of 10% body weight associated with

50% reduction in pain scores

Messier SP, Mihalko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA 2013; 310:1263.

Genu Varus/Valgum – Orthosıs

Pharmacologic Therapy

• Oral and topical NSAIDs

• Opioids

• Duloxetine

• Topical capsaicin

• Intraarticular glucocorticoids

• “Structure modifying treatments”


• Topical oral NSAIDs

• Lowest dose required to control symptoms

Cycle

• COX-2 selective NSAID or a nonselective NSAID

associated with a proton-pump inhibitor should be

used in patients with comorbidities (DM, HTN,

elderly, etc.)

• Use caution in high comorbidity risks (e.g.,

previous gastrointestinal bleeding or chronic renal

failure)


• Opioids

• Short term use

• Caution in elderly

• Duloxetine (60-120mg QD)

• If contraindication to NSAIDs or not responded

to NSAIDs

• Topical capsaicin

• One (or few) joints involved

• Lack of response or contraindications to other Tx


• Acetaminophen

• Not considered first-line

• Negligible effects on pain

• Toxicity

Roberts E, Delgado Nunes V, Buckner S, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis 2016; 75:552


• “Structure modifying treatments”

• Intraarticular hyaluronic acid (HA)

• Controversial for knee and hip OA

• Evidence demonstrates only a small superiority

over intraarticular placebo

Bannuru RR, Schmid CH, Kent DM, et al. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 2015; 162:46

Biologic Injections

• Platelet-rich Plasma (PRP)

• Mesenchymal stem cells

• Many ?? about effectiveness

• Long-term clinical trials still needed

• Preparation techniques make effective evaluation and

comparison difficult

• Bone marrow mesenchymal stem cells currently only

stem cell product that appears to be approved by FDA

• Adipose stem cell use complicated by warning letters

from the FDA suggesting orthopaedic use to be improper

Matthew J. Kraeutler, Jorge Chahla, Robert F. LaPrade, Cecilia Pascual-Garrido, Biologic Options for Articular Cartilage Wear (Platelet-Rich Plasma, Stem Cells, Bone Marrow Aspirate Concentrate), Clinics in Sports Medicine, Volume 36, Issue 3, 2017, Pages 457-468.


• Nutritional supplements

• Glucosamine, chondroitin, vitamin D, diacerein,

avocado soybean unsaponifiables (ASU), fish oil,

etc.)

• Golden milk (turmeric spice + coconut milk/oil)

Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis

management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum 2014; 43:701

Alternative Therapies

• Acupuncture

• Traditional Chinese medicine

• Transcutaneous nerve stimulation (TENS)

Surgical Treatment

• Arthroscopy

• No clinically significant benefits over conservative

treatment or placebo surgery for knee OA

involving partial meniscectomy +/- debridement

Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015; 350:h2747

Surgical Treatment

• Osteotomy

Surgical Treatment

• Arthroplasty (joint replacement) is highly effective

in patients with advanced knee and hip OA when

conservative therapies have failed to provide

adequate pain relief

Skou ST, Roos EM, Laursen MB, et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med 2015; 373:1597Beswick AD, Wylde V, Gooberman-Hill R, et al. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012; 2:e000435

Total Knee Replacement

• Indications• Symptomatic knee osteoarthritis

• Failed non-operative treatments

• Usually only considered in people over the age of 60

• Typically last about 12-15 years in an

elderly population

• Not recommended in younger patients• Younger patients are more active more stress on

the artificial joint

• Revision surgery is more difficult with poorer results

MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2018 April 5]. Knee joint replacement. Available from: https://medlineplus.gov/ency/article/002974.htm

Unicompartmental Knee Replacement

• Careful patient selection is critical• Single compartment involvement

• Malalignment is passively correctable

• Knee is stable

• Similar to total knee replacement• Smaller incisionless blood loss

• Less morbidity

• Less expensive

• Quicker recovery and faster rehabilitation

• Preservation of normal kinematics

Knee Arthroplasty

Hip Arthroplasty

• Cemented• Elderly (>65)

• Low demand

• Better early fixation

• ? late loosening

• Porous coated• Younger

• More active

• Protected weight-bearing first 6 weeks

• Better long-term fixation

Hip Replacement

Other Types of Hip Replacement

• Hemi-arthroplasty• Only the femoral side is replaced

• When acetabulum is intact

• May not be efficient in pain relief

• Hip Resurfacing• In younger patients

• Complication of a neck fracture

Take Home

• Primary symptoms are joint pain, stiffness, and

locomotor restriction

• Age ≥45 years

• ♀ > ♂• Morning stiffness ≤30 minutes

• Physical exam reveals joint tenderness, crepitus,

+/- swelling, weakness, decreased motion late

• Imaging reserved for atypical symptoms or pre-

operative planning

Take Home

• Exercise

• Bracing

• Cane

• Pain-coping skills

• NSAIDs

• Duloxetine

• Intraarticular glucocorticoid injections

• Surgery when significant joint-related symptoms

persist despite nonsurgical interventions

Questions?

An evidence-based

approach to the patient with

hip or knee osteoarthritis

Larry Collins, MPAS, PA-C, ATC, DFAAPA

Assistant Professor, Physician Assistant Program

Assistant Professor, Department of Orthopaedics & Sports Medicine

USF Health, Morsani College of Medicine

[email protected]

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