Konservative Therapie der Gonarthrose

Acute effects of an exercise based multimodal in-patient rehabilitation protocol in male knee osteoarthritis patients and the two years follow-up sustainability

BACKGROUND

Working with lifting and carrying heavy loads and kneeling postures with crawling, squats or heel seat position lead to progressive cartilage wear with premature degenerative changes.

OBJECTIVE

To investigate the effects of the exercise based multimodal 'knee college' and its sustainability in patients with knee osteoarthritis with data assessments before and after a starter course, before a 1-year and a 2-year follow-up refresher course in a retrospective observational study.

METHODS

A sample of 401 male patients (ICD10: M17 [arthrosis of knee]/ICF: s75011 [knee joint]) from the construction industries were assessed with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol (EQ-5D), Performance Assessment Capacity Testing (PACT), Isokinetic torque H/Q ratio and Physical Work Capacity Test (PWC). Retrospectively, after two years they were divided into three groups based on their intermediate sporting activity: gym (n = 194, age: 50.8±7.0, BMI: 28.8±4,3), home training (n = 110, age: 50.2±7.0, BMI: 28.4±4,2), no exercising (n = 97, age: 48.2±7.0, BMI: 29.2±4,6).

RESULTS

Patients did not differ significantly in their demographic and anthropometric data prior to the rehab program. Significant interaction effects indicated group-dependent differing sustainability effects for the 2-year follow-up (all outcomes: p < 0.001, except for H/Q ratio: p = 0.03). Group-wise analyses revealed significant acute improvements (after 3-week in-patient starter rehab program: p < 0.05) for all groups in almost all outcomes (except the 'no sport' group, H/Q ratio p = 0.08). These effects remained significant (p < 0.001) only for the 'gym' group during the 1-year and 2-year follow-up.

CONCLUSION

Our data indicate that 2-year sustainability of acute rehabilitation starter effects was demonstrated especially for patients with adherence and compliance to long-term gym based exercises.

Routine data-based quality indicators for the treatment of gonarthrosis and coxarthrosis patients in the ambulatory care sector - A study protocol for a cluster-randomised pilot trial to evaluate the MobilE-ARTH study

BACKGROUND

In 2019, Germany had the highest rate of hip replacement surgery and the fourth highest rate of knee replacement surgery among more than 30 OECD countries. The age-standardised rates were estimated at 174 hip joint and 137 knee joint replacements per 100,000 population. Against this background, the contrast between financial incentives for surgery and missing incentives for non-surgical treatment options is repeatedly discussed. Quality indicators (QIs) can serve to measure and transparently present the quality of evidence-based care. Comparing results in the form of audit and feedback has been shown to improve e.g. guideline-compliant ambulatory care. Existing QIs targeting the care of gon- and coxarthrosis mainly focus on discharge management after joint replacement surgery and/or require additional data collection. Therefore, as part of the MobilE-ARTH project, a set of QIs for ambulatory care prior to joint replacement surgery calculable based on routine data is being developed. The present study's aim is to evaluate the impact of this QI set in terms of providing feedback on the quality of care.

METHODS

The MobilE-ARTH project comprises (Phase 1) developing a QI set following the RAND/UCLA Appropriateness Method, (Phase 2) implementing the QIs in established physician networks of a German statutory health insurance (SHI) within a prospective, non-blinded, cluster-randomised pilot study, and (Phase 3) evaluating the QI set's effectiveness. The physicians in the intervention networks will (a) receive feedback reports providing information about the routine data-based QIs of their gon- and/or coxarthrosis patients and aggregated results for their network, and (b) be invited to two voluntary, facilitated network meetings. In these network meetings, the physicians can use the information provided on the feedback reports to discuss multiprofessional care pathways for patients with gon- and/or coxarthrosis. Selected indicators of the QI set will serve as primary and secondary outcome measures. Routine data will be analysed within multi-level models using an intention-to-treat approach.

DISCUSSION

Feedback reports help maintaining clinical standards and closing the gap between evidence and medical practice, thus enabling an overall improvement in health care. Providing physicians with QI-based information on quality of care promotes identifying strengths and weaknesses in medical treatments.

TRIAL REGISTRATION

German Clinical Trials Register, number DRKS00027516 , Registered 25th January 2022 - Prospectively registered.

[Treatment options for femoroacetabular impingement syndrome and osteoarthritis]

Femoroacetabular impingement syndrome (FAIS) is a prearthritic deformity. Many patients with FAIS show signs of osteoarthritis at the time of initial presentation. Ideally, surgical correction of FAIS should stop the progression of osteoarthritis. However, biological changes in the joint, inflammatory processes, and patient-specific factors, which are not influenced by surgery, show a role in the progression of joint degeneration. Thus, it is not surprising that the results of joint-preserving surgery in FAIS and osteoarthritis Tönnis grade 2 and higher are bad, and patients often need to undergo total hip replacement (THR).Even in patients with initial osteoarthritis (Tönnis grade 1) the results of joint-preserving surgery are significantly worse in comparison to in patients without osteoarthritis. As this pathology occurs mainly in young patients, efforts should be made to avoid THR, as the risk of loosening and revision surgery is increased. Analysis of risk factors that lead to worse outcome in joint-preserving surgery can be helpful. Age > 45 years, adiposity, high alpha angle, CE angle < 25° and female sex are risk factors that lead to worse outcome in patients with risk factors and osteoarthritis Tönnis grade 1, the success rate of joint-preserving surgery after 5 years is below 50%. Therefore, we recommend non-surgical treatment. Promising is the use of mesenchymal progenitor cells (MPCs), even if their routine use has not been established. If conservative therapy is not successful, THR is indicated. With the use of modern bearings, a survival rate of THR of more than 90% after 15 years is reported in patients < 50 years. Patient satisfaction after THR is higher than after joint-preserving surgery.The combination of treatment modalities like joint-preserving surgery in combination with the application of MPCs to both correct the mechanical conflict and also influence progression of osteoarthritis is promising the from a biological point of view.

Results of genicular nerve ablation by radiofrequency in osteoarthritis-related chronic refractory knee pain

Background/aim

The aim of this study was to investigate the medium- to long-term effects of radiofrequency (RF) ablation of genicular nerves for chronic refractory knee pain due to osteoarthritis (OA).

Materials and methods

Forty-eight patients who underwent RF ablation of the genicular nerves were evaluated retrospectively. The visual analogue scale (VAS) score, Western Ontario and McMaster universities osteoarthritis index (WOMAC index), opioid and nonsteroidal antiinflammatory drug (NSAID) use score, quality of life score, and treatment satisfaction score were examined at 1, 3, and 6 months after the procedure.

Results

The mean VAS scores were significantly lower at the 1-, 3-, and 6-month evaluations compared with the preoperative values (P < 0.001). A significant decrease was observed in the WOMAC index compared with preoperative values (P < 0.001). It was found that 66.7% of opioid users and 56.3% of NSAID users stopped using medication. No serious complications were encountered during or after the procedure.

Conclusion

In chronic refractory knee pain due to OA, the application of RF ablation to the genicular nerve is an effective and safe treatment option in the medium to long term.

[Effects and sustainability of knee school : 2-year results of a secondary prevention program for gonarthrosis]

BACKGROUND

Craftsmen and workers in the construction industry are at an increased risk of developing gonarthrosis due to their work-related burdens. In order to maintain the ability to work, occupational co-operative measures for secondary prevention can be carried out (BG Bau/Kniekolleg). The aim was to evaluate the efficacy after 2 years, depending on the degree of exercise adherence.

MATERIAL AND METHODS

In a repeated measurement design (T1 before, T2 after knee school, T3 after 1 year, T4 after 2 years), 140 construction patients were assessed for their dynamic muscular strength (knee extension, 60°/s,); their quality of life (SF-36) and characteristics for gonarthrosis (WOMAC) were evaluated using analyses of variances, whereby one group trained after the knee training in the gym with instruction (Gr. 1 n = 63), one group completed a home-training program (Gr. 2 n = 38), and one group completed exercises outside of knee school (Gr.3 n = 39).

RESULTS

For all parameters, significant acute efficacy and 2‑year sustainability effects were observed (p ≤ 0.05, d: 0.2-0.8). There was no interaction with adherence during training after knee school (p > 0.05).

CONCLUSION

Knee school has proved to be effective in the long term, leading to a critical questioning of future research, why there are no differences between guided, reduced or even missing long-term maintenance training.

[Knee school as a secondary preventive approach : The sustainable treatment of occupational gonarthrosis]

BACKGROUND

2-6 months after successful medical rehabilitation in gonarthrosis, the positive effects remit without the implementation of adequate aftercare strategies.

OBJECTIVES

A prospective comparative study aimed to investigate whether and to what extent the sustainability model of knee school for the secondary preventive treatment of occupational gonarthrosis is able to maintain positive treatment effects in the medium term.

MATERIAL AND METHODS

A total of 292 male employees from the building trade went through the three-week phase 1 of the biopsychosocial knee college with a focus on ergonomics and muscle strength training. In the following 12 months (Phase 2), the participants were contacted several times by telephone in order to motivate them to continue the training. While 178 employees voluntarily and locally continued their training in selected fitness centers with financial support (VG 1), and 38 employees opted for an individual home program (VG 2), 76 participants stopped all training (KG).

RESULTS

After Phase 1, all groups showed significant improvements in the parameters mobility, as well as stretch ability and strength endurance of the thigh muscles, complaints of the knee and quality of life. While the parameters in VG 1 continued to develop positively after 12 months, the measured values in VG 2, with the exception of muscle strength, moderately remitted. By contrast, a significant decline in the measurement values partly below the status quo ante was observed for the KG.

CONCLUSIONS

As part of the aftercare, financially supported training in a fitness center with accompanying regular telephone contacts for male construction workers with knee discomforts shows positive effects if the participation is voluntary. Organized training in the fitness center is superior to individual home programs.