Arthritis is a health crisis in the United States.
CDC estimates that 1 in 4 adults in the US have some form of arthritis.
This estimate accounts for 55 million US adults and the figure is projected to reach close to 80 million in the coming years.
There are approximately 100 different forms of arthritis but the most common form is Osteoarthritis affecting 32.5 million Americans.
43% of people with OA are 65 or older.
88% of people with OA are 45 or older.
Highest incidence of OA is between 55 and 64 years of age.
62% of individuals with OA are female.
In the younger population, under 45, OA is more common in males and above 45 OA is more common in females.
78% of individuals with OA are non- Hispanic whites.
World-wide 242 million people have symptomatic OA of the hip and knee alone
OA is the 3rd most common associated disability behind diabetes and dementia
Reduced level of activity and subsequent comorbid conditions OA causes a 55% increase in all -cause mortality
OA increases the risk of developing heart disease by 50%
One third of people with OA have 5 or more chronic medical conditions
One fourth of adults with OA experience severe joint pain. 7 on a scale of 1-10
99% of all hip and knee replacements are done to address pain and functional limitations
Over 50% of people with OA will have a total knee replacement done in their lifetime
Economics
In the United States, the overall economic burden associated with OA is currently $136.8 billion annually
This figure has doubled over the last decade.
Knee OA contributes $27 billion yearly to heath care costs alone
One million knee and hip replacements are now being done yearly in the US
In 2013, total lost wages due to any form of arthritis were $164 billion
In 2013, OA was the 2nd most costly health condition treated in US hospitals accounting for 4.3% of all hospitalization expenditures
Pathogenesis of OA
For years Osteoarthritis was thought to be caused by “wear and tear” of the joint. This is no longer the explanation for this disease. OA is a complex disorder characterized by molecular, anatomic and physiologic changes. Research over the last 20 years has learned a great deal about the pathogenesis but effective disease modifying treatment options have yet to be completely defined.
Definition of osteoarthritis is currently as follows:
A disorder involving movable joints characterized by cell stress and extracellular matrix degradation initiated by micro and macro injury that activates maladaptive repair responses including pro-inflammatory pathways on innate immunity. The disease manifests first as a molecular derangement (abnormal joint tissue metabolism) followed by anatomic and physiologic derangements (characterized by cartilage degradation, bone remodeling, osteophyte formation, joint inflammation and loss of normal joint- function) that can culminate in illness
Normal Joint
Hyaline cartilage is a avascular substance that covers the ends of the bones in a joint. Cartilage is only about 2-5 mm thick and is very compressible when under a load. Water is the primary component of cartilage but it also contains collagen, proteins and chondrocytes. The chondrocytes control the internal remodeling of the cartilage. Synovial fluid found in the joint capsule is viscous and aids in the lubrication of the joint. It also allows the nutrients to reach the cartilage while blocking other harmful substances. Hyaluronic acid is the key component of both synovial fluid and cartilage which acts as a shock adsorber under loading of the joint.
Abnormal Joint
After joint injury by either trauma or repeated stress, pro-inflammatory mediators such as cytokines and chemokines are naturally produced leading to matrix degradation and loss. As part of this process proteoglycans attract water and the articular cartilage expands. Chondrocytes begin to proliferate due to the matrix loss.. When cartilage degeneration exceeds the rate of repair and remodeling by the chondrocytes, OA occurs. With this process, collagen is lost and the cartilage has limited ability to repair and the chondrocytes die.
The soft tissue damage causes the capsule to thicken and swelling can occur. Bone Sclerosis and osteophyte formation occurs when this process is moderate or severe.
Risk Factors
- Age- OA is not a normal part of aging in fact a 2018 survey among US adults reported 57% of OA patients were under 65
- Sex- OA is more common in women
- Ethnic-African- American, Native American and Non-White Hispanic women were most likely to develop OA
- Genetic- Heritability of Hip OA to be 60%, knee 40%, hand 65%, spine 70%
- Prior Joint Injury- post traumatic OA comprises 12% of all cases
Prior knee injury are 3-6 times more likely than baseline
ACL tear confers 2.5 times the risk and 4 times risk of total knee
- Weight- 10 lbs of weight increases force of 60 lbs on knee with each step
Joint Position and Strength
Formal training exercise programs and reduce risks of injury by 70%
Knees that are not mechanically aligned properly (valgus or varus deformity) have an increased risk of OA
Weak quadriceps result in increased functional disability and OA
Treatment for Osteoarthritis
Weight loss can significantly decrease the stress and therefore the pain in the joint from excess loads on the joint
Exercise can keep the joint more flexible and strengthening the muscles supporting the joint
Pain Relievers and anti-inflammatory drugs can give temporary relief but should not be taken any longer than 10 days due to the multiple side effects
Alternative Therapies such as topical creams (capsaicin) may give relief. Acupuncture, supplements may also be effective
Bracing is effective in taking the stress away from the side of the joint affected by arthritis and allow from better pain free motion
Physical Therapy can help strengthen supporting muscles and increase flexibility
Injections
- Steroids are potent anti-inflammatory drugs that cannot be used long term and can actually degrade tissue and cartilage
- Hyaluronic Acid for cushioning and lubrication of the joint space
- Platelet Rich Plasma is an autologous blood concentrate used to restore, revive and rejuvenate damages tissues. It is a bio-active concentrate with little to no side effects since it is from one’s own blood
Surgery
Arthroscopic surgery has been challenged world- wide for the effectiveness in OA patients. An international panel of surgeons has recommended against the use of arthroscopic surgery for patients with degenerative knee problems. In the British Medical Journal, 13 studies involving 1700 patients were reviewed and found the surgery did not provide lasting pain relief or improve function. Fewer than 15% of patients felt improvement in pain and function 3 months after the procedure and those effects disappeared after 1 year.
The panel reviewing these studies said the surgery is performed more than 2 million times a year across the world and in the US alone the yearly cost is $3 billion.
Another study in Denmark showed that arthroscopic surgery for repair of the meniscus in middle aged people was not much better than exercise in pain relief and carried the risk of side effects.
The New England Journal of Medicine reported a trial of older veterans where arthroscopic surgery was no more effective in treating pain than placebo. Since, 3 other studies in this journal found arthroscopic surgery is not better than sham surgery or physical therapy in relieving arthritis pain in the knees of older adults.
Studies
The Impact of Excluding Patients with End-Stage Knee Disease in Intra-Articular Hyaluronic Acid Trials: A Systemic Review and Meta-Analysis
Adv Ther 2019; 36(1): 147-161 PMID 30506407
Purpose: Osteoarthritis is the most common joint disorder in the US estimated to affect over 30 million adults and the prevalence is expected to increase in the future. Joint pain is a common complaint among individuals with OA and the primary reason to seek medical care. While surgical intervention is typically reserved for the most severe OA, more conservative therapies are initiated earlier in the disease process in an effort to alleviate symptoms and delay progression. Treatment with hyaluronic acid is one of these options although there is inconsistency in its recommendations in the treatment guidelines.
The purpose of this review was to determine if the inclusion of end stage OA participants reduced the measured effectiveness of HA in randomized controlled trials measuring its effect on knee OA pain
Conclusion: HA provides significant pain relief compared to saline for patients with early moderate knee OA compared to cohorts including patients with end stage (KL grade 4) with no increase in the risk of treatment, up to 6 months
The results of this systemic review suggest that future clinical practice guidelines base their treatment recommendations on the individual patient’s disease state and focus on the potential for greater benefit when HA is provided earlier stage knee OA
Association Between Hyaluronic Acid Injections and Time to Total Knee Replacement Surgery
J Knee Surg 2016 Oct;29(7): 564-570 PMID 26641076
Purpose: This study addressed the association between hyaluronic acid injections and time to total knee replacement surgery with patients with knee osteoarthritis.
Study: All patients 18-64 years of age who had total knee replacement surgery. 22,555 patients, 14132 in the non-HA group and 8423 in the HA group
Results: The median time to TKR was 326 days for the non-HA group and 908 for the HA group
Conclusion: Those receiving HA injections had a median 1.6 year longer time to TKR versus those who did not get HA. These results have both clinical and economic implications
A Retrospective Analysis of Characteristic Features of Responders and Impaired Patients to a Single Injection of Platelet Rich Plasma in Knee Osteoarthritis
J Clin Med 2021 Apr; 10(8): 1748 PMID 33920633
Background: The aim of this study was to retrospectively correlate an extensive biological characterization of injected PRP to clinical responses of patients presenting knee OA
Methods: This retrospective study included 75 patients with knee OA. Cartilage lesions were assessed using MRI and the International Cartilage Regeneration Society classification. PRP characterization was performed before injection 3 and 6 months after using the Knee Injury Osteoarthritis Outcome Score and responders were defined by an improvement of 10 points on this score.
Results At 6 months 63% of the patients were responders
Conclusion: Single injections of PRP resulted in significant clinical improvement in the management of knee osteoarthritis
Studies of Combination Therapy
Platelet Rich Plasma Combined with Hyaluronic Acid Improves Pain and Function Compared with Hyaluronic Acid Alone in Knee Osteoarthritis: A Systemic Review and Meta- Analysis
Arthroscopy 2021 Apr: 37(4): 1277-1287 PMID 33278533
Purpose: To evaluate the efficacy of Platelet Rich Plasma combined with Hyaluronic Acid injections versus HA injections alone for the management of knee osteoarthritis
Conclusions: Symptomatic patients with knee OA who were injected with a combination of PRP and HA demonstrated greater improvement in pain and function compared to those who received HA injections alone as assessed by 3, 6, and 12 month analog scale scores. This study provided encouraging evidence for the use of combined PRP-HA injections in the management of systematic patients with knee OA
Hyaluronic Acid and Platelet Rich Plasma for the Management of Knee Osteoarthritis
Int Orthop 2021 Feb; 45(2): 345-354 PMID 32935198
Purpose: Intra-articular injections represent a viable option in the non-operative treatment of knee OA. Hyaluronic acid and Platelet Rich Plasma are two commonly utilized intra-articular treatment modalities that are of particular clinical interest in the current literature. The purpose of this manuscript is to provide a concise review of the current literature on the use of HA, PRP, and HA-PRP for the treatment of symptomatic knee OA
Results: Despite limited data, the combination of different formulations of HA-PRP may provide synergistic effect resulting in a clinically significant improvement in pain and function
Effects and Safety of the Combination of Platelet Rich Plasma and Hyaluronic Acid in the Treatment of Knee Osteoarthritis: A Systemic Review and Meta- Analysis
BMC Musculoskelet Disord 2020; 21:224 Apr 11. PMID 32278352
Background: Studies have shown that the combined application of Hyaluronic Acid and Platelet Rich Plasma can repair degenerated cartilage and delay the progression of knee osteoarthritis. The purpose of this study was to explore the efficacy and safety of the intra-articular injection of PRP combined with HA compared with the injection of PRP or HA alone in the treatment of knee OA
Conclusions: The results of this study indicate that PRP combined with HA may have promising clinical effects on knee osteoarthritis. Compared with intra- articular injection of PRP alone, PRP combined with HA can improve WOMAC Function Scores, WOMAC Total Scores, VAS ratings after 6 months of treatment and Lequesne Index Scores. In terms of abnormal events, PRP-HA is not significantly different from either injection alone.
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Regenerative Regards,
Dr. Robert McGrath
