Keogh Osteoarthritis Presentation

8/2/2019 Keogh Osteoarthritis Presentation

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OSTEOARTHRITISOSTEOARTHRITISKNEES AND HIPSKNEES AND HIPS

GARY KEOGH MDGARY KEOGH MD

Musculoskeletal RehabilitationMusculoskeletal Rehabilitation

InstituteInstitute


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RISK FACTORSRISK FACTORS

Osteoarthritis is the most common type ofarthritis. In the U.S., about 12.1% of Americans(21 million people) age 25 and older have

osteoarthritis. The prevalence in osteoarthritisincreases as people age. Experts estimate thatby 2030, 20% of Americans (72 million people)

age 65 years and older will be at risk fordeveloping osteoarthritis


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RISK FACTORSRISK FACTORS Geography

Although the average rate of osteoarthritisamong older adults in the U.S. is 60%, it can

vary widely in certain geographical regions. Inthe U.S., the rates in older adults are lowest(34%) in Hawaii and highest (70%) in Alabama.In general, the highest prevalence of arthritis in

America occurs in the central and northwesternstates.


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RISK FACTORSRISK FACTORS Gender

Before age 45, osteoarthritis occurs more frequently in males(although it is not common in younger adults). After age 55, itdevelops more often in females. In a 2000 study, 33% ofwomen had osteoarthritis compared to 25% of men. Someresearch suggests that women may also experience greater

muscle and joint pain, in general, than men. And, women alsotend to be undertreated for pain compared to men. The causesof such differences in pain sensitivity and treatment are largelyunknown and most likely are due to a complicated mix ofbiologic, psychologic, and social factors.

Education The incidence is highest in lower educational levels. In a 2000

study, 41% of adults with less than a high school education hadarthritis compared to 21% of college graduates.


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OBESITYOBESITY Obesity, defined as being 20% over one's healthy

weight, places people (particularly women) at increasedrisk for osteoarthritis. It also worsens osteoarthritis oncedeterioration begins. This higher risk is due to increasedweight on the joints. However, being obese alsoincreases the risk for osteoarthritis in the fingers as wellas the knees and hips, suggesting that being overweightmay contribute to osteoarthritis in other ways. Someresearch indicates that obesity may produce aninflammatory response, which is now a major suspect in

age-related diseases -- not only osteoarthritis but alsoheart disease.


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MENISCUS OR CARTILAGEMENISCUS OR CARTILAGE Osteoarthritis can cause loss of cartilage in the knee.

The meniscus, the cartilage pad between the jointformed by the thighbone and the shinbone, plays animportant role in protecting the joint. It acts as a shockabsorber. In knee surgery called meniscectomy, thedoctor removes the damaged cartilage. However, a 2006study suggested that preserving the meniscus, even if itis damaged, is better than removing it. Researchersshowed that even a small amount of meniscus helpsprotect the joint and prevent osteoarthritis from

worsening. Experts recommend that patients try lifestylechanges (exercise and weight loss), braces, andmedication before undergoing knee surgery.


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How common is arthritis?How common is arthritis? 1 in 8 people have osteoporosis.

1 in 10 people have osteoarthritis. 1 in 33 people have fibromyalgia. 1 in 100 people have rheumatoid arthritis.

1 in 1,000 children havejuvenile chronicarthritis. 1 in 1,000 people have ankylosing spondylitis. 1 in 2,000 people have systemic lupus

erythematosus. 1 in 10,000 people have scleroderma.


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WHERE DOES IT AFFECT?WHERE DOES IT AFFECT?Unlike some other types of arthritis, such as

rheumatoid arthritis, osteoarthritis does notspread through the entire body. (In other

words, it is not systemic.) Rather, it affectsone or several joints. Osteoarthritis affectsjoints differently depending on their location inthe body.

Osteoarthritis is commonly found in joints ofthe fingers, feet, knees, hips, and spine.

It sometimes occurs in the wrist, elbows,shoulders, and jaw, but is not common in

these locations.


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KNEE AND HIPKNEE AND HIP Recent studies suggest that osteoarthritis of the hand

may predict the later development of osteoarthritis inthe hip or knee. A 2005 study found that patients withhand osteoarthritis were three times more likely todevelop hip arthritis. Osteoarthritis of the hand also

slightly increased the risk for knee osteoarthritis.

Knee. Osteoarthritis is particularly debilitating in the

weight-bearing joints of the knees. The joint is usuallystable until the disease reaches an advanced stagewhen the knee becomes enlarged and swollen.

Although painful, the arthritic knee usually retainsreasonable flexibility.


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VISCOSUPPLEMENTATIONVISCOSUPPLEMENTATION

INJECTIONSINJECTIONS Hyaluronic Acid Injections (Viscosupplementation)

Injections of hyaluronic acid (Hyalgan, Synvisc, Artzal,Nuflexxa) into the joint -- a procedure calledviscosupplementation -- is now recommended as one of

the treatments for osteoarthritis. Hyaluronic acid is anaturally occurring substance in joints that acts as alubricant for slow movements and a shock absorber forfast motions. In high amounts, it also may have anti-

inflammatory effects. Patients receive a series of three to five injections once aweek.


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HERBS AND SUPPLEMENTSHERBS AND SUPPLEMENTS Oral Enzymes. People in Europe have used natural enzymes -- includingbromelain, trypsin, papain, and rutin -- to treat arthritic pain. Such enzymeshave been marketed alone and in combinations (Wobenzym, Phlogenzym).They are not painkillers, and any benefits derived from them may takeseveral weeks.

Ginger (Zingiberaceae). A 2001 study of patients with knee arthritis foundthat an extract of ginger reduced pain while standing and after walking. Byusing ginger, patients were able to reduce their pain medications after 6weeks. Side effects included mild digestive upset.

S-adenosylmethionine (SAMe). S-adenosylmethionine (SAMe, pronounced"Sammy") is a synthetic form of a natural byproduct of the amino acidmethionine. It has been marketed as a remedy for both depression andarthritis. Some research suggests that it may work as well as NSAIDs forshort-term treatment of osteoarthritis. Other studies suggest that it may helprebuild damaged cartilage


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MOREMORE.... Diacerein inhibits an inflammatory substance in arthriticjoints called interleukin-1b. It has shown promise inclinical trials. A 2006 review indicated that diacerein may

be slightly better than NSAIDs for pain relief. Botulinum toxin type A (Botox) injections may provide

sustained pain relief for patients with knee osteoarthritisaccording to research presented at the 2006 American

College of Rheumatology annual meeting. Nitric oxide increases blood flow in the mucous lining

and secretions of mucus and bicarbonate. Combiningnitric oxide with NSAIDs may reduce the adverse effects

on the gastrointestinal tract. Trials of gene therapies that either fight joint degradation

or strengthen cartilage are in very early stages


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INVESTIGATIONAL THERAPIESINVESTIGATIONAL THERAPIES Researchers are studying various drugs that may provide pain relief

or stop the disease process itself: Bisphosphonates such as alendronate (Fosamax) and risedronate

(Actonel) help prevent bone loss in people with osteoporosis. Theyare currently being investigated for osteoarthritis as well. A 2005study reported that risedronate may delay joint destruction inpatients with knee osteoarthritis.

Lidocaine, a local anesthetic, is available in patch form (Lidoderm)

and has been used specifically for herpes zoster pain. Early studiesindicate that it may provide significant pain relief for osteoarthritis. Tetracycline antibiotics, such as doxycycline, may have a role to

play in treating osteoarthritis. At low concentrations, the drugreduces the production of collagenases, which are enzymes criticalto disease development and progression. Initial results from clinicaltrials suggest that doxycycline may help delay joint space narrowing.


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SURGERYSURGERY

ARTHROSCOPY

TOTAL JOINT REPLACEMENT


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ARTHROSCOPYARTHROSCOPY Arthroscopy Arthroscopy is performed to clean out bone and cartilage fragments that, in

theory at least, may cause pain and inflammation. More than 650,000 ofthese procedures are done on arthritic knees each year in the U.S., andabout half of patients report less pain after the procedure.

A rigorous 2002 trial, however, found that arthroscopic knee surgery was nomore effective than sham surgery, (in which surgeons only pretended tooperate on the knee), for relief of osteoarthritic pain or stiffness. The study,

which followed patients at a Veterans Affairs hospital for 2 years, has calledinto serious question whether the popular procedure has any real benefitsfor osteoarthritis beyond what might be achieved by a placebo response.Research and debate continues on whether arthroscopy provides truebenefits for those with osteoarthritis and, if so, which patients it may mosthelp.


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Joint Replacement (Arthroplasty)

When osteoarthritis becomes so severe that pain andimmobility make normal functioning impossible, manypeople become candidates for artificial (prosthetic) jointimplants using a procedure called arthroplasty. Hipreplacement is the most established and successfulreplacement procedure, followed by knee replacement.Knee replacement, in fact, has a slightly better long-termsuccess rate than hip replacement. Other joint surgeries(shoulders, elbows, wrists, fingers) are less common,

and some arthritic joints (in the spine, for instance)cannot yet be treated in this manner. When two joints,such as both knees, need to be replaced, having theoperations done sequentially rather than at the same

time may result in fewer complications.


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REHABILITATIONREHABILITATION Limitations After Surgery. While many patients find that joint

replacement provides remarkable pain relief and restores some

mobility, they need time to adjust to the artificial joint. Limitations after hip surgery include: Usually patients with new hips are able to walk several miles a day

and climb stairs, but they cannot run. Prosthetic hips should not be flexed beyond 90 degrees, so patients

must learn new ways to perform activities requiring bending down(like tying a shoe). Limitations after knee surgery include: Walking distance improves in 80% of patients after knee

replacement surgery, but patients still cannot run.

Only slightly more than half of patients report improvement in stairclimbing. (Artificial knee joints generally have a range of motion ofjust 110 degrees.)


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REHABILITATIONREHABILITATION Rehabilitation. Aside from the surgeon's skill and the patient's

underlying condition, the success rate depends on the kind anddegree of activity the joint receives following replacementsurgery.

The patient is urged and aided into getting out of bed andwalking the day after surgery. Most hip replacement patientsleave the hospital within a week and can walk with crutcheswithin 2 - 4 weeks, recovering fully in about 3 months.

Physical therapy takes about 6 weeks to rebuild adjoiningmuscle and strengthen surrounding ligaments. Studies suggestthat an exercise program started before surgery and resumedafterward can improve recovery. Continuous passive motion

(CPM) is an effective regimen for knee replacement patients. Ituses a mechanical device that slowly moves the joint throughan arc of motion for an extended period of time. It is used toprevent scar tissue from developing. In one review, acombination of physical therapy and CPM were more beneficial

than physical therapy alone


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COMPLICATIONSCOMPLICATIONS Deep blood clots (known as deep vein thrombosis) and pulmonary

embolism. Deep blood clots can develop in the legs after this surgery. Thisposes a very small risk (0.9%) for pulmonary embolism -- a dangerous

condition in which the clot travels to the lungs. Anticoagulants (bloodthinners) are important for preventing blood clots. These drugs includewarfarin and low-molecular weight heparin. Anticoagulant therapy is givenduring the hospital stay and continued for several weeks at home. Thepatient also wears specially fitted elastic stockings to help prevent clots.Patients who are overweight are at higher than average risk for post-operative blood clots

Infection. Wound infection occurs in about 0.2% of joint replacements andrequires prompt removal of the implant to treat the infection. A newprosthesis must be re-implanted at a later time. Any pre-existing infectionmust be treated and cured before surgery is performed. (Older womenshould be aware of urinary tract infections, which may require postponingsurgery.) After surgery, patients should take certain precautions. Forexample, they should take antibiotics before invasive dental procedures orother surgery because bacteria can be introduced into the bloodstream andinfect the areas around the artificial joints.

Hip dislocation. Occurs in about 3.1% of first hip procedures. The rate ismuch higher (14.4%) in revision operations.


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COMPLICATIONS CONTINCOMPLICATIONS CONTIN Pain. Thigh pain can occur after hip replacement. Porous hip

prostheses are more likely to produce thigh pain than cement

implants, although advanced techniques using a tapered shaft arereducing this complication. Failure. The primary reason for implant failure is osteolysis (bone

destruction) caused by long-term wear. The main source of wear isfrom tiny particles released from the prosthesis.

Other complications. These include uneven leg lengths, nervedamage that can cause numbness or weakness, urinary tractinfections, delayed healing, and allergic reactions to the metal.Long-term, there have been rare reports of a possible autoimmuneresponse, in which loose particles released from the prostheticdevice trick certain immune system factors into attacking healthy

cells. Any incidence of unexplained weight loss and fatigue may besymptoms of this uncommon event.


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TYPES OF EXERCISETYPES OF EXERCISE Range-of-Motion Exercise. These exercises increase the amount of

movement in a joint and muscle. In general, they are stretchingexercises. The best examples are yoga and tai chi, which focus onflexibility, balance, and proper breathing. In one study, older adultswho practiced the gentle movement, breathing, and meditationexercises of tai chi for 10 weeks reported less pain than their peerswho did not learn the technique.

Aerobic (Endurance) Exercise. These exercises help control weightand may reduce inflammation in some joints. Low-impact workoutsalso help stabilize and support the joint. Cycling and walking arebeneficial, and swimming or exercising in water is highlyrecommended for people with arthritis. (Patients with osteoarthritis

should avoid high-impact sports, such as jogging, tennis, andracquetball.)


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THERAPY AND WEIGHTTHERAPY AND WEIGHT

REDUCTIONREDUCTION Physical Therapy In addition to exercise, manipulation of muscles and

joints by a trained therapist may be helpful. In one study,patients who had a combination of physical therapy andan exercise program reported 30 - 40% improvementafter only two to four visits.

Weight Reduction Overweight patients with osteoarthritis can lessen the

shock on their joints by losing weight. Knees, forexample, sustain an impact three to five times the bodyweight when descending stairs. Losing 5 pounds ofweight can eliminate 20 pounds of stress on the knee.The greater the weight loss, the greater the benefit.


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MusculoMusculo--Skeletal RehabilitationSkeletal Rehabilitation

InstituteInstitute

If you or your physician need a second

opinion, pain management assessment ornonsurgical treatment for neck and backpain, joint pain or nerve damage problemscall Dr Gary Keogh, M.D.

251 6214220

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Keogh Osteoarthritis Presentation