Osteoarthritis

Question 1

What is OA?

Answer 1

Joint disease resulting in breakdown of articular cartilage & underlying bone - due to mechanical ‘wear & tear’ of the joint

Question 2

How common is OA?

Answer 2

Very common in the elderly

>50% of >60s have osteoarthritis

Question 3

What are risk factors for OA?

Answer 3

Old age

Obesity

Persistently heavy activities - eg running

Physically demanding occupations - eg farmers

Certain conditions - esp DDH

Certain injuries:

• intra-articular fractures
• meniscal injuries
• ligament ruptures

Question 4

What are the 2 types of osteoarthritis?

Answer 4

Primary - relating to peristent microtrauma (eg high load due to obesity)

Secondary - occuring after single acute trauma (eg fractures) or related to another condition (eg DDH)

Question 5

Describe the pathogenesis of OA

Answer 5

Development of osteoarthritis revolves around trauma & mechanical imbalances damaging the articular surface of a joint - and an inadequate repair process for that joint

Inadequate repair process leads to structural issues - which leads to more damage occurring with usage

There is also inflammation (but OA is not an inflammatory disorder)

Question 6

Although osteoarthritis is not an inflammatory arthritis - inflammation is still a feature

What inflammatory features are seen in OA?

Answer 6

Synovial hypertrophy
Subchondral changes
Joint effusion

Question 7

What joints are typically affected by OA?

Unilateral or bilateral?

Answer 7

Knee

Hip

DIP & PIP

Carpometacarpal joint (of thumb)

Cervical spine (aka cervical spondylosis)

Typically unilateral (but can be bilateral - esp late disease & in hips)

Question 8

Describe the typical presentation of OA

What key feature must you check to differentiate between OA & RA?

Answer 8

>45 yo - with fairly gradual onset of:

• pain - worse on activity, relieved by rest
• stiffness
• reduced function

No morning stiffness! _{or morning stiffness of <30 mins} - morning stiffness is a key feature of RA

Question 9

How would a patient with OA of the a) hip and b) knee typically describe their pain?

Answer 9

a) hip - groin pain +/- radiation down to knee
b) knee - pain in anterior knee

Question 10

What are the differentials for OA?

Answer 10

Gout

Rheumatoid arthritis (+other inflammatory arthritides)

Septic arthritis

Malignancy

Question 11

RA is a key differential for OA

What are their main differences in terms of symptoms?

Answer 11

Pain & stiffness:

• OA - worsened by activity, relieved by rest
• RA - worst in morning, improves with activity

Joints typically affected:

• OA - typically unilateral, of the large joints*
• RA - always bilateral, small joints of hands & feet

Systemic symptoms/features:

• OA - rarely any systemic upset
• RA - systemic upset/features are common

*OA commonly affects the small joints of hands too

Question 12

How is OA investigated & diagnosed?

Give the criteria for diagnosis…

Answer 12

Can be diagnosed clinically (ie without investigation) if:

• >45 yo
• typical activity related joint pain
• absence of morning stiffness or morning stiffness lasting less than 30 mins

But if uncertainty:

• Xray
• CRP / ESR

Question 13

What xray findings indicate OA?

Answer 13

Mnemonic - LOSS

Loss of joint space

Osteophytes - spurs of bone

Subarticular sclerosis

Subchondral cysts

Question 14

Give an overview of the management of OA…

Answer 14

First steps following diagnosis:

• Self management & holistic care
• Exercise & weight loss

If above fails:

• Non-pharmacological treatment
• Pharmacological (analgesia & topicals)
• Surgery

*see NICE guidelines below

Question 15

Self management is the first management option for OA

What does it involve?

Answer 15

Thermotherapy i.e. heat/ice
Rest or changed activities
OTC painkillers

Question 16

Describe the importance of holistic care

Answer 16

Most cases are dealt without meds/surgery

Need to address the patient’s:

• Depression
• Ability to work
• Family roles
• Social isolation
• Daily living/hobbies

Question 17

What non-pharmacological treatments are available for OA?

Answer 17

Thermotherapy
Electrotherapy (TENS)
Aids/devices e.g. walking stick
Manual Therapy e.g. Physio

Question 18

What pharamacological therapies can we offer for OA?

Answer 18

Oral Analgesia e.g. paracetamol or NSAIDs
Topical e.g. NSAIDS or Capsaicin cream

Question 19

When would surgery be considered for OA?

What surgical options are available for OA?

Answer 19

If substantial impact on QoL

If refractory to other treatments

Joint replacements