Emory Osteoarthritis Clinical Pathway. Brandon Mines, MD Emory Sports Medicine Center

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Priscilla Johns
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1 Emory Osteoarthritis Clinical Pathway Brandon Mines, MD Emory Sports Medicine Center

2 Nothing to disclose

3 Osteoarthritis Overview The Graying of America % of Population Aged Year Manek NJ, et al. Am Fam Physician. 2000;61: Centers for Disease Control and Prevention. MMWR. 2004;53:

years of age and older Symptomatic OA of knee 11% of people

4 OA Prevalence Most common form of joint disease worldwide Radiographic evidence >50% at 65 years of age 80% at 75 years of age and older Symptomatic OA of knee 11% of people >64 years of age Manek NJ, et al. Am Fam Physician. 2000;61:

$lubricating and cushioning properties of the joint Secondary inflammation Subchondral damage Microfractures Cyst$

5 OA Pathophysiology Erosion of cartilage Decrease in concentration and viscosity of synovial fluid Decreased lubricating and cushioning properties of the joint Secondary inflammation Subchondral damage Microfractures Cyst formation

6 Clinical Pathway A work in progress Broad spectrum of physicians, interests, experiences and opinions We see different types of patients Different patients have different expectations

7 That being said Clinical Pathway First, do no harm Least Most invasive Educate Don t give false hope, but be optimistic Be brutally honest...in a nice way Social network is important Friends Family Support groups/system If one feels defeated, then one is defeated

8 Case 45 yo male, recreational athlete Enjoys running, tennis, mountain biking and cross fit Intermittent knee pain No reported injuries Overall, feels limited on how much he can do and how long he can do it

9 Case Finally, patient visits Emory Sports Medicine Center History, exam & x-rays Mild knee osteoarthritis Devastating news Lifestyle changes Lots of questions What do I do now, doc?

10 Osteoarthritis

11 Osteoarthritis Pathway Currently a work in progress for us Reviewing data & best clinical practices Evidence based medicine vs. consensus statement What I have always done versus what the evidence says I should do

12 What does our patient need to hear 1 st?... Education: Takes time, but needs to understand what he is up against Needs to be in terms he can digest & accept Don t forget learner types See it, read it, hear it Needs to absorb/accept diagnosis

13 Education This gets glossed over very often At Emory: Anatomical models Tablet videos Pictures Website recommendations Takes time, but time well spent!

14 Rehabilitation I already have a trainer at the gym I ll just get some exercises off the internet At Emory: Vitally important to discuss the role of rehabilitation Explain differences personal trainer google-derived exercises physical therapy Several studies have shown beneficial outcomes in regards to rehabilitation and self-management programs

15 Rehabilitation Coleman et al, 2012 Patients in a 6 week self-management program Statistically significant Improved WOMAC score Less stiffness Improved function

16 Rehabilitation Deyle et al, 2000 Physical therapy and Osteoarthritis Statistically significant: Improvement in WOMAC scores with PT and knee exercises

17 What fits your schedule better? Exercising 1 hour per day or being dead 24 hours a day?

18 Ok, Ok, I hear ya doc, but what exercise CAN I do? Exercise: At Emory: Keep moving! Watch out for impact activities Prefer bike, elliptical, walking, etc. Water sports/aerobics Everything in moderation Case

19 We assume patient KNOWS they need to lose weight... Makes an out of you & me Patient says, you think that would make a real difference?

20 Case: Weight Loss How much is suggested? At Emory: Goal is getting to ideal body weight Surgical standpoint: Under BMI at least

21 Weight Loss Toivanen et al 22 year follow up Risk of knee OA was 7 times greater for BMI > 30 compared to BMI < 25

23 Case Doc, how am I suppose to lose weight and stay active if my knee hurts so bad right now? NSAIDs: At Emory: Start with OTCs Less $ Easier access Educate on how to take them

24 NSAIDS Many studies have looked at this Selective NSAIDs (i.e. Celebrex) Non-selective NSAIDs (i.e. Ibuprofen) Statistically significant improvements in pain Compared to placebo

25 Case: NSAIDs May need to try prescription NSAIDs Topicals may be better tolerated Diclofenac less cardiac, GI, renal side effects Tylenol has been shown to not be better than placebo We recommend avoiding Tylenol at this time Not helping pain People tend to take too much

26 Case I m going to need something that starts making me feel better faster than that! Corticosteroid injections: Widely done and widely accepted as OK to do Chao et al, 2010 Compared to saline WOMAC scores statistically better at 4 weeks

27 Case: Corticosteroid Technique may make a difference Ultrasound guidance, when needed/able Patient comfort for knee aspiration Quick point-of-care hip joint injection No need to re-schedule for fluoro-guided injection If time allows, can do right there in office Mild OA responds better than severe OA

28 Case that s great doc, but do you have something that may give relief longer than cortisone? Viscosupplementation: Hyaluronic acid Rooster comb; recombinant DNA/bacteria Lubricate joint Controversial product Does it really work?

29 Case American Academy of Orthopaedic Surgeons (AAOS) does not recommend but American Medical Society for Sports Medicine (AMSSM) does recommend Based on method of reviewing the data Complicated but related to how you interpret patient pain scores In either case, it is still covered by insurance plans In my hands 70% - 75% of mild/moderate knee OA patients are happy they did it Severe OA success drops to 20% - 30% of patients get relief Generally getting 6-9 months of some type of relief (mild/moderate OA) Typically, start with CSI, then add on visco when needed

30 Viscosupplementation Several preparations One injection 3 injections 5 injections No clinical difference seen in any of them Some are more biologically clean Less inflammatory reactions

31 Case But what can I do myself. I m not that excited about injections! Unloader knee braces: Medial > lateral Custom fit Bulky to low-profile Literature is +/- with utility of these braces Will offer, for the willing patient, who may be adverse to injections

34 Knee braces Brouwer et al, 2006 Multi-center RCT; medial knee OA Showed small effects in improving pain scores Kirkley et al 1999 RCT; medial knee OA Significant benefit from using medial unloader

35 Knee braces Anecdotally, seems to work minority of the time Doesn t fit well with the more obese leg Insurance covered expense, but tends to still be expensive for patient As a general rule, we aren t that excited about it, but we don t steer people away from it

36 I heard supplements are good to take?! Glucosamine/chondroitin: Studies are 50/50 on if it helps or not Hard to know what to take from that Glucosamine tends to be the more important ingredient We consider risk/benefit with this $$, allergies, mild increase in diabetic blood sugar Not invasive, patient is doing something, placebo affect? Definitely not something we tend to outright recommend, but if all else fails, tend to be OK with people trying it

37 Case I still don t want joint replacement. What about those platelet injections, or stem cells? PRP or Stem cell injections: Controversial Studies are hit and miss regarding efficacy Seems to be better for knee than hip

38 Orthobiologics May be helpful in mild/moderate knee osteoarthritis Insurance not covering these injections Offer it as an option but with caveats Still under heavy research/scrutiny Won t hurt you, but not sure if it will help as much as you want You are not re-growing cartilage You still have osteoarthritis & we don t know how to stop it from progressing

39 Surgery I m ready to get this problem fixed Total joint replacement When patient is fed up with pain Pros outweigh cons

40 Thank you! Brandon Mines

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