A 72-year-old retired plumber comes to the office to discuss treatment of chronic right knee pain. Over the past 10 years, the patient has had multiple rounds of glucocorticoid injections and physical therapy to manage the pain, which has increasingly worsened; using a cane, he can now walk only 2 blocks before it becomes unbearable. Medical history is notable for type 2 diabetes mellitus, hypertension, and depression. Blood pressure is 130/78 mm Hg and pulse is 80/min. BMI is 26 kg/m². On examination, the right knee is stiff and swollen but has no erythema. There is tenderness on palpation at the medial and lateral joint lines, and patella grind test is positive. Ligament testing is stable to varus and valgus stress. Passive and active range of motion is limited because of pain. X-ray of the right knee shows bicompartmental joint space narrowing and multiple osteophytes. Which of the following is the best treatment option for this patient?

Question

Quizplus · Accepted Answer

11ec25c8_d86e_0abd_bc81_61dca880b38a_MD0003_00 This patient has chronic joint pain and stiffness consistent with osteoarthritis (OA). The x-ray shows typical findings, including narrowing of the joint space and periarticular osteophyte formation. Initial management of OA of the knee includes nonpharmacologic and lifestyle measures, including weight loss, regular moderate activity (eg, walking), and exercises to strengthen the quadriceps muscle. Simple analgesics (eg, nonsteroidal antiinflammatory drugs) may also be helpful. If conservative management is inadequate, injectable glucocorticoids or possibly hyaluronic acid may relieve symptoms. However, appropriate measures have failed in this patient, so he is a candidate for surgical intervention with total knee arthroplasty, an elective surgery consisting of replacement of the articular surface of the knee with prosthetic components. Total knee arthroplasty has been associated with significant improvements in pain level, function, and quality of life. total knee arthroplasty (Choice A) Arthroscopic meniscectomy is indicated for symptomatic tears of the meniscus. Long-term complications include increased risk of OA in the operated knee. In general, arthroscopic intervention is not helpful in patients with established OA. (Choice B) Systemic glucocorticoids (eg, methylprednisolone) are occasionally considered for mild to moderate OA of the knee, but their side effect profile makes them an unattractive option. They are relatively contraindicated in this patient with comorbid diabetes, due to possible hyperglycemia. (Choice C) Hinged unloader (valgus) knee braces transfer load from the medial to the lateral joint compartment and are useful for patients with medial unicompartmental OA associated with varus deformity. This patient has more generalized OA and would be unlikely to benefit from the use of a brace. (Choice D) Therapeutic arthrocentesis is usually used for inflammatory or rapid-onset effusions (eg, septic arthritis, hemarthrosis). It is rarely helpful in the small effusions of OA. (Choice E) Chronic treatment of OA with long-acting opioids does not appear to provide substantial improvements in pain or function; it also carries significant risk. Educational objective: Management of osteoarthritis of the knee should include weight loss, regular activity, and exercises to strengthen the quadriceps muscle. Simple analgesics may also be helpful. If conservative management is inadequate, injectable glucocorticoids may relieve symptoms. Total knee arthroplasty is indicated for those who fail less aggressive measures. References: Total joint arthroplasty for persons with osteoarthritis. (http://www.ncbi.nlm.nih.gov/pubmed/22632709)

A 72-Year-Old Retired Plumber Comes to the Office to Discuss