Osteoarthritis (Degenerative Joint Disease)

Introduction

Osteoarthritis (OA) is a form of arthritis that features the breakdown and eventual loss of the cartilage of one or more joints. It is a degenerative arthritis.

  • All forms of assault on the joint or any other arthritis will result in OA
  • It is a degenerative disease of synovial joint – osteoarthritis
  • Degenerative disease of
    intervertebral disc is spondylosis
  • OA is the commonest type of arthritis and affects mostly middle aged to elderly persons
  • Females are more frequent affected than males:
  • OA causes are mostly primary, but can be secondary
  • Secondary causes include
    • previous trauma to the joint,
    • meniscal injury,
    • any previous arthritis e.g. Gout, RA;
    • Congenital hip dysplasia;
    • Epiphyseal: dysplasia;
    • hypermobility syndromes,
    • previous poliomyelitis in the limb,
    • glycogen storage disorder.
  • Joints affected mostly are the knee, hip, ankle, distal and proximal interphalangeal joints of the hands, cervical, & Lumbosacral.
  • Rarely thoracic spine.

Clinical features:

  • Joint pain developing over several weeks or even years
  • Initially pain on movement but later at rest
  • Joint warm to touch
  • Minimal joint morning stiffness
  • Creakiness (crepitus) on walking
  • Swelling of the joint may be bony
    osteophytes, or soft due to effusion
  • Presence of Heberden’s nodes (Distal Interphalangeal joint); & Bouchards nodes (proximal interphalangeal joint)
  • Joint deformities – knee – Genu Varus, Genu Valgum

Complications

  • Joint deformity
  • Joint subluxation
  • Immobility

Differential Diagnosis

  • Rheumatoid Arthritis
  • Gout
  • Psoriatic arthritis
  • Bursitis
  • Ankylosing spondylitis

Investigations

None diagnostic

  • Investigations are done to exclude other diagnosis
  • No blood tests diagnostic
  • Imaging – X-ray; CT, MRI

Treatment objectives

  • Reduce pain
  • Enhance mobility
  • Prevent deformities

Treatment

A. Non-drug  treatment

  • Patient education
  • Weight loss
  • Avoidance of excessive flexion of joint such as the knee
  • Knee brace, feet insoles, walking sticks
  • Regular exercise walking, bicycling,
    swimming. Avoid jogging, if knee is
    affected
  • Physical therapy – Quadriceps strengthening exercise, range of motion exercises
  • Occupational therapy
  • Acupuncture
  • Transcutaneous electrical nerve stimulation (TENS) therapy

B. Drug Treatment

Paracetamol

500 mg to 1g orally every 8 hours daily (up to 4gm daily in divided dose)

NSAIDs

Oral or local application

  • Mainstay of treatment is NSAIDs (none is superior to the other); depends on patients response
  • Ibuprofen
    • 400mg – 800 mg every 8 hours daily (up to 2400mg daily in divided doses)
  • Diclofenac
    • 75mg-150mg in two to three divided doses daily
  • Naproxen 500mg BD
  • COX 2 inhibitors- Celebrex- 200mg daily;
  • Diclofenac gel 
    • Apply on the affected part up to 3 – 4 times daily
  • Capsaicin cream 0.075%
    • Apply on the affected part up to 3 – 4 times daily

NSAIDs with misoprostol or PPI

Intra- articular steroid

Not to be given more than four times in the year

  • Triamcinolone
    • 5- 40 mg by intra articular/ intradermal injection
      according to patient’s size (maximum 80 mg), may be
      repeated when relapse occurs

Or:

  • Methylprednisolone
    • 4- 80 mg (depending on patient’s size) intra articularly; may be repeated at intervals of 7-35 days

Intra-articular platelet rich plasma

  • Intra-articular platelet rich plasma is a promising treatment option for OA. Read more about it here in comparison with intra- articular steroid

Hyaluronate

    • Injected into the joint (usually the knee), results in pain relief in 1- 6 months, but increases inflammation in the short term.

Glucosamine/chondroitin

  • (triple strength i.e. 750/600 mg) one tablet orally every 12 hours.

Narcotic analgesics:

  • Morphine 5 – 20 mg orally every 4 hours
  • Codeine based compound,
  • Tramadol

Adverse Drug reactions

NSAIDS

  • Dyspepsia
  • Peptic Ulcer Disease,
  • Gastro-intestinal haemorrhage,
  • Perforation,
  • Hepatotoxicity,
  • Impairment of renal blood
    flow
  • Pyloric stenosis
  • Fixed drug eruptions,
  • Constipation
  • Skin rashes

Indications for surgery

  • Intractable pain
  • Disability
  • Deformity

Prevention

  • Reduce weight
  • Regular exercise