Rheumatology

Osteoarthritis

Does this patient have osteoarthritis?

Osteoarthritis is a slowly progressive joint disease caused by breakdown of articular cartilage and subsequent remodeling of the subchondral bone. It typically occurs in patients over 40. Risk factors for the development of osteoarthritis include age, family history of osteoarthritis, obesity, joint injury due to trauma or repetitive use, and congenital malalignment of the joint.

Patients present with pain and stiffness in the cervical or lumbar spine, hands (first carpometacarpal joint, proximal interphalangeal joints (PIPs) or distal interphalangeal joints (DIPs), hips, knees, ankles (subtalar joint), and feet (first metatarsophalangeal joint). The wrists, elbows, and metacarpophalangeal joints of the hands are generally not affected. The pain is typically slowly progressive.

Physical exam shows bony enlargement of the joint, crepitus with motion, tenderness to palpation, possible joint effusion or malalignment such as varus (bowlegged) or valgus (knock-kneed) deformities of the knee.

Differential diagnosis includes joint injury, inflammatory arthritis such as psoriatic arthritis or rheumatoid arthritis, crystal related arthritis (gout or pseudogout), septic arthritis, soft tissue process such as bursitis, or pain syndromes such as fibromyalgia.

What tests to perform?

Laboratory testing should include: CBC (check for anemia), complete metabolic panel (baseline liver and kidney function), erythrocyte sedimentation rate (ESR), c-reactive protein (CRP), rheumatoid factor, and anti citrullinated peptide antibody (anti-ACPA).

If the joint pain is acute and severe and a joint effusion is present, fluid should be aspirated and sent for cell count, gram stain, culture, and crystal analysis. The inflammatory markers ESR and CRP will screen for inflammatory arthritis, and the RF and anti-CCP screen for rheumatoid arthritis.

Imaging studies should include weight bearing x-rays to allow an assessment of joint space narrowing. X-rays suggestive of osteoarthritis would show joint space narrowing, subchondral sclerosis, and osteophytes. Ultrasound or MRI should be reserved for cases in which there is a possibility of inflammatory arthritis not seen on x-ray. MRI can also be useful when there is locking or giveway of the knee and the differential includes injury to ligaments or the meniscus.

A patient with osteoarthritis should have a normal ESR and CRP, a negative rheumatoid factor and anti-CCP, and normal synovial fluid (WBC <2000/mm3).

How should patients with osteoarthritis be managed?

Nonpharmacologic therapies

  • Weight loss.

  • Physical therapy

  • Walking aids: When properly used, assistive devices such as canes and walkers can reduce joint forces at the hip by up to 50%. A review of the literature conducted by the Royal Australian College of General Practitioners concluded that interventions such as braces and orthoses, electromagnetic fields, and therapeutic ultrasound were not supported by the literature.

Pharmacologic therapies

NSAIDS

There is good evidence for the short term efficacy of oral NSAIDs. However, their use is often limited by hypertension, chronic renal insufficiency, and GI bleeding. There is a higher risk of adverse events in patients who use diuretics, ACE inhibitors or ARBs, cyclosporin, warfarin, oral corticosteroids, or aspirin.

Pain management should begin with acetaminophen. In patients for whom acetaminophen is not effective and who have contraindications to NSAIDs and/or surgery, opioids are an opinion.

Topical preparations

Diclofenac 1% gel and diclofenac patch both appear to have short-term benefit. To date there is no evidence for long term efficacy. Capsaicin cream is derived from hot chili peppers. It has been shown to have short term efficacy in clinical trials and it appears to be safe.

Intra-articular glucocorticoids

Intra-articular glucocorticoids are indicated in patients with active osteoarthritis of one or a few joints despite the use of an NSAID. In a controlled trial of osteoarthritis of the knee, patients who received intra-articular glucocorticoids were twice as likely to have short term relief as those receiving a sham procedure. Repeat injections over a period of up to 2 years appear to be safe.

Intra-articular hyaluronans

Intra-articular hyaluronans have been shown to provide a small pain relieving advantage when compared to placebo injections and oral NSAIDs. Their efficacy is comparable to intra-articular glucocorticoids.

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 HCl was used in the GAIT trial.

Acupuncture

Clinical trials have shown it to be more efficacious than sham procedures, but it is unclear if it is a clinically significant difference.

Experimental therapies

Tetracyclines

A study of doxycycline compared to placebo suggested that doxycycline may slow the rate of osteoarthritis progression. Its anti-inflammatory properties may be mediated by inactivation of matrix metalloproteases.

Tanezumab

Tanezumab is a monoclonal antibody which inhibits nerve growth factor (NGF). Nerve growth factor is increased in inflamed tissue and is associated with increased pain. A clinical trial showed that NGF significantly reduced knee pain compared to placebo. However, clinical trials were halted when it was found that some patients treated with NGF had progression of osteoarthritis with osteonecrosis which required joint replacement.

Surgical therapies

Referral to orthopedics should be considered in the setting of an acute injury with damage to a meniscus or ligaments producing localized symptoms. There is controversy about the efficacy of arthroscopy surgery for osteoarthritis of the knee. A randomized, placebo controlled trial of patients assigned to arthroscopic lavage, arthroscopic debridement or placebo surgery suggested that the patients who had arthroscopic surgery did no better than those who received the placebo procedure.

Hip preservation procedures such as surgery for hip impingement have become popular. However, there is some controversy about whether these procedures slow or prevent progression to osteoarthritis.

A referral for joint replacement surgery should be considered if a patient has severe osteoarthritis which has not responded to conservative treatment and is impacting the patient's quality of life and/or ability to do his activities of daily living.

What happens to patients with osteoarthritis?

Osteoarthritis is the most common form of arthritis and is the leading cause of disability in the elderly. It is slowly progressive and prognosis can depend on the joint involved. In patients with osteoarthritis of the knee, higher body mass index and varus or valgus deformities of the knee have been associated with radiographic progression. In hip osteoarthritis, risk factors for progression to joint replacement include female gender, night pain, and lower baseline functional capacity.

How to utilize team care?

Specialty consultations

Orthopedic surgery referral (see above).

Pharmacists

Pharmacists can assist in reviewing medication risk including polypharmacy and use of diuretics, ACE inhibitors, or anticoagulants which may affect a patient's ability to tolerate NSAIDs.

Dieticians

A nutrition consult should be considered for patients with a BMI over 30. Weight loss is recommended for people with osteoarthritis of the knees. Modest weight loss has been shown to improve joint pain and function. A 10 lb. weight loss of 10 years can decrease the risk of development of osteoarthritis of the knees by 50%.

Therapists

Physical therapy can improve functional outcomes and pain scores by improving flexibility and strengthening muscles.

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.

What is the evidence?

Losina, E. " Impact of obesity and knee osteoarthritis on morbidity and mortality in older Americans". Ann Intern Med.. vol. 154. 2011. pp. 217.

Moseley, JB. " A controlled trial of arthroscopic surgery for osteoarthritis of the knee". N Engl J Med.. vol. 347. 2002. pp. 81.

Lane, NE. " Progression of radiographic hip osteoarthritis over eight years in a community sample of elderly white women". Arthritis Rheum.. vol. 50. 2004. pp. 1477.

Lane, NE. "Tanezumab for the treatment of pain from osteoarthritis of the knee". N Engl J Med. vol. 363. 2010. pp. 1521.

Brandt, KD,. "Effects of doxycycline on progression of osteoarthritis: results of a randomized, placebo-controlled, double-blind trial". Arthritis Rheum. vol. 52. 2005. pp. 2015.

Manheimer, E,. "Meta-analysis: acupuncture for osteoarthritis of the knee". Ann Intern Med. vol. 146. 2007. pp. 868.

Vlad, SC,. "Glucosamine for pain in osteoarthritis: why do trial results differ". Arthritis Rheum. vol. 56. 2007. pp. 2267.

Clegg, DO. "Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis". N Engl J Med. vol. 354. 2006. pp. 795.

Leopold, SS. "Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective, randomized trial". J Bone Joint Surg Am. vol. 85. 2003. pp. 1197.

Lo, GH. "Intra-articular hyaluronic acid in treatment of knee osteoarthritis: a meta-analysis". JAMA.. vol. 290. 2003. pp. 3115.

Raynauld, JP. "Safety and efficacy of long-term intra-articular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial". Arthritis Rheum. vol. 48. 2003. pp. 370.

Arroll, B. "Corticosteroid injections for osteoarthritis of the knee: meta-analysis". BMJ.. vol. 328. 2004. pp. 869.

Deal, CL. "Treatment of arthritis with topical capsaicin: a double-blind trial". Clin Ther. vol. 13. 1991. pp. 383.

Lin, J. "Efficacy of topical nonsteroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomised controlled trials". BMJ.. vol. 329. 2004. pp. 324.

Hartofilakidis, G. " An examination of the association between different morphotypes of femoroacetabular impingement in asymptomatic subjects and the development of osteoarthritis of the hip". Journal of Bone and Joint Surgery - British Volume. vol. Vol 93-B. pp. 580-586.

Neumann, DA. "Biomechanical analysis of selected principles of hip joint protection". Arthritis Care Res. vol. 2. 1989. pp. 146.

Fransen, M. "Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial". J Rheumatol. vol. 28. 2001. pp. 156.

Messier, SP. "Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial". Arthritis Rheum. vol. 50. 2004. pp. 1501.

Felson, DT. "Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study". Ann Intern Med. vol. 116. 1992. pp. 535.

Kirwan, JR, Elson, CJ. "Is the progression of osteoarthritis phasic? Evidence and implications". J Rheumatol. vol. 27. 2000. pp. 834.

Sharma, L, Song, J, Felson, DT, Cahue, S, Shamiyeh, E, Dunlop, DD. "The role of knee alignment in disease progression and functional decline in knee osteoarthritis". JAMA.. vol. 286. 2001. pp. 188.

"Royal Australian College of General Practitioners guidelines for nonsurgical management of hip and knee osteoarthritis". http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/Guidelineforthenonsurgicalmanagementofhipandkneeosteoarthritis/RACGP_OA_guideline.pdf.

"Royal Australian College of General Practitioners guidelines for diagnosis and management of hip and knee osteoarthritis". http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/Guidelineforthenonsurgicalmanagementofhipandkneeosteoarthritis/OA_algorithm.pdf.

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