Osteoarthritis

Introduction

Osteoarthritis (OA) is the most common joint disease and a major cause of morbidity
and disability.

Osteoarthritis is commonly seen in the elderly population; however, its appearance at

an early age is possible. Thus, the disease can no longer be considered a simple
consequence of aging and cartilage degeneration. Unfortunately, in young patients,
arthritis is often confused with traumatic arthritis, which occurs after an injury to a
joint, whether by a macroincident or by repeated microincidents.1,2,3,4

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see
eMedicine's patient education article Osteoarthritis.
Problem

Complications due to immobility, deconditioning, medication, and joint-related

surgery can be fatal. OA is a major cause of disability in the United States, with
approximately 68 million workdays lost and 4 million hospital admissions per year.
Frequency

Osteoarthritis (OA) is the most common form of progressive joint disease worldwide,
affecting 16 million (6%) American adults.5

Racial differences exist for both the prevalence and the pattern of joint involvement.
Compared with whites, South African blacks and persons of Chinese, East Indian, or
Native American descent have a lower prevalence of hip OA.

Females have a higher prevalence of OA of the knees and hands, whereas males have
a higher prevalence of OA of the hips. For knee OA, the female-to-male incidence
ratio is 1.7:1.

Age is the strongest determinant of OA; the prevalence of OA at all joint sites
progressively increases with age. Estimates of the true prevalence of OA are
imprecise because of the difficulties associated with the diagnosis. Estimates based
on the radiographic evidence of knee OA are as follows: OA affects 25-30% of
persons aged 45-64 years, 60% of persons older than 65 years, and more than 80% of
persons older than 75 years.5
Etiology
The daily stresses applied to the joints, especially the weight-bearing joints (eg, ankle,
knee, hip), play an important role in causing osteoarthritis (OA). The hereditary
component has long been recognized, particularly with generalized OA; a gene for
OA has been identified and plays an important role. Potential risk factors include age,
obesity, trauma, genetics, sex hormones, muscle weakness,6 and environment.7,8

Old joints and osteoarthritic joints differ. With advancing age, cartilage volume,
proteoglycan content, cartilage vascularization, and cartilage perfusion are reduced
and may result in certain characteristic radiologic features that include joint-space
narrowing and marginal osteophytes. However, biochemical and pathophysiologic
findings support the notion that age alone is an insufficient cause of OA.

Obesity increases the mechanical stress in a weight-bearing joint. It has been strongly
linked to OA of the knees and, to a lesser extent, of the hips.

Traumatic insults to the articular cartilage, ligaments, or menisci lead to abnormal

biomechanics in the joints and enhance their premature degeneration.

Menopause often increases the progression of OA; however, estrogen replacement

therapy lowers the expected rate of radiographic and clinical findings in the knees and
hips.

Muscle dysfunction compromises the body's neuromuscular protective mechanisms,

leading to increased joint motion, resulting in OA. This effect underscores the need
for continued muscle toning exercises in all individuals to prevent muscle
dysfunction.

One should not confuse environmental factors as causes of OA, because these factors
actually cause traumatic arthritis on a macrotraumatic or microtraumatic basis. This is
especially true of individuals whose lifestyles require squatting, climbing stairs, or
excessive kneeling.

Pathophysiology
The pathology of osteoarthritis (OA) is the result of both the combined effect of
tissue damage and an immune reaction to that damage. Changes resulting from
repetitive microtrauma are usually seen in the load-bearing areas of the articular
cartilage. OA usually begins with the swelling of the cartilage due to the increased
synthesis of proteoglycans, which reflect an effort by the chondrocytes to repair the
damage sustained. This stage may last for years or decades, and it is characterized by
hypertrophic repair of the articular cartilage.

As the disease progresses, the thickness of the joint surface is reduced. However, the
level of proteoglycans is remarkably diminished, causing a loss of elasticity in the
cartilage, which leads to its softening. As a result, loss of joint surface integrity
occurs, and cartilaginous vertical clefts develop (fibrillation); deeper lesions expose
the subchondral bone.

Compression of the exposed trabecular bone can cause a fracture, and new bone
formation (bony eburnation) can take place. The exposed bony surface can have
necrotic lesions that lead to the formation of bone cysts. Simultaneously,
angiogenesis of subchondral bone marrow as a result of the initial insult to the bone
tissue causes calcification of the affected cartilage that stimulates endochondral
ossification (osteophytes). In addition to the articular cartilage, the synovium,
subchondral bone, ligaments, and neuromuscular apparatus may also show
pathophysiologic changes.
Presentation

Pain is the most important symptom of osteoarthritis (OA). It begins early in the
course of the disease, usually occurs after joint activity, is mild to moderate in
intensity, and is relieved with rest. When pain occurs at rest, it is indicative of severe
OA.
Morning stiffness in OA is brief and localized, with the duration usually being less
than 30 minutes, whereas the duration is much longer in inflammatory rheumatoid
arthritis.

Stiffness after a period of inactivity and gradual improvement after a short period of
movement is known as the "gel phenomenon."

Muscle activity in patients with OA is lessened because of pain and increased

symptomatology, causing ambulatory episodes of giving way or buckling to occur.

Excessive pain causes a loss of full joint extension and limited range of motion
(ROM) during ambulation, leading to inevitable joint deformity and a loss of
function.

When an osteoarthritic knee or ankle joint is examined, bony enlargement due to

proliferative change is often noted.

Frequently, in affected osteoarthritic hands, Heberden nodes occur around the distal
interphalangeal joints, and Bouchard nodes are seen at the proximal interphalangeal
joints.

Localized tenderness, especially in superficial joints, such as the knee or ankle, is

often present, and a loss of motion and a crepitant feeling are detected. Secondary
genu varum or valgum deformity may be present when patients ambulate. The
tenderness experienced by osteoarthritic patients usually emanates from arthritis
changes in the hip; this pain is difficult to mask and is accompanied by a hip flexion
contracture. Not only is there loss of hip motion, but a loss of extension also occurs,
as evidenced by the hip flexion contracture.When the spine is involved in OA,
especially the lumbar spine, the associated changes are very commonly seen from L3
through L5. Symptoms include pain, stiffness, and occasional radicular pain from
spinal stenosis. Spinal stenosis is caused by facet arthritic changes that result in
compression of the nerve roots. The occurrence of an acquired spondylolisthesis is a
common denominator of arthritis of the lumbar spine.

Indications

Before any surgical procedure is considered, its risk-to-benefit ratio must be carefully
evaluated, especially in young patients with OA that is secondary to trauma or sports-
related injuries.9

Although no surgical procedure is absolutely indicated or contraindicated for

osteoarthritis (OA), certain general aspects are important to consider—for instance,
pain at rest that requires narcotics for control. Also, limitations in a patient's ability to
climb stairs and to get into and out of an automobile may affect the patient's quality
of life. Another important aspect in selecting a surgical procedure is its long-term
functional outcome in patients. These factors must be integrated into an overall
evaluation in selecting the appropriate surgical procedure.
Relevant Anatomy

See Treatment, Surgical therapy.

Contraindications
Patients with osteoarthritis (OA) must be evaluated for contraindications to surgery.
Local and remote (eg, dental, urinary) infections must be ruled out or cured. Patients
may need to be medically cleared for surgery by their primary care physician. The
patient's vascular status may need to be evaluated.
Laboratory Studies
Hematologic findings: Generally, no abnormal hematologic findings are seen in
patients with osteoarthritis (OA). The erythrocyte sedimentation rate (ESR) is normal,
except in those patients with the erosive inflammatory or generalized forms of the
disease.
Synovial fluid: The viscosity is good, and the cell count is slightly increased but
always less than 1000/mm3.
Imaging Studies
The diagnosis of osteoarthritis (OA) is usually made based on the history and
physical examination findings; however, radiographic evaluation is often needed.
Conventional radiographs are sensitive and cost-effective and should be the initial
imaging study in the routine evaluation of OA10,11,12,13,14 .
Characteristic findings of degenerative arthritis are osteophytes and joint-space
narrowing. When radiographic findings are normal but the pain is persistent, consider
a magnetic resonance image (MRI) study, which would provide the most information
about what is occurring in the affected area. An MRI could confirm the diagnosis of
such conditions as avascular necrosis and/or soft-tissue meniscal changes or tearing.
Radiographic evidence of osteophytes, in the absence of other bony changes such as
subchondral cysts or sclerosis, may be a manifestation of aging and not OA.
MRI is indicated whenever there is confusion regarding the diagnosis, especially if
osteonecrosis of the hip, knee, or ankle may be occurring. MRI is very sensitive and
is useful at times; however, it is also expensive and should never be the primary
imaging study.
Computed tomography (CT) scanning has no advantage in the primary diagnosis of
OA. The main indication for this imaging modality is the detection of the small
intraarticular bodies seen in advanced cases of OA.
Diagnostic Procedures
Arthrocentesis is often performed for osteoarthritis (OA) to assist with the differential
diagnosis of a septic or crystal-induced arthritis. This procedure also relieves the pain
associated with the effusion. Samples of the joint fluid may be sent for analysis,
especially if a crystalline arthritis or an infection is suspected.
Arthroscopy is indicated after all conservative treatments have failed. The procedure
supplies a direct vision of what is going on and is often all that is necessary to relieve
the patient's pain. Arthroscopy is also used for visual inspection for pathology.
Staging

Outerbridge classified articular cartilage damage based on the arthroscopic findings

in patients affected with osteoarthritis (OA).7 The 4 grades are as follows:

Grade I - Softening and swelling

Grade II - Fragmentation and fissuring of less than 0.5 inches
Grade III - Fragmentation and fissuring of greater than 0.5 inches
Grade IV - Erosion down to the subchondral bone
Treatment
Medical Therapy

Currently, the various treatments of osteoarthritis (OA) are aimed at controlling the
symptoms of pain, including physical therapy to increase muscle tone and joint
motion; medications; weight loss; avoidance of certain activities (eg, kneeling,
squatting); and pharmacotherapy, including aspirin and nonsteroidal anti-
inflammatory drugs (NSAIDs).

Topical analgesic creams may be appropriate early on, along with the injection of
hyaluronic acid medications, such as Synvisc (Hylan G-F 20; Genzyme Biosurgery,
Ridgefield, NJ) and Hyalgan (sodium hyaluronate; Fidia Farmaceutici SpA, Abano
Terme, Padua, Italy). Prior to using the hyaluronic injections, one should aspirate the
knee and instill steroids. If steroids are overutilized, one has to be careful of infection
and/or increased deformity of the knee due to the microfractures that occur from the
use of the steroids.

Glucosamine and chondroitin sulfate may also have a role in the treatment of OA;
products containing these agents have not been proven to work (although they may),
and they are costly.15

Physical therapy

Physical therapy has an important role in the management of OA.16 Exercise

programs can be designed to achieve various goals, including muscle strengthening
and improving ROM, flexibility, and aerobic conditioning. Modification of the
patient's lifestyle is also important; measures may include weight reduction,
restriction of vigorous activities, and use of supportive devices.
Physical modalities may include the application of cold to affected areas to decrease
pain during the acute inflammation phase, the use of superficial heat in the subacute
phase, and the use of deep heat in the chronic phase of the disease.

Chaipinyo et al found no significant difference between home-based strength training

and home-based balance training for knee pain caused by osteoarthritis. However,
greater improvement was noted in the strength group regarding knee-related quality
of life (improved 17 points out of 100 [95% confidence interval (CI), 5-28] than in
the balance group.17

Nonpharmacologic modalities

Nonpharmacologic modalities should be considered as initial management in the

early stages of OA disease. Patients should be educated about OA, weight control,
and avoiding activities such as kneeling and squatting that increase stress to weight-
bearing joints.

Physical modalities that can reduce OA pain include cold application in the acute
phase, superficial-heat application in the subacute phase, and deep-heat application in
the chronic phase.

Range-of-motion (ROM) exercises and stretching may be helpful. Muscle

strengthening, aerobic conditioning, and the use of gait aids (eg, cane, walker) and/or
orthoses (eg, hand splint, knee brace) may be useful as well.

Pharmacotherapy

Nonpharmacologic strategies should be considered as adjuncts to pharmacologic

measures. Pain relief can be achieved with low-to-moderate doses of simple
analgesics and anti-inflammatory medications such as acetaminophen, aspirin, and
NSAIDs. In a recent meta-analysis of trials comparing simple analgesics with
NSAIDs in patients with knee OA, NSAID-treated patients had significantly greater
improvement in both pain at rest and pain during motion. Other alternative or
additional pharmacologic agents should be considered in patients in whom
symptomatic relief is inadequate. The agent should be carefully selected after risk
factors such as serious gastrointestinal and renal toxicity are evaluated.

A topical analgesic cream (eg, methylsalicylate or capsaicin cream) is appropriate in

cases of knee OA with mild to moderate pain, either as an adjunctive treatment or as
monotherapy. Cyclooxygenase 2 (COX-2)–specific inhibitors, inhibitors such as
celecoxib (Celebrex; Pfizer Inc, New York, NY) have been studied in patients with
OA. COX-2 inhibitors have a more specific anti-inflammatory effect with fewer
adverse effects. Celecoxib is more effective than placebo and has an efficacy
comparable to that of naproxen in patients with hip or knee OA.

The COX-2 inhibitors rofecoxib (Vioxx; Merck & Co, Inc, Whitehouse Station, NJ)
and valdecoxib (Bextra; Pfizer Inc) were withdrawn from the US market on
September 30, 2004, and April 7, 2005, respectively, because of their association with
an increased rate of cardiovascular events (including heart attacks and strokes),
compared with that of placebo. Additionally, Vioxx was withdrawn from the world
market. Severe dermatologic toxicities resulting in death have occurred with Bextra.

Oral corticosteroids have no place in the management of OA. However, occasional

intra-articular injections of corticosteroids may provide temporary benefit in flare-ups
and in the relief of symptoms.

Paracetamol (acetaminophen) is the drug of choice in the management of OA.

Hyaluronic acid therapy consists of a series of injections, and it may exert its effect
by providing physical cushioning or viscosupplementation of the joint. Oral
glucosamine may have a role in the treatment of OA.15 NSAIDs and topical creams
containing an NSAID or capsaicin may have a role as well.

Surgical Therapy
Surgery is indicated in those patients who have significant symptoms that have not
responded to conservative therapy, whether it is treatment by oral or injected
medications or the supportive role of physical therapy. The lower extremity surgical
procedures include arthroscopy with debridement, valgus osteotomy for significant
genu varum, or total knee arthroplasty. Fusion of a joint (eg, hip, knee, ankle) is
rarely done today, but this procedure may be the only one that will work in a patient
with infection following one of the other procedures.

Arthroscopy

Arthroscopy is a procedure of low invasiveness and morbidity and will not interfere
with future surgery. This procedure is especially indicated for removal of meniscal
tears and of any loose bodies that can occur. Less predictable arthroscopic procedures
include debridement of loose articular cartilage with a microfracture technique,
cartilaginous implants in areas of eburnated subchondral bone, or an arthroplasty such
as the Genzyme procedure; these procedures have varying success rates and should
only be used by those surgeons experienced with arthroscopic surgical
techniques.18,19,20,21

Arthroscopic view of a torn meniscus before (top) and after (bottom) removal of
loose meniscal fragments.
Arthroscopic view of an arthritic knee.

Arthroscopic view of a knee after the removal of loose fragments of articular and
meniscal cartilage.

Arthroscopic view of the removal of cartilaginous loose body.

In a study by Kirkley et al published in the New England Journal of Medicine in

September 2008 (" A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of
the Knee "), it was found that "arthroscopic surgery for osteoarthritis of the knee
provides no additional benefit to optimized physical and medical therapy."18 In an
accompanying editorial, Marx stated, "However, osteoarthritis is not a
contraindication to arthroscopic surgery, and arthroscopic surgery remains
appropriate in patients with arthritis in specific situations in which osteoarthritis is not
believed to be the primary cause of pain."19 Also see the Medscape article
"Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis."20

Osteotomy

Osteotomy is used in active patients younger than 60 years who want to continue with
reasonable physical activity.22 The principle underlying this procedure is to shift
weight from the damaged cartilage on the medial aspect of the knee to the healthy
lateral aspect of the knee. Osteotomy is most beneficial for significant genu varum or
bowleg deformity. (Note: The osteotomy for genu valgum is not a procedure of high
predictability regarding its effectiveness.) Osteotomy often can save individuals from
having a total knee replacement until they are older.

Contraindications for an osteotomy are knee flexion less than 90°, a flexion-extension
contracture of more than 15°, and a significant amount of varus over 15°-20°.
Instability due to previous trauma or surgery, severe arterial insufficiency, and
bicompartmental involvement are also contraindications.

Arthroplasty

Arthroplasty (total joint replacement) is an excellent treatment in individuals with

moderate to severe OA.10,9,23 This procedure is the most reliable, can significantly
improve the patient's quality of life, and has results that last the longest. The rate of
revision for arthroplasty has decreased with advances in the technique and prosthesis
design. Candidates are preferably older than 60 years, so that they are less likely to
need a repeat procedure.

Anteroposterior radiograph shows knee replacement in 1 knee and arthritis in the

other, with medial joint-space narrowing and subchondral sclerosis.

Anteroposterior radiograph of the pelvis and hips shows an arthritic hip not treated
surgically and a total hip replacement.

Anteroposterior radiograph obtained after knee replacement (see Image below).

Lateral radiograph obtained after knee replacement (same patient as in Image above).

Arthroplasty consists of the surgical removal of joint surface and the insertion of a
metal and plastic prosthesis. The prosthesis is held in place by cement or bone
ingrowth into the porous coating. The use of cement relieves pain more quickly, but a
porous coating may last longer; therefore, a porous coating is used in younger
patients.

Resection arthroplasty and fusion

Older procedures that were used in major joints are now used in small joints and in
large joints in which there is extensive bone destruction and/or persistent infection.

Resection arthroplasty consists of the removal of the joint and allowing the scar to
separate the bones and to help in reducing pain. This procedure is sometimes used
after the failure of hip replacements if there is extensive bone destruction or persistent
infection.

Fusion consists of the union of bones on either side of the joint. This procedure
relieves the pain but prevents motion and puts more stress on the surrounding joints.
Fusion is sometimes used after knee replacements fail or as a primary procedure for
ankle or foot arthritis.
Preoperative Details

See Contraindications.
Intraoperative Details
See Treatment, Surgical therapy, above.
Postoperative Details

Postoperative care for the lower extremities may vary depending on the treatment
used. Patients who undergo arthroscopy usually require a period of crutch use and/or
exercise therapy; this typically lasts days or sometimes weeks. Those patients
undergoing osteotomy and fusion require partial weight bearing until bony healing
occurs; afterward, exercise is indicated. After joint replacement, patients require
partial weight bearing, which progresses to full weight bearing in 1-3 months; ROM
and strengthening exercises are started within a few days after joint-replacement
surgery and continued until the patient has good ROM and strength. After resection
arthroplasty of the hip, patients require instruction in the use of crutches or a walker,
which is usually needed permanently.
Follow-up

Patients are monitored regularly until they have recovered from surgery. Afterward,
they are examined at least yearly.
Complications

Infection is the most feared postsurgical complication, especially in cases of total

joint replacement. This complication is now rare, especially with the use of
perioperative antibiotics.

The prevention of thrombophlebitis and resultant pulmonary embolism is important

in patients who undergo lower extremity arthroplasty procedures for osteoarthritis.
The surgeon must use all of the material available to prevent these complications,
especially initiating early motion and ambulation when possible. The use of low-
molecular-weight heparin or warfarin is also indicated.
Outcome and Prognosis

Success rates with hip and knee arthroplasty are generally more than 90%. The
longevity of the prosthetic implant depends upon the patient's activity. Younger and
more active patients will require revisions, whereas the majority of older patients do
not require revision.
Future and Controversies

Improvements in the prostheses designs and in surgical techniques should continue to

increase success rates and decrease the rate and severity of complications.