Makindo Medical Notes.com

Related Subjects: |Monoarticular arthritis |Polyarticular arthritis |Rheumatoid arthritis |Gout |Pseudogout |Septic Arthritis |Systemic Lupus Erythematosus (SLE) |Enteropathic Spondyloarthritis |Reactive Arthritis

There may be morning stiffness which usually lasts less than 30 minutes which is much shorter than with RA. Cartilage loss

About

• Very common seen with increasing age
• Affects the synovial joints with loss of articular cartilage
• Commoner in whites and women and familial tendency
• Strong heritability - polygenic
• Affects 70% of those over age 70

Main Joints affected

• Hand, Knee, Hips, Spinal apophyseal joints

Aetiology

• Not just "wear and tear" but destruction and loss of articular hyaline cartilage
• There is sclerosis and cyst formation due to adjacent bone remodeling
• Attempts at repair lead to osteophyte formation
• Possible due to metalloproteinases degrading collagen and proteoglycans
• Interleukin 1 and TNF may also affect collagen production
• Genetic susceptibility and inherited genetic defects

Secondary OA may result from other causes

• Trauma with previous fractures through the joint
• Metabolic diseases, Haemochromatosis - check Ferritin and Iron and transferrin saturation
• Chondrocalcinosis, Acromegaly - Measure GH following OGTT
• Ochronosis,Perthes disease, Congenital dislocation of the hip
• Systemic diseases: Haemophilia, Sickle cell disease, Joint damage, Rheumatoid arthritis, Gout, Seronegative arthropathies
• Septic arthritis, Paget's disease, Avascular necrosis, Thiemann's disease
• Osteochondrosis affecting the hands, Obesity, Previous fractures and trauma

Clinical

• Activities which worsen with activity and decrease on rest
• Morning stiffness < 30 minutes and Age > 50
• If age < 50 or morning stiffness > 30 mins consider alternative diagnoses
• Crepitus on joint movement, not warm or inflamed
• Bony tenderness/enlargement on examination
• Hands: Involves the DIPJ and 1st MCP
• Heberden's nodes at DIPJ and Bouchard's nodes at the PIPJ
• Foot 1st MTP. Involves Spine, hips and knees
• Knee - varus and valgus deformities +/- knee effusion
• Baker's cyst behind knee. Hip pain can radiate to knee

Investigations

• FBC: Normal. ESR < 40 mm/hr. RF titre < 1:40
• Radiology: Joint narrowing, sclerosis, osteophytes, localised osteoporosis, cyst formation
• Arthroscopy may show cartilage destruction
• MRI shows cartilage changes

Differential

• Age < 45 consider inflammatory arthritis, severe trauma, metabolic disease
• Marked early morning stiffness > 1 hour - inflammatory arthritis
• Unusual joints e.g. MCPs - Metabolic disease e.g. haemochromatosis
• Multiple regional pains 'tender spots' - fibromyalgia
• Joint locking or giving way - meniscal or ligamentous injury
• Fever or systemic upset - consider joint sepsis
• Warm and erythema - sepsis or crystals
• Pain mainly at night - malignancy, osteonecrosis

Management

• All patients should be offered analgesia and help with weight loss to reduce an increased BMI, given advice about local muscle strengthening exercises and general aerobic fitness
• Heat therapy is useful, physiotherapy and OT. Correct use of walking stick can reduce hip loading by 1/5th
• 1st Line Pharmacology: Oral Paracetamol and topical NSAIDs are first-line analgesics for OA of the knee or hand. Topical capsaicin should be considered as an adjunct to core treatments for knee or hand osteoarthritis.
• 2nd line treatment is oral NSAIDs/COX-2 inhibitors. Start a PPI with NSAIDs and COX-2 inhibitors.
• 3rd line is NSAID/Paracetamol plus the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people. Intraarticular steroids can give approximately 4 to 6 weeks of pain relief. Sepsis is a very rare complication.
• Non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes
• Surgery: If conservative methods fail then refer for consideration of joint replacement for Hip and Knee pain especially for severe pain, especially at night and associated poor mobility. Total hip and knee replacement has transformed the management of severe symptomatic OA. There is reduced pain and stiffness and an associated increase in function and mobility. Complication rates are low with loosening and late bone infection being the most serious.
• Glucosamine sulphate may be added but the 2008 NICE guidelines suggest it is not recommended as lack of good evidence of benefit

References

• Osteoarthritis: care and management NICE 2020