What’s New in Adult Reconstructive Knee Surgery

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The American Academy of Orthopaedic Surgeons (AAOS) published appropriate use criteria for various treatment modalities in the nonoperative management of osteoarthritis of the knee1. Among modalities, weight loss, regular low-impact exercise, oral analgesics, and intra-articular injections are commonly used to reduce symptoms and optimize knee function. Weight loss and exercise were shown to be most effective in providing durable pain relief in patients with knee arthritis2. In a systematic review, Alrushud et al. demonstrated that combining exercise and dietary interventions in patients ≥55 years of age with a body mass index (BMI) of ≥25 kg/m2 improved 6-minute walking distance and reduced body weight3. Furthermore, Gersing and colleagues showed that weight loss over a 48-month period significantly slowed the rate of cartilage degeneration on magnetic resonance imaging (MRI). The rate of joint degeneration was inversely proportional to the degree of weight loss4. However, other authors found that weight loss was not associated with a decrease in serum biomarkers for cartilage breakdown5, and improvements in the radiographic appearance of articular cartilage may not be noticeable in patients with advancing degrees of knee osteoarthritis6.
Various exercise and therapy modalities were demonstrated to improve knee symptoms and function in patients with knee osteoarthritis7,8. Park et al. found that a chair yoga program was effective in reducing pain and fatigue and improving gait in older patients with knee osteoarthritis. However, these improvements were not maintained beyond 3 months of discontinuation of the program9. The additions of adjuvant modalities to regular exercise, such as the practice of mindfulness10, laser therapy11, and even the use of cabbage leaf wraps12, have also been shown to improve pain and function. Neither the setting of the exercise program (i.e., home therapy) nor the degree of supervision appeared to impact the beneficial effects of regular physical activity on knee joint function13. Finally, Alentorn-Geli et al. showed in a meta-analysis that recreational runners had a lower risk of developing symptomatic hip and knee osteoarthritis compared with either sedentary individuals or high-impact runners with exposure equivalent to running >15 years14.
The use of oral analgesics and intra-articular injections can help reduce pain and inflammation in knee osteoarthritis. While Reginster et al. found that pharmaceutical-grade chondroitin can be as effective as celecoxib15, others found glucosamine and/or chondroitin comparable with placebo16. Currently, there is no evidence to support that any particular nonsteroidal anti-inflammatory drug (NSAID) formulation is more effective than another17. In addition, even though intra-articular corticosteroid injections are commonly administered to mitigate pain and joint inflammation, McAlindon et al. raised concerns that 2 years of triamcinolone injections compared with saline solution resulted in a significantly greater degree of cartilage loss without significant differences in symptoms18. Intra-articular ketorolac19 and periarticular prolotherapy20 were also reported to have similar effects compared with corticosteroid controls. In terms of viscosupplementation, the efficacy of hyaluronic acid in patients with knee osteoarthritis continues to be debatable21. The treatment duration22 and the number of viscosupplementation injections23 do not appear to impact clinical results. Ertürk and colleagues demonstrated that the combined use of viscosupplementation and corticosteroids allowed for earlier return to daily activities compared with viscosupplementation alone24. Finally, there is heterogenous evidence on the use of platelet-rich plasma in the treatment of knee osteoarthritis25. Compared with hyaluronic acid and saline solution placebo, platelet-rich plasma appeared to be more effective in terms of pain relief at 6 and 12 months26 and more effective compared with acetaminophen in reducing symptoms related to joint inflammation27.

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