Osteoarthritis and management Flashcards
What is Osteoarthritis?
Wear and tear of joints
Wear = micro-damage to the articular cartilage of the joint which causes a typical inflammatory response and pain is felt (although it is not an inflammatory condition!).
There is ongoing attempts by chondrocytes to repair the damage but eventually the damage overcomes the repair mechanism and osteoarthritis develops.
What are some causes of / factors leading to OA?
- Abnormal anatomy - such as Developmental dysplasia of the hip - reduced surface area in the cup relative to the head therefore you get increased load on the cartilage which creates repetitive damage
- Intra-articular fracture = rapid degradation of articular cartilage – may be possible to repair (with scar tissue however)
- Ligament rupture/injury – abnormal movement then abnormal load
- Meniscal injury – the meniscus normally protects the cartilage and if you take it away, the abnormal loads will produce biomechanical forces injuring the cartilage
- Occupation – farmers, football players may predispose them
Risk factors of osteoarthritis (6)
- Obesity
- Age
- Occupation
- Trauma
- Female
- FH
Why is obesity such a major risk factor for OA?
If the weight transmitted through the joint exceeds that for which it was originally designed then this can damage joints.
Also if you are obese you are in a chronic state of low-grade inflammation and this pro-inflammatory state is thought to be linked to the development of osteoarthritis
What inflammatory changes occur as a result of micro-damage to the joint? (3)
- Synovial hypertrophy/ enlargement
- Subchondral changes – subarticular sclerosis - bone thickens beneath the articular cartilage
- Joint effusion
Which chemical mediators are known to drive articular change?
MMP - matrix metalloproteases
Typical presentation of OA
- >45 y/o
- Activity related joint pain
- Has either no morning joint stiffness or morning stiffness that lasts no longer than 30 minutes i.e pain is better at rest and worsens through activity
NICE suggests that a diagnosis can be made if the patient shows all of the above.
What presenting features would NOT be indicative of OA?
- Prolonged morning-related stiffness – this would have an inflammatory cause
- Rapid deterioration of symptoms – not normal in osteoarthritis – worrying
- Hot, swollen joint – not common in osteoarthritis
What imaging modality is used to confirm a clinical diagnosis of OA?
X-ray
4 key x-ray changes in OA
LOSS
- Loss of joint space
- Osteophytes
- Subarticular sclerosis (thickening of bone under articular cartilage)
- Subchondral cysts (fluid filled holes in bone - show up black on x-ray)
What non-pharmacological treatments are used for OA? (6)
- Thermotherapy – heat application
- Electrotherapy – stimulate muscles to strengthen them
- Aids and devices – splints – support joints, walking sticks (relieve weight on joints)
- Manual therapy – massage, physio etc
- Patient education
- Exercise - weight loss, muscle strengthening
What pharmacological treatments are used for OA? (4)
- Oral analgesia: paracetamol, NSAIDs
- Topical treatments: NSAIDs, capsaicin/pepper (knee, hand)
- Steroid injections
- Joint replacement in severe cases - the hip and knee are most commonly replaced joints
When should a patient with OA be referred for surgery? (2)
- When the OA has a substantial impact on QOL
- Other options have been exhausted - pain is refractory to non-surgical treatment – i.e nothing relieves it
Diagram of the pathogenesis of OA
NICE guidelines for treatment of OA
What is meant by taking a ‘hollistic approach’ in the management of OA?
The idea that the patient can take charge of their own well-being - ‘self management’
Aim to find out how their condition affects their day to day life and use this to guide the management. So treatment is unique to the patient.
