T&O - Arthritis

Question 1

Osteoarthritis

What is it?
Risk Factors
Clinical Features
Investigations

Answer 1

1.) What is it? - progressive loss of articular cartilage and remodelling of the underlying bone
- loss of articular cartilage due to inflammatory cells
- bone remodelling due to chondrocytes

2.) Risk Factors for Primary OA
- ↑age, obesity, female, manual labour

3.) Clinical Features
- joint pain and stiffness worsened by activity and relieved by rest
- pain worsens through the day, stiffness improves
- main joints: hip, knee, small joints of hands (CMCJ, DIPJ) and feet
- Heberden’s (swelling DIPs) and Bouchard (PIPs) nodes
- bilateral hand OA isn’t uncommon due to the frequency of usage
- squaring of the thumb is a sign of hand OA
- sx are insidious, chronic, and gradually worsening
- prolonged OA leads to deformity and reduced ROM

4.) Investigations - to exclude differentials
- bloods: rule out inflammatory or infective
- X-ray: confirm diagnosis, exclude fractures

Question 2

Management of Osteoarthritis

Conservative
Medical
Surgical

Answer 2

1.) Conservative - all patients should be offered help with:
- weight loss, general aerobic fitness, activity modification
- physiotherapy: local muscle strengthening exercises
- non-pharmacological: mobility aids, joint supports and braces, TENS and shock-absorbing insoles or shoes

2.) Medical
- 1°PO paracetamol +/- topical NSAIDs (only in knee/hand OA)
- 2°PO NSAIDs/COX-2 inhibitors (avoid if on aspirin)+ PPI
- 3°opioids, capsaicin cream and intra-articular corticosteroids

3.) Surgical - if others fail, options include:
- total joint arthroplasty is the gold standard in patients with severe end-stage symptomatic osteoarthritis
- joint replacements last roughly 20 years
- others: osteotomy, arthrodesis
- complications of THR: aseptic loosening (most common reason for revision), leg length discrepancy, posterior dislocation, prosthetic joint infection

Question 3

4 Cardinal Radiological Features of Osteoarthritis (LOSS)

Answer 3

1.) Loss of Joint Space
- lost progressively overtime

2.) Osteophytes
- reactive remodelling changes

3.) Subchondral Sclerosis
- destroying articular cartilage exposes underlying subchondral bone which leads to sclerosis

4.) Subchondral Bony Cysts
- reactive remodelling changes

Question 4

Rheumatoid Arthritis

Clinical Features
Investigations
EULAR Classification
Management

Answer 4

1.) Clinical Features - swollen, painful, red joints
- autoimmune inflammatory condition/features
- affects small joints in the hand and feet
- systemic sx: fatigue, lethargy, pyrexia, weight loss

2.) Investigations
- routine bloods: ↑CRP, ↑ESR, normocytic anaemia
- RF and anti-CCP/ACPA can also aid diagnosis
- X-ray (LESS): loss of joint space, erosions (periarticular), subluxations, soft tissue swelling

3.) EULAR Classification - diagnostic criteria for RA using 4 categories, score >6/10 definitive for RA
- joint distribution (0-5): ↑no and smaller joints ↑score
- serology (0-3): RF and ACPA, the more +ve, ↑score
- duration (0-1): <6wks = 0, >6wks = 1 point
- acute phase reactants: abnormal CRP/ESR = 1 point

4.) Management - by rheumatologists
- NSAIDs for pain, DMARDs, biologic agents
- methotrexate (weekly) is gold standard for RA