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Osteoarthritis is the commonest arthritis and is
characterized by degeneration of the cartilage with associated reactive bony changes at
the margins of the joints It affects up to 10% of the world's population and typically
occurs more commonly with age.
It commonly involves:
The distal joints of the fingers- to form bony swelling
- the Heberden nodes
The proximal interphalyngeal finger joints -to form bony swelling - the Bouchard nodes.
The base of the thumbs.
The cervical spine - cervical spondylosis.
The lumbar spine - lumbar spondylosis.
The large joints - including Hips and Knees.
Other joints may be involved.
The characteristic feature is degenerative joint disease
with mechanical problems. The inflammatory reaction within the joint - whilst present is
low grade, and the symptoms in general are different from the inflammatory arthropathies
such as rheumatoid arthritis.
Mechanical symptoms are characterized by :
Pain - The pain is usually worse through the day and with activity. It is usually relieved
by rest.
Night pain may be a feature.
Pain on weight-bearing if the lower limb joints are involved.
Stiffness after rest - called gelling - usually lasting
less than 5 minutes - with the patient loosening up quickly by moving the joints.
Morning stiffness is not a prominent feature and short lived if present at all.
Swelling is usually bony rather than soft tissue in
character.
Classification criteria identified and described by the
American College of Rheumatology - but these are NOT diagnostic criteria and are used
simply to standardize reporting of cases in the medical literature.
Associated Factors
Age. Obesity Repetitive stress injury / trauma to
joints.
Racial predisposition / protection - for example - the problem is rare in South African
Blacks.
Sex - Females are more frequently involved (10:1)
Genetics - this is a problem often seen within families.
Other diseases causing cartilage damage - resulting in secondary osteoarthritis. These
include:
Hereditary disease ie
Haemochromatosis
Epiphyseal dysplasia
Slipped epiphysis
Congenital dislocation of the hips
Neuropathic arthropathy - Charcot joints
Pagets
Acromegaly
Inflammatory joint disease - i.e. Rheumatoid arthritis
Gout
Post infective arthritis - i.e. sceptic arthritis / Tuberculosis.
Pathology.
There is a tendency to fissuring of the cartilage, with
erosion of the surface.
Ultimately the cartilage wears through to the bone and there is poor apposition of
opposite joint surfaces.
The joint margins develop enlarging protuberances - called osteophytes. It is the
osteophytes that are responsible for the apparent swelling of the joints and are permanent
and progressive.
However, inflammatory flares can occur with mild soft tissue thickening of the joints -
which cause temporary swelling.
The reason for the deterioration process is because of an abnormality of the collagen
fibre network - with damage and the water content of the cartilage is increased - with
increased hydration of the proteoglycan constituent of the cartilage, and loss of these
proteoglycans from the cartilage. The cartilage matrix cells - in the connective tissue -
secrete glycoproteins such as fibronectins and enzymes that further denature the
cartilage. These include the interleukins and proteoglycanases and collagenases from the
chondrocytes.
Attempts by the cartilage to repair with increased matrix synthesis and cell proliferation
- initially balance the degenerative process - but ultimately fail.
Whilst in the past it was believed that the process was predominately a degenerative one -
there is increased belief that the immune system is playing an active role in progression
of the disease through T cell and immune complex mechanisms.
This has opened the therapeutic options to include disease modifying drugs rather than
symptomatic therapies alone.
The Examination
This reveals the characteristic bony swellings and the
feeling of crepitus - a sensation of fine crackling within the joints on movement in the
classically affected joints.
A small degree of soft tissue thickening may be seen. The joints may be locally tender. In
certain patients an inflammatory form may be seen with an aggressive erosive change to the
underlying joints. These patients have usually a significant soft tissue swelling and also
stiffness may be more prominent in the history.
Gelatinous cystic swelling may sometimes be seen at the distal finger joints of
fluctuating size.
The Laboratory.
Usually blood tests are normal.
The ESR and CRP - inflammatory indicators are usually normal.
The blood counts are usually normal.
Radiology.
X-rays may show joint space narrowing and bony spurs -
osteophytes.
There may be Subchondral cyst formation and sclerosis of the opposing bone surfaces.
Technetium bone scanning may show uptake in the
classical distribution of involved joints with osteoarthritis described above.
Treatment.
The brunt of therapy is still a symptomatic
approach-using a combination of analgesics and possibly introduction of
antiinflammatories.
However - the therapy is individually based as every
patient is different.
My approach is to assess on history and examination how
much inflammatory involvement there is at a clinical level.
The greater the soft tissue swelling and stiffness - especially morning stiffness - the
more likely I am to introduce an antiinflammatory.
The choice of antiinflammatory is individually based, but I generally prefer COX2 selective antiinflammatory
drugs such as celecoxib, Celebrex, which offers
gastroprotection. Caution with ALL antiinflammatory drugs is required for
cardiovascular risk factors, as there is a slight increase in cardiovascular
events with them. Celecoxib is NOT worse than the old anti-inflammatory
drugs contrary to general lay public belief. Old antiinflammatories provide
a 20% risk of stomach ulceration and a 3% risk of haemorrhage. Celebrex is
safer in this regard.
However the majority of patients do not require an NSAID and can be treated with
analgesics such as paracetomol or acetaminophen with codeine combinations (in low dosage)
for more severe pain. Tramadol may also be useful.
The patients in severe pain may require even stronger analgesia such as
propoxyphene.
More severe agents such as the narcotics are very very rarely required and should be only
used with great caution.
I personally do not use them as holistic therapy usually obviates their need.
Tramadol (Ultram, Tramal, Tramacet) has been seeing increased usage in the USA and other countries as a
therapeutic option with little tolerance and addictiveness. I find it
useful for very severe pain and usually use it mainly in low back pain situations.
For chronic pain , the use of
tricyclic antidepressive medication, such as amitryptilline in low dose
starting at 10mg, is
very useful. This is especially for chronic low back pain.
The application of a topical anti-inflammatory poultice
to the regional skin, is an option I have found very useful clinically - but this is not
available widely. In South Africa I use a poultice called Transact - with embedded
flurbiprofen. Other poultices with ketoprofen are available in France and Japan and are
also excellent. In the USA topical application of Capsaicin cream has been potentially
helpful. This is also available in South Africa as
capsicum cream. Local burning of the skin may be a problem with this when
applied. Contact with the eyes must be avoided.
The use of corticosteroid
joint injections I mainly reserve for joints with a
soft tissue swelling component. The knees are most effectively treated in this way. Local
corticosteroid injections are also useful for ligamentous and tendonous problems that we
frequently see with the disease.
The concept of joint protection
This is vital for these patients - especially where
large joints are involved.
Protection from overuse is important:
Assistant devices to reduce weight bearing joint pain - i.e. canes
Reduce impact exercise. Increase non weight bearing exercise - i.e. swimming cycling
Good shoes - reebock / saucony Adidas and Nike etc.... when walking recreationally.
Ensure leg length discrepancy is corrected
Plan your day - avoid wasted weight bearing activity / stair climbing
Weight reduction is crucial especially in obese patients with large joint problems on
weight bearing. Physical therapy will maintain joint protection through optimizing the
strength of adjacent supportive muscles.
Heat and ultrasound may relieve muscle spasm
Diet
In general besides weight reduction advice, there is no
specific diet that is proven as helping the problem.
However we know that certain foods exasperate the pain of individual patients, and I
always advise these patients to leave out that individual food.
I also advise my patients to reduce red neat in general and eat more vegetables, fish and
fibre.
Other Remedies
There are countless claimed cures - from magnets to
celery to oils and dietary therapies...but none have been shown in good clinical trials to
be of any significant benefit.
Glucosamine Sulphate and chondroitin sulphate
have received wide publicity, and are now under trials for
management of osteoarthritis. Results suggest that there is some efficacy and benefit for
patients with osteoarthritis. There is good evidence for
Glucosamine SULPHATE and NO evidence for Glucosamine CHLORIDE. Dose of the
Glucosamine sulphate should be 1500mg taken in one dosing. Remember - it is
made from shrimp and crab shell, so beware in shellfish allergy. Use with
chondroitin increases price but there is NO evidence that it improves the
response. I therefore recommend the cheapest Glucosamine sulphate from a
reputable supplier.
Disease Modifying drugs.
There is a new movement toward the use of these by
rheumatologists, as there is a recognition that the disease is not as simple as the old
degenerative concept.
These therapies now include the use of Salazopyrine / Azulphidine and Antimalarials -
Nivaquine / Plaquenil. Trials on these are in progress.
I generally suggest low dose
anti-malarial for those patients who have an inflammatory variant of
osteoarthritis, with stiffness and soft tissue swelling. This is often the
case in the early perimenopausal phase. Also strong family history may
influence me to use this as a disease modifying therapy to reduce the long
term damage.
There is no indication for oral Corticosteroids in the therapy of osteoarthritis however
as a general rule.
Newer meds on the horizon
Hyaluronan injections
are also now being employed but offer at this stage only symptomatic benefit of
the same order as corticosteroid injections - but do represent a movement to additional
solutions. However my personal experience shows no major
benefit.
Surgery
Surgery is an option where there is a failure of medical
therapy to control pain and where function is significantly impaired.
In the hands PIP surgery and DIP surgery is not often
successful. Surgery to the base of thumb at the IP and CMC joints are
however more efficaceous.
Options include:
Excision Arthroplasty - excising the joint margins - ie in the metatarsals of the feet.
Osteotomy - realignment of bone surfaces.
Fusion - fusing the joint.
Arthroscopic joint debridement - with removal of loose bodies and smoothing Articular
surfaces. Partial or total replacement - especially Hip / Knee.
The advent of total hip and knee replacement has been a
development in medicine that has been a new lease of life for millions of patients
world-wide.
However these operations do have significant morbidity and require screening for
appropriate indications and are best done by experienced surgeons.
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