Osteoarthritis of the Knee
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The comprehensive discussion of the medical management of osteoarthritis by Felson (Feb. 23 issue)1 made no mention of the role of surgery, particularly when the disease is severe. Conclusions from the 2003 National Institutes of Health (NIH) consensus statement on total knee replacement2 identified operative interventions as perhaps the most effective treatments for osteoarthritic knees. An evidence compendium published by the American Academy of Orthopaedic Surgeons (AAOS)3 and AAOS practice guidelines4 summarize both surgical and nonsurgical options for managing this prevalent health problem.
Effective surgical options for management of osteoarthritis include arthroscopy (not for purposes of joint débridement5 but for correction of mechanical symptoms), realignment osteotomies of the femur or tibia or both, and total knee replacement.6 Although approximately 300,000 total knee replacements are performed annually in the United States, this option may actually be underused in certain demographic groups, according to the findings of the NIH consensus development panel.2 Referral to an orthopedic surgeon for surgical intervention is indicated to address severe symptoms and loss of function in patients with osteoarthritis of the knee.
Stuart L. Weinstein, M.D.
Joshua J. Jacobs, M.D.
Michael J. Goldberg, M.D.
American Academy of Orthopaedic Surgeons
Rosemont, IL 60018
stuart-weinstein@uiowa.edu
References
Felson DT. Osteoarthritis of the knee. N Engl J Med 2006;354:841-848.
NIH consensus statement on total knee replacement. NIH Consens State Sci Statements 2003;20:1-32.
American Academy of Orthopaedic Surgeons (AAOS). Osteoarthritis of the knee: a compendium of evidence-based information and resources. September 2002. (Accessed May 18, 2006, at http://www.aaos.org/wordhtml/research/oainfo/oainfo_knee_main.htm.)
Idem. AAOS clinical guideline on osteoarthritis of the knee (phase I). (Accessed May 18, 2006, at http://www.guidelines.gov/summary/summary.aspx?doc_id=3856&nbr=003069&string=osteoarthritis.)
Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88.
American Academy of Orthopaedic Surgeons. Osteoarthritis of the knee: treatment options. (Accessed May 18, 2006, at http://www.aaos.org/wordhtml/research/oainfo/oainfo_knee_treatment.pdf.)
To the Editor: In Felson's article, Table 2 indicates that acetaminophen should be avoided in the care of patients with liver disease or alcoholism. Hepatotoxicity has not been found in prospective trials involving patients with alcoholism who were treated with the maximum recommended dosage of 4 g per day for two, three, or five consecutive days.1,2,3 Most patients with alcoholism do not need to avoid acetaminophen, although caution is prudent in such cases. Acetaminophen may be the preferred analgesic for patients with alcoholism, because of the antiplatelet and gastrointestinal effects of nonsteroidal antiinflammatory drugs (NSAIDs).
The association of massive overdoses of acetaminophen with acute hepatic failure has created the perception that acetaminophen should be avoided by patients with liver disease. To the contrary, a large body of evidence supports the notion that acetaminophen at a dosage of 4 g per day is safe for patients with a variety of liver diseases.4 From the point of view of a hepatologist, acetaminophen is the analgesic of choice for patients with liver disease, given the absence of gastrointestinal toxicity and inhibitory effects on platelets and renal sodium handling.
Raymond S. Koff, M.D.
University of Connecticut Health Center
Farmington, CT 06030
rkoff@comcast.net
Richard C. Dart, M.D.
Rocky Mountain Poison and Drug Center
Denver, CO 80204
Dr. Koff reports having served as a consultant to McNeil Consumer Healthcare, and Dr. Dart reports having received research funding from McNeil Consumer Healthcare.
References
Kuffner EK, Dart RC, Bogdan GM, Hill RE, Casper E, Darton L. Effect of maximal daily doses of acetaminophen on the liver of alcoholic patients: a randomized, double-blind, placebo-controlled trial. Arch Intern Med 2001;161:2247-2252.
Kuffner EK, Green JL, Bogdan GM, Know P, Dart RC. Effect of maximal therapeutic acetaminophen (APAP) dosing in alcoholics. Clin Pharmacol Ther 2005;77:P94-P94.
Green JL, Kuffner EK, Bogdan GM, Dart RC. Hepatic function in alcoholics throughout 5 days of maximal therapeutic dosing of acetaminophen (APAP). J Toxicol Clin Toxicol 2005;43:683-683.
Benson GD, Koff RS, Tolman KG. The therapeutic use of acetaminophen in patients with liver disease. Am J Ther 2005;12:133-141.
Dr. Felson replies: I agree with Weinstein et al. that total knee replacement is a remarkably successful operation that reduces pain and improves function in the vast majority of treated patients. Patients should be referred for total knee replacement when medical treatments have failed. The patient I described, although symptomatic, had not yet been treated with exercise, NSAIDs, or any methods of unloading, and thus it would have been too early in her treatment course to send her for a surgical referral.
Koff and Dart note that acetaminophen at doses up to 4 g per day has been shown in a clinical trial of 201 patients not to produce elevations in liver-enzyme levels above 200 U per liter.1 This suggests that therapeutic doses of acetaminophen are safe in most patients, but perhaps not all.2 Ingestion of 4 to 10 g per day for analgesic purposes has been associated with hepatic failure in patients with alcoholism.3
David T. Felson, M.D., M.P.H.
Boston University School of Medicine
Boston, MA 02118
jendez@bu.edu
References
Benson GD, Koff RS, Tolman KG. The therapeutic use of acetaminophen in patients with liver disease. Am J Ther 2005;12:133-141.
Oviedo J, Wolfe MM. Alcohol, acetaminophen, and toxic effects on the liver. Arch Intern Med 2002;162:1194-1195.
Whitcomb DC, Block GD. Association of acetaminophen hepatotoxicity with fasting and ethanol use. JAMA 1994;272:1845-1850.
Effective surgical options for management of osteoarthritis include arthroscopy (not for purposes of joint débridement5 but for correction of mechanical symptoms), realignment osteotomies of the femur or tibia or both, and total knee replacement.6 Although approximately 300,000 total knee replacements are performed annually in the United States, this option may actually be underused in certain demographic groups, according to the findings of the NIH consensus development panel.2 Referral to an orthopedic surgeon for surgical intervention is indicated to address severe symptoms and loss of function in patients with osteoarthritis of the knee.
Stuart L. Weinstein, M.D.
Joshua J. Jacobs, M.D.
Michael J. Goldberg, M.D.
American Academy of Orthopaedic Surgeons
Rosemont, IL 60018
stuart-weinstein@uiowa.edu
References
Felson DT. Osteoarthritis of the knee. N Engl J Med 2006;354:841-848.
NIH consensus statement on total knee replacement. NIH Consens State Sci Statements 2003;20:1-32.
American Academy of Orthopaedic Surgeons (AAOS). Osteoarthritis of the knee: a compendium of evidence-based information and resources. September 2002. (Accessed May 18, 2006, at http://www.aaos.org/wordhtml/research/oainfo/oainfo_knee_main.htm.)
Idem. AAOS clinical guideline on osteoarthritis of the knee (phase I). (Accessed May 18, 2006, at http://www.guidelines.gov/summary/summary.aspx?doc_id=3856&nbr=003069&string=osteoarthritis.)
Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88.
American Academy of Orthopaedic Surgeons. Osteoarthritis of the knee: treatment options. (Accessed May 18, 2006, at http://www.aaos.org/wordhtml/research/oainfo/oainfo_knee_treatment.pdf.)
To the Editor: In Felson's article, Table 2 indicates that acetaminophen should be avoided in the care of patients with liver disease or alcoholism. Hepatotoxicity has not been found in prospective trials involving patients with alcoholism who were treated with the maximum recommended dosage of 4 g per day for two, three, or five consecutive days.1,2,3 Most patients with alcoholism do not need to avoid acetaminophen, although caution is prudent in such cases. Acetaminophen may be the preferred analgesic for patients with alcoholism, because of the antiplatelet and gastrointestinal effects of nonsteroidal antiinflammatory drugs (NSAIDs).
The association of massive overdoses of acetaminophen with acute hepatic failure has created the perception that acetaminophen should be avoided by patients with liver disease. To the contrary, a large body of evidence supports the notion that acetaminophen at a dosage of 4 g per day is safe for patients with a variety of liver diseases.4 From the point of view of a hepatologist, acetaminophen is the analgesic of choice for patients with liver disease, given the absence of gastrointestinal toxicity and inhibitory effects on platelets and renal sodium handling.
Raymond S. Koff, M.D.
University of Connecticut Health Center
Farmington, CT 06030
rkoff@comcast.net
Richard C. Dart, M.D.
Rocky Mountain Poison and Drug Center
Denver, CO 80204
Dr. Koff reports having served as a consultant to McNeil Consumer Healthcare, and Dr. Dart reports having received research funding from McNeil Consumer Healthcare.
References
Kuffner EK, Dart RC, Bogdan GM, Hill RE, Casper E, Darton L. Effect of maximal daily doses of acetaminophen on the liver of alcoholic patients: a randomized, double-blind, placebo-controlled trial. Arch Intern Med 2001;161:2247-2252.
Kuffner EK, Green JL, Bogdan GM, Know P, Dart RC. Effect of maximal therapeutic acetaminophen (APAP) dosing in alcoholics. Clin Pharmacol Ther 2005;77:P94-P94.
Green JL, Kuffner EK, Bogdan GM, Dart RC. Hepatic function in alcoholics throughout 5 days of maximal therapeutic dosing of acetaminophen (APAP). J Toxicol Clin Toxicol 2005;43:683-683.
Benson GD, Koff RS, Tolman KG. The therapeutic use of acetaminophen in patients with liver disease. Am J Ther 2005;12:133-141.
Dr. Felson replies: I agree with Weinstein et al. that total knee replacement is a remarkably successful operation that reduces pain and improves function in the vast majority of treated patients. Patients should be referred for total knee replacement when medical treatments have failed. The patient I described, although symptomatic, had not yet been treated with exercise, NSAIDs, or any methods of unloading, and thus it would have been too early in her treatment course to send her for a surgical referral.
Koff and Dart note that acetaminophen at doses up to 4 g per day has been shown in a clinical trial of 201 patients not to produce elevations in liver-enzyme levels above 200 U per liter.1 This suggests that therapeutic doses of acetaminophen are safe in most patients, but perhaps not all.2 Ingestion of 4 to 10 g per day for analgesic purposes has been associated with hepatic failure in patients with alcoholism.3
David T. Felson, M.D., M.P.H.
Boston University School of Medicine
Boston, MA 02118
jendez@bu.edu
References
Benson GD, Koff RS, Tolman KG. The therapeutic use of acetaminophen in patients with liver disease. Am J Ther 2005;12:133-141.
Oviedo J, Wolfe MM. Alcohol, acetaminophen, and toxic effects on the liver. Arch Intern Med 2002;162:1194-1195.
Whitcomb DC, Block GD. Association of acetaminophen hepatotoxicity with fasting and ethanol use. JAMA 1994;272:1845-1850.