Degenerative Joint Disease Session Introduction (02:21)

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Jennifer Scott Koontz discusses how sports medicine professionals are focusing on moving away from fee for service to high quality patient care. Research is crucial in developing new quality measures.

Long-term Degenerative Risks in the Skeletally Immature ACL (03:24)

Dr. Stephanie Martin will discuss osteoarthritis risks after an ACL injury. Tearing the ACL does cause OA in adults. Non-operative treatment does not stop OA, and reconstruction lowers relative risk.

Non-Operative ACL Management (02:11)

Some studies show short term success with random controlled trials comparing non-operative versus operative treatment, but there are no long term random controlled trials. Correct rehabilitation can allow patients with unstable ACLs to return to sports briefly, before reconstruction.

Surgical Techniques and OA Risk (00:47)

BPTB has a slightly higher risk of OA than HS tendons. Waiting longer than three months to reconstruct an ACL will increase the risk of meniscus tear and additional chondral injuries.

Skeletally Immature ACL Patients (04:07)

A natural history of non-operative treatment shows increased risk of OA in children. ACL reconstruction is safe in open growth plate patients; growth disturbance risk is low. Surgical timing is also important for decreasing meniscal tear risk.

Research Gaps and Summary (02:46)

Dr. Roberts summarizes facts about ACL tears and OA risk in adults and children. Prospective, multi-center cohort studies are needed to determine the best surgery type for children. She believes all ACLS require reconstruction, particularly since compliance is compromised in children.

Stem Cell Therapy for Osteoarthritis (02:54)

Dr. Alfred Gellhorn calls for research on how stem cells might treat arthritis. He will define Mesenchymal stem cells and discuss the results of injections into animal and human knees.

Mesenchymal Stem Cells (02:44)

Most current clinical studies involve osteoarthritis; research is happening outside the U.S. Mesenchymal cells were discovered in the 1970s in bone marrow and can develop into different cell types. They are not embryonic nor induced pluripotent stem cells.

Mesenchymal Stem Cell Function (01:08)

MSC do direct differentiation and serve as secretory sources with a broad spectrum of growth factors and cytokines. Learn about cytokine functions and trophic effects.

Bone Marrow v. Adipose MSC Stem Cells (00:50)

MSCs in bone marrow are drawn from the iliac crest; adipose stem cells are easy to collect and last longer. Both types are multipotent and share an immunophenotype, but adipose cells are more likely to differentiate into myocytes.

Animal Studies using MSC in OA (01:33)

Adipose MSCs were injected into OA rabbit knees against an albumin injected control group. Researchers looked at femoral condyle cartilage, menisci, and synovial tissue. Once injected, stem cells went to the synovium and meniscus but not to cartilage defects or the damaged ACL.

MSC Effects on OA Parameters (01:25)

Mesenchymal stem cells decreased knee cartilage destruction and decreased inflammation in the synovium and meniscus.

Human Studies (03:53)

A meta-analysis showed stem cells injected generally improved knee osteoarthritis. In 2014, a randomized, double blind controlled study injected allogeneic bone marrow stem cells into meniscectomy candidates with little meniscus regeneration. However a subgroup of OA patients improved.

MSC in OA Conclusion (01:59)

Animal and human data support an action mechanism hypothesis. Dr. Gellhorn believes MSC intervenes to decrease the synovial macrophage response to OA cartilage debris. Further research will identify whether there is a trophic or direct differentiation effect and clarify the action mechanism.

Managing Chondral Lesions Overview (02:45)

Dr. Mark Hutchinson asks conference attendees whether they treat with microfracture, OATS, PRP or Mesenchymal stem cells.

Types of Chondral Injury (02:28)

Hyaline cartilage is difficult to regrow. Dr. Hutchinson provides an overview of subchondral bone bruise and partial thickness. Patient age, fragment stability, joint stability, joint alignment, and lesion geography are treatment factors.

Historical Chondral Treatment Options (01:21)

Ideally, cartilage restoration will be minimally invasive, inexpensive, have no added patient risk, and regrow hyaline cartilage. View success rates of viscosupplementation, physical therapy, debridement, abrasion chondroplasty, microfracture, OATS, and autologous cell implantation. Most studies fail to consider returning athletes to play.

Current Return to Play Outcomes (03:01)

Studies on cartilage injuries in the NFL showed a slower RTP after surgical treatment. Both NBA and NFL patients treated with concomitant microfractures are less likely to RTP. Autogenous OATS and osteochondral allografts had higher RTPs than microfracture.

Allograft OATS and Autologous Cell Implantation (02:29)

Military studies showed osteochondral allograft transplantation resulted in lower returns to active duty. ACI treatments took longer for athletes to return to play, but were more durable. OATS and ACI were better than microfracture for athletes.

PRP or Mesenchymal Cells (01:45)

Studies have found decreased pain from platelet-rich plasma treatments but no return to play or long term data. Mesenchymal stem cell treatment is in the trial stage.

Knowledge Gaps (01:47)

There are limited studies on surgical versus non-surgical chondral injury treatment outcomes and no studies on PRP or Mesenchymal stem cell outcomes. Dr. Hutchinson is phasing out microfracture due to poor outcomes, and uses OATS and ACI as a last resort.

Viscosupplementation Overview (02:29)

Dr. Tom Trojian will present a study on viscosupplementation injections for knee osteoarthritis patients versus a placebo or steroid injection using the OMERACT-OARSI responder rate. This looks at individual patient responses.

OA Introduction (02:29)

Knee osteoarthritis decreases physical activity in adults; prevalence increases with age. There is a dose-response relationship between weight and arthritis. Initial treatment is weight loss and strengthening exercises; controversial treatments include total knee arthroplasty (TKA), viscosupplementation and intra-articular steroids.

Total Knee Arthroplasty (02:20)

TKA has increased in patients under 60; there is a racial disparity among patients receiving the OA treatment. Failure rates increase with age, but life expectancy also increases with age.

Viscosupplementation Indications (01:26)

Indications include documented knee OA, three months of physical therapy and NSAIDs, and failed response to aspiration and intra-articular steroids. Insurance companies recommend conservative therapy. Dr. Trojian outlines the OMERACT-OARSI responder rate.

Controversies (04:14)

The AAOS recommended not using HA, and found IAS data inconclusive. Guidelines relied upon the Minimal Clinical Important Improvement (MCII) outcome. The MCII for NSAIDs was 8 for WOMAC stiffness and 10 for viscosupplementation. Dr. Trojian cites studies finding viscosupplementation more cost effective than conventional care.

Viscosupplementation Findings (01:34)

Dr. Trojian's colleagues conducted a network meta-analysis of intra-articular injection of HA versus IAS. There is a benefit for groups and individuals treated with viscosupplementation injections.

Future Research (01:20)

Dr. Trojian's colleagues recommend viscosupplementation for knee OA patients over 60. He calls for investigating whether it delays total knee arthroplasty in patients between 40 and 60, and whether high molecular weight is more effective.

Best Practice Guidelines in OA Treatment (02:46)

Dr. Jason Matuszak will incorporate the National Quality Forum's patient outcome focused grade system of analyzing research to review evidence behind knee osteoarthritis treatment.

GRADE Approach to Evidence (01:52)

Dr. Matuszak explains the patient oriented approach, including developing a PICO question. Recommendation strength is not necessarily equal to evidence quality, but must balance the benefits and risks.

Patient Oriented Outcomes (02:55)

Chronic OA affects 40% of Americans older than 45. Treatment outcomes should help patients live longer or better, improve their experience, and be importance driven, rather than evidence driven. Goals include pain relief, quality of life, and improved function. The AAOS has developed a "clinically important change" measure.

Clinical Practice Guidelines (01:11)

Guidelines include the ACR and AAOS' GRADE rating systems, the EULAR, and OARSI. ACR and AAOS guidelines fall into pharmacologic and non-pharmacologic categories; data focuses on pain and functional status.

Pharmacologic Management (03:02)

A meta-analysis looked at whether medications were effective at reducing pain and improving function, compared to oral and injection placebos. Intra-articular placebos may be effective pain interventions. Acetaminophen, Celecoxib, Ibuprofen, Diclofenac and Intraarticular HA outperform the placebo for function.

Pharmacologic Management: Quality of Evidence (01:18)

Dr. Matuszak discusses factors raising or lowering evidence quality of randomized trials and observational studies.

Pharmacologic Management Recommendations (00:48)

Using oral and/or injectable medications for knee OA pain relief is strongly recommended with high evidence quality; using them for functional improvement is weakly recommended with high evidence quality. Considering individual risks/benefits and favoring injection therapy for mono-articular arthritis are weakly recommended with low evidence quality.

Pharmacologic Management: Topical NSAIDs (00:36)

Oral analgesics and topical analgesics yield similar results. For pain, there is a weak recommendation and moderate evidence quality; for function, there is a weak recommendation and low evidence quality.

Non-Pharmacologic Management: Nutraceuticals (00:30)

Dietary supplements and alternative medications for knee OA pain management are weakly recommended with low evidence quality.

Non-Pharmacologic Management: Exercise (01:22)

Performing kinesthesia and balance exercises in addition to strengthening exercises are weakly recommended with low evidence quality. Cardiovascular land exercise is strongly recommended with high evidence quality.

Non-Pharmacologic Management: Wedged Insoles (00:41)

There is a strong recommendation with moderate evidence quality against lateral wedged insoles for improving knee OA pain; and a strong recommendation for medial wedged insoles.

Non-Pharmacologic Management: Weight Loss (00:15)

There is a strong recommendation with moderate evidence quality for weight loss to improve knee OA pain.

Non-Pharmacologic Management: Knee Braces or Patellar Taping (00:32)

There is a weak recommendation with low evidence quality for using a knee brace. However, for varus gonarthrosis patients, there is a strong recommendation with moderate evidence quality. There is a weak recommendation with low evidence quality for patellar taping.

Practice and Research Gaps (01:49)

Dr. Matuszak calls for longer term studies on OA knee pain and function; studies on multimodal treatment efficacy; and discovering other primary outcome measures.

Credits: Degenerative Joint Disease (00:22)

Credits: Degenerative Joint Disease