Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

Featured on Channel NewsAsia

Osteoarthritis

Basics
Description
  • The most prevalent form of arthritis
  • May occur in virtually any joint of the body
  • Has no cure and leads to pain and joint dysfunction
  • The end result is loss of articular cartilage with secondary bone changes, including osteophytes, subchondral sclerosis, and subchondral cysts.
  • Classification is by single or multiple joint involvement.
  • Synonyms: Degenerative joint disease; Wear-and-tear arthritis
Epidemiology
Incidence
  • The knee is the most commonly affected joint, followed by the hand and hip.
  • In a study of 697 females >65 years old, knee arthritis occurred in 30%, hand arthritis in 15%, and hip arthritis in 8%.
Prevalence
  • Osteoarthritis, the most common form of arthritis, affects females more often than males.
  • In contrast to inflammatory arthritis, osteoarthritis occurs principally in individuals >60 years old.
  • In 1 study:
    • Hand osteoarthritis occurred in 23% of females >65 years old.
    • The most commonly affected joints were the DIP and 1st CMC joints.
Risk Factors
  • Obesity
  • AVN
  • Septic arthritis
  • Advancing age
  • Female gender
Genetics
A genetic predisposition is thought to exist, but genes have not yet been identified.
 
Etiology
  • No known cause of osteoarthritis (idiopathic osteoarthritis):
    • The common pathway is loss of the articular cartilage with progressive overloading of the joint.
  • Many conditions that injure the joint may lead to secondary arthritis.
    • Trauma: Posttraumatic arthritis
    • Infection: Postinfectious arthritis
    • AVN: Arthritis associated with the condition
Associated Conditions
No conditions are associated with osteoarthritis.
 
Diagnosis
Signs and Symptoms
  • Discomfort with weightbearing and joint motion
  • Stiffness
  • Loss of function:
    • Inability to do heavy work
    • Inability to tie or put on shoes
    • Limitation to short distance walking
History
Pain and swelling that increase with activity or prolonged inactivity
 
Physical Exam
  • The principal features are:
    • Stiffness and loss of ROM
    • Joint effusion
    • Limb deformity
    • Painful joint motion
    • Gait disorder
Tests
Lab
No specific laboratory features
 
Imaging
  • Radiography:
    • AP and lateral radiographs are the main imaging modalities.
    • In the knee, foot, and ankle, weightbearing radiographs are obtained.
  • MRI can be used to exclude other diagnoses such as AVN, stress fractures, and neoplasms.
Pathological Findings
Loss of the thickness and organization of the articular cartilage
 
Differential Diagnosis
  • The diagnosis of osteoarthritis is not difficult when the disease is in the moderate or advanced stage.
  • Early arthritis can be confused with the following conditions:
    • Tendinitis or bursitis
    • Stress fractures
    • Synovial proliferative disorders
Treatment
General Measures
Rest, activity modification, weight loss, and NSAIDs
 
Special Therapy
Physical Therapy
  • Patients should begin a program to preserve muscle strength and ROM and to avoid contractures.
  • Heavy-impact activity (such as running, contact sports, and heavy work) exacerbates symptoms.
  • A cane used in the opposite hand substantially reduces the forces across the hip joint and will relieve discomfort and improve gait.
Complementary and Alternative Therapies
  • Acupuncture may provide pain relief for knee arthritis in the short term.
  • Many herbal medicines are used for the treatment of osteoarthritis.
    • Evidence to support their use is limited.
Medication
First Line
  • NSAIDs, including COX-2 inhibitors, are mainstays in the nonoperative treatment of arthritis.
    • Meta-analysis shows these medications to be slightly more effective than a placebo in the short term.
    • NSAIDs have a high rate of side effects, including gastrointestinal bleeding.
  • Acetaminophen is widely used for pain relief.
Second Line
  • The use of nutraceuticals, such as glucosamine and chondroitin sulfate, is controversial, with a recent study showing no benefit.
  • Intra-articular injection:
    • With corticosteroids, decreases pain for short periods
    • With hyaluronic acid, may have a small effect on knee pain
  • Opioid pain medicine may be used for severe pain in patients who are not operative candidates.
Surgery
  • 2 main types of surgery: Realignment osteotomy and joint replacement
    • Realignment osteotomy:
      • The joint surfaces are repositioned by cutting the bone and changing the axis of weightbearing.
      • Purpose: Allows the healthiest articular cartilage to bear the most weight
      • May be combined with ligament or meniscal repair
    • Arthroplasty:
      • The arthritic joint surfaces are removed, and a new joint surface is implanted.
      • The bearing surface is typically metal on high-density polyethylene.
      • Examples are total hip arthroplasty, total knee arthroplasty, and total shoulder arthroplasty.
Follow-up
Disposition
Issues for Referral
Patients with end-stage arthritis or severe pain from arthritis should be referred to an orthopaedic surgeon for consideration of surgical treatment.
 
Prognosis
  • Osteoarthritis progressively worsens with time.
  • No cure exists.
  • Modern methods of joint replacement provide excellent function and pain relief.
Complications
  • Progressive arthritis leads to worsening deformity and stiffness.
    • In the lower extremity, patients may stop walking and rely on wheelchairs
    • In the upper extremity, prevents activities and leads to lack of function
  • Treatment also may lead to complications.
    • The side effects of NSAIDs include gastritis and gastrointestinal bleeding.
    • Surgical intervention may lead to infection, DVT, or failure of the replacement mechanical joint.
Patient Monitoring
  • Patients are followed at 3-12-month intervals, depending on the severity of their symptoms.
  • Plain radiographs are taken every 6-12 months.
Miscellaneous
Codes
ICD9-CM
715.9 Osteoarthritis, unspecified whether generalized or localized
 
Patient Teaching
  • Patients are:
    • Taught to avoid activities that worsen the pain
    • Shown how to prevent contractures
    • Encouraged to lose weight
Activity
  • Patients should be encouraged to maintain muscle strength and joint mobility.
  • Exercises that do not cause pain are best.
  • Activities with little or no impact include elliptical trainers, bicycling, swimming, and water aerobics or running.
Prevention
Weight loss may help prevent joint degeneration.
 
FAQ
Q: What can be done to prevent osteoarthritis?
A: In general, interventions have not been found to prevent osteoarthritis. However, osteoarthritis is associated with obesity, and weight loss may help prevent joint degeneration.
 
Q: When is surgery indicated for the treatment of osteoarthritis?
A: Surgery is the final treatment after nonoperative measures (such as muscle strengthening, ambulatory aids, and medications) have been tried. The most commonly performed surgery is total knee replacement.

Comments are closed.