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Consensus Guidelines on Pain Treatment: From The American Society of Pain and Neuroscience


Joint and muscle pain treatment Birmingham


Within musculoskeletal practice, one of the biggest causes of pain and disability is back pain and knee pain. These can affect many tens of millions of people in the worldwide very year. The pain can be highly disabling and can hugely affect function and quality of life. There are many different causes, but progressive degenerative diseases like osteoarthritis are the most common.


There are a wide variety of treatments available to treat musculoskeletal pain and injury, however, there is no consensus on which treatments should be offered over others and in what order. These general guidelines will consolidate available data on the various treatment options available, ranging from pharmacological interventions – medication, physical therapy, injection therapy, regenerative therapies and surgery. These clinical guidelines are based on a systematic clinical reviews published clinical studies examining the conservative, interventional, and surgical treatment options for the most common sources of pain and injury in adults.


Specifically looking at knee pain - knee osteoarthritis, post-surgical knee pain, soft tissue injury to the knee, and complex regional pain syndrome (CRPS) are what we are first off going to cover below.


The intent and purpose of these guidelines is to integrate the current evidence into clinical practice, to provide patients with the best clinical care and functional outcomes.



This article will focus mainly on the biggest cause of musculoskeletal pain and injury - the knee.




COMMON CONDITIONS CAUSING KNEE PAIN


Ligament spins


Knee ligaments sprains are very common and include injury and damage to any of the ligaments within the knee joint. Major ligaments include the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), and lateral collateral ligament (LCL).


Ligament sprains are mainly due to trauma (direct or repetitive) or injury. The ACL is commonly injured during plant and twisting actions. PCL injuries are less common and can occur with the combination of injury to other ligaments particularly when varus or valgus stress or rotational forces. The PCL is injured with backward forces of the tibia in relation to the femur. MCL injuries can occur in isolation or in combination with the ACL or PCL. The MCL originates on the inside section of the knee and blends with adductor muscle tendons. It functions as the primary medial knee stabiliser and resists excessive stress rotation. The LCL is the primary stabiliser of the lateral knee. It resists excessive stress, external rotation and displacement of the fibula (the muscle on the outside of the lower leg). Common mechanism of injury is direct force to the medial knee or hyperextension stress across the knee.


Knee ligament sprain is can be graded into:

Grade1 - mild, painful stretching and minimal tearing of the ligament fibres.

Grade 2 – moderate, painful, partial tearing of fibres.

Grade 3 – severe, painful or sometimes not painful, complete rupture of ligament and may demonstrate instability. The gold standard for diagnosis of ligament injury in the knee is MRI.



Treatment for knee ligament injuries:

Many cases are managed conservatively with appropriate physical therapy and rehabilitation, alongside non-steroidal anti-inflammatory drugs (NSAIDs) in those without contraindications. Grade I and II sprains are treated with progressive weight bearing as tolerated, bracing, gentle active assisted mobility exercise, and strengthening and stabilisation exercises of surrounding supportive muscles. Some isolated Grade 3 sprains are treated with a longer period of immobilisation and bracing, toe touch weight bearing, followed by progressive mobility exercises. However, combined injury or severe Grade 3 sprains with complete ligament rupture can be treated surgically, particularly if the ACL is involved. In selected cases, therapeutic regenerative injection therapy can be used to boost and encourage healing. This supportive treatment is minimally invasive, safe and effective, examples being platelet rich plasma (PRP) injection treatment.


The ultimate focus of a knee ligament sprain is to promote healing and knee stabilisation progressively. If stabilisation is compromised and this can lead to re-tearing of the ligaments and ultimately traumatic induced cartilage degradation.



Meniscal injuries


The knee meniscus act to absorb shock and transmit load forces across the joint and protect the articular cartilage. The medial meniscus is attached to the tibia by ligaments and is C-shaped. The lateral meniscus is circular and more mobile with loose attachments. The outermost 3 mm is the “red zone”, this area has a blood supply and has better healing abilities. The remaining inner two-thirds, has a poor blood supply, and receives nutrients from the joint synovial fluid, and most tears hear have a poor healing capacity.


Types of traumatic meniscus tears:

  • Longitudinal vertical tear: if stable then conservative management.

  • Radial tear: debridement vs surgical repair.

  • Root tear: often associated with ACL tear, debridement vs surgical repair.

Types of degenerative meniscus tears:

  • Horizontal cleavage in young athletes: rare, due to overuse, if cessation of the activity fails then proceed to

  • Degenerative meniscal tear: prevalence increases with progressive wear and tear, and age. Can also be asymptomatic. High association with progressive cartilage degenerative changes and


If pain persists despite conservative therapy, MRI is obtained to evaluate the menisci.


Treatment of knee meniscus injuries:

Similar to sprains - physical therapy, manual therapy, and NSAIDs. If the pain fails to respond to conservative care and/or persists beyond the acute phase, intra-articular injections should be considered.


Intra articular platelet-rich-plasma (PRP) injection can be used to try and stimulate meniscus healing. If the joint is unstable and/or non-invasive treatment modalities fail, surgical intervention is usually indicated, depending on the type and severity of the tear.



Tendon injury


Tendon injury or tendinopathy is commonly due to excessive load or strain. In active patients and athletes, overuse can lead to chronic tendon injury. The most common tendon injury in the knee is of the patellar tendon which comes off the lower part of the kneecap and inserts onto the bony part of the tibia at the front of the knee. Patella tendon injury is commonly seen in jumping athletes, and can lead to microtears at the tendon and the tendon insertion on to the bone.


Other tendon injuries present with tenderness and and pain at the tendon insertion site with activation of the muscle. Ultrasound can assist in confirming diagnosis and will show loss of the normal tendon pattern. MRI will show increased signal at the tendon insertion.


Treatment of tendon injury:

Rest from excessive forces, ice, NSAIDs and physical therapy with a progressive loading program. Additional supportive treatment such as peritendinous injection with platelet-rich plasma (PRP). In some cases extracorporeal shockwave therapy can be considered if the pain fails to respond. Ultrasound-guided needle tenotomy, percutaneous needle scraping, and high volume injection, and stem cells are at the forefront of regenerative medicine for tendinopathy and are currently showing good results. Surgical intervention is a last case resort with mixed results.



Bursitis


Bursa are fluid filled sacs that act to reduce friction and provide cushion between structures. There are 10 bursa within and around the knee, and the 4 major bursa are the prepatellar, suprapatellar, infrapatellar, and pes anserine bursa. When friction or trauma irritates a bursa, it can become swollen and inflamed and be a significant source of pain. Septic bursitis may also present with erythema, warmth, and systemic symptoms such as fevers and leukocytosis.


The treatment of bursitis-related knee pain is typically focused on initially reducing pain and inflammation of the bursa and then to correct any predisposing biomechanical contributing factors. Initially, treatment in may include ice NSAIDs, activity modifications, alongside physical therapy and manual therapy. If necessary, injections of corticosteroid, and therapeutic aspiration. For patients with active lifestyle or occupational demands and non-septic bursitis, intrabursal injection of corticosteroids provides acute pain relief. If septic bursitis is suspected, infectious workup includes blood sampling for evaluation and aspiration of bursal fluid. Treat septic bursitis with antibiotics.



Osteoarthritis


Osteoarthritis is extremely common and can hugely affect quality of life. It is a progressive degenerative disease that can develop due to many different contributing factors. Commonly, repetitive micro-trauma leads to maladaptive repair of the joint cartilage, activation of the pro-inflammatory immune response, ultimately leading to cartilage degradation. Osteoarthritis can involve one or both knees and can occur in any of the three compartments of the knee, most commonly in the medial compartment. MRI can be used to assess for diagnostic severity of degenerative changes, including soft tissue. osteoarthritis.


Treatment of osteoarthritis:

Treatments depend on the severity and stage. Conservative management includes activity modifications, weight loss if appropriate, exercise, physical therapy, manual therapy and education. NSAIDs are only routinely use, if necessary but they are not a long-term option. Opioids have minimal benefit in the treatment of osteoarthritis and are associated with undesirable side effects and safety risks. Intra-articular injections with corticosteroid are often used to manage pain in the short term, but are not a long-term solution and can be counter-productive in managing osteoarthritis long-term due to aiding cartilage degradation. Hyaluronic acid (HA) is another well- accepted treatment for symptomatic pain relief, and can be good for slowing disease progression. Hyaluronic acid injection treatment is used to replace crucial lost joint fluid, and acts as a lubricant, slowing the progression of further degenerative changes and reducing pain. Biologics and regenerative therapies such as PRP or mesenchymal stem cells are extremely popular treatments, used to stimulate healing and repair of damaged tissues. Regenerative therapies such as PRP are also used to slow and manage disease progression. By far the most popular platelet rich plasma (PRP) which can be used to attenuate the pro-inflammatory degradation in OA and potentially remodel the joint, at the same time as reducing inflammatory cytokines. Several adjunct medications such as cathepsin K inhibitors, Wnt inhibitors, anabolic growth factors, nerve growth factor inhibitors are being studied as a means of not only reducing the pain from knee OA but potentially stopping the progression of structural damage. For patients with advanced knee osteoarthritis who failed conservative therapy and who are candidates, total joint replacement is proposed.



Complex regional pain syndrome (CRPS)


CRPS is a chronic neurological pain condition associated with increased sensitivity and autonomic dysfunction. CRPS is a combination of nervous system sensitisation, autonomic dysfunction, and inflammatory changes in response to injury. Shortly after injury, inflammatory cytokines are released which leads to peripheral pain sensitisation. There is thought to be probable change in the peripheral nervous system leading to fibre degradation.


Treatment of CRPS:

A proactive, multidisciplinary approach that includes pain management, psychiatric and physical therapy. Acute treatment focuses on pain control with local nerve blocks and rehabilitative modalities to alleviate pain. Pain management includes systemic steroids, tramadol, gabapentin, antidepressants, ketamine, calcium channel blockers, bisphosphonates, and baclofen. Therapeutic modalities include physical therapy, manual therapy, mirror therapy, acupuncture, biofeedback, stress loading, and aerobic conditioning. Chronic pain that is refractory to acute treatment is managed by progressing to spinal cord stimulator, dorsal root ganglion stimulator, or botulinum toxin (Botox) injection.



Chondromalacia patella


Chondromalacia is progressive softening and segregation of the cartilage at the back of the kneecap and is a common source of front knee pain. The cartilage at the back of the kneecap is often predisposed to friction, inflammation and progressive degradation. This can also predispose osteoarthritis at a later date.


Friction between the back of the kneecap and the tibia can again relate to breakdown of the patella cartilage. Malalignment and/or knee cap maltracking is often related to this friction and is often related to muscle imbalances of the quadriceps.


Treatment of chondromalacia patella:

Joint mobility, corrective strengthening exercise and stability exercise. Weight loss (if appropriate), activity modification, and a physical therapy regimen that focuses on stretching and strengthening the lower extremity kinetic chain. Moderate cases of chondromalacia may require intra-articular injection therapy of hyaluronic acid and PRP. Insert in case is steroid is used to control pain, however this is not advised as it can cause further cartilage degradation, and is therefore not a long-term solution. If conservative management. Surgical intervention is fortunately not often required. Biologic treatments and regenerative therapies such as PRP and stem cell therapy are of particular interest due to their ability to potentially slow or even reverse progression of cartilage degradation.



Post-Surgical Knee Pain


Postsurgical knee pain may be a difficult to diagnose, especially in the acute phase, as reports of pain after surgery are common. If pain persists for over several weeks post surgery it is to often be suspected that something does not seem right. Before a diagnosis is clear, it is important to rule out any post surgical complications surgery (ie, infection, prosthesis malfunction, fracture, etc) have been ruled out. Many patients who undergo arthroscopic knee surgeries for knee OA eventually undergo total knee replacement.


With postsurgical knee pain, it is important to initially find out the course of the problem, which can be many different factors. As far as treatment goes, multimodal pain control is the optimal perioperative pain control regimen and reduces long-term opioid use with improved patient outcomes.



Recommendations For Conservative Care Medication


NSAIDs

Twenty-one randomised control trials were included in this systematic review of oral NSAIDs for knee pain. Each of the studies reported at least 30% reduction in knee pain with NSAID use. Of note, one study reported non-superiority of naproxen over placebo. Regarding pain following total knee replacement, each of the eight included studies supported the use of NSAIDs. In summary, oral NSAIDs are moderately effective in controlling pain in patients with moderate-to-severe pain due to knee osteoarthritis and pain s/p total knee arthroplasty.


Consensus Points for NSAIDs

1. NSAIDs can be an effective treatment option for mild-to-moderate pain secondary to osteoarthritis knee pain when exacerbations occur.


2. Topical NSAIDs are recommended before oral treatments because of their lower systemic exposure/toxicity.


3. Topical anti-inflammatory should be considered as first-line


4. NSAIDs should not be used for patients with comorbidities due to risk of adverse events;


5. NSAIDs should not be used on a long-term basis due to side effect profile (cardiovascular and gastrointestinal)


Topicals

1. Topical NSAIDs can be an effective treatment for knee osteoarthritis.


2. Topical NSAIDs are recommended to be used before oral NSAIDs.



Opioids

The use of chronic opioids for osteoarthritis, neuropathic, and non-surgical pain syndromes is currently under scrutiny.


1. Due to low effect on pain and physical function, regardless of dose, the potential clinical benefit of opioids does not outweigh the potential harm in patients with knee OA.


2. There is no evidence to support the use of opioids over NSAIDs.



Physical Therapy and Rehabilitation

Physical therapy and rehabilitation is always a very good recommendation for individuals with knee pain and osteoarthritis. This should in tailored to the individual of courses, with the focus placed on improving fitness, losing weight, quadriceps muscle strength and stabilisation exercises.



Injection Therapy Treatment


Corticosteroid Injections

Intra-articular corticosteroid injections are very often used for the treatment of knee osteoarthritis. However, there is still debate on the efficacy. A Cochrane review in 2015 evaluated 27 trials with a total of 1767 participants comparing IAC injections with a sham injection or no treatment and the quality of evidence was “low” due to a high or unclear risk of bias in many studies. There was also a significant amount of inconsistencies regarding the dosage of steroid and type used. It was reported that an improvement of pain after injection was moderate at 1–2 weeks following treatment, mild to moderate at 4–6 weeks, and minor at 13 weeks. There was no statistically significant evidence of treatment effect longer term. The Cochrane review concluded, given the poor quality and variability in the studies, it is uncertain if there is a significant advantage of treatment for knee OA after 6 weeks post-treatment. Conversely, a more recent systematic review and meta-analysis evaluating the magnitude and duration of the effect for knee OA found moderate evidence for steroid injections to reduce pain related to knee OA. The treatment effect is found to be short lived, up to 3 months.


In summary, corticosteroid joint injections may provide short-term mild-to-moderate pain relief for patients with knee osteoarthritis, but is not a long-term solution.

Intra-Articular Corticosteroid Injections

1. Intra-articular corticosteroids may provide short-term pain relief for patients with symptomatic OA of the knee

2. Treatment is associated with an increase in cartilage volume degenerative loss. Caution should be exercised with repeat injection to prevent progression of disease



Hyaluronic Acid

HA, is a large glycosaminoglycan that is one of the natural components of cartilage, which aids protection, lubrication and health. Studies have shown that HA can stimulate the synthesis of cartilage and reduce inflammation. These injections are referred to as viscosupplementation.


A meta-analysis published in JAMA in 2003 reviewed a total of 22 trials with a review of a total of 2927 patients. Overall, there was a noticeable effect of HA injections when compared to placebo. A systematic review and meta-analysis of randomized trials, which included a total of 831 patients, showed that HA injections had statistically significant improvement in knee pain. The long-term side effect profile of HA is better than with oral NSAID. A meta-analysis of randomised controlled trials published in 2018 compared HA injections to steroid injections for knee osteoarthritis with a total of 1004 patients showed that both HA and steroid injection therapies were safe and effective treatments that were effective in pain and physical function and stiffness at multiple time points (4 weeks, 12 weeks, and 26 weeks), but with the negative impact of steroid being short lived and having negative side-effects.


Overall, viscosupplementation is a safe, well-tolerated procedure that has been shown to have an improvement in pain and function.


Points for Hyaluronic Acid

1. Intra-articular hyaluronic acid is a safe and effective therapeutic option for patients with symptomatic OA of the knee.

2. Demonstrates superior, longer-lasting efficacy post-injection in comparison to intra-articular corticosteroids.



Genicular Nerve Ablations


Genicular nerve ablation is a percutaneous, needle-based therapy option designed to palliatively treat knee pain. This I s not intended to remedy the root cause of pain or structurally alter the joint in any way; rather, the goal is to block/interrupt the transmission of pain signals from the knee, itself, thus eliminating the perception of pain by the brain.



REGENERATIVE THERAPIES


Platelet-Rich Plasma

PRP was first introduced in the 1970s for increasing wound and bone healing in various different areas of medicine and surgery. Recently, PRP use has become far more popular, and shows great promise for treating various orthopaedic, musculoskeletal, and pain conditions. PRP has varied components including platelets and other cell types, growth factors, and cytokines. These cells are used to reduce inflammation and facilitate a repair and healing process. These changes are seen in intra-articular PRP injection for symptomatic knee osteoarthritis where studies demonstrate a significant decrease in protein concentration of immunoglobulins associated with inflammation. Additionally, post PRP injection proteins associated with chelation and anti-aging physiological functions increase significantly, including matrilin, transthyretin, and complement. Moreover, these laboratory findings are complemented with ongoing clinical success, including improvements in symptoms and function in various different cases of severity. This enhanced environment for healing can be an inherent advantage of PRP in comparison to other injectable therapies. For instance, repeated intra-articular corticosteroids may have detrimental systemic and local effects, including greater cartilage volume loss.


The combined data from the reviews discussed support PRP’s excellent safety profile. A total of 26 studies reported adverse events demonstrated non-significant differences between other conservative treatments and PRP injection. The other reviews show agreement that PRP-treated patients did not display significant increased adverse events or additional side effects. Meta-analysis of 10 clinical trials revealed that at 6 months post injection, PRP and hyaluronic acid had similar effects with respect to pain relief and functional improvement. However, at 12 months, PRP was associated with significantly better pain relief and functional improvement that exceeded the minimal clinically important difference.


High amounts of recent clinical trials are presenting good clinical evidence in favor of PRP for treatment of symptomatic knee osteoarthritis pain. A review in 2020 investigated PRP versus hyaluronic acid in the treatment of knee osteoarthritis by including 14 individual. PRP had higher scores in long-term in pain, stiffness and Physical Function. The authors conclude that PRP demonstrates more advantages over hyaluronic acid in the conservative treatment of knee osteoarthritis. However, both treatments together provide best success rates long term, due to acting in 2 slightly different separate roles.


A recent comprehensive systematic review and meta-analysis in 2020 largely supported the above findings and divided the meta-analysis by both reported pain score and function. This included 22 studies investigating pain comparing PRP versus placebo, corticosteroids, or hyaluronic acid. PRP showed significant improvements in pain compared to both subgroups. The pooled estimates, as well as each subgroup, showed significant differences in favor of PRP.


There are also many clinical trials investigating PRP versus corticosteroid. In 2017, a trial looked at both treatments are then analyses quality of life differences at 3 and 6 months. Out was found that there were significant improvements in the PRP group and so did general health perception differences at 6 months. It was concluded that a single PRP intra-articular injection is effective for relieving pain and improving activities of daily living and quality of life. Furthermore, for patients older than 67 years, a single intra-articular injection of PRP has similar results to a single injection of corticosteroid, but is safer and better longer term.


Another trial by Guvendi et al in patients with grade III knee osteoarthritis looked at three groups: single corticosteroid injection group, PRP injection, and three PRP injection group. Function scores at the 6-month follow-up were significantly improved in the PRP groups compared to the corticosteroid group. The same systematic review reported that PRP was significantly superior compared to corticosteroid in terms of functional outcomes. Compared to corticosteroid injection for symptomatic knee osteoarthritis, PRP intra-articular injection shows superior outcomes, including improved knee joint function and quality of life.



PRP treatment in soft tissue pain and injury


Patella tendinopathy

PRP has been studied in chronic patellar tendinopathy. In 2014, patients with patellar tendinopathy on examination and MRI who had failed conservative treatment received ultrasound-guided dry needling alone (n=13) or with injection of leukocyte-rich PRP. The PRP group had improved significantly more than the dry needling group. The authors conclude that PRP treatment accelerates the recovery from patellar tendinopathy relative to exercise and dry needling alone.


In 2015, a trial further investigated PRP to treat chronic patellar tendinopathy. Patients received either PRP injection 2 weeks apart. The results shown most patients significantly improved. Those receiving two PRP injections had better outcome measures. These studies suggest, PRP can improve outcomes of chronic patellar tendinopathy.


Pes anserinus

In 2014, a trial investigated a group of patients with chronic pain in the pes anserinus who were treated with PRP. Most of these patients demonstrated total or near-total pain relief within 2-6 months of treatment.


Medial collateral ligament sprains

46 healthy athletes with high grade II or III medial collateral ligament sprains were randomly allocated to two groups - PRP injection and both groups went on to participate in a 12-week functional rehabilitation program. In the PRP treatment, pain was significantly reduced.


Meniscal injury

One case report describes a bucket handle meniscal tear treated with three separate PRP injections in and around the meniscus within 7 months of the diagnosis. Patient-reported resolution of pain 8 months post injury and MRI 10 months post injury and arthroscopy 47 months post injury showed complete resolution of the meniscal tear. Ongoing promising reports are being shown for the treatment of ligaments, cartilage, and tendons with PRP injection treatment.


In conclusion, PRP is a safe and effective tissue stimulant, for the ongoing use of reducing pain/inflammation and stimulating the healing and repair process.


1. Intra-articular PRP is an effective and safe treatment for knee pain secondary to osteoarthritis

2. Intra-articular PRP is at least as effective as an entire series of viscosupplementation with hyaluronic acid

3. Intra-articular PRP can improve function in patients with knee pain secondary to osteoarthritis.

4. Intra-articular PRCan improve symptoms of long-term in comparison to go to go steroid injections.



Mesenchymal Stem Cells


Mesenchymal stem cells (MSCs) are sometimes also used in hopes of promoting an tissue healing and stimulating a repair. MSCs have the ability to provide tissue regeneration as well as the additional potential to differentiate into a variety of cells.


In 2020, an investigation take place for the use of autologous MSCs for the treatment of knee osteoarthritis. In the 29 studies of 1063 treated knees included, pain scores were statistically significant with improvements greater than the minimally important clinical difference at a post-treatment mean of 6 months. Those post MSC injection showed continuing functional improvements greater than 6 months and continued to improve up to 1 year. This review concludes that autologous MSCs are effective to improve both pain and function for those suffering from knee osteoarthritis.


A second review in 2020 by Migliorini et al had a total of 1069 osteoarthritic knees from 18 studies. The authors agree that autosomal MSCs are safe and show favorable results in improving both pain and function in treating knee osteoarthritis.


1. Intra-articular MSCs are a safe treatment for knee OA.

2. MSCs can be effective for treating pain and improving function in patients OA.



Amniotic Tissue


Amniotic tissues consist of anti-inflammatory factors that upregulate anti-inflammatory pathways, as well as regenerative properties.


In a multicenter randomised single-blinded controlled trial conducted by Farr et al, ASA was injected in subjects with knee OA and compared to saline and HA. The study included 200 patients. Significant differences were found between ASA and HA at the 3-month.



Knee arthroscopy


Several randomised controlled trials and subsequent meta analyses have demonstrated that arthroscopic management of degenerative joint disease has limited midterm benefits and does not represent a significant benefit versus conservative management. Specifically in middle-aged or older individuals with symptomatic degen- erative knee joint disease, arthroscopic management has been shown to have minimal pain improvement and physical function improvement up to 3 months with no difference at 2 years compared to conservative management.



Consensus Points for Knee Arthroscopy

1. Arthroscopic knee surgery is a safe and effective treatment option for repairing soft tissue injuries and minor bony pathologies that cannot be rectified via conservative measures.

2. Arthroscopic knee surgery can be effective for the treatment of knee OA.



Joint Preservation Techniques


With increased life expectancy, the concern surrounding articular cartilage damage continues to increase. Increasing obesity rates, changing lifestyles and an increasingly aging population have contributed to a double prevalence of OA over the 1999–2014 time period.


The intrinsic biomechanical property of cartilage itself makes it specifically at risk for progressive injury. Joint cartilage is on average 2–4 mm thick with a notable absence of blood vessels or innervation, relying on diffusion as a primary source of obtaining nutrients. As such, injury through this complex structure represents a significant challenge for healing and a compromise to the entire structure. Attempts at regeneration of type II cartilage are ongoing, but nevertheless, treatment of isolated articular lesions remains a clinical focus.


The techniques traditionally employed to treat these lesions have included marrow stimulation, autologous chondrocyte implantation, chondral transplantation soft tissue procedures such as meniscal transplantation, and alignment surgeries such as osteotomies.


Marrow Stimulation

Microfracture, or subchondral drilling aims at brining bleeding through the subchondral plate in the area of cartilage injury with the end goal of relocating stem cells into the area of injury.


Autologous Chondrocyte Implantation

Harvest and cartilage cells and reimplantation into the defect. Current indications for this treatment include young active patients who have failed conservative management with isolated cartilage lesions ≥2 cm2 with no subchondral bone involvement. The majority of failures happen early with this treatment (<24 months). Despite this, good short-to-midterm results have been reported with >70% of the grafts intact at long-term follow-up in some series.



Meniscal Transplant

This technique is used to reduce contact pressure with inside the joint. Typically, patients are younger with symptomatic meniscal deficiency, without arthritis, and with normal mechanical alignment and ligamentous stability.



Femoral and Tibial Osteotomies

another technique used to preserve thw joint.



1. Marrow stimulation can be an effective treatment for younger patients with small, isolated hyaline defects.

2. Autologous chondrocyte implantation can be an effective treatment for young patients with small, isolated cartilage lesions ≥2 cm2 who have tried and failed conservative care.

3. Meniscal transplantation can be an effective treatment option for patients with symptomatic meniscal deficiency.

4.Osteotomy can be an effective treatment options that can delay the need for a partial or total knee replacement by preserving damaged joint tissue.



Knee Joint Arthroplasty (Replacement)


Total knee replacement is a popular solution for painful end-stage knee arthritis. Modern implant designs come from further focus on knee functional movement after replacement.


Total knee replacement is a well-described treatment for painful knee arthritis that has failed appropriate conservative therapy. The goal of treatment is to alleviate pain and improve function. Appropriate conservative therapy can include non-steroidal anti-inflammatories, weight loss, activity modification, bracing, physical therapy, walking aids, and intraarticular injections and regenerative therapies.


Conclusion


The diagnosis and management of knee pain is constantly evolving. The guidance provided here is intended to understand which treatments are proven to be the most efficacious and suggest an appropriate order based on current peer reviewed evidence supplemented with expert opinions of well-experienced clinicians.


Full article can be found here:





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