MRCGP AKT Question - Management of osteoarthritis

by BMJ OnExamination Editor 23. November 2009 16:46

A 62-year-old lady who is known to have severe OA of her right knee presents to you wanting referral to a knee surgeon for a knee replacement. She smokes 15 cigarettes a day and is obese, with a BMI of 32. She has tried changing her footwear and was referred last year to an exercise programme but she had to stop because the exercise made her pain worse. Subsequently she is unable to lose weight.

Despite being on regular paracetamol, ibuprofen and tramadol, the pain is slowly increasing week by week, to the point where she is having difficulty leaving the house, and has taken to sleeping downstairs in a reclining chair because she finds the stairs too painful to climb.

Which one of the following options is your best next step?

  1. Intra-articular corticosteroid injection
  2. Intra-articular hyaluronan injection
  3. Intra-articular traumeel injection
  4. Morphine sulphate sustained release 5 mg BD
  5. Referral for TKR
  6. Rubefacients

If you would like to discuss this question with the Editor, please post your comments below:

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MRCGP

Comments

11/12/2009 6:00:19 PM #

med doc

Wouldn't you refer her for physio first? I would normally consider paracetamol first line. What's the answer?

med doc France |

11/12/2009 6:34:54 PM #

Editor

Thanks for your comment. First read the question. She's already taking paracetamol and the question doesn't ask you about physiotherapy. The first rule with any postgraduate exam is to read the question carefully then answer the questions posed. Of the options given, which one do you think would be the most appropriate, given her management so far? If you're finding the question difficult have a think about any published guidance. You might want to consider further reading here: cks.nhs.uk/.../detailed_answers#-332692

Editor United Kingdom |

11/25/2009 4:07:33 PM #

Rachel

I'd refer her.  How do we find out the answer?

Rachel United Kingdom |

11/26/2009 4:36:44 PM #

Editor

Thank you for your comment Rachel. We'll reveal our author's answer and explanation later, following discussion of the case. What factors in the history point you towards referral?

Editor United Kingdom |

11/25/2009 4:29:04 PM #

SURA IBRAHIM KADHIM

My next step is Intra-articular corticosteroid injection

SURA IBRAHIM KADHIM United Kingdom |

11/26/2009 3:40:46 PM #

Editor

Thank you for your contribution, Sura. A popular answer. Would you consider referring this lady at this stage? Do you know where steroid injections fit in with the latest NICE guidance?

Editor United Kingdom |

11/25/2009 4:29:48 PM #

Dito Anurogo, MD

Dear honorable editor,

I just want to know, what is the best website/link/journals to get the most uptodate Guideline or Management of osteoarthritis"? Here in Indonesia, almost the most uptodate journals link can't be accessed, coz I need the most evidence based to answer my patients' question.

Would you like to guide (help) me?


Thank you,
Best and warmth regards,


Dito Anurogo, MD
Health consultant in Netsains.com

Dito Anurogo, MD Indonesia |

11/26/2009 3:21:37 PM #

Editor

Thank you for your contribution, Dito. I'm sorry to hear that you experience difficulties getting access to the relevant journals in Indonesia.
We have set this question to test candidates sitting the MRCGP AKT exam, so our answers are going to reflect consensus opinion as it applies to UK practice and guidelines. In this respect, if you can access this sites, you might find the NICE guideline and the NHS Clinical Knowledge base useful. Click on the osteoarthritis links in our LinkList on the right of this page for further reading

Editor United Kingdom |

11/25/2009 4:29:52 PM #

jatinder

After discussion could you kindly post the correct answer.  Thanks.

jatinder United Kingdom |

11/26/2009 2:21:48 PM #

Editor

Yes we will. Thanks for taking part. Which option would you go for and why?

Editor United Kingdom |

11/25/2009 5:49:26 PM #

Aiman Dablouk

I think this is the correct answer: Referral for TKR

Aiman

Aiman Dablouk United States |

11/26/2009 3:33:49 PM #

Editor

Thank you for your answer, Aiman. Would you like to elaborate on why you have selected this answer? Have you referred to any clinical guidleines in coming to this conclusion? It's a very good answer and I'm interested to hear why you opted for this

Editor United Kingdom |

11/25/2009 6:19:13 PM #

Rozimon Hoque

Intra-articular corticosteroid injection.

Rozimon Hoque United Kingdom |

11/26/2009 3:07:48 PM #

Editor

Thanks for your comment, Rozimon. Why would you opt for intra-articular corticosteroids?

Editor United Kingdom |

11/25/2009 7:08:17 PM #

Syed Shakeel Ahmad

Since she has been on simple nalgesics she may now be tried on opids, ie. sustained release morphine 5 mg bd. As she has shifted to the ground floor she may start to take walk as soon as pain is decreased, continue or restart the weight reduction program. She will need physio in the form of quadriceps strengtheing before she decides to climb upstairs again.

Syed Shakeel Ahmad Saudi Arabia |

11/26/2009 3:19:47 PM #

Editor

Thank you for your contribution, Syed. You've opted for one of the less popular answers. Most of our participants have gone for either referral or steroid injection. What do you think about giving her a steroid injection to alleviate her discomfort? Would you consider this lady suitable forreferral at this stage?

Editor United Kingdom |

11/25/2009 8:56:08 PM #

Vishisht

I would like to prefer a multi specilaty aproach as my main concern is her her pain, Fat (obesity),life-style modification (advising the out comes and to neutralize her expectation after surgery) and her smoking while she is getting over them I'll give her a intraarticular corticosteroid for a few months.
After that having a look at her co-morbid conditions i'll go for a high tibial osteotomy or TKR.

Vishisht India |

11/26/2009 2:29:33 PM #

Editor

That's a very good answer, Vishisht, and you're clearly thinking of the wider management of the patient. For the AKT exam, try not to dwell too much on other issues and focus on the options presented. You have raised some very pertinent points, however.

Editor United Kingdom |

11/26/2009 12:47:27 AM #

simple arora

The answer could be intraarticular corticosteroid or intraarticular hyaluronan injection.As hyaluronan is expensive,I think if there are no contraindications for corticosteroid use ,this should be tried before TKR.

simple arora Australia |

11/26/2009 2:53:12 PM #

Editor

Thank you for your comments. Few users have mentioned intra-articular hualuronan injections - why would you select this and what evidence do you have that would support the use of this treatment? Do you know what NICE have to say about intra-articular hyaluronan injections?

Editor United Kingdom |

11/26/2009 9:19:26 AM #

Omar

I will givw her intra-articular injection of steroid. I do not think that she will be fit for surgery as she is Obeses and I do not think that knee replacement is a good option taking into account her obesity problem and that she has not been successful in losing weight.
I am aware that there are new guidlines for the management of OA and I need to review these!

Omar United Kingdom |

11/26/2009 2:50:33 PM #

Editor

Thank you for your comments, Omar. You've raised a very important issue with regard to her weight. These patients are often overweight and, as a number of doctors have commented here, losing weight will help. However, would you consider that a BMI of 32 would preclude her from surgery (or, to be more precise, would be a reason for NOT referring her in the first place)? Remember, for the AKT exam, your answer would be expected to be broadly in keeping with consensus opinion. According to the latest NICE guidance, patient specific factors, including obesity, should not be barriers to referral for joint replacement surgery.
One of the reasons we selected this question was that we felt that there would be a healthy debate about the answers and that it may stimulate some of our users to look at the latest guidelines.

Editor United Kingdom |

11/26/2009 10:24:36 AM #

chris

Seems reasonable to try an intra-articular corticosteroid injection. This should be preceded by withdrawal of sinovial liquid from the joint if possible, as this has been shown to increase the duration of response to cortico-steroids in osteoarthritis. We could anticipate a significant initial response to the injection, however it is unlikely to be a long term solution. If steroids fail or have already been used intra articular hyaluronic acid could be trialed. In the long run these are likely to act more as bridging therapy while awaiting a more definitive surgical resolution.
With regards the other options I don't actually know what traumeel is, unless its a brand we dont have in Australia. Morphine could be an option allthough she is already using tramadol.... probably just increase her side effect profile. I think she is a bit past Rubefacients.

chris Australia |

11/26/2009 2:40:58 PM #

Editor

Thank you for your contribution, Chris. Although I am a working GP in the UK, I'd not heard of "Traumeel" either, but our author (a GP with a special interest in sports medicine) tells me that it's widely available and used by some doctors (hence the addition in our question). Traumeel isn't mentioned in the NICE guidelines. I'm told that it's a formulation of 12 botanical substances and one mineral substance, which includes mountain arnica among several other homeopathic substances. The manufactures claim Traumeel Injection Solution is an anti-inflammatory, anti-edematous, anti-exudative combination. It can also take the form of creams, ointments, tablets and oral solutions. There is no established literature supporting its use in acute or chronic joint pain.

Editor United Kingdom |

11/26/2009 2:42:57 PM #

Editor

As a matter of interest, are you studying for the MRCGP AKT exam? I've mentioned NICE guidance, but you may be unfamiliar with this in Australia. If you are sitting the MRCGP AKT you'd need to have a general understanding of the main clinical guidelines as they apply to UK practice.

Editor United Kingdom |

11/26/2009 10:25:32 PM #

chris

No I am not preparing for the MRCGP exam. I wouldnt mind having a look at the guidelines anyway though.

chris Australia |

12/3/2009 10:16:11 PM #

Editor

Thanks for your comments, Chris. We've included the guidelines in the links on the top right hand side of the page. NICE (National Institute of Clinical Excellence)publish guidelines in a number of subject areas to assist doctors in the UK. They are broadly useful but there are sometimes conflicts with other national guidelines and sometimes there is disagreement amongst doctors about their conclusions. Our advice to candidates sitting UK postgrad exams is that a broad knowledge of published guidelines is useful but they should go with consensus opinion. Good examination questions, however, shouldn't focus on one guideline that contradicts all others, if such a discrepancy exists. Thanks for your interest and for your contribution to the discussion.

Editor United Kingdom |

11/26/2009 3:57:06 PM #

Prasadth

I would go for the intra-articular corticosteroid injection and releave her symptoms till she goes for TKR.

Prasadth |

11/26/2009 4:52:39 PM #

Editor

That's a good answer, Prasadth. Do you know where do steroid injections fit in with the latest NICE guidance?

Editor United Kingdom |

11/26/2009 4:56:32 PM #

Editor

According to NICE, intra-articular corticosteroid injections can be used as adjuncts to core therapies when pain is moderate to severe. Does anybody know what treatments are NOT recommended by NICE? (Clue: one of the options given in our questions)

Editor United Kingdom |

11/26/2009 4:05:36 PM #

Gavin

My answer in real life would be to present the options to the patient. For example it is obvious that weight loss would potentially benefit her. I may therefore propose that a steriod injection/inc analgesia to sustained release opiates, would allow her to mobilise in an attempt to lose weight. The question would suggest however this is unlikely to work as the patient has tried (and failed) an exercise programme and is requesting referral.

In that case I would consider referral for an "opinion" from an orthopaedic surgeon as ultimately the severity of the OA, her fitness and the Surgeon's opinion will dictate whether they would operate on her knee. They could always offer intra-articular injection too.

Given the information available, I would refer due to the severe impact her knee is having on her life.

Gavin United Kingdom |

11/26/2009 4:49:43 PM #

Editor

That's an excellent answer, Gavin. You have covered a number of important issues. The only problem with AKT style questions is that they often involve a fairly restricted learning point, but, as have you have correctly pointed out, our management as GPs involves a consideration of the wider issues (lifestyle issues, care at home, screening ofr depression etc). Obviously, the other areas of the MRCGP exam would delve into this. Many thanks for your contribution this afternoon.

Editor United Kingdom |

11/26/2009 4:36:17 PM #

Rana Inam

This patient has taken all the core treatment. She's unable to carry her daily routine work. She cannot exercise due to pain. She should be first offered intra articular steroids. Apart from that she should be given Orlistat to manage her garde1 obesity, as she's suffering from a co morbidity.  

Rana Inam Kuwait |

11/26/2009 5:16:33 PM #

Editor

Thank you for your comments, Rana. Nobody has mentioned Orlistat as an option, but this would be something to consider.

Editor United Kingdom |

11/26/2009 5:30:18 PM #

Editor

Correct answer: Referral for TKR

Author's explanation:
This lady has established severe OA that is impinging on her daily activities. NICE recommends that clinicians with responsibility for referring a person with osteoarthritis for joint surgery should be sure that the patient has been offered the non-surgical core treatments available.
Hospital referral for joint replacement surgery should be considered for those with osteoarthritis who have symptoms in their joints such as pain, stiffness and/or reduced function. Referral should be made before there is prolonged and established limitation in joint function and/or worsening or severe pain.
Patient-centred factors like age, sex, smoking, obesity and co-morbidities should not be barriers to joint replacement therapy referral. Decisions on referral thresholds should be based on discussion between patient representatives and referring clinicians and surgeons.
In this scenario all other core therapies have been exhausted.
Intra-articular hyaluronan injections, rubefacients, chondroitin, glucosamine, or chondroitin and glucosamine combinations are not recommended.
Traumeel injections are not mentioned in the NICE guidelines. Traumeel is a formulation of 12 botanical substances and one mineral substance, which includes mountain arnica among several other homeopathic substances. The manufactures claim Traumeel Injection Solution is an anti-inflammatory, anti-edematous, anti-exudative combination. It can also take the form of creams, ointments, tablets and oral solutions. There is no established literature supporting its use in acute or chronic joint pain.

Editor's comments:
Thank you to all of the doctors who have taken part in this discussion. We have chosen this question for discussion because we felt that the author's answer might stimulate debate! The author of this question is a working GP and member of the Royal College of General Practitioners who also holds a diploma in sports medicine. Very often in general practice, there are a number of correct options and I don't think that those who answered in favour of steroid injections could be criticised for their choice of answer. Our author has opted for referral because he feels that this patient has fulfilled the criterea for referral. Whilst some, more experienced GPs, may consider steroid injection as an adjunct to core therapies, the majority of GPs would be referring this patient at this stage and using steroid injection to alleviate symptoms, having already referred. Some of you may have further views to the contrary and we would welcome your comments.
As I said earlier, we selected this question because the two most appropriate answers (steroid injection vs Referral) would stimulate debate. If you would like to comment further on this question, I will endeavour to answer your queries. I will also be happy to forward a selection of comments to our author for further feedback.
To those sitting the AKT exam in the new year, good luck and please return for further questions dissected!

Editor United Kingdom |

11/26/2009 10:31:57 PM #

chris

I don't disagree with referral, however I would be injecting her knee with corticosteroids in the mean time (unless there is a contraindication of course, and with the patients consent). The layout of the question is somewhat misleading... my next step would be intra-articular steroids, allthough of course she will be referred for a TKR possibly simultaneously. The questions only asks for the NEXT best step. Interesting discussion and contributions. Thanks.

chris Australia |

12/3/2009 10:14:10 PM #

Editor

Thanks for your comments and for taking part in the discussion, Gavin. I'm glad that you found the discussion interesting and I hope that you will visit us again when we will be discussing further questions.

Editor United Kingdom |

11/27/2009 2:13:04 PM #

Rana Inam

I agree with referral for TKR; but the question is "which one of the following is the best next step?"

    Only after giving intra articular steroid, I'll refer the patient. The patient has to have some relief of pain during the waiting period for surgery.

Rana Inam Kuwait |

12/3/2009 10:14:50 PM #

Editor

Thank you Rana. I think that's a very reasonable answer and a fair comment. Thanks for taking part in the discussion and I hope that you will visit the site again.

Editor United Kingdom |

11/29/2009 8:46:15 PM #

Mario Bonilla

Dear editor:
For certain reasons you did not give the answer I would give. If the woman had had a right gym such as hydrogym, the Archimedes principle would have let her continue with gym and swimming.A good program directed by a sports physician. A diet between 1000 an 1500 cal. A smoking cessation plan. Counceling.
Analgesics as indicated, diminishing tramadol and stop it soon.
Thank you,
Mario

Mario Bonilla Uruguay |

12/3/2009 10:12:44 PM #

Editor

Thank you for your commnets, Mario. Guidelines on the management of osteoarthritis may vary by region. There is nothing wrong with what you have said, although this patient would fulfill the criterea for referral in the UK.

Editor United Kingdom |

11/30/2009 4:04:11 AM #

Bosbos

intra articular steroids

Bosbos United Kingdom |

12/1/2009 5:53:35 PM #

Mario


Dear Bosbos,
Thank you for your answer. Intra articular steroids alleviate the patient for a while but the pressure under which the joints work remains the same. It can be tried out but the etiology is untreated.
Steroids increase calcium excretion then increase this woman's osteoporosis, decrease muscle mass and more secondary effects.Be cautious with steroids, they pass to the circulation.
Bye,
Mario

Mario Uruguay |

12/3/2009 3:44:25 PM #

Athanasios Pantelis

I believe that we must search the correct answer between intra-articular corticosteroid injection (choice 1) and referral for surgery (choice 5).  In general, analgesics are used to improve the symptoms of OA, but they do not significantly change its natural course.  Moreover, lifestyle modifications are necessary for OA patients, but this patient has shown reduced compliance and response to them, subsequently every pharmaceutical measure is rendered less effective.  The efficacy of intra-articular hyaluronic acid, although practiced, has doubtful efficacy.  Furthermore, this patient's pain in not relieved, even with high potency analgesics, like tramadol (centrally action on mu-opiod receptors). Finally, considering the patient's co-morbid conditions (smoking, morbid obesity) and gradually worsening pain, avascular necrosis of the femoral head cannot be ruled out.  In this setting, corticosteroids would lead to deterioration of her condition.  Whatsoever, failure of a OA patient to respond to aggressive analgesic treatment, as well as poor quality of life ensuing from this degenerative arthropathy, constitute well-established reasons for arthroplasty.  To conclude, orthopedic referral is the best option for the patient presented in this vignette, with the aim of total hip replacement.

Athanasios Pantelis Greece |

12/3/2009 10:07:40 PM #

Editor

Thank you for your comments, Athanasios. That is a very comprehensive and intelligent answer. There's very little to add to what you have said, although I would personally consider steroid injection having already referred this lady.

Editor United Kingdom |

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About the editor

Dr Geraint Preest
BSc MB BCh DRCOG MRCGP
Primary Care Editor BMJ Onexamination
GP Principal Pencoed Medical Centre Pencoed