Degenerative Joint Disease (Osteoarthritis)

Osteoarthirtis

Osteoarthritis is a chronic, progressive, non-inflammatory degenerative joint disease. It is associated with aging (primary osteoarthritis) though other arthropathies and weight can predispose to osteoarthritis (secondary osteoarthritis). There is loss of articular cartilage with bone remodelling, osteophyte formation, ligamentous laxity, periatricular muscle weakness and synovitis. It most commonly affects the joints of the hands and weight-bearing joints (knees and hips)

SLICE Mnemonic

Mnemonic	Description
Systemic	No systemic. Primary osteoarthritis is not associated with systemic symtpoms
Locations	Hands (wrists, MCPs, PIPs, DIPs) and weight bearing joints (hips, knees). Not necessarily symmetrical
Inflammation	Joints are not externally inflammed
Chronicity	Chronic and progressive. Insidious onset. Worsens with activity, improves with rest. There may be morning stiffness but is shorter than inflammatory arthropathies (< 30 minutes)
Evidence of trauma	May occur secondary to trauma to a specific joint

• Risk factors
  • Age
  • Obesity
  • Repetitive joint use
  • Inflammatory conditions and arthritides
  • Hemoglobinopathies (sickle cell disease)
  • Metabolic disorders (diabetes mellitus)
  • Congenital and acquired disorders (developmental dysplasia of the hip, traumatic limb deformitites): leads to abnormal joint mechanics
  • Previous surgery (meniscectomy)
  • Genetics
• Patient history
  • Older patient (> 50 years) with joint pain
  • Overweight (obesity)
  • Repetitive joint work
  • Other arthropathies
• Signa and symptoms
  • Joint pain
    • Weight-bearing joints or those involved in repetitive activity
    • Worsened with activity
    • Improves with rest
    • Eventually becomes constant
• Physical examination
  • Normal joints externally
  • Decreased range of motion
  • Crepitus
  • Nodes on the DIPs (Herberden’s) and PIPs (Bouchard’s)
• Investigations
  • X-ray of the affected joint (weight-bearing): to assess joint space and surrounding bony changes
    • Reduction in joint space
    • Bone spurs
  • Other labs should be normal (CBC, ESR, Rheumatoid Factor and others depending on presentation)
• Overview of treatment
  • Palliative (reduce pain and maximize function)
  • NSAIDs (ibuprofen, ketoprofen, meloxicam, diclofenac and celecoxib). Add a PPI. Avoid COX-2 inhibitor in patients with a histor of heart disease.
  • Duloxetine or tramadol: second-line
  • Weight loss, exercise, splinting, physical therapy, occupational therapy and hot/cold compression as adjuncts
  • Intra-articular injections
  • Operative treatment (arthroplasty, arthrodesis or osteotomy for severe disease)

Non-operative Treatment

• Weight loss
  • Weight loss of as little as 5kg decreases the risk of developing knee osteoarthritis in women by 50%
  • Weight loss of 10 kg significantly improves existing symptoms
  • Regular physical activity reduces the incidence of arthritis
• Activity modification
  • Limit joint stresses in regular activity by decreasing high-impact activities such as running and jumping
• Rest
  • Resting reduces repetitive microtrauma and promotes healing
• Steroid injection
  • Corticosteroids with local anaesthesia can be used
• Others
  • Bracing
  • Physical therapy

Operative Treatment

Procedure	Indication
Osteotomy	Isolated medial compartment arthritis in knees aligned in varus
Arthrodesis (joint fusion)	Severe arthritis, especially of the ankle
Arthroplasty (joint replacement)	End-stage hip and knee degenerative joint disease