Panel discusses nonoperative treatment options for patients with knee osteoarthritis
Treatment for knee osteoarthritis is being looked at with more scrutiny as more than 10 million adults in the United States are estimated to have symptomatic osteoarthritis of the knee. Nonoperative treatment options are increasing and it is difficult to know which treatment option is better for which patient. Some insurance plans require clinical documentation that a patient has failed nonoperative treatment prior to pre-certifying the patient for a surgical procedure.
Clinical practice guidelines for knee osteoarthritis (OA) were developed and published by the American Academy of Orthopaedic Surgeons (AAOS) in 2008. The guidelines have been helpful and have stimulated discussion among physicians as some more popular treatments were considered “inconclusive” or “of poor quality evidence.”
The purpose of this Orthopedics Today Round Table is to solicit advice from high-volume knee physicians as to how they treat patients with knee OA in their respective practices. Drs. Beaver and Mont are orthopedic surgeons and Dr. Genin is a nonoperative sports medicine specialist, so it is interesting to see any differences in their approaches to nonoperative treatment of the OA knee. I hope this information is as useful to you as it was for me.
Frank R. Kolisek, MD
- Frank R. Kolisek, MD
- Greenwood, Ind.
- Walter B. Beaver, MD, MS
- Charlotte, N.C.
- Michael A. Mont, MD
- Jason A. Genin, DO
Frank R. Kolisek, MD: What are your indications for injecting an arthritic knee? What do you inject?
Walter B. Beaver, MD, MS: There are many reasons to inject an arthritic knee. In my practice, most patients have been previously seen and have been referred for joint replacement. For these patients, I will only inject their knee if their surgery is more than 3 months away. If the patient has severe degenerative joint disease (DJD) and is within 3 months of joint replacement, I do not inject secondary to lowering the immune system and increasing the infection rate.
If the patient has had inadequate conservative measures or does not need knee replacement, then I do inject at that point. I will usually inject steroid and marcaine in the severely arthritic knee. If there is minor arthritis, then I inject steroid only because of recent studies showing that marcaine can be detrimental to cartilage. If patients with arthritis have short-term positive results with the steroid injection and do not need an arthroplasty, then I will use viscosupplement injections.
Michael A. Mont, MD: Patients are offered an injection if they have knee pain associated with OA as it can offer a rapid reduction in symptoms and reduce inflammation. Our injections consist of 40 mg/10 mL of triamcinolone acetonide and lidocaine. We also use various hyalgans as a second-line method. Occasionally, we find that these two strategies work synergistically when alternating them.
Jason A. Genin, DO: Indications for corticosteroid injections are complaints of significant pain, crepitus and effusion, failure of oral medications, activity limitation, or for diagnostic/therapeutic purposes. I also prefer injection of corticosteroid in preparation for viscosupplementation. Typically, I limit injection of cortisone to three times per year.
In the younger patient (age 35 years or younger), I prefer ropivacaine 0.5% mixed with 1 mL to 2 mL of betamethasone sodium or 40 mg to 80 mg Kenalog. I will also use 1% lidocaine without epinephrine and have rarely used marcaine). Steroid preferences are the aforementioned cekotone or kenalog 40 mg to 80 mg. I bear in mind the patient with diabetes and their glucose control, typically only doing a unilateral injection, halfdosing the corticosteroid, or moving straight to intra-articular hyaluronic acid (HA) injections.
For HA injections, I typically use Euflexxa (Ferring Pharmaceuticals Inc.; Parsippany, N.J.), Gel One (Zimmer; Warsaw, Ind.), or Monovisc (DePuy-Mitek; Raynham, Mass.). In my clinical practice, HA injections would follow cortisone injections by 1 week, 2 weeks and 3 weeks (stacked method). HA injection is approved for use in mild to moderate knee OA. That being said, I have had good success for inclusion of patients with moderate-to-severe medial knee arthritis.
Kolisek:When do you decide to use bracing in the treatment of knee OA?
Beaver: Because of the nature of my practice, I use little bracing secondary to patients being referred for arthroplasty. I have seen multiple patients who have had unloader braces applied by other physicians who have done well and have put off knee replacement for years.
Mont: We use braces often in the treatment of knee OA. We use unloader braces for unicompartmental disease when the opposite compartment is well-preserved. We also use certain types of extension-assist braces for patients experiencing weakness or instability and to strengthen the quadriceps and hamstrings muscle groups.
With a team approach to bracing to increase patient compliance, we have had tremendous success with this group of patients who will often prefer braces to taking medications or receiving shots. Several studies have been conducted at our institution to evaluate the role of bracing in knee OA, and these have demonstrated that patients treated with the brace had greater improvements in quadriceps muscle strength, improvements in gait, activity and functional ability (demonstrated with the LEFS, KSS and SF-36 scores), and improvements in pain.
Genin: Dependent on the location of the OA, I favor both short-term and long-term usage of various bracing for knee OA. If a patient has significant vastus medialis oblique muscle quadriceps atrophy and anterior based knee pain, I will rely on reaction knee bracing until appropriate knee and CORE strength have been gained. Hinged knee braces are ideal for the patient who is responding to conservative measures but often feels “unstable or loose.” Medial unloader bracing, now made significantly lighter and more tolerable, is a good fit for patients with medial compartmental arthritis or even bicompartmental (medial and patellofemoral) arthritis. I encourage all my patients to not rely solely on bracing alone, and encourage as much time out of the brace, or “brace holidays” as tolerated. The goal of this is to promote self-proprioception and strength techniques that are integral to the multimodal approach to our treatment of OA.
Despite lack of definitive evidence, I will still use medial or lateral heel wedges (valgus or varus deformities, respectively) and unloader shoes. This holds especially true when patients are intolerant to knee bracing, but still require some external support.
Kolisek:What are your thoughts about prehabilitation prior to total knee arthroplasty (TKA)?
Beaver: Prehabilitation prior to TKA is an important part of the continuum. Multiple studies have shown that a structures prehab program will improve results after TKA. The important part of preoperative rehabilitation is to have a program that will help strengthen the muscles without irritating or inflaming the joint. Too many patients will try to prehab on their own and will irritate the joint which can slow down the recovery after TKA. They should concentrate on strengthening and not range of motion. Range of motion is usually locked and can only be improved after surgery.
Mont: Prehabilitation prior to TKA is a strong predictive factor for the success of the procedure. We have observed that greater preoperative weakness may be associated with worse postoperative outcomes. We use specialized strengthening braces to build muscle strength prior to surgery.
A study we are currently performing has demonstrated greater quadriceps strength preoperatively in patients who underwent prehabilitation with a brace, with improvements maintained in the postoperative period. In addition, neuromuscular electrical stimulation (NMES) and transcutaneous electrical nerve stimulation (TENS) can be used to strengthen muscles around the knee prior to surgery. Our study on the use of TENS in 23 patients with early OA has shown an improvement in quadriceps strength and a reduction in pain compared to standard therapy.
Genin: Current literature is suggestive of benefit in exercise and weight management in treatment of knee OA. The Arthritis, Diet and Activity Promotion Trial (ADAPT) had found that adherence to an 18-month program of exercise and calorie-restrictive diet demonstrated 24% improvement in physical function and 30.3% decrease in knee pain. Adherence to well-developed strengthening programs prior to TKA can lead to improved exercise and function after TKA. I prefer to educate the patient at the initial visit of the importance of regular cardiovascular exercise and strength training for the prolonged management of OA, whether patient elects surgical or conservative management.
Kolisek: What are your indications for using muscle stimulation in the treatment of knee OA?
Beaver: Neuromuscular electrical stimulation is something I have been more interested in the more I learn. After reviewing the literature, which is mostly in the physical therapy area, I have been using more NMES. The advent of these simple knee sleeves with the NMES units has made their use attractive for patients. The patients usually use the device 20 minutes a day and this can be monitored by the physician for compliance. These devices will then be incorporated into the postoperative protocols for continued adjuvant strengthening programs.
Mont: The degenerative changes associated with OA lead to inactivity and consequently decreased extensor strength and improper balance, which perpetuate muscle weakness and atrophy. In our institution, muscle stimulation is indicated in patients with knee OA when they have a quadriceps lag greater than 15° in a seated or supine straight leg position. In addition, we use muscle stimulation for patients with greater than 50% deficit compared to the opposite side.
We are currently carrying out studies on the role of NMES on quadriceps muscle strengthening, which works by recruiting a greater number of muscle fibers during exercise. It has been recommended that using NMES alongside exercise results in faster and greater improvements in muscle strength than exercise alone. We have also conducted a study on the use of TENS in patients with OA. Our results demonstrated improvements in KSS, LEFS and SF-36 scores, as well as a significant reduction in pain.
Genin: Current recommendations from the AAOS are inconclusive for either the use or non-use of muscle stimulation for knee OA. Quadriceps strengthening is integral in my treatment plan for overall care of the arthritic knee. Neuromuscular electrical stimulation can improve knee strength, and potentially aid in the recovery of TKA. In my clinical practice, if patients are relatively inactive or have difficulty with adherence to exercise regimens, then I will employ NMES.
Kolisek: Which oral medications/supplements do you frequently use for knee OA?
Beaver: I use several oral medications for DJD of the knee. I feel strongly that patients with symptomatic DJD should be on an NSAID. I will usually use one of the COX-2 inhibitors for ease of use (once a day) and for gastrointestinal tolerance. I will usually have the primary care physician prescribe the NSAID since they are usually more familiar with the patient’s medications and drug interactions. If patients want a supplement or cannot tolerate NSAIDs, then they can try glucosamine with or without chondroitin sulfate. The AAOS guidelines do not support the use of these supplements, but in some cases, patients feel some improvement without risk of gastrointestinal adverse events.
Mont: Medications we frequently use for OA comprise of a combination of acetaminophen, over-the-counter NSAIDs and COX-2 inhibitors. If pain is uncontrolled, then we may escalate to tramadol, OxyContin and oxycodone.
Genin: Acetaminophen is a good choice as first-line therapy in the treatment of OA, but not as useful if the patient has ongoing synovitis, effusion and stiffness. With NSAIDs, patients need monitored dosing regimens and may require concomitant initiation of proton pump inhibitors. This has become less utilized in my practice. Topical compounding with NSAIDs can be beneficial as well.
Ultram (Janssen Pharmaceuticals Inc.) is considered first-line therapy for the treatment of OA although recent 2014 regulation changes have placed Ultram as a schedule IV medication for its risk of abuse. Opiate medication has limited usage in chronic treatment although I will use it in the acute setting if I am concerned for controlling acute pain. If narcotics are written, my patients are educated about limited use.
Vitamin D has been recently considered to have vast health benefits. There is some suggestion that lower levels of serum vitamin D can increase the progression of pre-existing OA. I will advise patients to take between 2,000 IU to 5,000 IU of vitamin D daily regardless of whether serum investigation has been initiated. If patients have known vitamin D deficiency, or are known to have less than 40 µg/L to 50 µg/L, I will start 50,000 IU weekly for 10 weeks and daily supplementation of 2,000 IU to 3,000 IU.
Omega 3 has promise in the treatment of OA. There is potential to consider eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in the reduction of inflammatory cytokines. I typically recommend 2 grams daily of EPA and DHIA-containing foods supplementation. Nutraceuticals, glucosamine and chondroitin have long been utilized and marketed to patients as potential pain relievers in patients with joint pain.
Kolisek: Do you use an actual conservative care protocol in your practice? If so, has it improved the function of your patients?
Beaver: We have a conservative care program in our clinic that is beneficial to the patient and physician. When we have a patient who is not a surgical candidate, either from health issues or the DJD is not severe enough, then we institute our conservative care program.
Our physicians fill out an order form that gives choices, such as bracing, physical therapy, NMES, etc. The patient’s medical record number is sent to the conservative care group who contacts the patient and institutes the program as outlined by the physician. They will contact the patients to see how they are progressing. If a patient is doing well, then the patient continues the program. If he or she is not doing well, then they are referred back to the physician. The patients are happy in that they feel they are getting hands-on care and the physician is happy in that they are not seeing the patient back unless further care in needed.
Mont: We do not currently use a conservative care protocol. In our practice, patients who are undergoing conservative management will initially trial one modality. If no improvement in symptoms is observed, then we would try other modalities. In addition, patients with multiple complaints may try several treatment options simultaneously, such as a combination of a brace, physical therapy and anti-inflammatory medications.
Genin: I have found using a multimodal approach to the treatment of pain/debilitation has greatly benefited my patients in the treatment of most musculoskeletal ailments, including knee OA. The first step is in education. To start, I gauge my patient’s willingness to be an active participant in the treatment plan.
Tier 1 includes probable medication — oral, topical and injectable — and are dependent on medical comorbidities and, to some degree, patient preference. Tier 1 also includes bracing, whether it is knee bracing or shoe inserts, and are customized to the patient’s symptoms. Those who display significant pain or functional disability will be prescribed a dedicated home-exercise program or formal physical therapy.
HA education is started at the first visit, with patients understanding the potential long-standing relief with HA injection in combination with all modalities. If tier 1 is effective in the reduction of patients’ symptoms, then they enter a monitored phase for several months. However, if there is no significant improvement, I will move towards tier 2. HA is the predominant feature of tier 2. I also discuss the use of TENS units. Once initiated, patients are advised to continue with daily strength and flexibility programs, altering where necessary. Also, patients are educated about the possibilities of either surgical treatment or regenerative therapies. Once the care plan fits the patient, I enter them into the maintenance phase, which requires regular follow-up at 4-month intervals.
Kolisek: I want to thank the panelists for a thorough discussion on nonoperative treatment of the osteoarthritic knee. I think it is clear we have many options that are both helpful and safe for our patients. Setting the patients’ expectations and communicating with them so they understand the treatment they receive is important. Moreover, allowing patients to participate in their care and educating them on the pros, cons and expected results of the various treatment modalities are critical to a successful outcome and improved patient satisfaction.
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For more information:
Walter B. Beaver, MD, MS, can be reached at OrthoCarolina Hip & Knee Center, 2001 Vail Ave. Suite 200A, Charlotte, NC 28207; email: firstname.lastname@example.org.
Jason A. Genin, DO, can be reached at Cleveland Clinic Sports Health, 850 Columbia Rd., Westlake, OH 44125; email: email@example.com.
Frank R. Kolisek, MD, can be reached at OrthoIndy, 1260 Innovation Pkwy., Suite 100, Greenwood, IN 46143; email: firstname.lastname@example.org.
Michael A. Mont, MD, can be reached at Sinai Hospital of Baltimore, RIAO, 2401 W. Belvedere Ave., Baltimore, MD 21215; email: email@example.com.
Disclosures: Beaver is a consultant for Stryker; Genin is a paid consultant for Ferring Pharmaceuticals; Kolisek is a consultant for Stryker and DJO Global; Mont is a paid consultant for and receives research support from DJO Global, Sage Products Inc., Stryker and TissueGene; is a paid consultant for Medical Compression Systems; receives research support from the National Institutes of Health (NIAMS & NICHD); and receives intellectual property royalties from Sage Products Inc.