Overview
·
Definition
and Risk Factors
·
Idiopathic
vs. Secondary OA
·
Clinical
Features
·
Diagnosis
·
Radiologic
Features
·
ACR
OA dx for knees, hands, hips
·
Goals
of Treatment
·
Non-pharmacologic
treatment
·
Pharmacologic
treatment
·
Surgical
Considerations
Osteoarthritis
·
Articular
cartilage failure induced by a complex interplay of genetic, metabolic,
biochemical, and biomechanical factors
·
With
secondary components of inflammation
·
Initiating
mechanism is damage to normal articular cartilage by physical forces
(macrotrauma or repeated microtrauma)
·
Not
necessarily normal consequence of aging
Risk Factors
1.
Age
2.
Female
versus male sex
3.
Obesity
4.
Lack
of osteoporosis
5.
Occupation
6.
Sports
activities
7.
Previous
injury
8.
Muscle
weakness
9.
Proprioceptive
deficits
10.
Genetic
elements
11.
Acromegaly
12.
Calcium
crystal deposition disease
13.
Idiopathic
Osteoarthritis
Localized or generalized forms
·
Localized
OA most commonly affects the hands, feet, knee, hip, and spine
·
Other
joints less commonly involved (shoulder, temporomandibular, sacroiliac, ankle,
and wrist joints)
·
Generalized
OA-three or more joint sites
Patterns of Presentation
·
Monoarticular
in young adult
·
Pauciarticular,
large-joint in middle age
·
Polyarticular
generalized
·
Rapidly
progressive
·
Secondary
to trauma, congenital abnormality, or systemic disease
Secondary Osteoarthritis
·
Trauma
·
Congenital
or developmental disorders
·
Calcium
pyrophosphate dihydrate deposition disease (CPPD)
·
Other
bone and joint disorder-Osteonecrosis, rheumatoid arthritis, gouty arthritis,
septic arthritis, and Paget disease of bone
·
Other
diseases -Diabetes mellitus, acromegaly, hypothyroidism, neuropathic (Charcot)
arthropathy, and frostbite
Specific
conditions may cause or enhance the risk of developing osteoarthritis.
likely to
present in an atypical fashion, such as acutely or with unusual patterns of
joint involvement
Clinical Features
Age of
Onset > 40 years
Commonly
Affected Joints
·
Cervical
and lumbar spine
·
First
carpometacarpal joint
·
Proximal
interphalangeal joint
·
Distal
interphalangeal joint
·
Hip
·
Knee
·
Subtalar
joint
·
First
metarsophalangeal joint
Uncommonly Affected Joints
·
Shoulder
·
Wrist
·
Elbow
·
Metacarpophalangeal
joint
·
TMJ
·
SI
·
Ankle
Clinical
Diagnosis
Symptoms
·
Pain
·
Stiffness
·
Gelling
Physical examination
·
Crepitus
·
Bony
enlargement
·
Decreased
range of motion
·
Malalignment
·
Tenderness
to palpation
The more
features, the more likely the diagnosis
Differential Diagnosis
·
Rheumatoid
Arthritis
·
Gout
·
CPPD
(Calcium pyrophosphate crystal deposition disease)
·
Septic
Joint
·
Polymyalgia
Rheumatica
Synovial fluid analysis
·
Severe,
acute joint pain is an uncommon manifestation of OA
·
Clear
fluidWBC <2000/mm3
·
Normal
viscosity
Radiographic Features
·
Joint
space narrowing
·
Subchondral
sclerosis
·
Marginal
osteophytes
·
Subchondral
cyst
Joint
Space Narrowing
OA
typically asymmetrical
Subchondral
Sclerosis
Increased
bone density or thickening in the subchondral layer
Osteophytes
Bone spurs
Subchondral
Cysts
Fluid-filled
sacs in subchondral bone
OA of the
Knee: Classic Criteria
1. Greater
than 50 years of age
2. Morning
stiffness for less than 30 minutes
3. Crepitus
on active motion of the knee
4. Bony
tenderness
5. Bony
enlargement
6. No palpable
warmth
3 of 6
criteria give sensitivity of 95% and specificity of 69%
The classic
criteria method for OA of the knee is based upon the presence of knee pain plus
at least three of the following six clinical characteristics
sensitivity
and specificity for OA of 95 and 69 percent
The
inclusion of laboratory criteria to these clinical characteristics alters the
accuracy of diagnosis of knee OA. As an example, if an ESR less than 40 mm/h, a
rheumatoid factor titer less than 1:40, and synovial fluid suggestive of OA
(clear color, viscous fluid, white blood cell count less than 2000/mm3) are
added to the six clinical characteristics, the diagnostic criteria of knee pain
and at least five of the nine features (six physical plus three laboratory) now
has a sensitivity and specificity for OA of 92 and 75 percent, respectively.
The
addition of radiographic data further alters the diagnostic accuracy. The
criteria of knee pain, radiographic evidence of osteophytes, and one of three
additional findings — age greater than 50 years of age, morning stiffness of
less than 30 minutes, or crepitus — has a sensitivity and specificity for OA of
91
OA of the Knee: Addition of X-rays
ACR
Criteria of:
1. knee
pain
2.
radiographic evidence of osteophytes
3. one of
three additional findings:
·
age
greater than 50 years of age
·
morning
stiffness of less than 30 minutes
·
crepitus
Sensitivity
and specificity for OA of 91 and 86%
Hand Osteoarthritis
Diagnosis
by hand pain
Plus at
least three of the following four features:
1. Hard
tissue enlargement of 2 or more of 10 selected joints.
The 10
selected joints are the second and third distal interphalangeal (DIP) joints,
the second and third proximal interphalangeal (PIP) joints, and the first
carpometacarpal (CMC) of both hands
2. Hard
enlargement of two or more DIP joints
3. Fewer
than three swollen metacarpophalangeal (MCP) joints
4.
Deformity of at least 1 of the 10 selected joints
Sensitivity
and Specificity for hand OA of 94 and 87%
Hip Osteoarthritis Diagnosis
Use
history, physical, laboratory, and radiographic features (ACR)
Hip Pain,
plus at least two of the following three features:
1. ESR of
less than 20 mm/h
2.
Radiographic osteophytes
3. Joint
space narrowing on radiography
Sensitivity
of 89 percent and a specificity of 91 percent
Distinction
between Osteoarthritis and rheumatoid arthritis
Typical OA work-up
·
History
·
PE
·
Consider
following (especially if OA of knees or hips)
Erythrocyte sedimentation rate (ESR)
Rheumatoid factor titers
Evaluation of synovial fluid
Radiographic study of affected joints
Overview
·
Definition
and Risk Factors
·
Idiopathic
vs. Secondary OA
·
Clinical
Features
·
Diagnosis
·
Radiologic
Features
·
ACR
OA dx for knees, hands, hips
·
Goals
of Treatment
·
Non-pharmacologic
treatment
·
Pharmacologic
treatment
·
Surgical
Considerations
Goals of Treatment
·
Control
pain and swelling
·
Minimize
disability
·
Improve
the quality of life
·
Prevent
progression
·
Education
·
Chronic
Condition and Management
Non-pharmacologic Treatment
Weight
Loss
Ten-pound
weight loss over 10 years decreased the odds for developing knee OA by 50%
Even a
modest amount of weight loss may be beneficial
Rest
Short
period of time, typically 12-24 hours
Prolonged
rest can lead to muscle atrophy and decreased joint mobility
Physical
Therapy
“Manual
therapy" may be more beneficial than exercise programs that focus on muscle
strengthening, endurance training, and improved coordination
May be more
beneficial in those with mild OA
Ultrasound
therapy may have some benefit based on 2009 Cochrane Review
Tens
·
SOR
B
·
Safety/Tolerability:
High
·
Efficacy:
Medium
·
20
points more effective on scale of 100 compared to placebo
·
Few
long term studies
·
Price:
Low to medium
Knee
Braces/Shoe Inserts - SOR C
Cochrane
reports a “sliver of benefit”
73% taping
for 3 weeks reported improvement (elastic knee sleeve)
Price: Low
$30
Acupuncture
Cochrane
January 2010
Very small
improvements in pain and physical function after 8 weeks and 26 weeks
A lot seems
to be placebo effect due to incomplete blinding
Price:
Medium to high, 1000$ over 3-4 months
Reasonable
to offer if patient resistant to conventional treatment and wants to try
alternative therapies
Exercise
– focus on low load exercise
Tai Chi
Yoga
Swimming
Biking
Walking
Most
important aspect to counsel patients for prevention and treatment
Cochrane
Review 2009 compares efficacy to NSAIDs in short-term benefits
Heat and
Cold
Lack of
convincing data despite being commonly used
Acetaminophen
·
Cochrane
2009 Review
·
NSAIDs
are superior to acetaminophen for improving knee and hip pain in people with OA
·
Treatment
effect was modest
·
Median
trial duration was only six weeks
·
In
OA subjects with moderate-to-severe levels of pain
·
NSAIDs
> Acetaminophen > Placebo
·
NNT
for Acetaminophen 4 to 16
·
1000mg
three to four times daily
NSAIDs
·
Tend
to avoid for long-term use
Rash and
hypersensitivity reactions
Abdominal
pain and gastrointestinal bleeding
Impairment
of renal, hepatic, and bone marrow function, and platelet aggregation
Central
nervous system dysfunction in the elderly
·
Low
dose ibuprofen (less than 1600 mg/day) may have less serious GI toxicity
·
Nonacetylated
salicylates (salsalate, choline magnesium trisalicylate), sulindac, and
nabumetone appear to have less renal toxicity
·
Indomethacin should
be avoided for long-term use in patients with hip OA
Associated
with accelerated joint destruction
Topical NSAIDs
·
A
2004 meta-analysis included 13 trials involving almost 2000 patients
·
Randomly
assigned to topical NSAID, oral NSAID, or placebo
·
Significant
short term (one to two weeks) efficacy for pain relief and functional
improvement when topical NSAIDs were compared to placebo
·
Effect
was not apparent at three to four weeks
·
Topical
NSAIDs were generally inferior to oral NSAIDs
·
However
topical route was safer than oral use
·
Topical
Diflofenac (1% gel or patch)
COX-2 Inhibitors
COX-2
inhibitors appear to be as effective NSAIDs
Associated
with less GI toxicity
However
increased risk of CV events
Use of low
dose ASA may negate the GI sparing effects of COX-2 inhibitors
Those who
are receiving low dose aspirin and a COX-2 selective agent may benefit
from antiulcer prophylaxis
Capsaicin
Capsaicin
Ointment 0.025% (qid) & 0.075% (bid)
·
Principle
ingredient of chili peppers (substance P)
·
Love
It!
·
Tolerability:
Medium
50%
experience burning which wanes
50%
decrease in pain, 25% with placebo
Price: 15$
per month
Apply 2-4
times per day
Glucosamine
·
Glucosamine
Sulfate 1500mg po daily
·
Supplement,
typically not covered
·
Cochrane
2009
Rotta
preparation glucosamine was superior to placebo in the treatment of pain and
functional impairment
Non-Rotta
preparation failed to show benefit
·
Majority
of trials that have evaluated the effectiveness of glucosamine sulfate
demonstrated significant clinical benefits
·
Glucosamine
hydrochloride trials are scarce and much less convincing
·
Bottom-Line,
most likely beneficial if Rotta brand and Sulfate formulation, not HCL
Injections
Corticosteroid
Safety:
High for short-term use, data on frequency and degree of use is limited.
Study of
pt’s receiving 8 injections over 2 year period showed no ill effects in
comparison with pt’s receiving placebo.
Tolerability:
Medium to high
Efficacy:
Low to medium. Modest benefit. 16 point
reduction in pain on 100-point scale for one month.
Price: Low,
100$-200$
SOR A
Hyaluronic
Injections of Knees
Safety:
High
Tolerability:
Medium. Small number pts get flare up of symptoms.
Efficacy:
Low. Recent Meta-analyses and reviews small clinical effect. 75% were satisfied with treatment. Lasts 3-4
months.
Price:
High. 3 injections costs $700 to $1000 per injection. Claims of substantial
savings d/t delayed joint replacement.
SOR A
Narcotics
for Refractory Pain
Vicodin/Oxycodone
Safety:
Medium
Tolerability: Medium
Constipation,
somnolence, mental status changes
Price:
Low,<$20 per month with vicodin
Use of
opiates indicated in those who are not candidates for surgery and who continue
to have moderate to severe pain despite being on NSAIDs or selective
cyclooxygenase (COX)-2 inhibitors
Arthroscopic
Interventions
Controversial
Arthroscopic
debridement with lavage
Sham-surgery
versus arthroscopic lavage/debridement study
Remove
loose pieces of bone and cartilage
Resurface
(smooth out) bones
A direct,
three-armed comparison of arthroscopically directed lavage, arthroscopically
directed lavage and debridement, and sham surgery was performed in a study that
randomized 180 patients with radiographic and symptomatic osteoarthritis of the
knee to one of the three procedures [7].
Patients were followed for 24 months; the result of this blinded study was that
there was no clinically important or statistically significant advantage in the
reduction in knee pain or improvement in knee function in the groups that
received an arthroscopic intervention (lavage alone or lavage and debridement)
when compared to the sham group
Prosthetic
Joints
·
Commonly
of the hip or knee or shoulder
·
Several
types: metal, plastic, ceramic
·
Last
10-15 years or more
·
About
10% need to be redone
·
Usually
a treatment of “last resort”
Joint
Replacement
·
Surgical
candidate?
·
Often
greater improvement in pain rather than function
·
Recovery
can be strenuous and lengthy
·
Infection
rate 1%
·
Low
mortality 0.6% to 0.7%
·
Complications
include thrombo-embolic events 5%
Education
and Self-Help
·
Understand
the disease
·
Reduce
pain but remain active
·
Clear
Functional goals
·
Cope
physically, emotionally, and mentally
·
Have
greater control over the disease
·
Build
confidence
