Osteoarthritis

Question 1

ESSENCE

Answer 1

Described as ‘wear and tear’ of joints

Not inflammatory condition like RA

Question 2

AETIOLOGY

Risk factors

Answer 2

• Age > 50
• Female sex
• Obesity
• Genetics
• Knee malignment
• Physical demanding occupation/sport

Question 3

AETIOLOGY

Pathophysiology

Answer 3

• Imbalance between cartilage breakdown and the chondrocytes repairing it, leading to structural issues in joints

Question 4

What kind of joints are affected

Answer 4

Synovial joints

Question 5

Commonly affected joints

Answer 5

• Hips
• Knees
• Sacro-iliac
• Distal interphalangeal joints (DIPs)
• Carpometacarpal joint base of thumb (CMC)
• Wrist
• Cervical spin (cervical spondylosis)

Question 6

4 key x-ray changes

Answer 6

• Remember LOSS
  
  • Loss of joint space
  • Osteophytes (bone spurs)
  • Subarticular sclerosis (increased density of bone along joint lines)
  • Subchondral cysts (fluid filled holes in bones)

Question 7

CLINICAL FEATURES

Presentation

Answer 7

• Joint pain and stiffness
  
  • Worse with activity and at end of day, contrary to inflammatory arthritis
• Bulky, bony enlargment of joint
• Restricted range of motion
• Crepitus on movement
• Effusions (fluid) around joint

Question 8

CLINICAL FEATURES

Signs in hands

Answer 8

• Heberden’s nodes (DIP joints)
• bouchards nodes (PIP joints)
• Squaring at base of thumb
• Weak grip
• Reduced range of motion

Question 9

Where does Heberdens and Bouchards nodes occur

Answer 9

Heberdens - DIP joints

Bouchard - PIP joints

Question 10

INVESIGATION

First choice

Answer 10

• Diagnosis can be made without investigation if
  
  • >45 years
  • Typical pain with activity
  • No morning stiffness
• X-ray affected joints
• Serum CRP - normal, differentiate inflammatory arthritis
• Serum ESR - normal, differentiate inflammatory arthritis

Question 11

MANAGEMENT

General principles

Answer 11

• Patient education
• Lifestyle changes
• Analgesia in stepwise approach
• Topical capsaicin
• Steroid injections
• Joint replacement

Question 12

MANAGEMENT

Lifestyle changes

Answer 12

• Weight loss
• Physiotherapy
• Occupational therapy - devices and adaptations at home
• Orthotics - knee braces to support function

Question 13

MANAGEMENT

Analgesia stepwise approach

Answer 13

1. Oral paracetamol and topical NSAID
2. Add oral NSAID (maybe also proton pump inhibitor to protect stomach)
3. Consider opiates such as codeine

Question 14

MANAGEMENT

Intra-articular steroid injection

Answer 14

• Methylprednisolone acetate
• Or triamcinolone acetonide

Question 15

NSAID SE

Answer 15

• GI
  
  • Gastritis and peptic ulcers
• Renal
  
  • AKI
• CVS
  
  • Hypertension, heart failure, MI, stroke
• Exacerbating asthma

Question 16

COMPLICATIONS

Answer 16

• Functional decline
• Spinal stenosis
• NSAID related renal dysfunction/GI bleeding

Question 17

PROGNOSIS

Answer 17

• Slowly progressive disease and common with advanced age