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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
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Disclosures
I have no real or apparent conflicts of
interest to report
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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
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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
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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
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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.
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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
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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
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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
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• 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
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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
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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.
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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.
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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
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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
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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
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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
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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
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Hip Physical Examination
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
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Hip Physical Examination
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
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Hip Physical Examination
Dr. Donald Corenman, MD - Colroado Spine Doctor. www.neckandback.com. http://www.flickr.com/photos/neckandback/6145561772/. Accessed 8/10/2017.
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Hip Radiographs
Weight bearing AP pelvis Lateral Hip
http://www.wikiradiography.net/page/Pelvis+Radiographic+Anatomy. Accessed 8/10/2017.
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Hip Radiographs
Case courtesy of Townsville radiology training, Radiopaedia.org, rID: 18287. Accessed 11/13/2017.
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Knee OA
• Obese females >50
• Joint stiffness (<30
minutes)
• Mechanical pain
• Crepitus
• Pain with pressure
• Painful ROM
• Functional limitations
• Limited ROM in later
stages
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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
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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
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Knee Physical Examination
• 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.
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Windswept Knee Deformity
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Knee Physical Examination
• 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.
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Knee Physical Examination
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.
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Knee Physical Examination
Effusion Bursitis
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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.
Knee Physical Examination
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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
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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
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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.
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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.
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Genu Varus/Valgum – Orthosıs
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Pharmacologic Therapy
• Oral and topical NSAIDs
• Opioids
• Duloxetine
• Topical capsaicin
• Intraarticular glucocorticoids
• “Structure modifying treatments”
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Pharmacologic Therapy
• 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)
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Pharmacologic Therapy
• 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
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Pharmacologic Therapy
• 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
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Pharmacologic Therapy
• “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
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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.
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Pharmacologic Therapy
• 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
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Alternative Therapies
• Acupuncture
• Traditional Chinese medicine
• Transcutaneous nerve stimulation (TENS)
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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
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Surgical Treatment
• Osteotomy
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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
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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
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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
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Knee Arthroplasty
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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
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Hip Replacement
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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
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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
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Take Home
• Exercise
• Bracing
• Cane
• Pain-coping skills
• NSAIDs
• Duloxetine
• Intraarticular glucocorticoid injections
• Surgery when significant joint-related symptoms
persist despite nonsurgical interventions
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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