Osteoarthritis and Principles of Management

Question 1

Who manages osteoarthritis?

Answer 1

Nurses

Patients

GPs

Physicians

Dieticians

Occupational therapists

Orthopaedic surgeons

Physiotherapists

Question 2

What are the characteristic features of osteoarthritis?

Answer 2

Osteo- arthritis is characterised by focal loss of articular cartilage, subchondral osteosclerosis, osteophyte formation at the joint margin, and remodelling of joint contour with enlargement of affected joints. There is also loss of space in the joint cavity. Also subchondral cysts. Inflammation can occur but is not a prominent feature

Question 3

What are the joints most commonly affected in OA?

Answer 3

Joint involvement in OA follows a characteristic distribution, mainly tar- geting the hips, knees, PIP and DIP joints of the hands, neck and lumbar spine

Question 4

What are the risk factors for OA?

Answer 4

Question 5

What is the pathogenesis of osteoarthritis?

Answer 5

• Trauma & mechanical imbalance
• Inflammation & pain
• Repair processes around the joint

Question 6

What are the biomechanical factors associated with osteoarthritis?

Answer 6

• Abnormal anatomy (DDH)
• Intra-articular fracture
• Ligament rupture
• Meniscal injury

(The medial meniscusof the knee is a thickened crescent-shaped cartilage pad between the two joints formed by the femur (the thigh bone) and the tibia (the shin bone).)

•Occupation – farmers, football players

Persistent heavy physical activity

Elite running

Obesity

Question 7

What are the inflammatory signs on OA?

Answer 7

• Synovial hypertrophy
• Subchondral changes
• Joint effusion

Question 8

What are the biochemical mediators?

Answer 8

•IL-1𝝱, TNF 𝜶, MMPs…

Higher levels of these are associated with arthritis

Question 9

Patient perspective of OA

Question 10

Patients suffer from – pain on movement, hip arthritis can causes pain in the groin – can radiate down the leg to the knee

Knee arthritis tends to go to the front of the knee

Stiffness (when they get out of bed in the morning – after a few minutes it wears away and they loosen up)

Rheumatoid arthritis causes prolonged early morning stiffness

Hip osteoarthritis – complain that they can’t reach down to put on their shoes or socks - maybe can’t cut their nails or toenails

Unlikely that a patient who is 10 years old will have osteoarthritis – tends to appear in 45’s and upwards

Question 11

What is the diagnosis of OA?

Answer 11

• 45 years +
• Activity-related joint pain plus
• has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes

Question 12

When should you pay special attention to the diagnosis - may be something else

Answer 12

• Trauma
• Prolonged morning-related stiffness
• Rapid deterioration of symptoms
• Hot, swollen joint

Question 13

What is the differential diagnosis for osteoarthritis?

Answer 13

Gout

Other inflammatory arthritides

Septic arthritis

Malignancy

Question 14

Here is the nice guidelines for OA

and also some discussion from the lecture

Answer 14

Firstly – conservative management and self care – anaelgesics (NSAIDS – gastric side effects – can exacerbate asthma symptoms)

Paracetamol often has synergistic effect

Morphine based pain killers often have undesirable side effects

Activity modification and weight loss

Question 15

What are non-pharmacological treatments for OA?

Answer 15

• Thermotherapy
• Electrotherapy
• Aids and devices
• Manual therapy
• NICE do not recommend: acupuncture, nutraceuticals (glucosamine, chondroitin)

TEAM

Aids – walking sticks, crutches and support bandages

Walking sticks are held in the opposite hand

Manual therapy is physiotherapy

Physiotherapy – improving strength of the muscle around the joint. Improving the quad strength can improve the knee pain

Question 16

What are pharmacological treatments for OA?

Answer 16

• Oral analgesia:paracetamol, NSAIDs
• Topical treatments: NSAIDs, capsaicin (knee, hand)

From Davidson’s:

‘Addition of a topical NSAID, and then capsaicin, for knee and hand OA can also be helpful. Oral NSAID should be consid- ered in patients who remain symptomatic. These drugs are significantly more effective than paracetamol and can be successfully combined with paracetamol or compound analgesics such as co-codamol if the pain is severe. Opiates may occasionally be required. For temporary benefit of moderate to severe pain, intra-articular injection of corticosteroids can be helpful’

Question 17

When is surgical referral indicated?

Answer 17

• Substantial impact on quality of life
• Refractory to non-surgical treatment
• Referral letter

Referral letter should list the things that you’ve tried already, also include the time frame of the condition. The patients quality of life should also be included. Include the patients BMI – if the patient is over 40 then surgery would probably be avoided just because of the risks assocaited.

X- ray is the only investigation that is needed – MRI is not necessary. Blood tests may be used to exclude rheumatoid arthritis.

Davidsons: ‘Osteotomy can prolong the life of malaligned joints and relieve pain by reducing intra- osseous pressure, but is performed infrequently. Total joint replacement surgery is by far the most common surgical procedure for patients with OA. It can trans- form the quality of life for people with severe knee or hip OA and is indicated when there is significant structural damage on X-ray, and pain and functional impairment are limiting quality of life despite the use of medical therapy’

Question 18

What is the only reason to perform a hip replacement in OA?

Answer 18

PAIN

Question 19

Why is obesity a risk factor for osteoarthritis?

Answer 19

Obesity is another strong risk factor. Although this is likely to be due in part to increased mechanical loading of the joints, it has been speculated that cytokines released from adipose tissue may also play a role

Question 20

What is the hereditability of OA?

Answer 20

Genetic factors play a key role in the pathogenesis of OA, and family-based studies have estimated that the heritability of OA ranges between about 43% at the knee to between 60% and 65% at the hip and hand, respectively

Question 21

What is the pain like in OA?

Answer 21

Insidious onset over months or years

Variable or intermittent over time (‘good days, bad days’)

Mainly related to movement and weight-bearing, relieved by rest

Only brief (< 15 mins) morning stiffness and brief (< 5 mins)

‘gelling’ after rest

Usually only one or a few joints painful

Question 22

What are the clinical signs of OA?

Answer 22

Restricted movement due to capsular thickening, or blocking by osteophyte

Palpable, sometimes audible, coarse crepitus due to rough articular surfaces

Bony swelling around joint margins

Deformity, usually without instability

Joint-line or periarticular tenderness

Muscle weakness and wasting

Synovitis mild or absent

Question 23

From Davidsons clinical medicine book

Answer 23

“Quadriceps strengthening exercises are particularly beneficial in knee OA. Weight loss can have a substantial beneficial effect on symptoms if the patient is obese and is probably one of the most effective treatments for reducing pain, particularly in OA of the lower limbs. Shock-absorbing footwear, pacing of activities, use of a walking stick for painful knee or hip OA, or provision of built-up shoes to equalise leg lengths can all improve symptoms.”