Osteoarthritis for the patient by drdoc on-line  

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.

 

 


finger osteoarthritis


Finger osteoarthritis


Knee osteoarthritis


knee osteoarthritis


Spinal osteoarthritis

Dr David Gotlieb
MBChB FCP(SA)
Rheumatologist
Cape Town
South Africa
December 1998

(Original Article - copyright)

revised 2011


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