Trauma and Orthopaedics

Question 1

What is osteoarthritis?

Answer 1

Osteoarthritis (OA) is a disabling joint disease characterized by a noninflammatory degeneration of the joint complex (articular cartilage, subchondral bone, and synovium) that occurs with old age or from overuse. It mainly affects the weight-bearing and high-use joints, such as the hip, knee, hands, and vertebrae. Despite the widespread view that OA is a condition caused exclusively by degenerative “wear and tear” of the joints, newer research indicates a significant heterogeneity of causation, including pre-existing peculiarities of joint anatomy, genetics, local inflammation, mechanical forces, and biochemical processes that are affected by proinflammatory mediators and proteases. Major risk factors include advanced age, obesity, previous injuries, and asymmetrically stressed joints. In early-stage osteoarthritis, patients may complain of reduced range of motion, joint-stiffness, and pain that is aggravated with heavy use. As the disease advances, nagging pain may also occur during the night or at rest. Diagnosis is predominantly based on clinical and radiological findings. Classic radiographic features of OA do not necessarily correlate with clinical symptoms and appearance. If lifestyle changes (moderate exercise, weight loss) and physical therapy fail to improve symptoms, nonsteroidal anti-inflammatory drugs (NSAIDs) in particular, are used for the management of active osteoarthritis. If medical interventions fail to improve the patient’s quality of life, surgical procedures such as joint replacement may become necessary.

Question 2

Epidemiology of osteoarthritis?

Answer 2

Most common joint disorder in the USA, affecting more than 20 million adults
Incidence: increases with age
Sex: ♀ > ♂, especially in patients older than 50 years
Incidence rates in specific joints: knee > hip > hand

Question 3

Aetiology of osteoarthritis

Answer 3

not found

Question 4

Risk factors of osteoarthritis

Answer 4

Modifiable risk factors: obesity, excessive joint loading or overuse.

Question 5

Nonmodifiable risk factors

Answer 5

Age >55 years.
Familial history
History of joint injury or trauma.
Anatomic factors causing asymmetrical joint stress.
Hemophilic hemarthroses and deposition diseases that stiffen cartilage.
Gender (male more likely)

Question 6

Classification of osteoarthritis

Answer 6

Idiopathic OA:
No identifiable, underlying cause
Genetic factors of causation have been implicated, but not definitively proven.

Secondary OA:
Hemochromatosis
Wilson disease
Ehlers-Danlos syndrome
Diabetes
Avascular necrosis
Congenital disorders of joints
Alkaptonuria
Joint trauma

Question 7

Pathophysiology of osteoarthritis

Answer 7

Joint damage/stress → cartilage damage → decreased proteoglycans levels → cartilage becomes friable and inelastic and starts to degrade → loss of joint space and bony surface → subchondral bone becomes thickened and sclerotic.

Question 8

Clinical features

Answer 8

Early clinical findings
Pain on exertion, which is relieved with rest
Pain in both complete flexion and extension
Crepitus on joint movement
Joint stiffness and restricted range of motion
Radiating or referred pain (e.g., coxarthrosis may lead to knee pain).

Late clinical findings
Constant pain (including at night)
Morning joint stiffness usually lasting < 30 minutes
More severely restricted range of motion

Question 9

Subtypes and variants of osteoarthritis

Answer 9

Heberden’s nodes: Pain and nodular thickening on the dorsal sides of the distal interphalangeal joints (DIP), ♀ > ♂
Bouchard’s nodes: Pain and nodular thickening on the dorsal sides of the proximal interphalangeal joints (PIP), ♀ > ♂.
Hallux rigidus: Arthrosis of the first metatarsophalangeal joint (between the first metatarsal and the first proximal phalanx), characterized by hypertrophy of the sesamoid bones.
Osteoarthritis of the hip and knee.

In contrast to osteoarthritis, rheumatoid arthritis does not affect the DIP joints.

Question 10

Investigations/diagnosis of osteoarthritis

Answer 10

Osteoarthritis is usually diagnosed on the basis of clinical and radiographic evidence of joint degeneration.
Radiological signs of osteoarthritis
Irregular joint space narrowing
Subchondral sclerosis 
Osteophytes (also: bone spurs) 
Subchondral cysts 

The patient’s history and clinical diagnosis are essential for the assessment and treatment of osteoarthritis! Radiographic signs often do not correlate with the patient’s perception and clinical findings!

Question 11

Ddx of osteoarthritis

Answer 11

?

Question 12

Treatment of OA

Answer 12

General:
Weight loss
Regular exercise
Shoe inserts (e.g., buffer insoles) in, e.g., valgus deformity of the knee
Targeted muscle growth, physiotherapy, and medical training therapy
Topical and heat therapy

Pharmacotherapy:
Peripheral analgesics
Acetaminophen
NSAIDs: e.g., ibuprofen
In combination with PPIs in patients with gastrointestinal risk (e.g., together with glucocorticoids)
Opioid analgesics: e.g., tramadol

Interventional therapy:
In severe courses: intraarticular glucocorticoid injections (not a long-term treatment!)

Surgical therapy: if conservative and interventional measures fail
Endoprosthesis (joint replacement)
In case of failure of endoprosthesis or in select OA subtypes (e.g., Heberden’s OA): arthrodesis (operative ankylosis)
Pharmacotherapy should be used as acute and symptomatic therapy only; long-term NSAID therapy should be avoided due to its many side effects!