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

Why pay attention today?  MS problems account for 30% of office visits Top 5 4 knee problems:  MS teaching accounts for 3% of A rational approach to knee pain med school Primary Care Sports Medicine 2018 • 1% of internal medicine curriculum • 56% Primary Care not prepared for MSK Brian Feeley, MD Associate Professor, Sports Medicine and Shoulder Surgery UCSF Department of Orthopaedic Surgery ‒ AAOS 2016  MRI is most commonly ordered 12/14/2018 imaging modality from primary care/IM for MS complaints 12/14/2018 Knee anatomy-keep it basic Goals for this presentation Differential Diagnosis of Knee Problems Differential Diagnosis of Knee Problems MCL MCL  Understand common knee problems  Cartilage ACL ACL • Common symptoms • Acute or degenerative (arthritis) • Imaging modalities—when to/not to PF Pain PF Pain  Meniscus use them • Acute or degenerative (arthritis) • Treatment options Meniscus Meniscus  ACL  Evidence-based approach  Collateral Ligaments  Recent high quality literature (when  Extensor Mechanism available) • Acute or activity related Arthritis Arthritis  All others are rare! 3 12/14/2018 4 12/14/2018 1

Case 1 56 year old male with a 7 month history of moderate knee pain, gradually Arthritis is a big problem 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 says his knee sometimes swells.  ARTHRITIS is COMMON! What is his most likely diagnosis? • 33% of all adults have arthritis 77% ‒ 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% D. Hip arthritis 6% • Arthritis prevalence increases with age 1% Osteoarthritis Meniscus tear Patellofemoral pain Hip arthritis 5 12/14/2018 6 Source: CDC 12/14/2018 Understanding Arthritis Understanding Arthritis  The articular changes found are IRREVERSIBLE (mostly) Cartilage properties Normal Cartilage Arthritis Cartilage Few cells Super smooth Cannot make more cartilage Healthy cartilage Advanced Arthritis Early Arthritis No nerve endings Don ’ t feel joints move Don ’ t sense early back and forth damage to the cartilage Best way to explain arthritis to patients seems to be this tire analogy. 2

History-Osteoarthritis Physical Exam-Osteoarthritis Symptoms of arthritis • Pain—’achy’  Physical Exam findings • Swelling/effusion • Deformity • Loss of range of motion • Deformity • Crepitus (grinding, popping) 56 year old male with a 7 month history of moderate knee • Loss of range of motion pain , gradually worsening, and described as ‘ achy ’. He had • Tenderness along the joint line a meniscus surgery 4 years ago which helped for a while. • Inability to exercise/perform daily activities/work He used to run, now mainly biking and swimming . • Weight gain Pain is medial, near the joint line. He says his knee • Depression sometimes swells . 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

Treatment options for arthritis Summary: both use MRI, possibly better used by Summary: both use MRI, possibly better used by ortho Still use it too often for patients with advanced OA 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 12/14/2018 16 12/14/2018 4

1. Activity/Lifestyle changes 1. Activity/Lifestyle changes The most important thing you Can tell patients is that losing weight Will improve symptoms Surgery does not lead to Weight loss (JBJS 2015) Weight loss DOES Markers of cartilage turnover Markers of cartilage turnover Lead to less knee pain And breakdown are decreased And breakdown are decreased After bariatic surgery After 2. Physical Therapy IDEA Trial (NIH/NIA) 1. Activity/Lifestyle changes  What about mild weight loss?  Does physical therapy work for patients with knee osteoarthritis? No single PT intervention was best No single PT intervention was best…aerobic Aquatic, strengthening worked well A Gimmicky things—didn’t work well (magnets, Gimmicky things Orthotics, ultrasound) O Wang et al, AIM 2015 Wang et al, AIM 2015 19 12/14/2018 20 12/14/2018 5

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. 12/14/2018 22 AAOS Clinical Guidelines 2013 12/14/2018 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 cells cartilage After lidocaine cells UCSF Orthopaedic Research 23 12/14/2018 6

4. Corticosteroid Injections 4. Viscosupplementation Summary: Favors Steroid 25 12/14/2018 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

4. Injections 4. Injections NEJM-2015  In this clinical setting of a prevalent disabling disease, for which the therapy  “The expert achieved unanimous agreement in favor of in question has, at best, modest efficacy for relief of pain, the tolerance for the following statements: VS is an effective treatment for treatment expense and adverse events is limited. Therefore, the current mild to moderate knee OA; VS is not an alternative to evidence base would not advocate the use of intraarticular hyaluronate for surgery in advanced hip OA; VS is a well-tolerated the management of knee osteoarthritis. treatment of knee and other joints OA” Conclusions— Conclusions mild benefit, often less than MCID mild benefit, often less than MCID May be worth trying in younger people with OA, mild disease May be worth trying in younger people with OA, mild disease 29 12/14/2018 30 12/14/2018 4. Injections—What’s next? AJSM 2017 3 meta-analyses Works better for people with less arthritis Higher rate of side effects No difference in WOMAC Pain No difference in WOMAC Pain Limited data, mildly promising 31 Arthroscopy, 2015 12/14/2018 32 12/14/2018 8

Systematic Reviews of Level 1 and Level 2 evidence Inflammatory markers Khoshbin et al Arthrosc 2013 Chang et al APMR 2014 Riboh et al AJSM 2015 AJSM 2017 Mild OA, lower BMI worked better Mild OA, lower BMI worked better lowers pro lowers pro-inflammatory cytokines. Improved IKDC Scores 6-12 Studies favor PRP with modest effect Studies favor PRP with modest effect Months with PRP Conclusion: “significant improvements were seen in Conclusion: “significant improvements were seen in No evaluation of alteration of natural history No evaluation of alteration of natural history other patient other patient-reported outcome measures, with results favoring PRP over HA.” results favoring PRP over HA.” 33 12/14/2018 34 12/14/2018 5. Surgery Knee Replacement  Surgery to debride meniscus/cartilage is not effective in the setting of  Final common pathway for all people with moderate to severe arthritis arthritis • Kirkley et al NEJM 2007 • Moseley et al NEJM 2002 35 12/14/2018 9