Bones and Joints 519/15

Question 1

1. OA History

Answer 1

• Duration, pattern of symptoms

–> worse or better in the morning

–> stiffness in the morning; how long for?

–> pain at night

• aggravating factors
• which joints

–> any associated swelling; constant or fluctuating

• any diseases associated with arthritis, such as psoriasis, inflammatory bowel disease or other autoimmune diseases
• family history of arthritis
• exercise levels, diet and weight changes
• hormonal changes/menopause.

Question 2

1. OA Examination

Answer 2

• weight and BMI
• joint examination to confirm changes associated with osteoarthritis such as bony enlargement and deformity
• signs of inflammatory joint disease such as ‘boggy’ swelling of joints, fluid in joints, heat and erythema
• muscle condition (ie weakness, wasting)
• extra-articular signs of rheumatic disease, such as psoriasis.

Question 3

1. OA Inx

Answer 3

• clinical dx
• blood tests and X-rays may not be necessary unless there are symptoms to suggest an alternative diagnosis

Typical clinical findings are

• bony enlargement,
• bony tenderness,
• crepitus,
• deformity and
• lack of inflammatory features such as boggy joint swelling or prolonged morning stiffness

The disorder most commonly affects the hands with nodal changes at the DIP and PIP joints, base of thumbs as well as the hips and knees.

Primary osteoarthritis occurs in isolation and it is generalised when at least three joints are involved

Secondary osteoarthritis is due to another underlying condition such as inflammatory joint disease or trauma.

Question 4

1. OA DDx

Answer 4

Depends on

• number of joints
• distribution
• nature of pain

Non-articular or mononoarticular

• Non-articular soft-tissue problem (eg bursitis)
• Inflammatory monoarthritis (eg gout, pseudogout, septic joint)

Polyarticular
• Crystal arthritis (eg pseudogout or gout)
• Inflammatory arthritis (eg rheumatoid arthritis, psoriatic arthritis)

Widespread pain
• Fibromyalgia
• Myalgias (eg statin-induced, polymyalgia rheumatic)

It is essential to exclude inflammatory arthritis that can arise in addition to features of primary generalised osteoarthritis.

Symptoms that will suggest inflammatory arthritis include pain at night or in the morning and prolonged early morning stiffness of more than 1 hour or intermittent joint swelling. Signs to look for include an unusual pattern of joint involvement (eg wrist, elbow or cervical spine involvement) and the presence of joint swelling. If these are seen, consider further investigations including:

• blood tests for inflammation markers: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
• basic autoimmune serology: antinuclear antibodies (ANA), rheumatoid factor (RHF), anti-cyclic citrullinated peptide (anti- CCP) antibody
• X-rays or ultrasound.

Drainage of fluid from the joint can be done to see if there is inflammatory synovial fluid. Referral to a rheumatologist is recommended if there are any concerns.

Question 5

1. OA Mx

Answer 5

Education

• chronic condition that can be managed
• currently no treatments available to slow or reverse joint degeneration, but the symptoms can be managed with simple analgesia and physical therapies.

Weight loss

• helpful for symptoms of osteoarthritis and may reduce the rate of joint degeneration, particularly knee and hip
• best achieved through a combination of diet and exercise.
• Referral to a dietitian
• Non-weight- bearing exercises, such as swimming or cycling, are helpful and can be done through group classes and government programs.

Physical therapies

• Although the underlying joint damage cannot be reversed, it is important to maintain muscle strength

Occupational therapy

• maintain function through the use of aids and splints
• Thumb splints and thermal gloves can be helpful for pain arising from OA of the first carpometacarpal (CMC) joint.
• Patients with painful knee or hip osteoarthritismay require walking aids or home modifications. The use of braces for knee osteoarthritis and orthotics to correct malalignment in the legs may be indicated, although guidelines vary.

Medications

• regular paracetamol first line
• NSAIDs: recent literature suggests NSAIDs may be more effective than paracetamol, particularly in the management of hand osteoarthritis.
• option of using non-selective or cyclooxygenase-2-selective NSAIDs if there are no contraindications such as uncontrolled hypertension or cardiovascular disease, significant renal impairment or history of peptic ulcer disease. Given their adverse effects, particularly cardiotoxicity, NSAIDs should always be used at the minimal effective dose and for the shortest possible time. However, it is important to allow an adequate therapeutic trial period of 2–4 weeks for a given NSAID, as its maximum beneficial effect may be delayed. Care must be taken with long-term use of NSAIDs, because there is a risk of cardiovascular disease, and caution should be exercised when prescribing NSAIDs for patients with renal impairment. Co-prescription with a proton-pump inhibitor will reduce the risk of gastrointestinal side effects, especially serious side effects such as bleeding peptic ulceration. Topical NSAIDs and capsaicin cream are recommended therapies for hand osteoarthritis.
• Opioid analgesics: these have not been shown to provide long-term benefits for patients with osteoarthritis but may be indicated in exceptional circumstances.
• Corticosteroids injections: the evidence suggests that corticosteroid injections into the joint are not particularly effective for pain associated with osteoarthritis. However, some patients benefit from them and they are used as an interim measure to alleviate pain and allow improved participation in physical therapies. Specialist referral is suggested to assess whether these may be appropriate.
• Hyaluronic acid injections: these are no more effective than corticosteroids and are more expensive. Referral to a rheumatologist if considering this.

Question 6

1. OA complementary medical Rx

Answer 6

Some studies have suggested chondroitin and glucosamine may slow cartilage breakdown, but the evidence is very weak and no firm conclusions can be drawn at this stage. A trial of these agents is reasonable, if the patient is keen to try them, to see if they improve pain.

Other agents that have been studied but have more limited evidence include:

• acupuncture (knee and hip osteoarthritis)
• fish oil
• avocado-soybean unsaponifiables
• ginger
• green-lipped mussel
• Indian frankincense (Boswellia serrate)
• phytodolor
• pine bark extracts
• rosehip
• S-adenosyl methionine
• gamma-linoleic acid (found in evening primrose oil, borage/ starflower seed oil and blackcurrant seed oil)
• Chinese herbal patches containing Fufang Nanxing Zhitong Gao and Shangshi Jietong Gao (SJG)
• devil’s claw
• SKI 306X
• turmeric
• vitamins A, C, E, and B complex
• willow bark extract.

It is important to emphasise that there is no ‘quick fix’ for osteoarthritis and that the most important treatment is to maintain a healthy weight and good muscle strength.

Question 7

1. OA surgical