Meniscus Meniscus Evidence-based approach Collateral Ligaments - PowerPoint PPT Presentation

Why pay attention today? � MS problems account for 30% of office visits � MS teaching accounts for 3% of Top 5 4 knee problems: med school A rational approach to knee pain • 1% of internal medicine Primary Care Sports Medicine 2015 curriculum • 56% Primary Care not Brian Feeley, MD prepared for MSK Associate Professor, Sports Medicine and Shoulder Surgery ‒ AAOS 2014 UCSF Department of Orthopaedic Surgery 12/11/2015 � MRI is most commonly ordered imaging modality from primary care/IM for MS complaints 12/11/2015 Goals for this presentation Knee anatomy-keep it basic Differential Diagnosis of Knee Problems � Understand common knee problems MCL MCL � Cartilage • Common symptoms • Acute or degenerative (arthritis) ACL ACL • Imaging modalities—when to/not to use � Meniscus PF Pain PF Pain them • Acute or degenerative (arthritis) • Treatment options � ACL Meniscus Meniscus � Evidence-based approach � Collateral Ligaments � Recent high quality literature (when available) � Extensor Mechanism • Acute or activity related Arthritis Arthritis � All others are rare! 3 12/11/2015 4 12/11/2015 1 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Case 1 Arthritis is a big problem 56 year old male with a 7 month history of moderate knee pain, gradually worsening, and described as ‘achy’. He had a meniscus surgery 4 years ago which helped for a while. He used to run, now mainly biking and swimming. Pain is medial, near the joint line. He � ARTHRITIS is COMMON! says his knee sometimes swells. 75% • 33% of all adults have arthritis What is his most likely diagnosis? ‒ 70 million people with arthritis A. Osteoarthritis ‒ 50% over the age of 65 have arthritis B. Meniscus tear • Arthritis is more common in women C. Patellofemoral pain 16% 8% • Arthritis prevalence increases with age D. Hip arthritis 1% 5 12/11/2015 6 Source: CDC 12/11/2015 Understanding Arthritis Understanding Arthritis � The articular changes found are IRREVERSIBLE (mostly) Cartilage properties Normal Cartilage Arthritis Cartilage Few cells Super smooth Cannot make more Don ’ t feel joints move Don ’ t sense early cartilage Healthy cartilage Advanced Arthritis Early Arthritis No nerve endings back and forth damage to the cartilage Best way to explain arthritis to patients seems to be this tire analogy. 2 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

History-Osteoarthritis Physical Exam-Osteoarthritis Symptoms of arthritis � Physical Exam findings • Pain—’achy’ • Deformity • Swelling/effusion • Crepitus (grinding, popping) • Loss of range of motion • Loss of range of motion 56 year old male with a 7 month history of moderate • Deformity • Tenderness along the joint line knee pain , gradually worsening, and described as ‘ achy ’. He had a meniscus surgery 4 years ago which helped for a w while. He used to run, now mainly biking and • Inability to exercise/perform daily activities/work swimming . Pain is medial, near the joint line. He says his • Weight gain knee sometimes swells . • Depression Imaging-Osteoarthritis Imaging-Osteoarthritis � Do I need an MRI? • Advanced arthritis, in general no (get an Xray first and DON’T get an MRI) • Early cartilage injuries � yes • Early arthritis � maybe yes Mild arthritis Moderate arthritis Severe arthritis Get STANDING weight bearing views, bilateral to compare 3 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Treatment options for arthritis Summary: both use MRI, possibly better used by ortho Still use it too often for patients with advanced OA 25% of knee visits resulted in MRI in ortho, 24% in Primary Care Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001) Bracing/Unloading Surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048). 1. Activity/Lifestyle changes 1. Activity/Lifestyle changes 15 12/11/2015 16 12/11/2015 4 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

1. Activity/Lifestyle changes 1. Activity/Lifestyle changes The most important thing you Can tell her is that she needs to Lose weight Surgery does not lead to Weight loss (JBJS 2015) Weight loss DOES Markers of cartilage turnover M Lead to less knee pain A And breakdown are decreased After bariatic surgery A IDEA Trial (NIH/NIA) 1. Activity/Lifestyle changes 2. Physical Therapy � What about mild weight loss? � Does physical therapy work for patients with knee osteoarthritis? No single PT intervention was best…aerobic N Aquatic, strengthening worked well A G Gimmicky things—didn’t work well (magnets, ts, Orthotics, ultrasound) O W Wang et al, AIM 2015 19 12/11/2015 20 12/11/2015 5 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

2. Physical Therapy 3. Orthotics for Osteoarthritis � Ettinger, et al. JAMA. 1997 � 439 community ambulators >60 yo � Randomized to aerobic, resistive exercises vs. nothing � Outcomes with pain, daily function scores � Conclusion: � Significant improvement in daily outcome measurements and knee pain scores with either exercises. � Benefits were best in those with mild to moderate OA 21 Ettinger, et al. JAMA 1997. 12/11/2015 22 AAOS Clinical Guidelines 2013 12/11/2015 4. Injections for Osteoarthritis 4. Corticosteroid Injections � Risks: � Not Risks: • Can kill cartilage cells • Will not turn you into this: ‒ Lidocaine and steroid • Transiently increase blood sugar Healthy cartilage Cartilage cells cells After lidocaine UCSF Orthopaedic Research 23 12/11/2015 6 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

4. Viscosupplementation 4. Corticosteroid Injections Summary: Favors Steroid 25 12/11/2015 4. Viscosupplementation 4. Viscosupplementation � Viscosupplementation (Synvisc, Euflexxa) � Who does it work for? • Lubricates and cushions joint • Mild to moderate arthritis • Made from a natural substance similar to healthy joint fluid • Already on an exercise/weight loss program but with continued pain � Improves viscosity • Low to moderate demand activities ‒ Limit high impact sports (running) • Increases molecular weight and quantity of synovial fluid synthesized by the synovium � Decrease pain (mechanism uncertain) • Decreases inflammatory mediators? 7 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

4. Injections 4. Injections � “The expert achieved unanimous agreement in favor of NEJM-2015 the following statements: VS is an effective treatment for � In this clinical setting of a prevalent disabling disease, for which the therapy mild to moderate knee OA; VS is not an alternative to in question has, at best, modest efficacy for relief of pain, the tolerance for surgery in advanced hip OA; VS is a well-tolerated treatment expense and adverse events is limited. Therefore, the current treatment of knee and other joints OA” evidence base would not advocate the use of intraarticular hyaluronate for the management of knee osteoarthritis. Conclusions— mild benefit, often less than MCID May be worth trying in younger people with OA, mild disease 29 12/11/2015 30 12/11/2015 4. Injections—What’s next? 5. Surgery � Surgery to debride meniscus/cartilage is not effective in the setting of arthritis • Kirkley et al NEJM 2007 • Moseley et al NEJM 2002 3 meta-analyses Works better for people with less arthritis Higher rate of side effects Limited data, mildly promising 31 Arthroscopy, 2015 12/11/2015 32 12/11/2015 8 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Knee Replacement Knee Replacement � How does it work? � Final common pathway for all people with moderate to severe arthritis • Designed cuts in the knee joint to remove injured cartilage • Replacement of cartilage surface with metal and plastic (Polyethylene) surface Knee Replacement Knee Replacement � Excellent procedure for low to moderate demand patients • Pain relief immediate (no more injured cartilage) • Good range of motion • 90-95% good to excellent results at 10-15 years 3 months Knee ‘75% 1 year ‘98% Surgery better’ better’ 6 weeks 6 months ‘50% ‘90% better’ better’ 9 12/11/2015 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]