Osteoarthritis

Does this patient have osteoarthritis?

Osteoarthritis is the most common joint disorder worldwide and a leading cause of pain and disability. Osteoarthritis is a slowly progressive joint disease, characterized by articular cartilage degeneration, osteophyte growth, and remodeling of the subchondral bone. It typically occurs in patients over 40. Patients present with initially episodic and later more chronic pain and stiffness in knees, hips, hands (first carpometacarpal joints, proximal and distal interphalangeal joints), feet (first metatarsophalangeal joints), and/or cervical or lumbar spine. The wrists, elbows, metacarpophalangeal joints of the hands, and ankles are generally spared. The pain is typically slowly progressive and may vary over time.

Physical exam can reveal bony expansion of the joint, crepitus with motion, tenderness to palpation, malalignment (such as varus or valgus malalignment of the knee), and possibly the presence of a joint effusion. Occasionally mild synovitis can be detected.

Differential diagnoses include joint injury, soft tissue disorders (e.g., pes anserinus pain syndrome, bursitis), generalized pain syndromes (e.g., fibromyalgia), and/or inflammatory arthritis with secondary osteoarthritis. Some of these may co-exist. Osteoarthritic joints are more susceptible to developing gout or pseudogout arthritis or septic arthritis.

What tests to perform?

Laboratory testing is not necessary for diagnosing osteoarthritis, but is mainly aimed at excluding other differential diagnoses and contra-indications for pharmacological therapy.

If the joint pain is acute and severe and/or a large joint effusion is present, fluid should be aspirated and sent for cell count, gram stain, culture, and crystal analysis (gout and CPPD crystals).

Imaging studies are not necessary for diagnosing osteoarthritis and only correlate with symptoms to a limited extent. Weight-bearing x-rays allow assessment of typical osteoarthritis features, such as joint space narrowing, osteophytes and/or subchondral sclerosis. Such films may also detect the rarer findings of insufficiency fractures in the pelvis if the history is suggestive. Ultrasound or magnetic resonance imaging (MRI) should be reserved for particular cases. MRI can also be useful when there is locking or ‘giveway’ of the knee and the differential diagnosis includes injury to ligaments or menisci.

How should patients with osteoarthritis be managed?

Non-pharmacologic therapies

Explanation.
Lifestyle advice.
Weight loss.
Physical and occupational therapy.
Walking aids: canes, braces, etc.

Pharmacologic therapies

Oral analgesics

Pain management should begin with acetaminophen.

There is good evidence for short-term efficacy of oral non-steroidal anti-inflammatory drugs (NSAIDs). Quite often this treatment is (initially) effective when used on demand. However, their use is often limited by hypertension, chronic renal insufficiency, and gastrointestinal bleeding – OA patients are often in the at risk age groups for NSAID induced toxicities, including polypharmacy. There is a higher risk of adverse events in patients who use diuretics, ACE (angiotensin converting enzyme) inhibitors or ARBs (angiotensin receptor blockers), cyclosporine, warfarin, oral glucocorticoids, or aspirin.

In patients for whom acetaminophen and NSAIDs are not effective and/or who have contraindications, opioids are an option. These should be used with caution due to their addictive properties and also their not inconsiderable adverse event profile.

Currently, there is insufficient evidence for recommending cannabinoid preparations for pain relief in patients with chronic pain from rheumatic diseases.

Topical preparations

Diclofenac, ketofen and other NSAID gels appear to have short-term benefit in a minority of osteoarthritis patients. Their long-term efficacy over placebo is uncertain. Capsaicin cream is derived from hot chili peppers and should be applied four times daily. It has been shown to have moderate short-term efficacy and appears to be safe.

Intra-articular glucocorticoids

Intra-articular glucocorticoids can be considered in patients with symptomatic osteoarthritis of one or a few joints despite conservative therapy. Their efficacy over placebo is unclear, however, due to methodological limitations of most trials. Their efficacy, if any, lasts no longer than six months.

Intra-articular hyaluronans

Intra-articular hyaluronans have been shown to provide a small, if any, pain-relieving advantage over placebo injections. Some experts and guidelines advise against their use. There is no reliable evidence suggesting superiority of one brand to others.

Intra-articular platelet-rich plasma (PRP)

PRP is an autologous blood product that contains an elevated concentration of platelets. It can be prepared by centrifugation or commercially available kits. Degranulation of the platelets releases growth factors and the plasma contains cytokines, thrombin and other growth factors. PRP is now used for knee and hip osteoarthritis. Available randomized clinical trials suggest that PRP is safe and has potential to provide symptomatic benefit. However, trials are heterogeneous and suffer from methodological flaws. Hitherto, none of the present treatment guidelines recommend the use of PRP.

There is no clear evidence supporting any specific clinical criteria to select individual patients who will be most likely to benefit from intra-articular injections. Patients treated with intra-articular injections in weight bearing joints should be advised to avoid strenuous or prolonged weight-bearing activities for approximately 48 hours after treatment.

Glucosamine and chondroitin

The GAIT Trial suggested that the combination of glucosamine and chondroitin sulfate was not significantly more effective than placebo for pain relief or functional improvement in patients with osteoarthritis of the knee. However, there is still controversy about the efficacy of glucosamine sulfate because glucosamine hydrochloride was used in the GAIT trial. The treatment has no side effects and many clinicians advise a trial for a period of three months.

Acupuncture

Some clinical trials have shown acupuncture to be more efficacious than sham procedures, but it is unclear if it is a clinically significant difference and the methodological quality of studies is not always high.

Surgical therapies

Referral to orthopedics could be considered when optimum conservative management fails, impacting the patients’ quality of life and/or ability to do their activities of daily living. There is controversy about the efficacy of arthroscopic surgery for knee osteoarthritis. Current guidelines and expert panels generally discourage arthroscopic therapy for patients with degenerative knee disease, including radiographic osteoarthritis and meniscal tears. Conservative management is equally effective on the long term, but without the potential adverse effects from arthroscopy (e.g., infection, venous thrombosis).

In selected patients, joint preservational surgery can postpone or prevent the development and/or progression of osteoarthritis and the need for joint replacement. For osteoarthritis of the knee, options include tibial or femoral osteotomy and knee joint distraction. There is growing evidence that these techniques can even stimulate articular cartilage regeneration. Osteotomy may be particularly useful for unicompartmental osteoarthritis (i.e. either medial or lateral), while distraction might also be effective in bicompartmental osteoarthritis. For the hip, arthroscopic or open surgery for hip impingement is popular nowadays, although there is some controversy about whether this slows or prevents progression to osteoarthritis.

What happens to patients with osteoarthritis?

Osteoarthritis is slowly progressive, although its course may be non-linear. Predicting incident osteoarthritis or future osteoarthritis course for individual patients is hard, although risk factors are known. In patients with osteoarthritis of the knee, knee pain, presence of Heberden nodes, and malalignment increase the risk for radiographic progression of knee osteoarthritis. Age, ethnicity, body mass index, comorbidity count, joint effusion and baseline osteoarthritis severity (both radiographic and clinical) are associated with clinical progression of knee osteoarthritis.

In hip osteoarthritis, age, baseline joint space width, femoral head migration, femoral osteophytes, bony sclerosis, and baseline hip pain predict progression of radiographic and/or clinical hip osteoarthritis.

Some studies suggest that osteoarthritis patients show increased mortality as compared to non- osteoarthritis controls, primarily due to cardiovascular disease.

How to utilize team care?

Specialty consultations

Rheumatologists, orthopedic surgeons, and plastic surgeons in selected cases of hand osteoarthritis.

Therapists

Physical therapy can improve pain and function in knee osteoarthritis patients, in particular aerobic, aquatic, and/or strengthening exercises and therapeutic ultrasonography. It may be better to combine interventions. There is no clear evidence to prefer one intervention over the other.

Occupational therapists can help patients develop, recover, or maintain activities through education and/or assistive devices.

Dieticians

A nutrition consult should be considered for patients with a body mass index over 30 kg/m². Weight loss is recommended for people with osteoarthritis of the knee to improve joint pain and function and slow progression.

Pharmacists

Pharmacists can assist in reviewing medication risk including polypharmacy.

Are there clinical practice guidelines to inform decision making?

Royal Australian College of General Practitioners guidelines for nonsurgical management of hip and knee osteoarthritis.
Royal Australian College of General Practitioners guidelines for diagnosis and management of hip and knee osteoarthritis.

Other considerations

ICD-10 codes

M18. Osteoarthritis of the first carpometacarpal joint.
M16. Osteoarthritis of the hip.
M17. Osteoarthritis of the knee.
M47. Osteoarthritis of the spine.
M15. Osteoarthritis of multiple sites.
M19. Other and unspecified osteoarthritis.

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