Options for Knee Osteoarthritis

Treatments for knee osteoarthritis (OA) fall into these basic categories: self-care, medically managed, minimally invasive, and surgical. Here we review what’s shown to be the most effective, relevant treatments according the degree of OA damage.

Advances in Understanding and Treatment

OA was once thought of as purely a “wear and tear” mechanical event, but a growing body of evidence supports the belief that joint inflammation also contributes to OA.

“In the knee joint there are many proinflammatory chemicals that eat away at the meniscus and cartilage,” explains UCLA Interventional Radiologist Sid Padia, MD. “With time, as the thick cartilage breaks and cracks, these chemicals are released and in turn cause more breaking and cracking. It’s a vicious cycle.”

Dr. Padia and other researchers and clinicians seek to stop this inflammatory process, preserve the joint, and in so doing decrease pain and improve mobility. Researched and validated in Japan and now refined and available at UCLA is a procedure called genicular artery embolization (GAE). It’s a minimally invasive, image-guided treatment that reduces the blood flow that feeds inflammation in the knee. Research presented at the 2018 Society of Interventional Radiology’s Annual Scientific Meeting suggests that this nonsurgical treatment could improve quality of life for patients with mild to severe OA knee pain.

A Minimally Invasive Procedure

Interventional radiologists perform GAE for knee pain by inserting catheters through a pinhole-sized incision in the leg and injecting particles that block the very small arteries or capillaries within the lining of the knee. This reduces the inflammation caused by OA, and can potentially decrease pain and restore mobility. As an outpatient treatment, GAE does not require open surgery and is performed with conscious sedation with intravenvous, not general, anesthesia.

“The final result is that the artery is maintained but inflammation has disappeared,” explains Dr. Padia. “The procedure takes about two hours. There are no stitches; just a bandage is applied. The patient is typically walking that evening.”

According to Dr. Padia, GAE is meant for moderate to severe OA and where other conservative methods have either failed or are no longer working. These include joint injections, such as steroids or hyaluronic acid, which can be helpful, but their effects can diminish over time. GAE is also an option for patients with conditions that make knee replacement difficult. For example, an 89-year-old patient of Dr. Padia was hesitant about undergoing the lengthy and often painful knee replacement physical therapy. He also has health conditions that increase anesthesia risk. GAE was a viable option.

“After two weeks he was able to walk three miles without pain,” says Dr. Padia. “The GAE success rate is 85 percent in patients with mild to moderate OA, and about 70 percent for those with severe pain.”

A 2017 study showed that GAE results are also progressive, meaning that pain decreases and function increases over time.

From Self-Care through Surgical Options

OA is categorized into five stages. Stage 0 is a normal healthy knee. To follow are the other stages and common treatment options for them.

Stage 1 is when bony outgrowths (bone spurs) begin developing and are visible on an x-ray. There is little to no pain at this stage. If you have a family history of OA, or are at increased risk (e.g., obesity, injury, overuse), your doctor might recommend an exercise routine and/or over-the-counter medications to relieve minor symptoms.

Stage 2, mild OA, results in more bone spur growth, and cartilage will be thinner on imaging (x-ray, MRI). Symptoms may include stiffness and joint pain, especially after prolonged sitting. Treatment can include physical therapy and strengthening the muscles around the joint. Braces and shoe inserts may help. Jumping, squatting, and kneeling should be avoided. NSAIDs, or acetaminophen (Tylenol) for pain as well as icing can also help.

Stage 3, moderate OA, is when damage to the cartilage is more obvious. Pain becomes more frequent with activities, such as knee bending, walking, and running. Joint swelling and stiffness are more common. Nonpharmacological treatments are typically less effective at this stage. Joint injections may be recommended. A steroid shot lasts up to six months. But the approach is limited as steroids can worsen joint damage in the long run. Hyaluronic acid injections may take several weeks to produce the full effect. It usually takes several injections, though there are now single-dose options available. Some people experience relief; others may not.

Stage 4 is severe OA. At this stage there is little to no cartilage remaining, and synovial fluid has diminished, resulting in bone-on-bone pain. Inflammation is severe, as is pain. Treatment often includes surgery for bone realignment, and partial or total knee replacement. Recovery can take months. Newer replacements can last for decades.

Research is under way on stem cell treatments, but the injections are not FDA approved. The advice is to avoid these treatments, unless they are part of an FDA-approved clinical trial. GAE is available at UCLA clinically (and then billed to insurance/Medicare). A trial seeking candidates is also under way at UCLA. The medical center covers the cost of the procedure and follow up. For more information on eligibility, contact Dr. Padia at spadia@mednet.ucla.edu.

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