surgery for OA.docx

Osteoarthritis Osteoarthritis (OA) is one of the most common forms of arthritis Impacts estimated 302 million people worldwide Knees, hips and hands are the most common sites Nonoperative Management of Osteoarthritis Non-opioid analgesia/Supplements Walking aids, bracing Weight loss, activity modifi...

Osteoarthritis Osteoarthritis (OA) is one of the most common forms of arthritis Impacts estimated 302 million people worldwide Knees, hips and hands are the most common sites Nonoperative Management of Osteoarthritis Non-opioid analgesia/Supplements Walking aids, bracing Weight loss, activity modification Physiotherapy Joint injections Non-operative management of Osteoarthritis involves a comprehensive multi-disciplinary approach involving many different modalities making up a “team” Nonoperative Management of Osteoarthritis Non-opioid analgesia/Supplements Walking aids, bracing Weight loss, activity modification Physiotherapy Joint injections Overall goal of non-operative management of osteoarthritis is to reduce pain, improve function and optimize quality of life Nonoperative Management of Osteoarthritis Management of Osteoarthritis is a team sport! Involves patient education on optimization of nonoperative measures Patients should understand the importance of nonoperative management Surgery isn’t necessarily the answer Guidelines ACR/AF 2019 (hip, knee, hand) OARSI 2019 (hip, knee, polyarticular) EULAR 2018 (hand), 2013 (hip, knee) NICE 2014 AAOS 2013 Eumusc.net – OA standards of care 2013 Health Quality Ontario – OA standards 2018 Physiotherapy/Exercise Is strongly recommended in patient with hip and knee arthritis Good evidence to show its use Ideal for optimization if surgery is anticipated Low demand (cycling, swimming, yoga) are more easily tolerated Successful physiotherapy involves in office and at home regimens Physiotherapists (PT) vs Occupational Therapists (OT) Walking Aids Walking aids are recommended by most guidelines for patients with hip and or knee arthritis causing an impact on ambulation Remember to use in the opposite hand! Frames or wheeled walkers for bilateral disease Moderate evidence for their use Supportive footwear can improve walking mechanics Not universally recommended in guidelines Low quality evidence Bracing For patients with mild/moderate instability associated with arthritis, bracing can reduce pain, improve stability and diminish risk of falling Evidence is only moderate, conflicting and often low quality Can be expensive, cumbersome for patients Weight Loss Is strongly recommended for patients how are overweight/obese – moderate evidence Frequently recommended in guidelines The greater benefit there is with more weight loss Important benefits begin >7.5% of body weight loss Nonopioid Analgesia Tylenol is an effective (up to 4 g a day) agent for arthritis pain in the hip and knee strong core recommendation NSAIDS can be added if Tylenol is inadequate (strong recommendation) Lowest effective dose Consider COX-2 selective agents in patients with GI upset or prescribe gastroprotection with non-selective agents Caution in patients with cardiovascular risk Consider topical (Voltaren) agents to avoid systemic route Intra-articular injections Glucocorticoids Hyaluronic Acid Platelet Rich Plasma Stem Cell Glucocorticoids Reduce inflammation with strong anti-inflammatory properties Catabolic properties is concerning in the long term May accelerate cartilage loss over time Short term solution Evidence is mixed for recommended use Placebo effect is though to be a factor What should we do in 2022? The evidence is mixed for corticosteroid use Short term benefit Select patients may benefit Strength of evidence varies What I tell my patients It is not a long-term solution Law of diminishing returns Hyaluronic Acid Hyaluronic Acid (HA) is the main component in viscosupplementation Naturally occurring polysaccharide within synovial fluid viscoelastic shock absorber in high shear movements Lubricant in slow movement Thought to have anti-inflammatory and anti-nociceptive properties Hyaluronic Acid Synthetic form of HA, first approved in Canada in 1992 Current preparations harvested from Rooster combs (avian-based) In vitro bacterial fermentation (non-avian) Hyaluronic Acid “Fewer Orthopaedic interventions have gained as much research attention recently as viscosupplementation; however, considerable controversy still persists regarding its clinical effectiveness and safety” -Johal et al, JBJS Reviews April 2016 Hyaluronic Acid – What should we do in 2022 There is no current evidence to support the routine use of HA There may be a role in the young active patient who is not ready for TKR Might give several months of symptom improvement Likely not harmful if patients wish to try What I tell my patients We do not know if it works based on our current literature It is up to them, I neither recommend nor discourage Expensive with no guaranteed outcome Cell Therapies Autologous Therapies Platelet Rich Plasma Bone marrow aspirate concentrate Adipose Tissue Injections Stromal vascular fraction “Stem” or stromal cell therapies Platelet Rich Plasma Autologous platelets, growth factors and cytokines that have been centrifuged to concentrate and re-injected into the patient’s knee – “orthobiologic” Another highly studied point of care therapy for OA Substantial variations in literature noted 13 meta-analysis by 2021 with varying results Marketed to regenerate cartilage It doesn’t! Platelet Rich Plasma There is no current evidence to uniformly support the routine use of PRP intra-articular injections for arthritis I do not offer as a treatment option It does not regenerate cartilage We do not know the proper dose or frequency Cell Therapies Mesenchymal ‘stem’ cells are undifferentiated cells capable of differentiating into other cell lines depending on their environment In vitro regenerative behavior Bone marrow aspirate concentrate (BMAC) Not mesenchymal cells – ‘minimally manipulated’ Frequently marketed as stem cells with regenerative capability Cell Therapies – Bottom Line Safety profile unclear Efficacy unclear Literature has multiple problems Small sample sizes Potentially inappropriate controls Short-term follow-up We aren’t there yet Cannot use in Canada unless part of study Cell Therapies – What should we do today? There is no current evidence to support the routine use of stem cell intra-articular injections Not approved in Canada for use outside of a study What I tell my patients It is not available We do not know the dose or frequency In its current state, it does not regenerate cartilage Operative Management in Hip and Knee Arthritis Indications: 1. Nonoperative management has been maximized 2. Pain from arthritis interferes with quality of life 3. Patient has reasonable expectations of joint replacement. Hip Arthritis – Operative Management in Arthritis Total Hip Arthroplasty (THA) ”Operation of the Century” – Lancet 2008 Highly successful operation (95%) to reduce pain and restore function of an arthritic joint Arthroscopic debridement Not effective in the routine management of arthritis Possible role for labral tears or femoral acetabular impingement Hip Arthritis – Operative Management in Arthritis Total Hip Arthroplasty (THA) Several recent advancements have allowed for increased lifespan of a total joint Modern hip replacements are lasting 30+ years More widely used in younger patients (45 and older) than previously Knee Arthritis – Operative Management in Arthritis Knee Arthritis– Operative Management in Arthritis Arthroscopic debridement Like hips, not effective in the routine management of arthritis that is progressing May have a use with mechanical symptoms (unstable meniscus) Knee Arthritis– Operative Management in Arthritis Arthroscopic Microfracture Technique Idea is to create micro fractures in areas of exposed bone to stimulate bone marrow stem cells for cartilage regeneration Appropriate for small symptomatic lesions (< 2 cm) Requires careful rehab Moderate improvement, but inconsistent results (20- 30% cannot return to level of sport) Knee Arthritis– Operative Management in Arthritis Autologous Cartilage Implantation “neocartilage” incorporates and functions to improve joint glide Good to excellent results in 60-80% depending on the study Knee Arthritis– Operative Management in Arthritis Autologous Cartilage Implantation Osteochondral autologous transplantation (OATS) Take several cylindrical plugs harvested from non weight bearing zone to deficient area Knee Arthritis– Operative Management in Arthritis Allograft Osteochondral Transplant (donor cadaver) Harvested from fresh cadaver Immediate transplantation Small numbers in studies Knee Arthritis– Operative Management in Arthritis High Tibial Osteotomy When medial compartment is arthritic with no changes to the rest of the knee, can be considered Meant to “offload” the medial compartment by realigning the tibia Option for young, active patients with moderate arthritis in the medial compartment Often require eventual conversion to TKR Knee Arthritis– Operative Management in Arthritis Knee Arthroplasty Partial or Total Critical to optimize nonoperative treatment options in knees prior to replacement Outcomes are not as successful as THR Active patients can be disappointed with their activity level post TKR Is meant to treat PAIN, not to restore high intensity athleticism High impact/running activities after TKR are not recommended Knee Arthritis– Operative Management in Arthritis Knee Arthroplasty Partial knee replacement replaces only part of the joint that is degenerative Narrow indications for its use Partial knee replacements do not last as long as total replacements 10% need revision in first decade 15-20% need revision in the second decade depending on study Knee Arthritis– Operative Management in Arthritis Knee Arthroplasty Total knee replacement replaces the entire tibiofemoral joint +/- patella Knee Arthritis– Operative Management in Arthritis Knee Arthroplasty Successful in 85% of patients for pain relief Return to sports can be unpredictable Young patients' activity levels must be considered Last on average 20 years if looked after Not for high intensity Athletes! Knee Arthritis– Operative Management in Arthritis Do not count out nonoperative treatment options! Arthritis management is a team process Patient education is critical Surgery isn’t for everyone, but it has a central role