JAMA Internal Medicine Patient Page
March 4, 2019
Michael A.Incze,MD, MSEd1,2
Author Affiliations Article Information
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1Department of Medicine, University of California, San Francisco
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2Editorial Fellow, JAMA Internal Medicine
JAMA Intern Med. 2019;179(5):736. doi:10.1001/jamainternmed.2018.8478
What Is Osteoarthritis?
Arthritis is a painful condition that affects joints. Infection, inflammation, and years of wear and tear can all cause different types of arthritis. Wear and tear, called “osteoarthritis,” is the most common type in middle-aged and older adults. In osteoarthritis of the knees, the protective padding (cartilage) in the knee joint has worn away. This causes pain at the knee joint with standing or movement.
Why Do I Have Arthritis of the Knees?
Osteoarthritis is very common. Nearly 1 in 5 adults older than 45 years has knee osteoarthritis. Risk factors include being older than 45 years, prior knee injury, obesity, female sex, arthritis in family members, and/or physically demanding occupations.
How Is Osteoarthritis Diagnosed?
Any knee pain lasting longer than 1 to 2 months should be discussed with your primary care physician. A thorough description of your symptoms and a physical examination are usually all that is necessary to diagnose knee osteoarthritis. Occasionally, additional tests such as x-rays may be recommended.
What Treatments for Knee Osteoarthritis Are Proven to Work?
Weight Loss
If you are overweight, losing weight may reduce knee pain and improve function. Most benefits occur once you have lost at least 5% to 10% of your body weight.
Regular Low-impact Exercise
Low-impact exercise such as cycling, rowing, swimming, water aerobics, walking, and tai chi has been shown to reduce pain and improve function. High-impact activities involving running and jumping should be avoided.
A physical therapist can help design the right exercise plan for you.
Medications
For mild symptoms, topical medications applied to the knees such as diclofenac gel relieve pain and have few adverse effects.
Nonsteroidal anti-inflammatory medications such as ibuprofen and naproxen are the most effective oral medications for osteoarthritis. They should be taken under the guidance of a doctor to ensure safe use. Talk with your doctor before starting these medications and avoid consistent long-term use.
Steroid injections into the knee can provide days or weeks of benefit for some people with more advanced symptoms. Frequent injections can harm the knee joint over time.
Some evidence suggests that prescription medications such as duloxetine may provide small benefit for some people.
Opiates such as hydrocodone and oxycodone are not recommended.
Surgery
If you have pain and lack of function despite treatment and physical therapy, a total knee replacement should be discussed with your primary care physician.
Are There Therapies That I Should Avoid?
There are many therapies promoted for knee arthritis that have no consistent evidence of benefit. These treatments are often expensive and aggressively marketed: insoles or special medical shoes; glucosamine, chondroitin, and other supplements; injections of hyaluronic acid or platelet-rich plasma; stem-cell treatments; and arthroscopic surgeries including debridement or partial meniscectomy.
For More Information
Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925National Institute on Aging
https://www.nia.nih.gov/health/osteoarthritis
Section Editor: Michael Incze, MD, MSEd.
The JAMA Internal Medicine Patient Page is a public service of JAMA Internal Medicine. The information and recommendations appearing on this page are appropriate in most instances, but they are not a substitute for medical diagnosis. For specific information concerning your personal medical condition, JAMA Internal Medicine suggests that you consult your physician. This page may be photocopied noncommercially by physicians and other health care professionals to share with patients. To purchase bulk reprints, call (312) 464-0776.
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Article Information
Published Online: March 4, 2019. doi:10.1001/jamainternmed.2018.8478
Conflict of Interest Disclosures: None reported.
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May 30, 2019
Arthroplasty is Last Resort
Fernando Manalac, MD, MMM | Holy Cross Orthopedic Institute
A study presented at 2018 American Academy of Orthopaedic Surgeons (AAOS) annual meeting reported the 2014 volumes of TKA and THA at 680,150 and 370,770 and projected that by 2030 those numbers would balloon to 1.28M and 635,000 respectively. I work in a "jointcentric" orthopedic group and see the great benefit arthroplastic surgery can bring to a suffering patient. I also experience and help manage many complications and varied levels of "successful" and "failed" arthroplastic surgeries. As someone on the frontlines, I can say first-hand that arthroplastic surgery should be a last resort in most cases. Those of us who practice orthopedic medicine understand that you need as many "tools in the bag" to successfully conservatively manage osteoarthritis. Therefore, it makes mean cringe like a baby fed lemons when articles like this one make it into circulation. The article reports that "therapies to avoid" include hyaluronic acid and platelet rich plasma. A simple PubMed search will provide level 1 evidence including systematic reviews of evidence in peer-reviewed journals that support use of both over placebo and/or current standard practice. Furthermore, my professional organization, the American Medical Society for Sports Medicine (AMSSM), released a position statement in 2015 advocating the use of viscoelastic supplementation. Here's my version of the article (for what it's worth): Also, scoping arthritis doesn't make sense. The patient doesn't have enough cushion, taking more from them makes no theoretical sense. If unicompartmental severe knee OA and the patient has exhausted conservative treatment then the patient is referred for osteotomy or hemiarthroplasty. If the patient has reached 65yo (or close to 65 but preferably 65-75) and has bi or tricompartmental disease and exhausted conservative management, I refer for TKR. For THR, I'm more liberal in regards to age, but expect the patient to optimize their weightloss using conservative measures for pain before I refer for replacement.
In clinical practice, the goal of care is to decrease pain and increase function to allow patients the opportunity to burn calories and unload the affected joint. I will try to decrease inflammation through use of occassional intra-articular cortisone/platelet rich plasma/Bone Marrow Stem Cells/ketorolac; oral NSAIDS (short term)/CBD; topical NSAID/CBD. I will try to reduce frictional force through use of Hyaluronic Acid; unloading bracing/taping; PT/HEP (especially patellofemoral disease); weight loss. Radiofrequency ablation of the peripheral nerves has gained traction recently. I've see this help with pain, but not the mechanical or inflammatory symptoms (ie- effusion or stiffness). Again the short term goal is to improve pain and function scores to allow increased activity. The long term goal is to push back arthroplasty until 65-70yo, which makes likelihood of revision surgery less likely. One replacement per joint at most should be the goal.
CONFLICT OF INTEREST: 2 years ago, I was given an honorarium to speak about hyaluronic acid
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