Treatment of Osteoarthritis of the Knee Case Study

Persons with knee osteoarthritis report joint pain, stiffness, and difficulty with mobility. The aim of treatment is to provide symptomatic pain relief, improve knee function, and improve a patient’s quality of life. Most interventions are associated with some risk, especially if the treatment is invasive and/or surgical. Treatment contraindications vary based on patient factors and comorbidities. Individual management options should be reviewed through a shared-decision approach to assess the efficacy, benefits, and risks of specific treatments. The American Academy of Orthopaedic Surgeons Clinical Practice Guideline Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline, 2nd Edition, summarizes the medical evidence of treatment efficacy when managing patients with knee osteoarthritis.⁴
 

History and Physical Examination
In April 2002, a 55-year-old man presented with right medial knee pain. He was an avid runner, running five days and approximately 25 miles per week. He ran multiple marathons. He had undergone a previous right knee arthroscopy and partial medial meniscectomy in the early 1990s, with an excellent result that allowed him to continue to run. At his presentation, he noted medial knee pain, mechanical catching symptoms, pain with pivoting (but no instability), and no specific re-injury episode. He felt his symptoms were similar to those of his previous meniscus tear. On physical examination, he tested positive on the McMurray test, with a painful meniscal click. Given that his history and physical examination results were consistent with a re-tear of the medial meniscus, he declined taking an MRI of the knee and instead wished to proceed with knee arthroscopy. He previously had had a left knee arthroscopy and partial medial meniscectomy, and he was not experiencing any left knee pain or symptoms.

Management
In May 2002, the patient underwent right knee arthroscopy. At the time of surgery, he was noted to have multiple cartilaginous loose bodies. His medial compartment demonstrated grade 4 changes of the medial tibial plateau, diffuse grade 2 to 3 changes of the medial femoral condyle and trochlear groove, a small retear of the medial meniscus in the posterior body, and a fixed osteochondral fragment adherent to the posterior horn of the medial meniscus remnant. The cartilaginous loose bodies were removed; the adherent osteochondral fragment was removed; and a chondroplasty was performed on the medial femoral condyle. At his postoperative clinic visit, he was advised to reduce his running mileage and modify his activities to low-impact activities, such as cycling.
 

Follow-up and Further Surgery
The patient was not seen again until April 2005. He had continued running shorter distances (5 km) after his right knee arthroscopy, and he had reduced his running frequency because of pain. He had recently started taking celecoxib, which helped in managing his pain. His body mass index was 25.9. He had a 5° extension block on examination. He asked about repeat arthroscopy but was advised that arthroscopy would be unlikely to help alleviate his pain. He also inquired about the possibility of using an unloader brace or undergoing an osteotomy, but because of lateral and patellofemoral compartment degenerative changes, it was felt that he was not a candidate for either treatment. He was advised to continue with the celecoxib and consider adding glucosamine for a 2- to 3-month trial to see whether this would help alleviate his knee pain.

In July 2005, the patient was seen in the clinic. Although his primary job was sales, he performed home remodeling projects and did concrete construction as a second, part-time job. He continued to play golf and usually walked the course. He felt that the celecoxib was reducing his pain, but he was unsure whether the glucosamine was helping. On physical examination, he had a 7° to 8° extension block and lacked 15° of flexion compared with his left knee. He declined corticosteroid or hyaluronic acid injections. He felt he could continue to manage his pain with celecoxib and activity modifications.

In February 2006, the patient noted that his right knee was increasingly painful and that he had to limit his weight-bearing activities. He started a new exercise program at his place of work, alternating weighttraining and core-strengthening exercises with an exercise bicycle. He felt this exercise program was very beneficial for his knees. He continued to use celecoxib and glucosamine. On physical examination, his right knee had a 10° extension block and an arc of motion from 10° to 100°. His left knee arc of motion was 2° or 3° to 125°. He again declined injections. He was advised to continue with his celecoxib and exercise/strengthening program.

In October 2006, he was seen for routine follow-up. He had continued his exercise program with an exercise bike, weight lifting, and core strengthening. The patient reported, “I feel the best I have in a long time.” Because of an increase in his blood pressure, he was advised to discontinue his use of celecoxib.

In September 2007, he wished to discuss surgery for bilateral knee replacements. Although he had continued weight lifting and using an exercise bike, he felt that he was incapacitated in weight-bearing activities because of the knee pain. He was using acetaminophen or ibuprofen occasionally for pain flares. On physical examination, his right knee arc of motion was 10° to 105°, and his left knee arc of motion was 5° to 110°. He met radiographic criteria for bilateral total knee arthroplasties and had no medical contraindications to undergoing bilateral procedures. He also met functional and quality of life criteria for surgery because his knee pain limited his weight-bearing activity and reduced his quality of life.

Outcome
Based on the medical evidence, the Clinical Practice Guideline Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline, 2nd Edition, recommends the use of nonsteroidal anti-inflammatory drugs, a self-managed exercise/strengthening program, and weight loss for management of knee osteoarthritis.

In November 2007, the patient, at age 61 years, underwent bilateral total knee arthroplasties. He managed his pain and symptoms for 5.5 years with nonsteroidal anti-inflammatory drugs and a self-managed exercise/strengthening program. He was not counseled to reduce his weight because his body mass index was 25.9.

References
1. Centers for Disease Control and Prevention: Arthritis FastStats. Table 1: Annual number and percent distribution of ambulatory care visits by setting type according to diagnosis group. United States, 2009-2010. Available at: http://www.cdc.gov/nchs/data/ahcd/combined_tables/AMC_2009-2010_combined_web_table01.pdf. Webpage updated: May 30, 2013.Accessed June 27, 2013.

2. Centers for Disease Control and Prevention: Arthritis: Spotlight Osteoarthritis. Lifetime Risk of Symptomatic Knee Osteoarthritis. Available at: http://www.cdc.gov/ arthritis/resources/spotlights/osteoarthritis.htm. Website updated:October 20, 2010. Accessed June 27, 2013.

3. Centers for Disease Control and Prevention: Arthritis: Osteoarthritis. Available at: http://www.cdc.gov/arthritis/basics/osteoarthritis.htm. Webpage updated: September 1, 2011. Accessed June 27, 2013.

4. American Academy of Orthopaedic Surgeons: Treatment of Osteoarthritis of the Knee: Evidence-Based Guideline, 2nd Edition. Available at: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed July 18, 2013.