High Yield Topics

Osteoarthritis

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Osteoarthritis

Osteoarthritis
Tariq A. Nayfeh MD, PhD
Tung B. Le MD
Basics
Description
  • The most prevalent form of arthritis
  • May occur in virtually any joint of the body
  • Has no cure and leads to pain and joint dysfunction
  • The end result is loss of articular
    cartilage with secondary bone changes, including osteophytes,
    subchondral sclerosis, and subchondral cysts.
  • Classification is by single or multiple joint involvement.
  • Synonyms: Degenerative joint disease; Wear-and-tear arthritis
Epidemiology
Incidence
  • The knee is the most commonly affected joint, followed by the hand and hip (1).
  • In a study of 697 females >65 years old, knee arthritis occurred in 30%, hand arthritis in 15%, and hip arthritis in 8% (2).
Prevalence
  • Osteoarthritis, the most common form of arthritis, affects females more often than males (3).
  • In contrast to inflammatory arthritis, osteoarthritis occurs principally in individuals >60 years old.
  • In 1 study (4):
    • Hand osteoarthritis occurred in 23% of females >65 years old.
    • The most commonly affected joints were the DIP and 1st CMC joints.
Risk Factors
  • Obesity
  • AVN
  • Septic arthritis
  • Advancing age
  • Female gender
Genetics
A genetic predisposition is thought to exist, but genes have not yet been identified.
Etiology
  • No known cause of osteoarthritis (idiopathic osteoarthritis):
    • The common pathway is loss of the articular cartilage with progressive overloading of the joint.
  • Many conditions that injure the joint may lead to secondary arthritis.
    • Trauma: Posttraumatic arthritis
    • Infection: Postinfectious arthritis
    • AVN: Arthritis associated with the condition
Associated Conditions
No conditions are associated with osteoarthritis.
Diagnosis
Signs and Symptoms
  • Discomfort with weightbearing and joint motion
  • Stiffness
  • Loss of function:
    • Inability to do heavy work
    • Inability to tie or put on shoes
    • Limitation to short distance walking
History
Pain and swelling that increase with activity or prolonged inactivity
Physical Exam
  • The principal features are:
    • Stiffness and loss of ROM
    • Joint effusion
    • Limb deformity
    • Painful joint motion
    • Gait disorder
Tests
Lab
No specific laboratory features
Imaging
  • Radiography:
    • AP and lateral radiographs are the main imaging modalities.
    • In the knee, foot, and ankle, weightbearing radiographs are obtained.
  • MRI can be used to exclude other diagnoses such as AVN, stress fractures, and neoplasms.
Pathological Findings
Loss of the thickness and organization of the articular cartilage
Differential Diagnosis
  • The diagnosis of osteoarthritis is not difficult when the disease is in the moderate or advanced stage.
  • Early arthritis can be confused with the following conditions:
    • Tendinitis or bursitis
    • Stress fractures
    • Synovial proliferative disorders
Treatment
General Measures
Rest, activity modification, weight loss, and NSAIDs
Special Therapy
Physical Therapy
  • Patients should begin a program to preserve muscle strength and ROM and to avoid contractures (5).
  • Heavy-impact activity (such as running, contact sports, and heavy work) exacerbates symptoms.
  • A cane used in the opposite hand
    substantially reduces the forces across the hip joint and will relieve
    discomfort and improve gait.
Complementary and Alternative Therapies
  • Acupuncture may provide pain relief for knee arthritis in the short term (6).
  • Many herbal medicines are used for the treatment of osteoarthritis.
    • Evidence to support their use is limited (7).
Medication
First Line
  • NSAIDs, including COX-2 inhibitors, are mainstays in the nonoperative treatment of arthritis.
    • Meta-analysis shows these medications to be slightly more effective than a placebo in the short term (8).
    • NSAIDs have a high rate of side effects, including gastrointestinal bleeding.
  • Acetaminophen is widely used for pain relief (9).
Second Line
  • The use of nutraceuticals, such as
    glucosamine and chondroitin sulfate, is controversial, with a recent
    study showing no benefit (10).
  • Intra-articular injection:
    • With corticosteroids, decreases pain for short periods (11)
    • With hyaluronic acid, may have a small effect on knee pain (12)
  • Opioid pain medicine may be used for severe pain in patients who are not operative candidates (13).

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Surgery
  • 2 main types of surgery: Realignment osteotomy and joint replacement
    • Realignment osteotomy:
      • The joint surfaces are repositioned by cutting the bone and changing the axis of weightbearing.
      • Purpose: Allows the healthiest articular cartilage to bear the most weight
      • May be combined with ligament or meniscal repair
    • Arthroplasty:
      • The arthritic joint surfaces are removed, and a new joint surface is implanted.
      • The bearing surface is typically metal on high-density polyethylene.
      • Examples are total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty.
Follow-up
Disposition
Issues for Referral
Patients with end-stage arthritis or severe pain from
arthritis should be referred to an orthopaedic surgeon for
consideration of surgical treatment.
Prognosis
  • Osteoarthritis progressively worsens with time.
  • No cure exists.
  • Modern methods of joint replacement provide excellent function and pain relief.
Complications
  • Progressive arthritis leads to worsening deformity and stiffness.
    • In the lower extremity, patients may stop walking and rely on wheelchairs
    • In the upper extremity, prevents activities and leads to lack of function
  • Treatment also may lead to complications.
    • The side effects of NSAIDs include gastritis and gastrointestinal bleeding.
    • Surgical intervention may lead to infection, DVT, or failure of the replacement mechanical joint.
Patient Monitoring
  • Patients are followed at 3–12-month intervals, depending on the severity of their symptoms.
  • Plain radiographs are taken every 6–12 months.
References
1. Felson DT, Lawrence RC, Dieppe PA, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Ann Intern Med 2000;133: 635–646.
2. Mannoni
A, Briganti MP, Di Bari M, et al. Epidemiological profile of
symptomatic osteoarthritis in older adults: a population based study in
Dicomano, Italy. Ann Rheum Dis 2003; 62:576–578.
3. Sharma L, Kapoor D, Issa S. Epidemiology of osteoarthritis: an update. Curr Opin Rheumatol 2006;18:147–156.
4. Hirsch
R, Guralnik JM, Ling SM, et al. The patterns and prevalence of hand
osteoarthritis in a population of disabled older women: The Women’s
Health and Aging Study. Osteoarthritis Cartilage 2000;8:S16–S21.
5. Devos-Comby
L, Cronan T, Roesch SC. Do exercise and self-management interventions
benefit patients with osteoarthritis of the knee? A meta-analytic
review. J Rheumatol 2006;33: 744–756.
6. Witt C, Brinkhaus B, Jena S, et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet 2005;366:136–143.
7. Ernst E. Musculoskeletal conditions and complementary/alternative medicine. Best Pract Res Clin Rheumatol 2004;18:539–556.
8. Bjordal
JM, Ljunggren AE, Klovning A, et al. Non-steroidal anti-inflammatory
drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee
pain: meta-analysis of randomised placebo controlled trials. Br Med J 2004;Epub. (DOI:10.1136/bmj.38273.626655.63):1–6.
9. Towheed TE, Maxwell L, Judd MG, et al. Acetaminophen for osteoarthritis. Cochrane Database Syst Rev 2006;1(CD004257):1–56.
10. Clegg
DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and
the two in combination for painful knee osteoarthritis. N Engl J Med 2006;354:795–808.
11. Bellamy N, Campbell J, Robinson V, et al. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006;2(CD005328):1–186.
12. Lo GH, LaValley M, McAlindon T, et al. Intra-articular hyaluronic acid in treatment of knee osteoarthritis: a meta-analysis. JAMA 2003; 290:3115–3121.
13. Dieppe PA, Lohmander LS. Pathogenesis and management of pain in osteoarthritis. Lancet 2005;365:965–973.
Additional Reading
Hunter DJ, Felson DT. Osteoarthritis. Br Med J 2006; 332:639–642.
Miscellaneous
Codes
ICD9-CM
715.9 Osteoarthritis, unspecified whether generalized or localized
Patient Teaching
  • Patients are:
    • Taught to avoid activities that worsen the pain
    • Shown how to prevent contractures
    • Encouraged to lose weight
Activity
  • Patients should be encouraged to maintain muscle strength and joint mobility.
  • Exercises that do not cause pain are best.
  • Activities with little or no impact include elliptical trainers, bicycling, swimming, and water aerobics or running.
Prevention
Weight loss may help prevent joint degeneration.
FAQ
Q: What can be done to prevent osteoarthritis?
A:
In general, interventions have not been found to prevent
osteoarthritis. However, osteoarthritis is associated with obesity, and
weight loss may help prevent joint degeneration.
Q: When is surgery indicated for the treatment of osteoarthritis?
A:
Surgery is the final treatment after nonoperative measures (such as
muscle strengthening, ambulatory aids, and medications) have been
tried. The most commonly performed surgery is total knee replacement.

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