Osteoarthritis

 ◦ Primary: Idiopathic. Usually affects hands, knees, hips, spine. Also MTP great toe.  ◦ Secondary: Due to trauma, infection, congenital, systemic diseases ** Risk Factors  ** ** Symptoms and Signs ** (General for all joints) ** Diagnosis ** (according to American College of Rheumatology) (89% sensitive/91% specific)  ||   Hand – clinical (94% sensitive/87% specific)  ||  · >50 yo    ·  Pain in hip AND 2 of:  · XR: osteophytes, joint space narroriwng  · Normal ESR   ||   Clinical: Pain/stiff/ache of hand + 3 of: hard tissue enlargement of at least 2/10 “selected” joints hard tissue enlargement of at last 2/10 DIPs <3 swollen MCP joints deformity of at least 1/10 “selected” joints  || ** Treatment: Goal is pain control and improve functioning  **  ◦ **Self-Management and patient education  ◦ Weight loss (slow)/maintaining optimal weight  ◦ Regular exercise  ▪ ** Low impact aerobic: ** walking, swimming, bike, water aerobics (decreases pain and improves function for knee OA)  ◦ Physical Therapy: ROM, strengthening, heat/therapeutic ultrasound, TENS  ◦ Braces, orthotics (evidence for wedged insoles for various knee deformity), walking aids  ◦ Proper footwear (hip, knee OA): flat/low heel, flexible shoe (rather than stiff)  ◦ patellar taping  ◦ acupuncture  ◦ ** Acetaminophen (up to 4 gm/day) - 1st line ** <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ NSAIDS – use if inadequate response to Acetaminophen. Ibprofen 200-800 mg TID-QID or Naproxen 200-500 mg BID. Start low, titrate up. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Topical NSAID – Voltaren (Diclofenac) 1% gel, approved for OA knee and hands. 4 gm QID max in LE; 2gm QID max in UE. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Topical Capsaicin: Use as adjunct, and OTC. TID-QID. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Tramadol (u-opioid agonist) 50 q6 prn <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Opiates – use sparingly, not strong evidence for benefit <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Joint injections <span style="margin: 0in 0in 0pt 1in; mso-list: l5 level3 lfo6; tab-stops: list 1.0in; text-indent: -0.25in;"> ▪ Corticosteroids: only shown beneficial for knee, hip, hand (typically provide short term pain relief (2-4 weeks)). No more than 4 injections/year. <span style="margin: 0in 0in 0pt 1in; mso-list: l5 level3 lfo6; tab-stops: list 1.0in; text-indent: -0.25in;"> ▪ Hyaluronic acid: Endogenous = lubricates, hydrates, provides elasticity to joint. Exogenous = viscosupplementation. Pros: Benefit in knee OA, use in those with C/I to NSAIDs, few adverse events. Cons: 3-5 weekly injections, duration of benefit shorter <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Glucosamine (500 mg TID)/Chondroitin (200-400 mg TID): <span style="margin: 0in 0in 0pt 1in; mso-list: l5 level3 lfo6; tab-stops: list 1.0in; text-indent: -0.25in;"> ▪ GAIT trial (large 1580 person NIH trial) showed no benefit compared to placebo, including 2 year out data showed no difference in pain compared with placebo. BUT is relatively safe, except do not take if have shellfish allergy. Trial for 60 days. <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Plaquenil for inflammatory OA   <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;">  ◦ Referral indications: <span style="margin: 0in 0in 0pt 1in; mso-list: l5 level3 lfo6; tab-stops: list 1.0in; text-indent: -0.25in;"> ▪ Failure of conservative therapy, with continued substantial impact on quality of life <span style="margin: 0in 0in 0pt 1in; mso-list: l5 level3 lfo6; tab-stops: list 1.0in; text-indent: -0.25in;"> ▪ To remove loose pieces bone/cartilage causing buckling or locking <span style="margin: 0in 0in 0pt 0.75in; mso-list: l5 level2 lfo6; tab-stops: list .75in; text-indent: -0.25in;"> ◦ Types: <span style="margin: 0in 0in 0pt 1in; mso-list: l5 level3 lfo6; tab-stops: list 1.0in; text-indent: -0.25in;"> ▪ Arthoscopy plus I &D – debridement of torn meniscus, ligaments, cartilage fragments; controversial. Controlled trial 2002 NEJM (Moseley et al) showed no better than placebo in 180 patients <span style="margin: 0in 0in 0pt 1in; mso-list: l5 level3 lfo6; tab-stops: list 1.0in; text-indent: -0.25in;"> ▪ Total joint replacement – most evidence for knee and hip. NIH data show 90% improvement pain/function by more than 20 years of follow-up data <span style="margin: 0in 0in 0pt 1.25in; mso-list: l5 level4 lfo6; tab-stops: list 1.25in; text-indent: -0.25in;"> · DVT prophylaxis needed <span style="margin: 0in 0in 0pt 1.25in; mso-list: l5 level4 lfo6; tab-stops: list 1.25in; text-indent: -0.25in;"> · PT post operatively at least 4-6 week; improvement plateaus around 12-26 weeks // figure 1  // ** Sources:  ** Weinstock, M et al. “Osteoarthritis.” Resident's Guide to Ambulatory Care, 6th ed. , 2009. “Osteoarthritis” CME Resource, October 2010, Vol. 136, No. 2. Felson DT. Osteoarthritis of the knee. NEJM 2006; 354: 841-8. ** Patient Education:  ** AAFP “How to Stay Active” [] Patellar taping instructions: [] AAFP “Glucosamine” []
 * General **
 * Most common arthritis with increasing prevalence due to aging and obesity!
 * Pathophysiology: Mechanical AND biochemical. As get older, disruption in cartilage remodeling process = Damage to articular cartilage → joint space narrows → subchondral cysts and osteophytes form.
 * Older, white, female, family history
 * ** Overweight/obese ** (usually affects knee), occupation, trauma/sports injury
 * Pain worse with activity/weight bearing, better with rest
 * Morning stiffness is short ( <30 min)
 * Enlarged joints that are tender (DIP = Herberden's nodules, PIP = Bouchard's nodules, knees, hip, spine)
 * Crepitus
 * Limited ROM
 * Knee – clinical dx  ||   Hip – clinical and XR dx
 * Clinical:
 * short AM stiffness (<30 min)
 * crepitus
 * bone tenderness
 * osseous enlargement
 * no palpable warmth   ||   Clinical:
 * XR: joint space narrowing, osteophytes, bony sclerosis, cyst formation, joint space collapse  ||   Strongest sign = worse hip pain with internal or external hip rotation (w/ knee fully extended) (Grade A rec)   ||   “selected joints” = 2nd, 3rd DIP; 2nd and 3rd PIP, 1st MCP (bilateral)    ||
 * Labs: Normal ESR and RF  ||   “Log roll” sign   || **  ** Usually DIP, PIP, or base of thumb  ** ||
 * Shoulder, Elbow, Ankle: Usually history of injury or other joints with OA. Need radiograph for diagnosis.
 * ** Non-pharmacologic:  **
 * ** Pharmacologic:  **
 * ** Surgical:  **