In this episode of PodMD, Australian trained Orthopaedic Surgeon Dr Terry Stephens will be discussing discussing knee osteoarthritis in the younger patient, including what knee osteoarthritis is, diagnosis, management, when a GP should refer and more.
- Transcript
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*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Terry Stephens
Dr Stephens is an Australian trained Orthopaedic surgeon with further training in Canada. His speciality interests are in revision procedures, general trauma including; fractures around joint replacements, close to joints, the pelvis, and soft tissue knee injuries.
Today, we’ll be discussing knee osteoarthritis in the younger patient
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.Terry, thanks for talking with us on Pod MD today.
Terry: Thank you very much for having me today
Question 1
First off can you give us a quick explanation on what exactly knee osteoarthritis is?Terry: Osteoarthritis is essentially the loss of the normal articular cartilage. And this exposes the underlying bone when it becomes severe enough resolving in pine. And if it’s left long enough can result in deformity and even instability as time goes on, which is less common in our society today.
Question 2
How should a GP go about diagnosing osteoarthritis in younger patients?Terry: It’s really the same sorts of signs and symptoms in the older patients in the first one is largely pain. And this is where it’s essential to get an x-ray and just not assume it’s a soft tissue problem and go straight to a, an MRI as you will often pick up the problem just with an x-ray and a physical examination.
Question 3
Is there any particular pathology that will aid in diagnosing in younger patients?Terry: Uh, well, not particularly, it’s really on history, so people are having pain. Um, the main thing you need to differentiate it from is if I do have a meniscal pathology or whether they have another ligamentous injury, but office in a ligamentous injury is not going to present primarily as pine, it will present as giving why it’s important to also differentiate knee pain from hip pain.
So, if they’ve got a normal knee x-ray and I’ve got acute knee pain and always consider that the pine could be coming from the hip, I think that’s an important point to consider in boys groups. Non-operative measures should always be instituted first. And these non-operative measures include neuromuscular strengthening programs, weight loss, simple analgesics, and modification of a lot of activities. And as pine becomes worse, you might consider adding in a walking guide. The specific things with the younger patient are, that, well, they do well after a knee replacement or an arthroplasty because they are young it’s likely that they need to have a second procedure down the track.
Question 4
What does management look like in younger patients compared to older patients?Terry: So, it’s best to try and prolong having that initial procedure as long as possible. The second point with the younger patient is they’re often more dissatisfied with their knee replacement than the older patient. Um, so this is also a second reason to try and delay that surgery as long as possible. And that’s why you really need to exhaust non-operative measures. In addition to arthroplasty, there are others for the younger patient with osteoarthritis and these include at least surgically, um, osteotomy in some patients, not all patients are candidates for this, but that’s something that can be considered. And in 2020, at least, or 21, that’s becoming less common, that arthroscopy is part of the surgical treatment algorithm if there’s multiple studies. Now that show arthroscopy is really not that beneficial for osteoarthritic patients, even in the setting of meniscal tears.
Question 5
It’s obviously not as common in younger people, but is there anything that predisposes a patient to osteoarthritis?Terry: Yeah, so, so the most common reason that younger people will have arthritis would be related to, or osteoarthritis is related to previous trauma. So, whether that’s a fracture or a ligamentous injury, so someone who has an ACL deficient knee in the youngest, probably at higher risk of developing osteoarthritis. So, they’re probably the major reasons people get osteoarthritis younger. Other factors might be if I had a joint infection, which is rare obviously, but a possibility, and it’s less common that it’s from a significant alignment problem with how the person’s just general alignment is. It’s usually related to trivial trauma to prevent it specifically as to avoid getting hurt in the first place. I think the better way to put it is if someone does have osteoarthritis, how can you prevent progression? And with osteoarthritis progression is usually over time. Things get worse that during that period, there’s going to be periods where there’s peaks of pain, and there’s going to be troughs where the pain is not so bad.
Question 6
Is there anything specific that should be considered for prevention of in osteoarthritis in younger patients?Terry: And it’s a matter of trying to make those peaks of pain less severe, and the troughs make them last a little bit longer and there’s clear programs, physiotherapy programs, and one such program called the glad program. This is essentially a combination of neuromuscular strengthening around the knee, but just not around the knee, also other joints there as well. And it’s also also teaches people that they’re going to have a degree of pain and that they learn how to deal with that pain from a psychological perspective, as much as a physical perspective, and to supplement all these problems it’s worthwhile considering pharmacological agents and in particular nonsteroidal anti-inflammatories are the best. And interestingly turmeric has been demonstrated in a number of trials that it may benefit symptoms of patients with osteoarthritis. I think it’s something worth trying.
Question 7
When should a GP refer?Terry: So, I definitely wouldn’t start referring immediately unless it’s very, or the GP is extremely concerned. Overall. I think that implementing a neuromuscular program with a physio or an exercise physiologist is important, trailing some lifestyle modification with some nonsteroidals is a good idea. If the GP starts to think that the person needs anything more than nonsteroidal anti-inflammatories. And they’re thinking about giving opiates, and I think you should refer because I don’t think patients on long-term opiates do very poorly. Once they’re started on these medications that are really only helpful for short term, uh, surgical pain, or to get over a very painful event and in the longer-term they can result in worse pain. So, I think that that would be the key for me.
Concluding Question
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on osteoarthritis in younger patients.Terry: I think that the first take home point really is that, uh, for patients with osteoarthritis, trying to delay the arthroplasty for as long as possible, and this can be done quite well with physiotherapy programs. One of which is the glad program, which I think works very well. The second one is to really try and stay away from opiate medications. And if you’re starting to go that way, then you really want to refer sooner rather than later. And the third is just keeping in mind that the surgical options are really large, they’re osteotomies or arthroplasty, and the place for arthroscopy in today’s orthopaedic practices is really limited in the setting of osteoarthritis. So, the first steps, really physiotherapy or neuromuscular strengthening to be more specific. Well, thanks very much for having me, Sean.
Thanks for your time and the insights you’ve provided.
Terry: Thank you for having me
