Osteoarthritis

From Ganfyd

Osteoarthritis(OA,osteoarthrosis, spondylosis, hypertrophic arthritis,degenerative joint disease) at its simplest can be thought of as joint wear and tear. However, matters are more complex than this^[1]. It can most certainly involve abnormal synthetic and degradative processes.

Joints may wear out at different rates associated with genetics, abnormal or misbalanced loads (such as can happen with a repetitive activity, musculoskeletal deformity, trauma to muscles, obesity) and pathology (such as past infection in joint, a primary rheumatological disease, recurrent crystal arthropathy)

NICE guidance 2008 is much more comprehensive than this article and is freely available

Presentation

The typical presentation of osteoarthritis that differentiates it from rheumatoid arthritis (although the two may co-exist) is a pain that gets worse with activity, is worse in weight-bearing joints and may well disturb sleep.

Common associations of generalised osteoathritis include

• Distal interphalangeal osteophytes - Specificity 81%, positive predictive value 61%
• Heberden's nodes - Specificity 52%, positive predictive value of 41%, sensitivity only 17% - 24%

Fixed flexion deformities may develop through reluctance to move affected joints. Examination may also reveal joint effusions and crepitus on movement

Investigation

Radiographs can often confirm osteoarthritic changes. However, the severity of symptoms does not correlate with radiographic appearences. Radiographs can assist pre-operative planning by allowing estimation of the size of implants as well as quantifying deformity.

Common features:

• Narrowing of joint space.
• Osteophytes
• Subchondrol sclerosis.
• Bone cysts.

Treatment

• Patient information
  • Self management plan in informed patient
• Maximise activity and exercise
  • Muscle strengthening
  • Pacing (avoid peaks)
• Weight loss if obese
• Targeted interventions
  • Appropriate footware for leg and spine symptoms
    • Shock absorbing properties
    • Shoe insoles
  • Local heat
    • Note poor evidence base for net clinical effectiveness rubefacients^[2]
  • Manipulation and stretching for OA hip
  • TENS
  • Support/bracing unstable joints
  • Acupuncture
    • May not be cost effective
    • No evidence base for effectiveness of electroacupuncture^[3]
• Analgesia
  • Paracetamol
    • Add in analgesic ladder approach modified by relatively strong evidence base in this indication
      • Opioid type particularly if patient already on low dose aspirin for another indication
      • Oral NSAIDs with PPIs
  • Topical NSAIDs for hand and knee OA
  • Topical capsaicin
• Intra-articular injection
  • Steroid into the joint space with or without local anaesthetic may provide some short term relief from the pain. Evidence suggests that this may hasten the destruction of articular cartilage however.
  • Hyaluronans are clinically effective but poor evidence of resource effectiveness
• The replacement of knee or hip joints has now become an established procedure in orthopaedic surgery in appropriately selected patients
• In younger patients, the technique of hip resurfacing is still finding its niche but is put forward as beneficial because these patients will almost always require revision operation.
• Arthroscopic lavage or debridement only for mechanical locking knee
  • No evidence base for gelling, giving way or X-ray loose bodies^[4]

References