Non-operative Treatment of Osteoarthritis. Health Chat June 21 & 22, 2016 Aaron Leininger, MD

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1 Non-operative Treatment of Osteoarthritis Health Chat June 21 & 22, 2016 Aaron Leininger, MD

2 About Me Aaron Leininger, MD Clemson University Mechanical Engineering Varsity Soccer, Formula SAE race car Class of 2001 University of North Carolina School of Medicine Class of 2006 Moses Cone Family Practice Residency Class of 2009 Moses Cone/Elon Univ Sports Medicine Fellowship Class of years at Carolina Family Practice & Sports Med University Orthopedics and Sports since July 2015

3 About Me Aaron Leininger, MD Married to Lara Leininger (Wound RN) with 2 kids Logan 6, Daniel 4 (Adopted from China) Hobbies: Soccer Varsity Clemson, Coach sons, Adult league Outdoor activities Camping, kayaking, disc golf, hiking Exercise - Triathlon/Running/Cycling Greenway Triple Tandem riding with my sons Organize 5K race Bella Rose Strides for Babies 5K August 6, 2016 (5 years) Vintage Video Games Multiple Arcade Machine and Virtual pinball Machine

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5 Arthritis Definition Arthritis - Painful inflammation and stiffness of the joints.

6 Types of Arthritis Non-inflammatory Osteoarthritis Most common Inflammatory Arthritis Rheumatoid Arthritis Gout Uric Acid Auto-Immune Arthritis Systemic Lupus Erythematous Other rare disorders/syndromes Infectious (Septic) Arthritis Bacterial Typically severe and need IV antibiotics and possibly surgery Viral typically self-limted.

7 Osteoarthritis Primary No specific injury Obesity Secondary Related to the effects of previous trauma Intra-articular fracture Ligament damage resulting in joint instability

8 Osteoarthritis Combination of Symptoms - pain, swelling, stiffness of joints X-ray changes Joint space narrowing Osteophytes (Bone spurs) Bony sclerosis (Thickening of bone just around joints) Subchondral cysts (cysts under the joint surface in the bone) Progressive loss of articular surface cartilage

9 Common Osteoarthritis Locations Neck Discs or Facet (rear) joints Shoulder Acromioclavicular joint ( AC collarbone to shoulder blade) Glenohumeral joint (ball and socket) Elbow Wrist Hand 1 st CMC joint Base of the thumb

10 Common Osteoarthritis Locations Back Discs or Facet joints (rear) Hips Knee Ankle Great Toe

11 Osteoarthritis Treatment Operative Exhaust non-operative treatment options first Typically replacement Removal of the ends of the bones of the joint and securing of anartificial joint to the area. Exceptions Distal clavicle excision Clean out arthroscopy Evidence is lacking.

12 Osteoarthritis Treatment Non-Operative Weight Loss Less weight means less stress/strain through joints Extremely important, but difficult to implement Non-Operative Exercise Consistent exercise like walking has been shown to decrease symptoms and progression of osteoarthritis Catch-22 Can t exercise due to pain and weight Have pain and weight because I don t exercise.

13 Osteoarthritis Treatment Non-Operative Physical Therapy Strengthen Muscles around the affected joint Bear some weight through muscles and not joints/bones Position joint such that less painful surfaces bear weight Increase joint stability decreasing stress Work to maintain Range of Motion Limit stress on joint or surrounding joints Maintains functionality eg. Inability to bend knees Can t sit in certain positions

14 Osteoarthritis Treatment Non-operative Bracing Immobilize Helpful for joints in the wrist or base of the thumb to rest Not helpful for many joints like the knee Simple compression Helpful for kneecap arthritis to help position the knee cap Supportive brace that maintains Range of motion Hinged Braces are helpful sometimes for the knee Sophisticated braces designed to shift weight off arthritic section of joint

15 Osteoarthritis Treatment Non-Operative Oral Medication Tylenol/Acetaminophen 1000mg Twice to Three times daily Lower dose for older age Scheduled tends to work better than as needed On average scientific studies show its equivalent and safer than NSAIDs Oral NSAIDs OTC Aleve (naproxen), Motrin/Advil (ibuprofen) Prescrition: Naproxen, Voltaren (diclofenac), Mobic (meloxicam) Higher risk, especially long-term (heart disease /reflux/diabetics) Kidney Failure, Ulcers, Raise BP, Some can cause Liver Failure Heart attack risk and interaction with blood thinners

16 Osteoarthritis Treatment Non-Operative Topical Medication Topical NSAIDs Much safer than NSAIDs Just as effective generally for single joint Can t use on the whole body Only prescription in the US (diclofenac or compound) Generally relatively expensive even with insurance Topical Capsaicin Burning sensation too intense for many people Menthol based topicals Limited effect

17 Osteoarthritis Treatment Steroid or Cortisone Injection Steroid Anti-inflammatory Medicine Actual Medicine usually Kenalog (Triamcinolone) or Depo Medrol When helpful, commonly 3+ months of improvement Early stages can be helpful for more than one year At least 3 months between injections Raises Blood Sugar It is unclear whether they have a negative longterm affect on the joint Several months of improvement is considered worth this risk when pain renders current joint status unusable.

18 Osteoarthritis Treatment Hyaluronic Acid Injection Most evidence for Knees Technically can be used in other joints, but may not be covered Only side effect is allergy or rare inflammatory reaction Response Hit or Miss Maybe 60% response Those that do respond typically are better for several months 6 months between injections More expensive than cortizone Usually 3 shot series 1 shot available, but it is considerably more painful

19 Osteoarthritis Treatment PRP Platelet Rich Plasma Still semi-investigational Clearly very safe Several supportive studies Best protocol is not clearly defined 1 shot? Schedule shots now, 1m, 6m? Expensive and not covered by insurance $500 out-of-pocket Last resort.

20 Osteoarthritis Treatment Future treatments: Stem Cells? Active area of research

21 Osteoarthritis Treatment Ultrasound Imaging Used to guide the needle to the correct location for injections In-Plane injection Visualize the needle completely Most larger, deeper joints Out-of Plane Visualize the needle in cross section Most Smaller, superficial joints Indications Deep joints with no accurate landmarks for palpation Hip, Glenohumeral shoulder joint Small joints that are a difficult accurate target Hand joints, Foot Joints, AC joint of shoulder, etc.

22 Thank you!