10. Treatments for OA (Robson) Flashcards
What are the symptoms of OA?
Joint pain when in use Morning stiffness - lasting less than 30 minutes Joint instability or joint buckling Loss of function of the joint Crepitus on motion of the joint
What are the signs of OA?
Bony enlargement at the affected joints - osteophyte formation Limited range of movement at the joint Crepitus on motion Malalignment and/or joint deformity Muscle atrophy/weakness
What is the core treatment in the management of OA and why?
Exercise and change in diet:
Allows for local muscle strengthening to increase the stability of the joint
Allows for weight loss - decreased weight being placed on the joints
What is TENS in the treatment of OA?
Transcutaneous electrical nerve stimulation - used as an adjunct for pain relief
What non-pharmacological methods can be used to treat OA?
Exercise and diet change
TENS
Acupuncture
Aids and devices e.g. walking stick, orthopedic insoles
What are neutriceuticals?
Give three neutriceuticals recommended for treatment of OA
Foods that can help to increase health
Omega-3 in diet
Chondroitin sulphate supplements
Glucosamine supplements
Why should you increase omega-3 in the diet of someone with OA?
Omega-3 - releases natural pain-relieving chemicals
How can doctors ensure that they are offering patient centred care?
Offer personalised plan
Carefully and explicitly outline to patients reasons for their medication prescribed
Should offer accurate verbal and written communication
What is the first line pharmacological management for OA?
Oral analgesics - paracetamol and/or topical NSAIDs
What oral analgesic can be prescribed to a patient if paracetamol/topical NSAID is ineffective and why?
Cox-2 inhibitor - should not cause the same side effects as cox 1 e.g. gastric ulcers
(cox-1 present all the time and cox-2 specific to inflammation)
Why might paracetamol/topical NSAID not be effective for some patients with OA?
Cox 1 inhibitor - may result in comorbidities or adverse side effects
Cox - inhibitors should not be used in certain patients e.g. with gastric ulcers
Why are topical NSAIDs particularly useful in relieving joint pain?
These target the specific joint and have very specific effects
These are absorbed through the skin directly into the synovial fluid - therefore the NSAID will be concentrated in and around the actual joint - does not pass first past metabolism
What are the two main benefits of topical NSAIDs?
Increased concentration - does not pass first pass metabolism
Does not result in gastric ulcers forming
What is the last line pharmacological management for OA?
Intra-articular injections - corticosteroids
Why are corticosteroids the last line treatment for OA and how should they be used?
Can further aggregate the OA - should be used sparingly only as an adjunct to get them through a particularly bad moment
When might a patient with OA be referred for surgery?
When pain stiffness and reduced function have a substantial impact on the quality of life of the patient e.g. waking up at night
What are the six different surgical treatment options for OA?
Arthroscopic lavage Arthroscopic lavage plus debridement Microfracture Mosiacplasty (osteochondral transplant) Chondrocyte grafts Joint replacement
What is meant by arthroscopic lavage and which joints can this be done to?
This is an arthroscopic knee washout - cleaning of the joint
Can only be done to big joints e.g. knee, hip, shoulder - needs to be big enough to get all of the instruments in
What is the purpose of an athroscopic knee lavage?
To clean the surfaces of the joint and to remove any cracked bits or loose hyaline cartilage from the joint - this may be causing the knee to lock or rub on the surface of the bone
What is debridement?
This is done to tidy up the edges of damaged cartilage - remove any torn or loose bits of meniscus - tidy and neaten the edges of the cartilage
Why is debridement commonly done with arthroscopic lavage?
Debridement aids with pain relief (also faster pain relief) compared to just lavage
Cleaning of the joint and then cleaning of the edges
What is microfracture?
Take a probe and push it through the bone into the bone marrow
This results in stem cells coming up to the surface of the bone
These stem cells differentiate into chondroblasts and osteoblasts and produce cartilage to fill spaces from cracks
Who does microfracture work best for?
People under the age of 40
Recent cartilage injury
People not overweight (too much stress on the joints)
What is viscosuplementation?
This involves putting artificial synovial fluid into the joint - injected as liquid
Why is viscosupplementation done?
Helps to support the joint whilst it is recovering
Gives pain relief for up to six months
What is the advantage of viscosupplementation compared to other treatments for OA?
Can go into any joint types
Works well at all stages of OA
Long term effectiveness
No long term loss or damage
What is the component injected in viscosupplementation?
Hyaluronic acid
What are the disadvantages of viscosupplementation?
Severe OA may not respond well
Has some local adverse effects at the injection side
How does viscosupplementation work?
Returns the synovial fluid back to normal viscosity so that the cartilages are no longer touching one another
What is chondrocyte grafting?
Grafting of chondrocytes - inject into the site so that they take up residence and produce the required cartilage
Where is the chondrocyte obtained for grafting?
Patients own costal cartilage e.g. rib OR from non-damaged part of the joint
Can buy off the shelf from companies
Where are chondrocytes injected for grafting and why?
Injected underneath a periosteal patch to ensure that they do not float away and are present in the required site
What is the main disadvantage of microfracture for the treatment of OA?
Microfracture tends to produce fibrocartilage rather than hyaline cartilage - less durable
What is mosiacplasty?
Find the non-damaged regions of the joint
Take a biopsy of the articular cartilage and the subchondral bone and graft this into sites of damge
What is osteotomy?
This is realigning the bones and the joint surfaces
How does osteotomy work?
If there is damage to just one side of the joint e.g. the medial knee - can take a wedge out of the lateral tibia to realign the surfaces
What is the final treatment option for OA?
Joint replacement
What are the two types of joint replacement?
Cemented - use cement to hold it in place - less accurate
Non-cemented - more precision required
Which components are replaced in a joint replacement?
Can replace the whole joint or may only replace parts
Which knee joint type tends to last longer and why?
Non-cemented - the bone cells actually integrate into the surface of the prothesis
