Definition
A.Osteoarthritis (OA) is defined as evident cartilage loss without inflammatory or crystal arthropathy, irrespective of whether the patient has symptoms.
Incidence
A.OA is the most common type of joint disease, affecting more than 20 million individuals in the United States alone.
B.Ninety percent of all people have radiographic evidence of OA in weight-bearing joints by age 40.
C.Symptomatic disease increases with age.
D.Develops in women more frequently than in men.
Pathogenesis
A.OA is characterized by degeneration of cartilage and by hypertrophy of bone at the articular margins.
B.Cartilage, subchondral bone, and synovium have been found to all have key roles in disease pathogenesis.
Predisposing Factors
A.Hereditary and mechanical factors may be involved.
1.Mechanical factors.
a.Excessive weight, causing additional pressure.
b.Repetitive movements or overuse, which causes damage to joints, tendons, and ligaments.
i.Can break down cartilage over time.
B.Obesity is a risk factor for OA of the knee, hand, and hip.
C.Playing competitive contact sports increases the risk for developing OA.
D.Jobs requiring frequent bending and carrying increase the risk of knee OA.
Subjective Data
A.Common complaints/symptoms.
1.The onset is insidious.
2.The disease process may start with articular stiffness or deep aching joint pain lasting less than 30 minutes; may be most prominent upon awakening.
B.Common/typical scenario.
1.Reduced range of motion and crepitus of affected joint is frequently present.
2.There are no systemic manifestations.
C.Family and social history.
1.May have genetic component.
2.Repetitive use and jobs requiring heavy lifting and bending may contribute.
3.Obesity.
D.Review of systems.
1.Elicit onset, frequency, duration, and location of symptoms.
2.Inquire if pain is worse during activity or at rest.
3.Inquire about exacerbating factors.
4.Inquire about presence and duration of morning stiffness.
5.Determine if there are any systemic signs such as fever.
Physical Examination
A.Comprehensive musculoskeletal examination may reveal:
1.Flexion contracture or varus deformity of the knee.
2.Palpable osteophytes of the distal interphalangeal (DIP; Heberden nodes) and proximal interphalangeal (PIP; Bouchard) nodes.
3.Limited range of motion of the affected joint or joints.
4.Crepitus felt over the knee joint.
5.Joint effusion and other articular signs of inflammation.
Diagnostic Tests
A.Laboratory test.
1.Erythrocyte sedimentation rate (ESR)—OA does not cause elevation of the ESR or other laboratory signs of inflammation.
2.Synovial fluid—tends to be noninflammatory.
B.Imaging.
1.Plain film radiographs of the affected joint may reveal.
a.Narrowing of the joint space.
b.Osteophyte formation.
c.Lipping of marginal bone.
d.Thickened, dense subchondral bone.
e.Bone cysts.
Differential Diagnosis
A.Gout.
B.Pseudogout.
C.Rheumatoid arthritis.
D.Psoriatic arthritis.
E.Reactive arthritis.
F.Septic arthritis.
G.Fibromyalgia.
H.Tendonitis.
I.Avascular necrosis.
J.Charcot joint.
K.Lyme disease.
L.Patellofemoral syndrome.
M.Prepatellar bursitis.
Evaluation and Management Plan
A.General plan.
1.Nonpharmacologic.
a.OA of the hand may benefit from assistive devices and instruction on techniques for joint protection.
2.OA of the first carpometacarpal joint may benefit from splinting.
3.OA of the knee or hip may benefit from a regular exercise program.
4.If patient is overweight, he or she should be instructed to lose weight.
5.The use of assistive devices (e.g., a cane on the contralateral side) can improve functional status.
6.Surgical intervention.
a.Total hip and knee replacements provide excellent symptomatic and functional improvement when involvement of that joint severely restricts walking or causes pain at rest.
b.Arthroscopic surgery for knee OA is ineffective.
B.Patient/family teaching points.
1.General education of patients regarding benefits of exercise and weight loss.
2.Exercise can strengthen muscles and reduce pain and potentially help patients to avoid surgery.
3.Weight loss will reduce pressure on joints and slow down destruction of cartilage.
4.Avoid repetitive movements of an affected joint.
5.Use protective gear such as joint padding when playing sports to avoid injury.
C.Pharmacotherapy.
1.Acetaminophen is first-line analgesic therapy (2.6–4 g/day orally).
2.Nonsteroidal anti-inflammatory drugs (NSAIDs) provide more pain relief but have greater side effects of toxicity.
3.Chondroitin sulfate and glucosamine, alone or in combination, are no better than placebo in reducing pain in patients with knee or hip OA.
4.Intra-articular injections.
a.Triamcinolone (20–40 mg) for patients with OA of the knee or hip may reduce the need for oral analgesics and can be repeated up to four times a year. The American College of Rheumatology does not recommend corticosteroid injections for OA of the hand.
b.Sodium hyaluronate produces moderate reduction in symptoms in some patients with OA of the knee.
Follow-Up
A.Follow-up with your provider on a regular basis until your pain and mobility level are optimized.
B.The patient should call once joint pain starts for better management.
C.Follow-up at least once a year with your provider once your symptoms are controlled.
Consultation/Referral
A.Refer to an orthopedic surgeon when pain, loss of function, or both warrant consideration of hip or knee joint replacement surgery.
Special/Geriatric Considerations
A.OA may account for up to 70% of the geriatric population’s joint pain.
B.This places geriatric patients at a higher risk for falls.
C.Nonsurgical candidates may be considered for physical reconditioning and pharmacologic pain control.
Bibliography
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