Osteoarthritis

Question 1

definition

Answer 1

Most common degenerative bone disease, affects articular cartilage

Question 2

Epidemiology

Answer 2

• commonest type of arthritis
• age
• after menopause
• female sex
• hypermobility
• obesity
• weight bearing joints

Question 3

Classification of osteoarthritis

Answer 3

• Primary
• Secondary

Question 4

Primary osteoarthritis

Answer 4

• Localised
  
  • hands
  • feet
  • knee
  • hip
  • spine
• generalised
  
  • 3+ joints

Question 5

Secondary osteoarthritis

Answer 5

• localised
  
  • hip
  • mechanical/local factors e.g obesity
• generalised
  
  • general e.g bone dysplasia
  • calcium disease e.g psuedogout
  • endocrine e.g acromegaly
  • bone joint disorders e.g avascular necrosis

Question 6

Pathology of osteoarthritis

Answer 6

All joint tussyes involved- bone, ligament, capsule, synovial membrane

dynamic process:

• most OA is primary with no obvious predisposing factor . Secondary OA occurs in joints that have been damaged in some way or are congenitally abnormal
• OA is a result of active, sometimes inflammatory but potentially reparative processes
• characterised by a progressive destruction and loss of articular cartilage
• the exposed subchondral bone becomes sclerotic with increased vascularity and cyst formation
• attempts at repair produce cartilagenous growth at the margins of the joints which later become calcified (osteophytes)
• most common in weight bearing joints

Question 7

Risk factors

Answer 7

Question 8

Symptoms of Osteoarthritis

Answer 8

• pain
  
  • aching
  • worse with weight bearing/activity, better with rest
  • from all tissues except articular cartilage e,g subchondral bone, synovtis, inflammatory effusions, capsular distention, enthesitis, muscle spasm
• transient stiffness- stiffness after rest or in the morning <30 minutes
• functional impairment due to restricted movement

Question 9

Signs of osteoarthritis

Answer 9

• Common joints - DIPJ and 1st carpometacarpal joint of the hands, 1st MTP join of the foot and weight bearing joints
• restriction of movement
• palpable bony swelling
• peri-articular/joint line tenderness
• joint deformitiy
• joint instability
• muscle weakness/wasting
• joint effusion
• palpable/audible crepitus

Question 10

Radiograph features

Answer 10

LOSS

• Loss of joint space
• Osteophytes
• Subchondral sclerosis
• Subchondrall cysts

Question 11

Management

Answer 11

Main aims:

• relieve symptoms
• maintain/improve joint function
• minimise disability.handicap

3 options

1. non-pharacological (education, weight loss, sensible footwear)
2. non pharma (physio, analgesiacs)
3. Pharma (opiods, NSAIDS)
4. surgery (total joint replacement)

Question 12

Investigations

Answer 12

• Blood tests
  
  • bone profile, ferritin
• synovial fluid analysis
  
  • exclude infection or crystal arthropathy
• Xrays
• MRI
• Istope scans
• Bone scintigraphy

Question 13

Non-pharmacological management

Answer 13

• education
• exercise
• weight loss
• appropriate footwear
• occupation injury prevention
• physiotherapy referral
• orthotics/braces
• heat or ice packs
• acupuncture
• TENS

Question 14

Pharmacological management

Answer 14

• paracetamol
• NSAIDs
  
  • lots of contraindications
  • Consider COX2 inhibitor for those with increased GI risk
  • Consider gastro-protective cover
• Topical NSAIDs or topical capsaicin- hand and knee OA
• intra-articular steroid injections
• intra-articular hyaluronate - as effective as steroids/NSAIDS but more expensive
• glucosamine and or chondroifin sulphate
• opiods

Question 15

Surgical management

Answer 15

• replacement arthroplasty
  
  • effective symptom relief
  • cost effective
• associated risks
  
  • infection
  • dislocation
  • loosening
• osteotomy/joint preserving surgery

Question 16

Prognosis

Answer 16

• joint and patient specific
• usually slow progression
  
  • 1/3rd to 2/3rd with knee OA have clinical and radiographic deterioration at 15 years
  • ½ to 2/3rd with hip OA progress over 10 years
  • ½ with hand OA progress over 10 years
  • Nodal OA associated with 6 fold increase in risk of progression of knee OA

Question 17

Risk factors for progression

Answer 17

• obesity
• low bone density
• chondrocalcinosis
• knee effusions
• low vitamin C and D intake
• Mechanical - injury, instability, mal-alignment

Question 18

Clinical presentation - Knee osteoarthritis

Answer 18

• symptoms
  
  • medial and patella-femoral compartment affected
  • anterior or medial joint pain
  • worse walking on uneven surfaces/going up and down stairs
  • difficulty rising from chair
  • bilateral> unilateral
  • women>men
• signs
  
  • antalgic gait
  • varus deformity
  • fixed flexion deformity
  • joint line tenderness
  • joint line bony swelling
  • crepitus
  • quadriceps muscle wasting

Question 19

Clinical presentations - hip

Answer 19

Symptoms

• Superior pole of joint typically
• Groin pain on exercise
  
  • Thigh/ medial knee
  • Buttocks
• Functional problems – socks/shoes/ toes
• Women > Men

Signs

• Antalgic gait
• Pain/restricted movement on
  
  • Internal rotation (early)
  • External rotation/ abduction (later)
• Fixed flexion/ external rotation
• Limb shortening
• Quadriceps/ gluteal muscle weakness and/or wasting

Question 20

Clincal presentations- hands

Answer 20

Symptoms

• DIP, PIP, CMC joints
• Pain, swelling and stiffness
• Restricted movements
• Hand function preserved
• Usually bilateral
• Women >> Men
• Peri-menopausal onset

Signs

• Heberdens (DIP joints) and bouchards nodes (PIP joints)
• subluxation 1st CMC
• squaring of hand
• Usually OA in other joints