Reachout Orthopedics - Issue 2

mortise view, and anterior and posterior from the lateral view, whilst joint space narrowing is graded in each joint in both views. The KL system is used to provide an overall OA grade as already described [38]. Using x-rays from 30 participants, the study found the atlas to possess good to excellent reliability for most radiographic features from most views. Treatments Although there are no clinical guidelines for the management of foot or ankle OA, it is reasonable to suggest that recommendations pertaining to the management of OA at other sites may be appropriately applied to the foot and ankle. The National Institute for Health and Care Excellence (NICE) guidelines for peripheral joint OA, developed largely from hip and knee OA trials, advise that core management strategies should include (1) advice and education regarding the disease and its prognosis; (2) strengthening and aerobic exercise; and (3) weight loss, where appropriate [44]. These recommendations are largely consistent with those from the Osteoarthritis Research Society International [45] and the most recent guidelines from the Royal Australian College of General Practitioners (RACGP) [46] and the European League Against Rheumatism [47]. It is probable, however, that many people with OA will experience symptoms that cannot be effectively managed by these non- pharmacological treatments. Sections 5.1 to 5.3 outline the use of pharmacological, injectable and conservative treatment strategies for foot and ankle OA. Pharmacological Management Acetaminophen (paracetamol) or topical non- steroidal anti-inflammatory drugs (NSAIDs) are generally recommended following first- line strategies. To date, there are no clinical trials of acetaminophen in foot or ankle OA. In knee OA, dosages from seven randomised controlled trials (RCTs) ( n = 2491 partici- pants) included in a systematic review andme- ta-analyses comparing acetaminophen with placebo ranged from around 1000 mg/day to nearly 4000 mg/day, with no clear benefit of one over the other [44]. The NICE guidelines advise clinicians to consider regular dosing of acetaminophen [44]; however, it should also be highlighted that the most recent RACGP guidelines were unable to recommend either for or against acetaminophen, and cautioned against regular dosing [46]. This was largely based on findings from a recent system- atic review of eight observational studies on adverse events (AEs) from standard analgesic doses, which found that acetaminophen was associated with potential for some harms due to both short-term excess doses and longer- term regular dosing [48]. Furthermore, a large systematic review also showed that acetami- nophen provided only minimal short-term OA-related pain reductions that were un- likely to be clinically relevant [49]. However, depending on the foot and/or ankle joint(s) affected, it is reasonable to suggest that lower doses in the order of 1000 mg/day may be tri- alled initially and gradually increased in case of ineffectiveness and the absence of AEs. Use should be discontinued if acetaminophen is not effective. Topical NSAIDs are both safe and effective and should be considered as an adjunct to non-pharmacological strategies. There are no clinical trials on the use of topical NSAIDs for the treatment of foot/ ankle OA. The most recent systematic review and network meta-analysis of 36 RCTs in predominantly hip and knee OA found that topical NSAIDs were superior to placebo for OA-related pain relief and significantly improved physical function [50]. Diclofenac patches, followed by ibuprofen cream, were found to be themost effective for pain. Topical salicylate gel was the only topical NSAID to be associated with AEs, with users of all other topical NSAIDs not experiencing a higher rate of AEs than non-users or placebo [50]. Likewise, application of topical capsaicin should also be considered as adjunct to either core non-pharmacological treatments, or in place of topical NSAIDs [44]. A recent systematic review and network meta-analysis concluded that capsaicin prescribed at the recommended British National Formulary dosage (0.025% four times per day) is superior to placebo for pain relief [51]. Although no RCT has directly compared capsaicin to topical NSAIDs, the analysis showed capsaicin resulted in clinically meaningful improvements in pain that were similar to topical NSAIDs, suggesting the cream could be used in its place. When acetaminophen and/or topical NSAIDs or capsaicin are ineffective for managing the symptoms of foot or ankle OA, clinicians should consider prescribing oral NSAIDs, including cyclo-oxygenase (COX)-2 inhibitors [44]. The clinical im- provement in OA-related symptoms from NSAIDs is small, but greater than that of acetaminophen for most patients, and is clinically meaningful [46]. We recommend trialling an oral NSAID or COX-2 inhibitor at the lowest effective dose, such as 1000 mg/ day of ibuprofen or naproxen or 100 mg/day of celecoxib, for the shortest possible period. This is consistent with the only published clinical trials of NSAIDs in foot OA. The first of these found similarly effective pain reduc- tions with 800 mg of etodolac and 1000 mg of naproxen at 5 weeks [52], whilst the second found similar results at 8 weeks with 20 mg/day of piroxicam and 1000 mg/day of naproxen [53]. There is also good evidence that diclofenac 150 mg/day results in clini- cally meaningful improvements in pain for knee OA [54]; however, it may be prudent to trial doses of around 100 mg/day in the first instance for foot or ankle OA. Patients should be carefully monitored, and the dosage may be gradually and slightly increased in the absence of symptomatic improvements and lack of AEs. Indeed, the potential for harm with NSAIDs is well-recognised, particularly in older persons; thus, the co-prescription of a proton pump inhibitor may also be consid- ered or, alternatively, clinicians may consider not prescribing oral NSAIDs in this popula- tion [45]. Evidence concerning opioid use is poor, and toxicity-related AEs (particularly in the elderly), in addition to dependence, remain serious concerns [44]. As such, the most recent guidelines recommend that both oral and transdermal opioids are not indicated for OA [46]. Additional pharmacological strategies that are either not recommended for peripheral joint OA or lack evidence include chondroitin, avocado soybean Although there are no clinical guidelines for the management of foot or ankle OA, it is reasonable to suggest that recommendations pertaining to the management of OA at other sites may be appropriately applied to the foot and ankle. 21