Alternate Recommendations

I was interested to note the recommendations of the Medical Journal of Australia. There are a few noted differences to those given by the American Academy of Orthopaedic Surgeons.
Rather than a simple "yes" or "no" to all treatment options, they suggest a sequence of treatments to be used as the disease progresses.
They advocate the use of glucosamine as it is a safe supplement (except for those with shellfish allergies) and as such the benefits are likely to outweigh any risks.

The use of intra-articular hyaluronic acid injections is noted to be expensive, not covered by insurance, and having results similar to oral non-steroidal anti-inflammatory medication.
As usual, a strong "thumbs up" has been given to weight loss and exercise.

The flow chart on the right is the suggested treatment progression.

The article is not long and is easy to read. To read it all, click here.

Treatment Guidelines

In December 2008, the American Academy of Orthopaedic Surgeons (AAOS) published their review of the research behind the various treatments for the osteoarthritic knee.

The paper looks at options other than knee replacement. They take a very strict objective view not only looking at the research conducted but also the quality of the data produced.

Anyone who is brave enough can look at the full 263 page report here.

I have had a look through it and there are few surprises.

Getting the thumbs up are:

Losing weight

Low Impact aerobic exercise

Self-management programs such as those by the Arthritis Foundation

Quadriceps strengthening

Non-steroidal Anti-inflammatory medication

Still Inconclusive - more study required:

Bracing for uni-compartmental arthritis

Acupuncture

Intra-articular Hyaluronic Acid injections

Not Recommended:

Lateral heel wedges

Glucosamine and / or Chondroitin sulfate or hydrocloride

The main discussion point would be the Glucosamine / Chondroitin recommendation. Although there were studies that showed a positive effect they were deemed weak studies with the potential for error. It is likely the larger, scientifically more powerful studies will be published in the future and it will be interesting to see how this one pans out.

The Knee X-ray: The Arthritic Knee

This is an x-ray of a right knee viewed from directly in front.

Notice the gap between the femur and tibia is uneven. The gap is easily seen on the left (the outside of the knee) but just a thin line on the right.

We don't actually have a gap in our knees. The gap seen is due to the cartilage covering the knee that does not show up on x-ray. When the gap is decreased or gone altogether, it indicates the loss of the articular cartilage.

When there is no gap at all it is described as "bone on bone"

Other features to notice are the little spurs of bone on the outside borders of the joint. The 'fish-hook' appearance at the bottom of the femur on the left is easily seen. There are similar, faint spurs on the right. These are called osteophytes.

Where the joint is down to 'bone on bone' there is usually an increased area of white bone, indicating sclerosis, at the very end of the bones. This is where the bone becomes very hard in response to the altered forces through the joint.

This knee would be described as having advanced degenerative changes especially in the medial joint

The Knee X-ray: The Normal Knee

This is a normal x-ray of the right knee viewed from directly in front.

The patella can be seen as a faint circle just touching the upper border of the film.

The joint space, the gap between the femur and tibia, is nice and even and the bony edges are well defined.

No irregular bony spurs are visible.

There is no obvious evidence of arthritis between the tibia and the femur. Different views would be required to comment on the presence or absence of arthritis of the patella.

This is the knee you used to have.

Hyaluronic Acid Injections

Another question I get asked a lot is "do injections work?"

Firstly we need to define which injection are we talking about.
Although not used much these days, corticosteroid injections (often combined with a local anaesthetic) have been used to decrease pain and inflammation. Because they have no lasting benefits they are used more for diagnostic reasons. If the injection helps, even briefly, it confirms the pain is coming from within the joint itself. This may help guide future treatment decisions.

Hyaluronic Acid injections are one of the latest treatments in the area.
They aim to increase the viscosity of the joint fluid as this is decreased in the osteoarthritic knee.
There are 2 products commercially available, Synvisc and Hyalgan.
Each is administered via multiple injections into the joint space over a period of weeks / months.

There is an increasing body of research into the efficacy of these injections but again the results are mixed.
Some studies have shown no long term benefits while others show promising results. This is another treatment that seems to help some more than others. Adverse reactions have been infrequent and minor so it appears a safe option.
There is a significant cost involved and once again this treatment will not make the knee 'unworn'.
As the use of these injections increases more information will be gained on who it helps and how effective it is.
Until then it should be another question to ask your surgeon. What does he / she think about these injections and do they think you will benefit?

For more information read this article by Dr Dennis Wen

Glucosamine and Chondroitin

Two supplements getting their fair share of press are Glucosamine and Chondroitin.

You won't have to look far to find people who swear by one or both but the evidence is not yet conclusive. We do know that it does not help everyone and despite much study in the area medical researchers have been unable to definitively prove their benefits.

Supplements for osteoarthritis are big business and there are plenty of over the top claims being made.

It does appear that they are safe to take in the medium to long term so discuss them with your doctor.

For a nice summarizing article click here