The Young Arthritic Knee
INCIDENCE OF KNEE OSTEOARTHRTIS IN THE YOUNG
HOW TO DIAGNOSE KNEE OSTEOARTHRITIS IN THE YOUNG?
HOW TO TREAT KNEE OSTEOARTHRITIS IN THE YOUNG?
NON-OPERATIVE TREATMENT FOR KNEE OSTEOARTHRITIS - ORTHOPAEDIC GUIDELINES (AAOS)
TREATMENT OF THE YOUNG ARTHRITIC KNEE IN MY PRACTICE
INCIDENCE OF OSTEOARTHRITIS IN THE YOUNG.
Osteoarthritis (OA) is the most common form of arthritis and the third-leading cause of life-years lost to disability.
By the age of 65 years, 50% of the population have OA and, as population ages in demographic terms, the prevalence of OA is expected to rise. 90% of people over the age of 40 years complaining of knee pain have OA even if their X-rays are normal.
The aging of the Baby Boom generation, who started reaching 65 years old in 2011, is a factor in the increased future demand for knee replacement surgery in the western world. Knee OA is diagnosed about 13 years earlier, from 69 years in the 1990’s to 56 years in 2010. In the US forecasts show an increase in demand for Total Knee Replacement (TKR) surgery by 673% by 2030. Recent literature reports tripling of TKR use in 45 to 65 years olds in the US. Currently in the US about 40% of all knee replacements are done in people under the age of 65. Similar data is emerging from Finland showing increased use of TKR in the young.
HOW TO DIAGNOSE OSTEOARTHRITIS IN THE YOUNG
CLINICAL DIAGNOSIS. Patients with knee OA complain of discomfort or pain in their knee, which could be consistent or intermittent. The pain is usually worse with activity such as climbing stairs or walking for long distances and relieved by rest. Stiffness of the knee often occurs. This is usually because of fluid accumulating inside the knee joint. The patient finds it difficult to fully straighten the knee and often there is a fixed flexion deformity at the knee joint. Crepitus or grinding is felt in more advanced stages of OA. In the young adult population (patients in their 40’s to 60’s) those signs and symptoms can be subtle and intermittent and always precipitated by a “loading event” such as for example: sudden increase in exercise, putting on weight, a recent holiday and long distance walking, moving house or increase or domestic duties etc Many people with arthritis note increase in their knee pain with rainy weather.
IMAGING. Weight-bearing Knee X-rays are best for screening for OA in the knee joint. When taken the X-rays the patient should be standing so reduction of the joint space will become evident under the body weight. Often sub-chondral bone sclerosis and formation of osteophytes is present on the X-ray. In the presence of a normal weight-bearing X-ray a MRI of the knee can be performed to determine the condition of the soft tissues around the knee. In reality, nowadays a lot of patients present to their GP or Specialist with a MRI report. The majority of MRI reports in patients of that age group (40’s – 60’s) will read a ‘meniscal tear’. There is published research showing that patients have an emotional reaction to the word ‘tear’ and associate it with something that would have to be ‘trimmed’, ‘cut’, ‘removed’ or ‘repaired’.
The majority of patients when reading the MRI report themselves they have a natural desire to improve the situation and therefore will be looking favorably towards surgery, such as ‘clean-out’ or ‘wash-out’ arthroscopic knee surgery. In reality ‘degenerative meniscal tears’ are normal for that age group (I call them ‘wrinkles and grey-hair’), as collagen degeneration happens naturally with aging. The large majority of the ‘degenerative meniscal tears’ do not require surgery and are best treated with non-operative treatment. That is why the MRI films should be reviewed by an Orthopaedic Specialist and interpreted in the patient’s clinical context.
The patient should be advised that not all meniscal tears need surgery.
There is increasing evidence (prospective randomised controlled trials) published in recent years, showing no benefit of surgical treatment for degenerative meniscal tears (arthroscopic partial meniscectomy) over physiotherapy. I often make the analogy of removing degenerative menisci with 'removing the shock absorbers from an old car, just because they squeak'. Like the old car, that side of the knee joint will further collapse after meniscectomy and the cartilage deterioration will be exacerbated. Often the symptoms are getting worse as it is the subchondral bone edema after partial meniscectomy in early OA. I call this 'post-meniscectomy syndrome'.
(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrows).
(Right) This x-ray of an arthritic knee shows severe loss of joint space.
HOW TO TREAT OSTEOARTHRITIS IN THE YOUNG?
The ultimate goal of knee OA treatment focuses on the reduction of symptoms, especially pain, in addition to optimization of joint function to support activities of daily living.
There are three major categories of treatment in osteoarthritis: pharmacological, non-pharmacological, and surgical. The most effective OA management is multidisciplinary and staged, using combinations of approaches and prioritizing the most conservative treatments over those which are move invasive or have more severe complications. Each of the three treatment categories is summarized below:
Pharmacological Treatments: A mainstay in OA management, drug therapy combines a variety of agents that are mostly analgesic or both pain-reducing and anti-inflammatory.
Non-Pharmacological Treatments: include a range of treatments such as physiotherapy; weight loss; nutritional supplements; exercise; and joint protection. Clinical guidelines indicate that non-pharmacological treatments should be a “cornerstone” of treatment, though more research is needed to produce evidence-based rationales for these conservative approaches to OA.
Surgical Treatments: Surgical intervention (such as re-alignment surgery or arthroplasty surgery) is warranted if conservative modalities have not sufficiently relieved pain or disability, with the choice of procedure being guided by the stage of disease, the type of symptoms and co-morbidities and patient expectations.
Patients with knee OA may move through all three levels of treatment and experience the full continuum of care. When the disease cannot be managed in the general practice setting, then a referral may be made to a physiotherapist or occupational therapist, rheumatologist or orthopaedic surgeon. Sometimes specialized education clinics may be appropriate. Education is not always a discrete treatment per se, but rather an adjunct to all the interventions requiring active involvement of the patient, and adherence to a treatment plan. In some instances patient education takes the form of a package of self-management approaches. In other instances it involves specific instruction and follow-up, or trouble-shooting and advice. Dedicated, multidisciplinary OA clinics are becoming the best environment for treatment of OA in the young adults around the world (i.e. Canada, Australia).
NON-OPERATIVE TREATMENT OF KNEE OA – ORTHOPAEDIC GUIDELINES (AAOS)
The American Academy of Orthopaedic Surgeons (AAOS) recently (2013) released a summary of recommendations for the non-operative treatment of knee OA based on the exiting evidence from medical research studies. The report is a 1,200 pages document and involved review of 10,000 published studies reporting on various non-operative treatments for knee OA. The presented evidence is controlled for bias, transparent and reproducible. The guidelines have been written by orthopaedic surgeons and scientists and are continuously revisited and updated.
The recommendations presented are classified as strong, moderate and inconclusive.
A Strong recommendation means that the quality of the supporting evidence is high. Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
A Moderate recommendation means that the benefits exceed the potential harm, but the quality/applicability of the supporting evidence is not as strong. Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.
An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm. Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
TREATMENT OF THE YOUNG ARTHRITIC KNEE IN MY PRACTICE
After taking a detailed history and performing a thorough clinical knee examination, I spend the required amount of time with the patient explaining the diagnosis of knee osteoarthritis. I find using a knee model and looking at the available images (Xray & MRI) together with the patient an easy way to give some insight in his/her condition. I then discuss in depth the natural course of the knee osteoarthritis and the expected results with all treatments, including surgical and non-surgical interventions. This will allow the patient to be actively involved in the decision-making process and make an informed decision on what is the best treatment option for him/her.
In the majority of cases I recommend initial non-operative treatment for knee osteoarthritis in the young patient in order to reduce the symptoms and improve the quality of life. I discuss in detail with each patient the available evidence and the AAOS recommendations for non-operative treatment of knee OA.
I do not recommend arthroscopic knee surgery for treatment of knee osteoarthritis.
If, despite aggressive and persistent non-operative treatment the symptoms continue to affect patient’s quality of life or are getting worse, then I discuss alternative surgical treatment (such as High Tibial Osteotomy or Total Knee Replacement) at subsequent visits. Proceeding with surgery in such situations is always an informed and joined decision with the patient. This ensures patient sound expectations and ultimately it will ensure the greatest satisfaction and best possible outcome form their treatment.
Below is one page summary of the AAOS Guidelines for non-operative treatment of knee osteoarthritis.
AAOS GUIDELINES FOR NON-OPERATIVE TREATMENT OF KNEE OSTEOARTHRITIS
Arthroscopy - Strong Recommendation: No benefit over physical therapy and medical treatment in 3 of 3 studies
Glucosamine, Chondroitin, Fish Oil - Strong Recommendation: No evidence of clinically important improvements over a placebo in 2 studies
Acupuncture - Strong Recommendation: No benefit over placebo in 8 studies
Hyaluronic Acid - Strong Recommendation: No benefit is demonstrated over placebo. 14 studies
Lateral wedge insoles - Moderate Recommendation: No improvement in 4 of 5 studies
Needle Lavage - Moderate Recommendation: No improvement in 2 of 2 studies
Electrotherapeutic modalities (electrical stimulation) - Inconclusive Recommendation
Medial compartment unloader braces - Inconclusive Recommendation
Corticosteriods - Inconclusive Recommendation
Growth factor injections or Platelet Rich Plasma - Inconclusive Recommendation
Low impact aerobic exercise (e.g. cycling, swimming, walking, yoga) - Strong Recommendation: Significant benefit in 5 of 7 high strength studies
Weight Loss for those with BMI >25 - Strong Recommendation: Beneficial in 3 of 3 studies
Non Steroidal Anti-inflammatory drugs (NSAIDs) - Strong Recommendation: quality of evidence demonstrating effectiveness is high.
Mobic, Naprosyn, Arcoxia, Mobic, Celebrex, Voltaren, Nurofen.
Supervised Physiotherapy aimed at improving strength, balance and, flexibility. - Strong Recommendation