Osteoarthritis

Question 1

A 65 year old man who presents with bilateral knee pain had crepitus r>l worse on physical activity, no joint line tenderness and you can see that he has difficulty standing. He describes that he cannot walk his dog anymore because of the pain. He is on candesartan for hypertension.

Impression/DDx/Goals

Answer 1

Impression:
Likely OA of the knee.

DDX:
- Joint threatening - septic arthritis, malignancy
- Osteoarthritis (most likely)
- Crystalline: Gout, pseudogout
- Autoimmune causes (RA, SLE, Sjrogen’s,
Seronegatives (psoriatic, reactive, ank spond, IBD-related)
- Trauma eg. fracture, contusion
- Soft tissue injury - ACL, PCL, ligamentous injury, meniscal tear and effusion, muscular strain

Also could be referred pain from the hip (consider joint above and below)

Goals:

• Would like to rule out other inflammatory arthritides and life-threatening causes of this presentation.
• Patient education
• Appropriate triaging and management

Question 2

Osteoarthritis - History

Answer 2

History:

• RF for OA- family hx, age, past trauma, obesity, surgical hx, occupation
• Natural hx of presentation
• 5 sx of OA- clicking, locking, instability, night pain, crepitations
• Other joints affected
• Inflammatory questions.
• SNAP
• Aged care assessment

Question 3

Osteoarthritis - Exam

Answer 3

Exam
- Obs - Fever, sepsis 
- Gait assessment
Knee: 
- Clicking, locking, instability, night pain, crepitations
- Reduced ROM in all directions 
- Hip, spine exam (joints above/below)

Question 4

Osteoarthritis - Investigations

Answer 4

Investigations

• Bedside - aspirate if effusion
• Bloods - CRP, FBC, RF, ESR - Pre op bloods (FBC, EUC, LFT, Coags, group and hold)
• Imaging: Knee x-ray (Weight bearing), AP + skyline

Question 5

Osteoarthritis - Management

Answer 5

Non-pharm:

• Weight loss
• Exercise
• Diet
• Physio
• Mobility aids
• Knee brace
• OT

Pharm:

• Panadol osteo
• NSAIDs/Cox-2 selective inhibitors with caution
• Intra-articular steroid injections
• Fish oil
• Gout: colchicine + allopurinol

Operative:

• TKR, meniscus or ligament repair
• Ortho referral

Long term management:

• Regular follow up to assess for worsening severity and need for TKR
• Mitigate falls risk - education, Physio, OT, mobility aids