Emerging Nonoperative Treatment Modalities for Knee Osteoarthritis Jeremy

Emerging Nonoperative Treatment Modalities for Knee Osteoarthritis Jeremy Coleman, MD Assistant Professor, Primary Care Sports Medicine University of Florida, College of Medicine-Jacksonville

n I have no actual or potential conflict of interest in relation to this program or presentation.

Knee Osteoarthritis: a prevalent disease 1/3 of all adults have radiological signs of osteoarthritis n Affects nearly 6% of all adults n Prevalence in 70 - to 74 -year-olds is ~40%. n Joem W, et al. The Epidemiology, Etiology, Diagnosis, and Treatment of Osteoarthritis of the Knee. Dtsch Arztebl Int. 2010 March; 107(9): 152– 162. (2009)

Clinical Criteria n Knee pain + at least three of the following n n n n (95% sensitivity, 69% specificity): Morning stiffness lasting < 30 minutes Crepitus on active motion of the knee > 50 years of age Bony tenderness Bony enlargement No palpable warmth

Imaging n AP or standing extended view (SEV) is common radiographic examination for evaluation of knee OA.

PMCID: PMC 2876837 The standing fixed flexion view detects narrowing of the joint space better than the s 1 Risto Ojala, 2 Jaakko Niinimäki, 2 and Juhana Leppilahti 1 Tuukka Niinimäki, Imaging n Narrowing of the joint space is better visualized in fixed flexion view (FFV) (Duddy et el 2004) Difference in joint space width SEV vs FFV Niinimaki, T et al. The standing fixed flexion view detects narrowing of the joint space better than the standing extended view in patients with moderate osteoarthritis of the knee. Acta Orthop. 2010 Jun; 81(3): 344– 346.

Management of Knee Osteoarthritis Overview n. Non-pharmacologic Treatment n. Oral Medications n. Injections n. Surgery

Nonpharmacologic Therapies n Physical Therapy/ Exercises Programs n Weight Loss n Braces n Transcutaneous Electrical Nerve Stimulation (TENS)

Nonpharmacologic Therapies n Physical Therapy/ Exercises Programs n Land-based exercise: Magnitude of the treatment effect comparable with NSAIDs. (Fransen 2015)

Nonpharmacologic Therapies n Physical Therapy/ Exercises Programs n Weight Loss n Modest weight loss (5 kg or 5% of BW) reduced OA by ACR criteria, K&L grades joint narrowing ≥ 1. 0 mm (Runhaar 2016)

Nonpharmacologic Therapies n Physical Therapy/ Exercises Programs n Weight Loss n Braces n n “Off loading” = Load redistribution and joint alignment Stabilize the joint to improve function and reduce pain

Nonpharmacologic Therapies n Physical Therapy/ Exercises Programs n Weight Loss n Braces n Transcutaneous Electrical Nerve Stimulation (TENS) n Improved QOL, function, pain control at 3 months Cherian JJ 1, Kapadia BH 1, Bhave A 1, Mc. Elroy MJ 1, Cherian C 1, Harwin SF 2, Mont MA 1. Use of Transcutaneous Electrical Nerve Stimulation Device in Early Osteoarthritis of the Knee. J Knee Surg. 2015 Aug; 28(4): 321 -7. doi: 10. 1055/s-0034 -1389160. Epub 2014 Aug 27.

Pharmacologic Therapies Glucosamine and Chondrotin n Non-Steroidal Anti-inflammatory Drugs n Analgesics n Tylenol for mild to moderate pain n Opiods for moderate to severe pain n

Glucosamine Chondrotin n Chondroitin +/- glucosamine statistically significant improvement in pain (2015 Cochrane Review) n Effect was 8 points on 100 -point scale Chondroitin sulfate and glucosamine vs. Celebrex n At 6 month follow-up: no difference in pain, stiffness, function, or swelling. Chondritin sulfate and glucosamine vs NSAIDs/Tylenol n After 24 months: GC group had less cartilage loss on medial central plateau http: //www. uptodate. com/contents/initial-pharmacologic-therapy-ofosteoarthritis? source=machine. Learning&search=glucosamine+chondroitin&selected. Title=1%7 E 37&section. Rank=1& anchor=H 1246033#H 1246033

Opiod Abuse/ Dependency n In 2014, 1. 9 million had a substance use disorder from prescription pain relievers n Drug overdose: n n Leading cause of accidental death in the US 47, 055 drug overdose deaths in 2014 18, 893 overdose deaths related to prescription pain relievers In 2012, 259 million Rx for opiods n > 1 bottle for every American adult http: //www. asam. org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures. pdf

n. Cortricosteroid Injections n Reduction of Inflammation and Pain n Risks

Deleterious Effects n n Chondrocyte viability after 14 days Braun HJ 1, Wilcox-Fogel N, Kim HJ, Pouliot MA, Harris AH, Dragoo JL. The effect of local anesthetic and corticosteroid combinations on chondrocyte viability. Knee Surg Sports Traumatol Arthrosc. 2012 Sep; 20(9): 1689 -95. .

Hyaluronic Acid Injections

Hyaluronic Acid (HA) n Articular cartilage n 1. Chrondrocytes 2. Pericellular matrix (PCM) 3. Extracellular matrix (ECM) n Collagens & Proteoglycans. n Proteoglycans Glycoaminoglycans (GAG) chains linked to proteins (ie. Hyaluronan) n n n Synvisc-One® (hylan G-F 20) n Elastoviscous fluid of crosslinked hylan A and hylan B n Produced from chicken combs.

n n HA vs oral NSAIDs for knee OA. (Bannuru et al. 2014) n No significant difference at 4 and 12 weeks. HA vs Corticosteroids for knee OA. (Bannuru et al. 2009) n n Weeks 0 -4: Intra-articular corticosteroids > HA Weeks 4 -8: Comparable Weeks 8+: Intra-articular corticosteroids < HA HA vs saline for knee OA. n n n (Jorgensen 2010) At 3 months, 53 (HA) and 47 (saline) patients did not respond to treatment. Mean time to recurrence: 172 days (HA) and 204 days (saline) No significant difference between HA and saline group

n Systematic reviews and a meta-analysis by Rutjes (2012) and Samson (2007) questionable clinical benefit n n Variable quality of trials Potential publication bias

Platelet Rich Plasma (PRP)

What is PRP? n Platelet-rich plasma (PRP) concentrated platelets after centrifugation of whole blood plasma. n n Platelets activated by thrombin and calcium chloride release of growth factors and cytokines Growth factors and cytokines healing of bone and soft tissue.

Advantages Easily obtained with centrifugation n Prepared from autologous blood n n n Minimal concerns of allergic reactions or disease transfer Does not promote hyperplasia, carcinogenesis, or tumor growth n But is it effective?

n PRP vs Placebo injections n n n PRP (n = 15) or saline (n = 15) for a series of 3 weekly injections. No statistically significant difference in baseline WOMAC scores After 12 months, PRP group improved WOMAC scores by 78% n 7% for the placebo group Smith PA 1. Intra-articular Autologous Conditioned Plasma Injections Provide Safe and Efficacious Treatment for Knee Osteoarthritis: An FDA-Sanctioned, Randomized, Double-blind, Placebo-controlled Clinical Trial. Am J Sports Med. 2016 Feb 1

WOMAC Osteoarthritis Index At 6 month follow-up: PRP: 18. 85 (+/- 14. 09) vs. HA : 30. 9 (+/- 16. 6)

11 -point pain intensity Numeric Rating Scale At 6 months followup: PRP: 2. 69 (+/- 1. 9) vs HA: 4. 3 (+/- 2. 1)

OA SEVERITY Limitations n n n n Total Knee Arthroplasty— undesired/unsafe Opiods—risk of dependence/abuse, GI SEs PRP/Hyaluronic injections– efficacy TBD Corticosteroid Injections— Chondrotoxic Tylenol– Hepatic impairment NSAIDS– Renal impairment, CAD risk Non-pharmacologic treatments

IOVERA

Cryoneurolysis In office procedure without sedation n Targeted cold therapy to a peripheral nerve n n Immediately prevents the nerve from sending pain signals. Vinod Dasa, MDa, n, Gabe. Lensing, BSa, Miles. Parsons, BSa, Ryan. Bliss, MDa, Jessica Preciado, Ph. Dc, Maged. Guirguis, MDd, Jason. Mussell, Ph. D. An ancient treatment for present-day surgery: Percutaneously freezing sensory nerves for treatment of postsurgical knee pain. Techniques in Regional Anesthesia and pain management 18 (2014) 145 -149.

Effect on the nerve is temporary n Does not cause permanent damage n n Structural components of the nerve remain.

www. iovera. com

TKA Adjunct n Improved postoperative pain control n Knee Injury and OA Outcome (KOOS) n n Improved symptom score Reduced pain score Dasa, V et al. Cryoneurolysis Nerve Block for total knee arthroplasty. Myoscience Clinical Reports. 2016; 1(1): 1 -4.

n. Questions?