Tag Archive | knee osteoarthritis

Microbiomes, OA, and Diabetic Foot Ulcers

This post comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson. 

We hear the term “microbiome” with increasing frequency nowadays. Merriam-Webster’s online dictionary defines it as “a community of microorganisms (such as bacteria, fungi, and viruses) that inhabit a particular environment and especially the collection of microorganisms living in or on the human body.” Two recent studies suggest how the microbiome can affect musculoskeletal health.

Incorporating the term “the arthritis of obesity,” Rochester, New York researchers1 used obese mice with trauma-induced knee osteoarthritis (OA) to provide evidence that there is a “gut-joint connection” in the OA degenerative process. After supplementing the diets of some of the mice with oligofructose (a prebiotic fiber), the authors found reduced systemic inflammation, reduced obesity-associated macrophage migration to the synovium, and suppressed obesity-induced joint-structure changes.

Another recent study investigated the on-body microbiome as it relates to diabetic foot ulcers (DFUs). Despite clinical signs and nonspecific biomarkers of infection, there is no specific and sensitive measure available to monitor or prognosticate the success of foot salvage therapy (FST) in patients with DFUs. These investigators hypothesized that the initial microbiomes of healed versus nonhealed DFUs are distinct and that the changes in the DFU microbiome during FST are prognostic of clinical outcome.2

Twenty-three DFU patients undergoing FST had wound samples collected at 0, 4, and 8 weeks following wound debridement and antibiotic treatment. Eleven ulcers healed and 12 did not. Healed DFUs had a larger abundance Actinomycetales and Staphylococcaceae (p < 0.05), while nonhealed ulcers had a higher abundance of Bacteroidales and Streptococcaceae (p < 0.05).

In the future, assessment of the initial microbiome and monitoring changes in the prevalence of specific microbiome constituents in patients with diabetic foot ulcers may be a clinical tool for predicting treatment response to foot salvage therapy. It’s also conceivable that microbiome analysis could eventually help patients and surgeons decide between FST and amputation.

References

  1. Schott EM, Farnsworth CW, Grier A, Lillis JA, Soniwala S, Dadourian GH, Bell RD, Doolittle ML, Villani DA, Awad H, Ketz JP, Kamal F, Ackert-Bicknell C, Ashton JM, Gill SR, Mooney RA, Zuscik MJ. Targeting the gut microbiome to treat the osteoarthritis of obesity. JCI Insight. 2018 Apr 19;3(8). pii: 95997. doi: 10.1172/jci.insight.95997. [Epub ahead of print] PMID: 29669931, PMCID: PMC593113
  2. MacDonald A, Brodell JD Jr, Daiss JL, Schwarz EM, Oh I. Evidence of differential microbiomes in healing versus non-healing diabetic foot ulcers prior to and following foot salvage therapy. J Orthop Res. 2019 Mar 25. doi: 10.1002/jor.24279. [Epub ahead of print] PMID: 30908702

RF Ablation for Knee Arthritis

Sometimes, patients with painful knee osteoarthritis do not get sufficient pain relief with conservative treatments and do not want (or are not suitable candidates for) arthroplasty. Now, with the advent of genicular nerve radiofrequency ablation (GNRFA), such patients have another option.

As described in a recent issue of JBJS Essential Surgical Techniques, GNRFA has been shown to provide consistent pain relief for 3 to 6 months. Using heat generated from electricity delivered via fluoroscopically guided needle electrodes, the procedure denatures the proteins in the 3 genicular nerves responsible for transmitting knee pain. Although there is a paucity of high-quality studies on the efficacy of this procedure, one study found that, on average, GNRFA led to improvement of >60% from baseline knee pain for at least 6 months.

In the authors’ practice, GNFRA is generally not repeated if it is ineffective the first time, but the procedure has been shown to be safe when administered repeatedly in patients who respond well. Proper positioning of the electrodes is essential, but the authors caution that without ample experience, “it may be difficult to isolate the exact anatomic location of ≥1 of the genicular nerves.”

General anesthesia is not required for the procedure, which is commonly performed by interventional pain specialists. Despite theoretical concerns, no Charcot-type joints have been reported after GNRFA. The authors emphasize, however, that the procedure provides temporary relief at best; it does not eliminate the potential for nerve regrowth and does not alter the arthritic disease process. Even more importantly, GNRFA needs to be studied with higher-level clinical research designs, ideally an adequately powered sham/placebo-controlled randomized trial.

For more information about JBJS Essential Surgical Techniques, watch this video featuring JBJS Editor-in-Chief Dr. Marc Swiontkowski.

Cost Analysis of Treatments for Unicompartmental Knee Arthritis: UKA Wins

UKA for OBuzzSurgical treatment for knee osteoarthritis (OA) has become increasingly common. The many people who have damage to only one part of their joint (unicompartmental knee OA) are faced with three options—total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), or nonsurgical treatment.  A study by Kazarian et al. in the October 3, 2018 issue of The Journal estimates the lifetime cost-effectiveness for those three options in patients from 40 to 90 years of age.

The authors used sophisticated computer modeling to estimate both direct costs (those related to medical/surgical care) and indirect costs (such as missed workdays) of the three options as a function of patient age at the time of treatment initiation. Here are the key findings:

  • The surgical treatments were less expensive and provided patients from 40 to 69 years of age with a greater number of quality-adjusted life years (QALYs) than nonsurgical treatment.
  • In patients 70 to 90 years of age, surgical treatments were still cost-effective compared with nonsurgical treatment, albeit less so than in younger patients. In this older age group, “cost-effectiveness ratios” of surgical treatment remained below a “willingness to-pay” threshold of $50,000 per QALY.
  • When the two surgical treatments were compared to one another, UKA beat TKA decisively in cost-effectiveness among patients of any age.

After crunching more numbers, Kazarian et al. estimated that, by 2020, if all of the patients with unicompartmental knee OA who were candidates for UKA or TKA (a projected total of 120,000 to 210,000 people) received UKA, “it would lead to a lifetime cost savings of $987 million to $1.5 billion.

From these findings, the authors conclude that patients with unicompartmental knee OA should receive surgical treatment, preferably UKA, instead of nonsurgical treatment until the age of 70 years. After that age, all three options are reasonable from a cost-effectiveness perspective.

But perhaps the most important thing to remember about these findings is that they add information to—but should not replace—clinical decision-making based on complete and open communication between doctor and patient.

German Knee OA Guidelines Mirror Findings in JBJS Reviews Article

knee-injection-for-obuzzOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Prof. Joerg Jerosch, in response to a recent article in JBJS Reviews.

I congratulate Vannabouathong et al. for the well-performed and relevant systematic review. In Germany, the Association of Scientific Medical Societies (AWMF) just published a guideline on the medical treatment of knee osteoarthritis (see: https://www.awmf.org/uploads/tx_szleitlinien/033-004l_S2k_Gonarthrose_2018-01_1.pdf), which comes to very similar conclusions as those presented in this systematic review.

The new German guideline suggests a four-stage algorithm starting with topical NSAIDs and escalating to oral NSAIDs (according to individual risks), then followed either by glucosamine, hyaluronic acid (HA), or corticosteroids, and ends finally with opioids. It was very useful that Vannabouathong et al. used the AAOS description for clinical significance, and it was elegant of them to include the effect of intra-articular placebo in their analysis of intra-articular treatments. This review compares treatment-group differences (not within-patient improvements) and considers that the placebo effect in osteoarthritis trials is typically large, particularly in the case of intra-articular injections. Consequently, the measured effect size would underestimate the clinical benefits for patients1, 2. It is valuable that this systematic review calculated the intra-articular placebo versus the oral placebo effect and added the resulting difference of 0.29 standard deviation (SD) units to the respective effect sizes of the intra-articular treatments.

This review concludes that the intra-articular injection of HA has the most concise effect estimate and exceeds the defined threshold of clinical importance of 0.5 SD units. Thus the clinical usefulness of HA is boosted from “possibly clinically important” to “clinically important” according to the AAOS definitions. This review also investigates HA formulations in terms of different molecular weights. It illustrates clearly the effect sizes of high-molecular-weight HA formulations between 1,500 kDa and 6,000 kDa, as well as those above 6,000 kDa.

One point requiring further discussion is that many patients have contraindications to NSAIDs due to comorbidities or comedications. Our new German guideline points out that NSAIDs are contraindicated for elderly patients (>60 years old) and those with existing ulcers, GI bleeding, or infections with H. pylori. Additional contraindicated factors are comedications such as corticosteroids, anticoagulants, or aspirin. In addition, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) reasons that oral NSAIDs have a moderate effect on pain relief, but they are associated with a 3- to 5-fold increase in the risk of upper GI complications, including peptic ulcer perforation, obstruction, and bleeding3.

Another analysis from the Coxib and Traditional NSAID Trialists (CNT) Collaboration shows that 2 to 4 out of 1,000 patients face GI complications after the daily intake of 150 mg of diclofenac. The same applies for 6 to 16 out of 1,000 patients taking 1,000 mg of ibuprofen per day4. An announcement of the Medicines Commission of the German Medical Profession also mentions high relative risks for GI complications associated with NSAIDs. The German guideline recommends intra-articular HA injections especially for individuals at risk for adverse NSAID side effects and for those for whom NSAIDs are not sufficiently effective.

The German guideline also discusses potentially beneficial effects of combining corticosteroids with HA. This should be a topic for a future systematic review.

Prof Joerg Jerosch is a professor of orthopaedic surgery at Johanna-Etienne Hospital in Neuss, Germany.

References

1. Bannuru RR et al., Therapeutic trajectory following intra-articular hyaluronic acid injection in knee osteoarthritis e meta-analysis, Osteoarthritis Cartilage. 2011 Jun;19(6):611-9. doi: 10.1016/j.joca.2010.09.014.
2. Bannuru RR et al., Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis, Ann Intern Med. 2015 Jan 6;162(1):46-54. doi: 10.7326/M14-1231
3. Bruyere O et al. A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting. Semin Arthritis Rheum, 2016. 45(4 Suppl): p. S3-11
4. Bhala N et al., Coxib and traditional NSAID Trialists’ (CNT) Collaboration, Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet 2013; 382(9894): 769-779

Impact of Clinical Practice Guidelines on Use of Injections for Knee OA

Knee Injection for OBuzzIn a recent OrthoBuzz post, I commented on the apparent benefits to patients when Scottish hip-fracture guidelines were followed. Now, in a “closer-to-home” study in the May 16, 2018 issue of JBJS, Bedard et al. examine the effects of AAOS clinical practice guidelines (CPGs) on the use of injections for knee osteoarthritis (OA). The authors used an insurance database housing more than 1 million knee OA patients to evaluate the change in rates of corticosteroid and hyaluronic acid injections from 2007 to 2015. This date range includes the periods before and after the publication of the AAOS CPGs for knee arthritis (both the first edition, published in early 2009, and the second edition, published in late 2013).

The authors found that the rate of hyaluronic acid injections by orthopaedic surgeons decreased significantly after both publications of the guidelines and that the utilization of corticosteroid injections appears to have plateaued since the most recently published guidelines. Still, almost 40% of all of the patients in the cohort received a corticosteroid injection, with 13% having received a hyaluronic acid injection. In absolute numbers, those percentages represent more than half a million injections, despite the facts that the evidence supporting either injection for the treatment of knee OA is weak at best and that almost half of the patients receiving one of these injections ended up getting a total knee replacement within a year.

While the changes in practice revealed by Bedard et al. may seem relatively small, they are a step in the right direction toward value-based care.  CPGs are easy to pick apart, but they are developed carefully and for a good reason—to provide us with evidence-based recommendations for excellent patient care. It is gratifying to see that such guidelines are having a positive impact in our field.

Chad A. Krueger, MD
JBJS Deputy Editor for Social Media

May 2018 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of May 2018, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Quality of Life in Symptomatic Individuals After Anterior Cruciate Ligament Reconstruction, With and Without Radiographic Knee Osteoarthritis.”

The authors conclude that diagnosing radiographic osteoarthritis in symptomatic individuals after ACL reconstruction may be valuable, because targeted strategies to facilitate participation in satisfying activities have the potential to improve quality of life in these patients.

What’s New in Adult Reconstructive Knee Surgery 2018, Part II

Knee_smPreviously this month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery. In this OrthoBuzz post, Gwo-Chin Lee, MD, author of the Specialty Update on Adult Reconstructive Knee Surgery, selects his “top five.”

Nonoperative Knee OA Treatment
—Atukorala et al. found a significant dose-response relationship between all KOOS subscales and percentage of weight change across all weight-change categories. Participants required ≥7.7% of weight loss to achieve a minimal clinically important improvement in function.1

Meniscal Injuries
—A prospective cohort study showed that patients undergoing arthroscopic procedures for degenerative meniscal tears did not have clinically meaningful differences in outcomes compared with patients with traumatic meniscal tears.2

Postoperative Pain Management
—Authors of a Cochrane Systematic Review ascertained that liposomal bupivacaine at the surgical site appears to reduce postoperative pain compared with placebo. However, because of the low quality and volume of evidence, it is not possible to determine its effect compared with conventional agents.3

Avoiding Post-TKA Complications
—In a randomized trial, the use of a tourniquet resulted in upregulation of peptidase activity within the vastus medialis but did not result in an increase in muscular degradation products. The authors concluded that the relationship between tourniquet-induced ischemia and muscle atrophy is complex and poorly understood.4

—The authors of a registry study found no evidence that fondaparinux, enoxaparin, or warfarin are superior to aspirin in the prevention of PE, DVT, or VTE—or that aspirin is safer than these alternatives. However, enoxaparin is as safe as aspirin with respect to bleeding, and fondaparinux is as safe as aspirin with respect to risk of wound complications.5

References

  1. Atukorala I, Makovey J, Lawler L, Messier SP, Bennell K, Hunter DJ. Is there a dose-response relationship between weight loss and symptom improvement in persons with knee osteoarthritis? Arthritis Care Res (Hoboken). 2016 Aug;68 (8):1106-14.
  2. Thorlund JB, Englund M, Christensen R, Nissen N, Pihl K, Jørgensen U, Schjerning J, Lohmander LS. Patient reported outcomes in patients undergoing arthroscopic partial meniscectomy for traumatic or degenerative meniscal tears: comparative prospective cohort study. BMJ. 2017 Feb 2;356:j356.
  3. Hamilton TW, Athanassoglou V, Mellon S, Strickland LH, Trivella M, Murray D, Pandit HG. Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb 1;2:CD011419.
  4. Jawhar A, Hermanns S, Ponelies N, Obertacke U, Roehl H. Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2016 Oct;24(10):3313-21. Epub 2015 Nov 14.
  5. Cafri G, Paxton EW, Chen Y, Cheetham CT, Gould MK, Sluggett J, Bini SA, Khatod M. Comparative effectiveness and safety of drug prophylaxis for prevention of venous thromboembolism after total knee arthroplasty. J Arthroplasty. 2017 Nov;32(11):3524-28.e1. Epub 2017 May 31.

What’s New in Adult Reconstructive Knee Surgery 2018

Knee_smEvery month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.

This month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery.

Nonoperative Knee OA Treatment

—Intra-articular corticosteroid injections are commonly administered to mitigate pain and inflammation in knee osteoarthritis (OA). However, a randomized controlled trial of 140 patients found that 2 years of triamcinolone injections, when compared with saline injections, resulted in a significantly greater degree of cartilage loss without significant differences in symptoms.1

Non-Arthroplasty Operative Management

—Knee arthroscopy continues to be largely ineffective for pain relief and functional improvement in knee OA. A randomized controlled trial found no evidence that debridement of unstable chondral flaps found at the time of arthroscopic meniscectomy improves clinical outcomes.

Cartilage restoration procedures continue to show varying degrees of success. Long-term results from a randomized trial demonstrated no significant differences in joint survivorship and function between patients undergoing microfracture versus autologous chondrocyte implantation (ACI) at 15 years of follow-up. Nearly 50% of patients in both groups had radiographic evidence of early knee OA.

Periprosthetic Joint Infection

—Periprosthetic joint infection (PJI) remains a leading cause of failure following total knee arthroplasty (TKA). Successful treatment requires accurate diagnosis, and alpha-defensin was found to be both sensitive and specific in the diagnosis of PJI. However, it was not significantly superior to leukocyte esterase (LE) in cases of obvious infection.

—Reported rates of reinfection after 2-stage reimplantation for treatment of a first PJI can be as high as 19%. A 3-month course of oral antibiotics following 2-stage procedures significantly improved infection-free survival without complications.2

Post-TKA Complications from Opioids

—Amid ongoing concerns about opioid misuse, two studies3 suggested that preoperative opioid use was found to be an independent predictor of increased length of stay, complications, readmissions, and less pain relief following TKA.

References

  1. McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M,Ward RJ. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. 2017 May 16;317(19):1967-75.
  2. Frank JM, Kayupov E, Moric M, Segreti J, Hansen E, Hartman C, Okroj K,Belden K, Roslund B, Silibovsky R, Parvizi J, Della Valle CJ; Knee Society Research Group. The Mark Coventry, MD, Award: oral antibiotics reduce reinfection after two-stage exchange: a multicenter, randomized controlled trial. Clin Orthop Relat Res.2017 Jan;475(1):56-61.
  3. Rozell JC, Courtney PM, Dattilo JR, Wu CH, Lee GC. Preoperative opiate use independently predicts narcotic consumption and complications after total joint arthroplasty. J Arthroplasty.2017 Sep;32(9):2658-62. Epub 2017 Apr 12.

August 2017 Article Exchange with JOSPT

JOSPT_Article_Exchange_LogoIn 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.

During the month of August 2017, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Clinical Prediction Models for Patients With Nontraumatic Knee Pain in Primary Care: A Systematic Review and Internal Validation Study.”

This systematic review yielded two new prognostic models for function and recovery in patients with nontraumatic knee pain. A longer duration of complaints predicted poorer function.

Chondroitin Sulfate Similar to Celecoxib in Easing Pain of Knee OA

Rich Yoon Headshot.jpgOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD, in response to a recent study in Annals of the Rheumatic Diseases.

European investigators recently reported on a trial comparing the efficacy of pharmaceutical-grade chondroitin sulfate (CS) (800 mg/day) with the NSAID celecoxib (CX) (200 mg/day) and placebo in more than 600 patients with painful knee osteoarthritis (OA).

In this well-designed, well-executed, double-blinded, 3-armed trial, investigators tracked patient pain scores at baseline and at 1-month, 3-month and 6-month intervals. This trial was characterized by strict adherence to blinded protocols, high levels of patient adherence, and meticulous review of patient diaries and adverse-event reports.

Patients in both the CS and CX groups experienced significantly greater pain relief when compared to those in the placebo group at every follow-up time point. In addition to tracking pain via the visual analogue scale (VAS), the investigators included the Lequesene index (LI)—which integrates both pain and function—along with the Minimal-Clinically Important Improvement (MCII) scale. While CX and CS were not superior/inferior to one another, both active treatments provided significant pain improvements relative to placebo according to all three measurements at all time points.

These findings showing the efficacy of pharmaceutical-grade CS are important for orthopaedic surgeons, rheumatologists, and general practitioners. Nonoperative management of knee OA remains an important modality that requires a multimodal approach, typically including NSAIDs and/or acetaminophen. These results suggest that there’s another safe medication that may prove especially helpful for OA patients who cannot tolerate NSAIDs or acetaminophen due to kidney, gastrointestinal, cardiovascular, and/or liver issues.

Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.