Referensi OA

Practice Essentials
Osteoarthritis is the most common type of joint disease, affecting more than 20 million individuals in
the United States alone. It can be thought of as a degenerative disorder arising from the biochemical
breakdown of articular (hyaline) cartilage in the synovial joints. However, the current view holds that
osteoarthritis involves not only the articular cartilage but also the entire joint organ, including the
subchondral bone and synovium.
Essential update: New AAOS guideline for knee osteoarthritis treatment
In June 2013, the American Academy of Orthopaedic Surgeons (AAOS) released a revised clinical
practice guideline (CPG) on the treatment of osteoarthritis of the knee. The 2 key changes from their
2009 guideline are the following
[1]
:
The recommended dosage of acetaminophen was reduced from 4,000 mg to 3,000 mg a day; this
change is not specifically for osteoarthritis patients but reflects a change made by the FDA since
2009 for all individuals who use acetaminophen
Intra-articular hyaluronic acid is no longer recommended as a treatment for patients with
symptomatic osteoarthritis of the knee
Other recommendations include the following
[1]
:
Patients with only symptoms of osteoarthritis and no other problems, such as loose bodies or
meniscus tears, should not be treated with arthroscopic lavage
Patients with a body mass index >25 should lose a minimum of 5% of their body weight
Patients should participate in low-impact aerobic exercise
Patients with symptomatic osteoarthritis of the knee can be treated with acetaminophen, intra-
articular corticosteroids, or non-steroidal anti-inflammatory drugs (NSAIDs)
Custom-made lateral wedge insoles, glucosamine and/or chondroitin sulfate or hydrochloride,
needle lavage, and acupuncture are not recommended
Signs and symptoms
Symptoms of osteoarthritis include the following:
Deep, achy joint pain exacerbated by extensive use - The diseases primary symptom
Reduced range of motion and crepitus - Frequently present
Stiffness during rest (gelling) - May develop, with morning joint stiffness usually lasting for less than
30 minutes
Osteoarthritis of the hand
Distal interphalangeal (DIP) joints are most often affected
Proximal interphalangeal (PIP) joints and the joints at the base of the thumb are also typically
involved
Heberden nodes, which represent palpable osteophytes in the DIP joints, are more characteristic in
women than in men
Inflammatory changes are typically absent or at least not pronounced
See Clinical Presentation for more detail.
Diagnosis
Osteoarthritis is typically diagnosed on the basis of clinical and radiographic evidence.
[2, 3, 4, 5, 6]
No
specific laboratory abnormalities are associated with osteoarthritis.
Imaging studies
Plain radiography - The imaging method of choice because radiographs are cost-effective and can
be readily and quickly obtained
[4, 7]
; in the load-bearing areas, radiographs can depict joint-space
loss, as well as subchondral bony sclerosis and cyst formation
Computed tomography (CT) scanning - Rarely used in the diagnosis of primary osteoarthritis;
however, it may be used in the diagnosis of malalignment of the patellofemoral joint or of the foot
and ankle joints
Magnetic resonance imaging (MRI) - Not necessary in most patients with osteoarthritis unless
additional pathology amenable to surgical repair is suspected; unlike radiography, MRI can directly
visualize articular cartilage and other joint tissues (eg, meniscus, tendon, muscle, or effusion)
Ultrasonography - No role in the routine clinical assessment of patients with osteoarthritis; however,
it is being investigated as a tool for monitoring cartilage degeneration, and it can be used for guided
injections of joints not easily accessed without imaging
Bone scanning - May be helpful in the early diagnosis of osteoarthritis of the hand
[8]
; bone scans
also can help differentiate osteoarthritis from osteomyelitis and bone metastases
Arthrocentesis
The presence of noninflammatory joint fluid helps distinguish osteoarthritis from other causes of joint
pain. Other synovial fluid findings that aid in the differentiation of osteoarthritis from other conditions
are negative Gram stains and cultures, as well as the absence of crystals when fluid is viewed under
a polarized microscope.
See Workup for more detail.
Management
Nonpharmacologic interventions
The cornerstones of osteoarthritis therapy, nonpharmacologic interventions include the following:
Patient education
Heat and cold
Weight loss
[9]

Exercise
Physical therapy
Occupational therapy
Unloading in certain joints (eg, knee and hip)
Pharmacologic therapy
For hand osteoarthritis, the American College of Rheumatology (ACR) conditionally recommends
using one or more of the following:
Topical capsaicin
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) - Including trolamine salicylate
Oral NSAIDs
Tramadol
For knee osteoarthritis, the ACR conditionally recommends using one of the following:
Acetaminophen
Oral NSAIDs
Topical NSAIDs
Tramadol
Intra-articular corticosteroid injections
For hip osteoarthritis, the ACR conditionally recommends using 1 or more of the following for initial
management:
Acetaminophen
Oral NSAIDs
Tramadol
Surgery
A referral to an orthopedic surgeon may be necessary if the osteoarthritis fails to respond to a medical
management plan. Surgical procedures for osteoarthritis include the following:
Arthroscopy
Osteotomy
Arthroplasty - Particularly with knee or hip osteoarthritis
Fusion
See Treatment and Medication for more detail.
Image library
This radiograph demonstrates osteoarthritis of the right hip, including the finding
of sclerosis at the superior aspect of the acetabulum. Frequently, osteoarthritis at the hip is a bilateral finding, but it may
occur unilaterally in an individual who has a previous history of hip trauma that was confined to that one side.
Background
Osteoarthritis is the most common type of joint disease, affecting more than 20 million individuals in
the United States alone (see Epidemiology). It represents a heterogeneous group of conditions
resulting in common histopathologic and radiologic changes. It can be thought of as a degenerative
disorder arising from biochemical breakdown of articular (hyaline) cartilage in the synovial joints.
However, the current view holds that osteoarthritis involves not only the articular cartilage but also the
entire joint organ, including the subchondral bone and synovium.
Osteoarthritis predominantly involves the weight-bearing joints, including the knees, hips, cervical and
lumbosacral spine, and feet. Other commonly affected joints include the distal interphalangeal (DIP),
proximal interphalangeal (PIP), and carpometacarpal (CMC) joints. This article primarily focuses on
osteoarthritis of the hand, knee, and hip joints (see Pathophysiology). For more information on arthritis
in other joints, see Glenohumeral Arthritis and Wrist Arthritis.
Although osteoarthritis was previously thought to be caused largely by excessive wear and tear,
increasing evidence points to the contributions of abnormal mechanics and inflammation. Therefore,
the term degenerative joint disease is no longer appropriate in referring to osteoarthritis. (See
Pathophysiology.)
Historically, osteoarthritis has been divided into primary and secondary forms, though this division is
somewhat artificial. Secondary osteoarthritis is conceptually easier to understand: It refers to disease
of the synovial joints that results from some predisposing condition that has adversely altered the joint
tissues (eg, trauma to articular cartilage or subchondral bone). Secondary osteoarthritis can occur in
relatively young individuals (see Etiology).
[10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20]

The definition of primary osteoarthritis is more nebulous. Although this form of osteoarthritis is related
to the aging process and typically occurs in older individuals, it is, in the broadest sense of the term,
an idiopathic phenomenon, occurring in previously intact joints and having no apparent initiating
factor.
Some clinicians limit the term primary osteoarthritis to the joints of the hands (specifically, the DIP and
PIP joints and the joints at the base of the thumb). Others include the knees, hips, and spine
(apophyseal articulations) as well.
As underlying causes of osteoarthritis are discovered, the term primary, or idiopathic, osteoarthritis
may become obsolete. For instance, many investigators believe that most cases of primary
osteoarthritis of the hip may, in fact, be due to subtle or even unrecognizable congenital or
developmental defects.
No specific laboratory abnormalities are associated with osteoarthritis. Rather, it is typically diagnosed
on the basis of clinical findings, with or without radiographic studies (see Workup).
The goals of osteoarthritis treatment include pain alleviation and improvement of functional status.
Nonpharmacologic interventions are the cornerstones of osteoarthritis therapy and include the
following:
Patient education
Application of heat and cold
Weight loss
Exercise
Physical therapy
Joint unloading, in certain joints (eg, knee and hip)
Intra-articular pharmacologic therapy includes corticosteroid injection and viscosupplementation,
which may provide pain relief and have an anti-inflammatory effect on the affected joint. (See
Treatment.) Oral pharmacologic therapy begins with acetaminophen for mild or moderate pain without
apparent inflammation.
If the clinical response to acetaminophen is not satisfactory or the clinical presentation is
inflammatory, consider nonsteroidal anti-inflammatory drugs (NSAIDs). (See Medication.) If all other
modalities are ineffective and osteotomy is not viable, or if a patient cannot perform his or her daily
activities despite maximal therapy, arthroplasty is indicated.
The high prevalence of osteoarthritis entails significant costs to society. Direct costs include clinician
visits, medications, and surgical intervention. Indirect costs include such items as time lost from work.
Costs associated with osteoarthritis can be particularly significant for elderly persons, who face
potential loss of independence and who may need help with daily living activities. As the populations
of developed nations age over the coming decades, the need for better understanding of osteoarthritis
and for improved therapeutic alternatives will continue to grow. (See Epidemiology.)

Anatomy
Joints can be classified in either functional or structural terms. A functional classification, based on
movement, would categorize joints as follows:
Synarthroses (immovable)
Amphiarthroses (slightly moveable)
Diarthroses (freely moveable)
A structural classification would categorize joints as follows:
Synovial
Fibrous
Cartilaginous
Normal synovial joints allow a significant amount of motion along their extremely smooth articular
surface. These joints are composed of the following:
Articular cartilage
Subchondral bone
Synovial membrane
Synovial fluid
Joint capsule
The normal articular surface of synovial joints consists of articular cartilage (composed of
chondrocytes) surrounded by an extracellular matrix that includes various macromolecules, most
importantly proteoglycans and collagen. The cartilage facilitates joint function and protects the
underlying subchondral bone by distributing large loads, maintaining low contact stresses, and
reducing friction at the joint.
Synovial fluid is formed through a serum ultrafiltration process by cells that form the synovial
membrane (synoviocytes). Synovial cells also manufacture hyaluronic acid (HA, also known as
hyaluronate), a glycosaminoglycan that is the major noncellular component of synovial fluid. Synovial
fluid supplies nutrients to the avascular articular cartilage; it also provides the viscosity needed to
absorb shock from slow movements, as well as the elasticity required to absorb shock from rapid
movements.

Pathophysiology
Primary and secondary osteoarthritis are not separable on a pathologic basis, though bilateral
symmetry is often seen in cases of primary osteoarthritis, particularly when the hands are affected.
[2,
21]
Traditionally, osteoarthritis was thought to affect primarily the articular cartilage of synovial joints;
however, pathophysiologic changes are also known to occur in the synovial fluid, as well as in the
underlying (subchondral) bone, the overlying joint capsule, and other joint tissues (see Workup).
[22, 23,
24, 25]

Although osteoarthritis has been classified as a noninflammatory arthritis, increasing evidence has
shown that inflammation occurs as cytokines and metalloproteinases are released into the joint.
These agents are involved in the excessive matrix degradation that characterizes cartilage
degeneration in osteoarthritis.
[26]
Therefore, it is no longer appropriate to use the term degenerative
joint disease when referring to osteoarthritis.
In early osteoarthritis, swelling of the cartilage usually occurs, because of the increased synthesis of
proteoglycans; this reflects an effort by the chondrocytes to repair cartilage damage. This stage may
last for years or decades and is characterized by hypertrophic repair of the articular cartilage.
As osteoarthritis progresses, however, the level of proteoglycans eventually drops very low, causing
the cartilage to soften and lose elasticity and thereby further compromising joint surface integrity.
Microscopically, flaking and fibrillations (vertical clefts) develop along the normally smooth articular
cartilage on the surface of an osteoarthritic joint. Over time, the loss of cartilage results in loss of joint
space.
In major weight-bearing joints of persons with osteoarthritis, a greater loss of joint space occurs at
those areas experiencing the highest loads. This effect contrasts with that of inflammatory arthritides,
in which uniform joint-space narrowing is the rule.
In the osteoarthritic knee, for example, the greatest loss of joint space is commonly seen in the medial
femorotibial compartment, though the lateral femorotibial compartment and patellofemoral
compartment may also be affected. Collapse of the medial or lateral compartments may result in
varus or valgus deformities, respectively.
Erosion of the damaged cartilage in an osteoarthritic joint progresses until the underlying bone is
exposed. Bone denuded of its protective cartilage continues to articulate with the opposing surface.
Eventually, the increasing stresses exceed the biomechanical yield strength of the bone. The
subchondral bone responds with vascular invasion and increased cellularity, becoming thickened and
dense (a process known as eburnation) at areas of pressure.
[27]

The traumatized subchondral bone may also undergo cystic degeneration, which is attributable either
to osseous necrosis secondary to chronic impaction or to the intrusion of synovial fluid. Osteoarthritic
cysts are also referred to as subchondral cysts, pseudocysts, or geodes (the preferred European
term) and may range from 2 to 20 mm in diameter. Osteoarthritic cysts in the acetabulum (see the
image below) are termed Egger cysts.
At areas along the articular margin, vascularization of subchondral marrow, osseous metaplasia of
synovial connective tissue, and ossifying cartilaginous protrusions lead to irregular outgrowth of new
bone (osteophytes). Fragmentation of these osteophytes or of the articular cartilage itself results in
the presence of intra-articular loose bodies (joint mice).
Along with joint damage, osteoarthritis may also lead to pathophysiologic changes in associated
ligaments and the neuromuscular apparatus. For example, lateral collateral ligament complex
abnormalities are common in knee osteoarthritis.
Pain mechanisms in osteoarthritis
Pain, the main presenting symptom of osteoarthritis, is presumed to arise from a combination of
mechanisms, including the following:
Osteophytic periosteal elevation
Vascular congestion of subchondral bone, leading to increased intraosseous pressure
Synovitis with activation of synovial membrane nociceptors
Fatigue in muscles that cross the joint
Overall joint contracture
Joint effusion and stretching of the joint capsule
Torn menisci
Inflammation of periarticular bursae
Periarticular muscle spasm
Psychological factors
Crepitus (a rough or crunchy sensation)
Central pain sensitization
When the spine is involved in osteoarthritis, 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. Foraminal narrowing is caused by facet arthritic changes that result in
compression of the nerve roots. Acquired spondylolisthesis is a common complication of arthritis of
the lumbar spine.

Etiology
The daily stresses applied to the joints, especially the weight-bearing joints (eg, ankle, knee, and hip),
play an important role in the development of osteoarthritis. Most investigators believe that
degenerative alterations in osteoarthritis primarily begin in the articular cartilage, as a result of either
excessive loading of a healthy joint or relatively normal loading of a previously disturbed joint.
External forces accelerate the catabolic effects of the chondrocytes and further disrupt the
cartilaginous matrix.
[28, 29, 30, 31]

Risk factors for osteoarthritis include the following
[32, 33, 34, 35]
:
Age
Obesity
[36, 37, 38]

Trauma
Genetics (significant family history)
Reduced levels of sex hormones
Muscle weakness
[39]

Repetitive use (ie, jobs requiring heavy labor and bending)
[40]

Infection
Crystal deposition
Acromegaly
Previous inflammatory arthritis (eg, burnt-out rheumatoid arthritis)
Heritable metabolic causes (eg, alkaptonuria, hemochromatosis, and Wilson disease)
Hemoglobinopathies (eg, sickle cell disease and thalassemia)
Neuropathic disorders leading to a Charcot joint (eg, syringomyelia, tabes dorsalis, and diabetes)
Underlying morphologic risk factors (eg, congenital hip dislocation and slipped femoral capital
epiphysis)
Disorders of bone (eg, Paget disease and avascular necrosis)
Previous surgical procedures (eg, meniscectomy)
Advancing age
With advancing age come reductions in cartilage volume, proteoglycan content, cartilage
vascularization, and cartilage perfusion. These changes may result in certain characteristic radiologic
features, including a narrowed joint space and marginal osteophytes. However, biochemical and
pathophysiologic findings support the notion that age alone is an insufficient cause of osteoarthritis.
Obesity
Obesity increases the mechanical stress in a weight-bearing joint. It has been strongly linked to
osteoarthritis of the knees and, to a lesser extent, of the hips. A study that evaluated the associations
between body mass index (BMI) over 14 years and knee pain at year 15 in 594 women found that a
higher BMI at year 1 and a significant increase in BMI over 15 years were predictors of bilateral knee
pain at year 15.
[38]
The association between BMI increase and knee pain was independent of
radiographic changes.
In addition to its mechanical effects, obesity may be an inflammatory risk factor for osteoarthritis.
Obesity is associated with increased levels (both systemic and intra-articular) of adipokines (cytokines
derived from adipose tissue), which may promote chronic, low-grade inflammation in joints.
[41]

Other causes
Trauma or surgery (including surgical repair of traumatic injury) involving the articular cartilage,
ligaments, or menisci can lead to abnormal biomechanics in the joints and accelerate osteoarthritis.
Although repairs of ligament and meniscal injuries usually restore joint function, osteoarthritis has
been observed 5-15 years afterward in 50-60% of patients.
[42]

Insults to the joints may occur even in the absence of obvious trauma. Microtrauma may also cause
damage, especially in individuals whose occupation or lifestyle involves frequent squatting, stair-
climbing, or kneeling.
Muscle dysfunction compromises the bodys neuromuscular protective mechanisms, leading to
increased joint motion and ultimately resulting in osteoarthritis. This effect underscores the need for
continued muscle toning exercises as a means of preventing muscle dysfunction.
Valgus malalignment at the knee has been shown to increase the incidence and risk of radiographic
progression of knee osteoarthritis involving the lateral compartment.
[43]

Genetics
A hereditary component, particularly in osteoarthritis presentations involving multiple joints, has long
been recognized.
[44, 45, 46]
Several genes have been directly associated with osteoarthritis,
[47]
and many
more have been determined to be associated with contributing factors, such as excessive
inflammation and obesity.
Genes in the BMP (bone morphogenetic protein) and WNT (wingless-type) signaling cascades have
been implicated in osteoarthritis. Two genes in particular,GDF5 (growth and differentiation factor 5)
and FRZB (frizzled related protein) have been identified in the articular cartilage in animal studies and
share a strong correlation with osteoarthritis.
[48, 49, 50, 51]

Genome-wide association studies (GWAS) have identified an association between osteoarthritis of
large joints and the MCF2L gene. This gene is key in neurotrophin-mediated regulation of peripheral
nervous system cell motility.
[52]

Genetic factors are also important in certain heritable developmental defects and skeletal anomalies
that can cause congenital misalignment of joints. These may result in damage to cartilage and the
structure of the joint.
Currently, clinical genetic testing is not offered to patients who have osteoarthritis unless they also
have other anomalies that could be associated with a genetic condition. In the future, testing may
allow individualization of therapeutics.

Epidemiology
United States and international statistics
Osteoarthritis affects more than 20 million individuals in the United States, though statistical figures
are influenced by how the condition is definedthat is, by self-report, by radiographic or symptomatic
criteria, or by a combination of these.
[53]
On the basis of the radiographic criteria for osteoarthritis, more
50% of adults older than 65 years are affected by the disease.
Internationally, osteoarthritis is the most common articular disease. Estimates of its frequency vary
across different populations.
Age-related demographics
Primary osteoarthritis is a common disorder of the elderly, and patients are often asymptomatic.
Approximately 80-90% of individuals older than 65 years have evidence of radiographic primary
osteoarthritis.
[54]

Symptoms typically do not become noticeable until after the age of 50 years. The prevalence of the
disease increases dramatically among persons older than 50 years, likely because of age-related
alterations in collagen and proteoglycans that decrease the tensile strength of the joint cartilage and
because of a diminished nutrient supply to the cartilage.
[54]

Sex-related demographics
In individuals older than 55 years, the prevalence of osteoarthritis is higher among women than
among men.
[54]
Women are especially susceptible to osteoarthritis in the DIP joints of the fingers.
Women also have osteoarthritis of the knee joints more frequently than men do, with a female-to-male
incidence ratio of 1.7:1. Women are also more prone to erosive osteoarthritis, with a female-to-male
ratio of about 12:1.
Race-related demographics
Interethnic differences in the prevalence of osteoarthritis have been noted.
[55]
The disorder is more
prevalent in Native Americans than in the general population. Disease of the hip is seen less
frequently in Chinese patients from Hong Kong than in age-matched white populations. Symptomatic
knee osteoarthritis is extremely common in China.
[56]

In persons older than 65 years, osteoarthritis is more common in whites than in blacks. Knee
osteoarthritis appears to be more common in black women than in other groups. Jordan et al found
that in comparison with whites, African American men and women had a slightly higher prevalence of
radiographic and symptomatic knee osteoarthritis but a significantly higher prevalence of severe
radiographic knee osteoarthritis.
[57]

Prognosis
The prognosis in patients with osteoarthritis depends on the joints involved and on the severity of the
condition. No proven disease- or structure-modifying drugs for osteoarthritis are currently known;
consequently, pharmacologic treatment is directed at symptom relief.
A systematic review found the following clinical features to be associated with more rapid progression
of knee osteoarthritis
[58]
:
Older age
Higher BMI
Varus deformity
Multiple involved joints
Patients with osteoarthritis who have undergone joint replacement have a good prognosis, with
success rates for hip and knee arthroplasty generally exceeding 90%. However, a joint prosthesis
may have to be revised 10-15 years after its placement, depending on the patients activity level.
Younger and more active patients are more likely to require revisions, whereas the majority of older
patients will not. (See Treatment.)
Patient Education
Educate patients on the natural history of and management options for osteoarthritis, emphasizing the
benefits of exercise and weight loss. Explain the differences between osteoarthritis and more rapidly
progressive arthritides, such as rheumatoid arthritis.
Several Arthritis Foundation studies have demonstrated that education in osteoarthritis benefits the
patient. Through education, patients can learn and implement strategies for reducing pain and
improving joint function. Emphasize the need for physician follow-up visits.
For patient education information, see the Arthritis Center, as well asOsteoarthritis.
History
The progression of osteoarthritis is characteristically slow, occurring over several years or decades.
Over this period, the patient can become less and less active and thus more susceptible to morbidities
related to decreasing physical activity (including potential weight gain).
Early in the disease process, the joints may appear normal. However, the patients gait may be
antalgic if weight-bearing joints are involved.
Pain is usually the initial source of morbidity in osteoarthritis, with the diseases primary symptom
being deep, achy joint pain exacerbated by extensive use. Also, reduced range of motion and crepitus
are frequently present. Stiffness during rest (gelling) may develop, with morning joint stiffness usually
lasting for less than 30 minutes.
Initially, pain can be relieved by rest and may respond to simple analgesics. However, joints may
become unstable as the osteoarthritis progresses; therefore, the pain may become more prominent
(even during rest) and may not respond to medications.
Physical Examination
Physical examination findings in patients with osteoarthritis are mostly limited to the affected joints.
[59,
60, 61]
Reduced range of motion and crepitus are frequently present.
Malalignment with a bony enlargement may occur. Most cases of osteoarthritis do not involve
erythema or warmth over the affected joint(s); however, a bland effusion may be present. Limitation of
joint motion or muscle atrophy around a more severely affected joint may occur.
Osteoarthritis of the hand most often affects the distal interphalangeal (DIP) joints but also typically
involves the proximal interphalangeal (PIP) joints and the joints at the base of the thumb. Heberden
nodes, which represent palpable osteophytes in the DIP joints, are more characteristic in women than
in men. Inflammatory changes are typically absent or at least not pronounced.
Progression of Osteoarthritis
The etiopathogenesis of osteoarthritis has been divided into 3 stages as follows:
Stage 1 Proteolytic breakdown of the cartilage matrix occurs
Stage 2 Fibrillation and erosion of the cartilage surface develop, with subsequent release of
proteoglycan and collagen fragments into the synovial fluid
Stage 3 Breakdown products of cartilage induce a chronic inflammatory response in the synovium,
which in turn contributes to further cartilage breakdown
Several systems have been advocated for use in the grading of focal cartilage change; however, a
simple description of the extent of disease (ie, surface, partial-thickness, or full-thickness irregularity
with or without underlying subchondral bone change) is generally sufficient and prevents the
confusion that may occur with numeric grading systems. Such systems are in any case intended more
for research purposes than for clinical use.
Certain diseases are often categorized as subsets of primary osteoarthritis. These include primary
generalized osteoarthritis (PGOA), erosive osteoarthritis, and chondromalacia patellae.
Diagnostic Considerations
The initial diagnostic goal is to differentiate osteoarthritis from other arthritides, such as rheumatoid
arthritis. The history and physical examination findings are usually sufficient to diagnose osteoarthritis.
Radiographic findings confirm the initial impression (see Workup), and laboratory values are typically
within the reference range.
Rheumatoid arthritis
Rheumatoid arthritis predominantly affects the wrists, as well as the metacarpophalangeal (MCP) and
proximal interphalangeal (PIP) joints. It rarely, if ever, involves the distal interphalangeal (DIP) joints
or the lumbosacral spine.
Rheumatoid arthritis is associated with prominent, prolonged (> 1 hour) morning stiffness and overtly
swollen, warm joints. Radiographic findings include bone erosion (eg, periarticular osteopenia or
marginal erosions of bone) rather than formation. Laboratory findings that further differentiate
rheumatoid arthritis from osteoarthritis include the following:
Systemic inflammation (elevated erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]
level)
Positive serologies (rheumatoid factor [RF] or anticyclic citrullinated peptide [anti-CCP] antibodies)
Inflammatory joint fluid with a predominance of polymorphonuclear leukocytes (PMNs)
Elevated white blood cell (WBC) count
Additional arthritides
Back pain may result from spondyloarthropathy or from osteoarthritis with sacroiliac and lumbosacral
spine involvement. Clinical history and characteristic radiographic findings can be used to differentiate
these disorders.
Secondary osteoarthritis must be considered in individuals with any of the following:
Chondrocalcinosis
History of joint trauma
Metabolic bone disorders
Hypermobility syndromes
Neuropathic diseases
The following disorders should also be considered in the differential diagnosis:
Crystalline arthropathies (ie, gout and pseudogout)
Inflammatory arthritis (eg, rheumatoid arthritis)
Seronegative spondyloarthropathies (eg, psoriatic arthritis and reactive arthritis)
Septic arthritis or postinfectious arthropathy
Fibromyalgia
Tendonitis
In patients with knee pain, other disorders to consider in the differential diagnosis are patellofemoral
syndromeand prepatellar bursitis.
Differential Diagnoses
Ankylosing Spondylitis
Avascular Necrosis
Fibromyalgia
Gout and Pseudogout
Imaging in Neuropathic Arthropathy (Charcot Joint)
Lyme Disease
Patellofemoral Arthritis
Psoriatic Arthritis
Rheumatoid Arthritis

Approach Considerations
Osteoarthritis is typically diagnosed on the basis of clinical and radiographic evidence.
[2, 3, 4, 5, 6]
No
specific laboratory abnormalities are associated with osteoarthritis.
Researchers have investigated the use of monoclonal antibodies, synovial fluid markers, and urinary
pyridinium cross-links (ie, breakdown products of cartilage) as osteoarthritic indicators.
[62]
No single
biomarker has proved reliable for diagnosis and monitoring, but combinations of cartilage-derived and
bone-derived biomarkers have been used to identify osteoarthritis subtypes, with possible impact on
treatment.
[63]

Levels of acute-phase reactants are typically within the reference range in patients with osteoarthritis.
The erythrocyte sedimentation rate (ESR) is not usually elevated, though it may be slightly so in cases
of erosive inflammatory arthritis. The synovial fluid analysis usually shows a white blood cell (WBC)
count below 2000/L, with a mononuclear predominance.
Plain Radiography
Plain radiography is the imaging method of choice because it is more cost-effective than other
modalities and because radiographs can be obtained more readily and quickly.
[4, 7]
One important
characteristic of primary osteoarthritis is that the abnormalities found in the load-bearing (ie, highly
stressed) areas of the affected joint differ from those found in the nonload-bearing areas. In the load-
bearing areas, radiographs can depict joint-space loss, as well as subchondral bony sclerosis and
cyst formation (see the image below).
The elbow is not commonly affected in osteoarthritis. However, elbow arthritis (see the images below)
can occur as a result of trauma.
Osteoarthritis of the elbow is not commonly seen; however, it can occur with a
history of previous trauma. Osteoarthritis of the elbow is not commonly seen;
however, it can occur with a history of previous trauma. Osteoarthritis of the
elbow is not commonly seen; however, it can occur with a history of previous trauma.
MRI, CT, and Ultrasonography
Magnetic resonance imaging (MRI) can depict many of the same characteristics of osteoarthritis that
plain radiography can, but it is not necessary in most patients with osteoarthritis, unless additional
pathology amenable to surgical repair is suspected. Pathology that can be seen on MRI includes joint
narrowing, subchondral osseous changes, and osteophytes. Unlike radiography, MRI can directly
visualize articular cartilage and other joint tissues (eg, meniscus, tendon, muscle, or effusion).
Computed tomography (CT) is rarely used in the diagnosis of primary osteoarthritis. However, it may
be used in the diagnosis of malalignment of the patellofemoral joint or of the foot and ankle joints.
Currently, ultrasonography has no role in the routine clinical assessment of the patient with
osteoarthritis. However, it is being investigated as a tool for monitoring cartilage degeneration, and it
can be used for guided injections of joints not easily accessed without imaging.
For more information, see Imaging in Osteoarthritis.
Bone Scanning
Bone scans may be helpful in the early diagnosis of osteoarthritis of the hand.
[8]
Bone scans in
osteoarthritis typically yield a symmetrically patterned, very mild increased uptake. In contrast, bone
scans are often negative in the early stages of multiple myeloma, a cause of bone pain in older adults
that can be confused with osteoarthritis. Bone scans also can help to differentiate osteoarthritis from
osteomyelitis and bone metastases.
Arthrocentesis
A diagnostic joint aspiration for synovial fluid analysis can help exclude inflammatory arthritis,
infection, or crystal arthropathy. The presence of noninflammatory joint fluid helps distinguish
osteoarthritis from other causes of joint pain. Other synovial fluid findings that aid in the differentiation
of osteoarthritis from other conditions are negative Gram stains and cultures, as well as the absence
of crystals when fluid is viewed under a polarized microscope.
For more information, see the following:
Knee Arthrocentesis
Metacarpophalangeal Arthrocentesis
Shoulder Arthrocentesis
Approach Considerations
The goals of osteoarthritis treatment include alleviation of pain and improvement of functional
status.
[64]
Optimally, patients should receive a combination of nonpharmacologic and pharmacologic
treatment.
[65]

Nonpharmacologic interventions, which are the cornerstones of osteoarthritis therapy, include the
following:
Patient education
Heat and cold
Weight loss
[9]

Exercise
Physical therapy
Unloading in certain joints (eg, knee, hip)
A physiatrist may help in formulating a nonpharmacologic management plan for the patient with
osteoarthritis, and a nutritionist may help the patient to lose weight. A referral to an orthopedic
surgeon may be necessary if the osteoarthritis fails to respond to a medical management plan.
Surgical procedures for osteoarthritis include arthroscopy, osteotomy, and (particularly with knee or
hip osteoarthritis) arthroplasty.
Pharmacologic Treatment
American College of Rheumatology guidelines
The American College of Rheumatology (ACR) has issued guidelines for pharmacologic treatment of
osteoarthritis of the hand, hip, and knee.
[57]
For hand osteoarthritis, the ACR conditionally recommends
using 1 or more of the following:
Topical capsaicin
Topical nonsteroidal anti-inflammatory drugs (NSAIDs), including trolamine salicylate
Oral NSAIDs
Tramadol
The ACR conditionally recommends against using intra-articular therapies or opioid analgesics for
hand osteoarthritis. For patients 75 years and older, the ACR conditionally recommends the use of
topical rather than oral NSAIDs.
For knee osteoarthritis, the ACR conditionally recommends using 1 of the following:
Acetaminophen
Oral NSAIDs
Topical NSAIDs
Tramadol
The ACR conditionally recommends against using chondroitin sulfate, glucosamine, or topical
capsaicin for knee osteoarthritis. The ACR has no recommendations regarding the use of intra-
articular hyaluronates, duloxetine, and opioid analgesics.
For hip osteoarthritis, the ACR conditionally recommends using 1 or more of the following for initial
management:
Acetaminophen
Oral NSAIDs
Tramadol
The ACR conditionally recommends against using chondroitin sulfate or glucosamine for hip
osteoarthritis. The ACR has no recommendation regarding the use of topical NSAIDs, intra-articular
hyaluronate injections, duloxetine, or opioid analgesics.
Agency for Healthcare Research and Quality findings
A comparison of analgesics for osteoarthritis carried out by the Agency for Healthcare Research and
Quality (AHRQ) found that no currently available analgesic reviewed in this report offers a clear
overall advantage compared with the others.
[66]
The choice of analgesic for an individual patient
should take into account the trade-off between benefits and adverse effects, which differs across
analgesics. Patient age, comorbid conditions, and concomitant medication are key considerations.
The AHRQ comparison found that acetaminophen was modestly inferior to NSAIDs in reducing
osteoarthritic pain but was associated with a lower risk of GI adverse effects.
[66]
On the other hand,
acetaminophen poses a higher risk of liver injury.
AHRQ findings on adverse effects included the following:
Selective NSAIDs as a class were associated with a lower risk of ulcer complications than were the
nonselective NSAIDs naproxen, ibuprofen, and diclofenac
The partially selective NSAIDs meloxicam and etodolac were associated with a lower risk of ulcer-
related complications and symptomatic ulcers than were various nonselective NSAIDs
The risk of serious GI adverse effects was found to be higher with naproxen than with ibuprofen
Celecoxib and the nonselective NSAIDs ibuprofen and diclofenac were associated with an
increased risk of cardiovascular adverse effects when compared with placebo
The nonselective NSAIDs ibuprofen and diclofenac, but not naproxen, were associated with an
increased risk of heart attack when compared with placebo
The AHRQ noted that topical diclofenac was found to have efficacy similar to that of oral NSAIDs in
patients with localized osteoarthritis. No head-to-head trials compared topical salicylates or capsaicin
with oral NSAIDs for osteoarthritis.
[66]

All NSAIDs had deleterious effects on blood pressure, edema, and kidney function. However, the
AHRQ found no consistent clinically relevant differences between celecoxib, partially selective
NSAIDs, and nonselective NSAIDs with regard to the risk of hypertension, heart failure, or impaired
kidney function.
[66]

Analgesics, NSAIDs, and COX-2 inhibitors
Begin treatment with acetaminophen for mild or moderate osteoarthritic pain without apparent
inflammation. If the clinical response to acetaminophen is not satisfactory or if the clinical presentation
of osteoarthritis is inflammatory, consider using an NSAID.
Use the lowest effective dose or intermittent dosing if symptoms are intermittent, then try full doses if
the patients response is insufficient.
Topical NSAID preparations, particularly diclofenac, are available. These preparations can be
particularly useful in patients with symptomatic disease that is limited to a few sites or in patients who
are at increased risk for adverse events with systemic NSAIDs.
In patients with highly resistant pain, consider the analgesic tramadol. Options in patients at an
elevated risk for GI toxicity from NSAIDs include the addition of a proton-pump inhibitor or misoprostol
to the treatment regimen and the use of the selective cyclooxygenase (COX)-2 inhibitor celecoxib
instead of a nonselective NSAID.
Duloxetine
The selective serotonin-norepinephrine reuptake inhibitor duloxetine has been found to be effective in
treating osteoarthritis pain.
[67]
For example, in patients with knee osteoarthritis who had persistent
moderate pain despite optimized NSAID therapy, a randomized, double-blind trial found significant
additional pain reduction and functional improvement with duloxetine as compared with placebo.
[68]

However, duloxetine was also associated with significantly more nausea, dry mouth, constipation,
fatigue, and decreased appetite than placebo was.
[68]
To date, trials of duloxetine in osteoarthritis have
been short in duration (10-13 weeks), and studies comparing duloxetine directly with other therapies
have not been performed.
Intra-articular injections
Intra-articular pharmacologic therapy includes injection of a corticosteroid or sodium hyaluronate (ie,
hyaluronic acid [HA] or hyaluronan), which may provide pain relief and have an anti-inflammatory
effect on the affected joint.
[69, 70]
Ultrasound guidance can facilitate arthrocentesis and injection and is
increasingly being adopted by physicians such as rheumatologists and physiatrists for this purpose.
Corticosteroid
After the introduction of the needle into the joint and before steroid administration, aspiration of as
much synovial fluid as possible should be attempted. Aspiration often provides symptomatic relief for
the patient and allows laboratory evaluation of the fluid, if necessary. Infected joint fluid and
bacteremia are contraindications to steroid injection.
In patients with osteoarthritic knee pain, steroid injections generally result in clinically and statistically
significant pain reduction as soon as 1 week after injection. The effect may last, on average,
anywhere from 4 to 6 weeks per injection, but the benefit is unlikely to continue beyond that time
frame.
[71]
For hip osteoarthritis, a randomized, placebo-controlled study confirmed the effectiveness of
corticosteroid injection, with benefits often lasting as long as 3 months.
[72]

Some controversial evidence exists regarding frequent steroid injections and subsequent damage to
cartilage (chondrodegeneration). Accordingly, it is usually recommended that no more than 3
injections per year be delivered to any individual osteoarthritic joint. Systemic glucocorticoids have no
role in the management of osteoarthritis.
For more information, see Corticosteroid Injections of Joints and Soft Tissues.
Sodium hyaluronate
Intra-articular injection of sodium hyaluronate, also referred to as viscosupplementation, has been
shown to be safe and possibly effective for symptomatic relief of knee osteoarthritis.
[73, 74]
In the United
States, intra-articular HAs are classified as medical devices rather than as drugs.
[75]

Intra-articular HAs approved by the FDA for the treatment of osteoarthritic knee pain include the
naturally extracted, noncross-linked sodium hyaluronate products Hyalgan,
[76]
Supartz, Orthovisc,
and Euflexxa, as well as the cross-linked sodium hyaluronate product known as hylan G-F 20
(Synvisc).
Euflexxa is derived from a fermentation process (Streptococcus), whereas the source material for the
other products listed is chicken combs. At present, no distinct advantage or disadvantage has been
associated with any particular source of HA.
Some differences between the viscosupplements do exist in the FDA-approved prescribing
information. For example, whereas Hyalgan and Synvisc have been established as safe for repeat
treatment, the safety and efficacy of other products for repeat treatment have not been established.
The exact mechanisms of action through which HAs provide symptomatic relief are unknown.
Possible mechanisms include direct binding to receptors (CD44 in particular) in the synovium and
cartilage that can lead to several biologic activation pathways.
[77, 78]

The HA class in general has demonstrated a very favorable safety profile for chronic pain
management in knee osteoarthritis, with the most common adverse event being injection-site pain.
Although any intra-articular injection (whether of HAs or of steroids) may elicit an inflammatory
response and possible effusion, only the cross-linked hylan G-F 20 product has been associated with
a clinically distinct acute inflammatory side effect (ie, severe acute inflammatory reaction [SAIR] or
HA-associated intra-articular pseudosepsis).
Prolotherapy
In a randomized, controlled trial of 90 adults with painful knee osteoarthritis who were randomized to
either dextrose prolotherapy, saline injections, or at-home exercise, the patients on prolotherapy
experienced significantly greater improvement in pain, function, and stiffness over the other 2 groups.
Injections were administered at 1, 5, and 9 weeks, with additional injections provided as needed at
weeks 13 and 17.
[79]

Additional pharmacologic agents
Muscle relaxants may benefit patients with evidence of muscle spasm. Judicious use of narcotics (eg,
oxycodone and acetaminophen with codeine) is reserved for patients with severe osteoarthritis.
Glucosamine and chondroitin sulfate have been used in Europe for many years and continue to be
popular with patients worldwide. In the United States, however, the glucosamine/chondroitin arthritis
intervention trial (GAIT) reported, at best, limited benefit from glucosamine (500 mg 3 times daily),
chondroitin sulfate (400 mg 3 times daily), or the combination of the 2 in patients with knee
osteoarthritis.
[80, 81]

In GAIT patients overall, glucosamine and chondroitin sulfate alone or in combination did not reduce
pain effectively at 24 weeks, but in patients with moderate-to-severe pain at baseline, the rate of
response was significantly higher with combined therapy than with placebo (79.2% vs. 54.3%).
[81]
At 2
years, no treatment achieved a clinically important difference in loss of joint-space width, though
treatment effects on Kellgren-Lawrence grade 2 knees showed a trend toward improvement relative
to the placebo group.
[80]

The AHRQ comparison found no clear difference between glucosamine or chondroitin and oral
NSAIDs for relieving pain or improving function.
[66]
However, the AHRQ observed that most trials
showing therapeutic benefits from glucosamine used pharmaceutical-grade glucosamine that is not
available in the United States, noting that the trial findings may therefore be inapplicable to currently
available over-the-counter preparations.
Another agent, S-adenosylmethionine (SAM-e), is a European supplement receiving significant
attention in the United States. A systematic review of SAM-e found that the evidence was
inconclusive, with a number of small trials of questionable quality; the authors concluded that the
effects of SAM-e on pain and function may be potentially clinically relevant but are expected to be
small.
[82]

Chondroprotective drugs (ie, matrix metalloproteinase [MMP] inhibitors and growth factors) are being
tested as disease-modifying drugs in the management of osteoarthritis. For example, MMP-13 is
specifically expressed in the cartilage of individuals with osteoarthritis but not in the cartilage of
normal adults.
[83]
German researchers reported on the synthesis and biologic evaluation of an MMP-13
selective inhibitor that has demonstrated efficacy as a disease-modifying intra-articular injection for
osteoarthritis.
[84]

Other investigational agents include monoclonal antibodies that inhibit nerve growth factor (NGF),
such as tanezumab. Anti-NGF agents have been shown to reduce chronic pain in patients with
osteoarthritis.
Lifestyle Modification, Physical/Occupational Therapy, and Other
Nonpharmacologic Measures
Lifestyle modification, particularly exercise and weight reduction, is a core component in the
management of osteoarthritis.
[85, 86]
Guidelines from Osteoarthritis Research Society International
(OARSI) advise that nonpharmacologic treatment of hip and knee osteoarthritis should initially focus
on self-help and patient-driven modalities rather than on modalities delivered by health
professionals.
[65]

The ACR strongly recommends the following nonpharmacologic measures for patients with knee or
hip osteoarthritis
[87]
:
Cardiovascular or resistance land-based exercise
Aquatic exercise
Weight loss, for overweight patients
The ACR conditionally recommends the following measures for patients with knee or hip
osteoarthritis:
Self-management programs
Manual therapy in combination with supervised exercise
Psychosocial interventions
Thermal agents
Walking aids, as needed
For patients with knee osteoarthritis, the ACR also conditionally recommends the following measures:
Medially directed patellar taping
Medially wedged insoles for lateral-compartment osteoarthritis
Laterally wedged subtalar strapped insoles for medial-compartment osteoarthritis
Tai chi
For knee osteoarthritis, an American Academy of Orthopaedic Surgeons (AAOS) guideline suggests
encouraging patients to participate in self-management educational programs such as those
conducted by the Arthritis Foundation and to incorporate activity modifications into their lifestyle (eg,
walking instead of running or engaging in alternative activities).
Instruct the patient to avoid aggravating stress to the affected joint. Implement corrective procedures if
the patient has poor posture.
Weight reduction relieves stress on the affected knees or hips. The benefits of weight loss, whether
obtained through regular exercise and diet or through surgical intervention, may extend not only to
symptom relief but also to a slowing in cartilage loss in weight-bearing joints (eg, knees).
[88]
In addition,
weight loss lowers levels of the inflammatory cytokines and adipokines that may play a role in
cartilage degradation.
[89]

Some patients with osteoarthritis benefit from heat placed locally over the affected joint. A minority of
patients report relief with ice.
[90]

Physical activity
Although people with osteoarthritis tend to avoid activity, exercise is an effective treatment for this
condition, producing improvements in pain, physical function, and walking distance. Long-term
walking and resistance-training programs have been shown to slow the functional decline seen in
many patients with osteoarthritis, including older patients.
[89]

Osteoarthritis of the knee may result in disuse atrophy of the quadriceps. Because these muscles
help protect the articular cartilage from further stress, quadriceps strengthening is likely to benefit
patients with knee osteoarthritis. Stretching exercises are also important in the treatment of
osteoarthritis because they increase range of motion.
In a study of patients with knee osteoarthritis, Jan et al found that in most respects, nonweight-
bearing exercise was as therapeutically effective as weight-bearing exercise.
[91]
After an 8-week
exercise program, the 2 types of exercise resulted in equally significant improvements in function,
walking speed, and muscle torque. However, patients in the weight-bearing group demonstrated
greater improvement in position sense, which may help patients with complex walking tasks, such as
walking on a spongy surface.
Chaipinyo and Karoonsupcharoen found no significant difference between home-based strength
training and home-based balance training for knee pain caused by osteoarthritis. However, greater
improvement in knee-related quality of life was noted in the strength-training group.
[92]

The importance of aerobic conditioning, particularly low-impact exercises (if osteoarthritis is affecting
weight-bearing joints), should be stressed as well. Swimming, especially the aerobic aquatic programs
developed by the Arthritis Foundation, can be helpful.
The benefits of exercise have been found to decline over time, possibly because of poor adherence.
Factors that determine adherence to exercise have not been carefully studied in patients with
osteoarthritis. In a review of this topic, Marks and Allegrante concluded that interventions to enhance
self-efficacy, social support, and skills in the long-term monitoring of progress are necessary to foster
exercise adherence in people with osteoarthritis.
[93]

Tai chi
A prospective, single-blind, randomized, controlled study by Wang et al suggested that tai chi is a
potentially effective treatment for pain associated with osteoarthritis of the knee.
[94]
In this trial, 40
patients with symptomatic tibiofemoral osteoarthritis who performed 60 minutes of tai chi twice weekly
for 12 weeks experienced significantly greater pain reduction than did control subjects who underwent
12 weeks of wellness education and stretching.
The mean difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
pain scores was 118.80 mm.
[94]
The tai chi cohort also had significantly better WOMAC physical
function scores, patient and physician global visual analog scale scores, chair stand times, Center for
Epidemiologic Studies Depression Scale scores, self-efficacy scores, and Short Form 36 physical
component summaries.
Similarly, a systematic review and meta-analysis concluded that research results are encouraging and
suggest that tai chi may be effective in controlling pain and improving physical function in patients with
knee osteoarthritis.
[95]
The researchers noted, however, that the strength of the evidence is limited by
the small number of randomized, controlled trials with a low risk of bias.
Assistive devices
The use of assistive devices for ambulation and for activities of daily living (ADLs) may be indicated
for patients with osteoarthritis. Braces and appropriate footwear may also be of some use. A cane can
be used in the contralateral hand for hip or knee osteoarthritis. The patient can be taught joint-
protection and energy-conservation techniques.
For patients with hand osteoarthritis, the ACR conditionally recommends evaluating the patients
ability to perform ADLs and providing assistive devices as needed. The ACR conditionally
recommends splints for patients with trapeziometacarpal joint involvement.
[87]

Occupational therapy and physical therapy
Occupational adjustments may be necessary for some patients with osteoarthritis. An occupational
therapist can assist with evaluating how well the patient performs ADLs, as well as with retraining of
the patient as necessary. Joint-protection techniques should be emphasized. Physical therapy
modalities, especially those aimed at deconditioned patients, can be helpful, particularly in patients
with hip or knee involvement.
Electromagnetic field stimulation and TENS
A pulsed electromagnetic field stimulation device (Bionicare) has been approved by the US Food and
Drug Administration (FDA) for use in patients with knee osteoarthritis. Pulsed electromagnetic field
stimulation is believed to act at the level of articular cartilage by maintaining the proteoglycan
composition of chondrocytes through downregulation of its turnover.
[96]

A multicenter, double-blind, randomized, placebo-controlled 4-week trial in 78 patients with knee
osteoarthritis found improved pain and function in those who were treated with the device.
[97]
A double-
blind, placebo-controlled 3-month trial in 58 patients with moderate-to-severe knee osteoarthritis
showed that the use of a highly optimized, capacitively coupled, pulsed electrical stimulus device
yielded significant symptomatic and functional improvement.
[98]

Another randomized clinical trial demonstrated that pulsed short-wave treatment was effective in
relieving pain and improving function and quality of life in women with knee osteoarthritis on a short-
term basis; additional studies are needed to validate the 12-month follow-up.
[99]

Transcutaneous electrical nerve stimulation (TENS) may be another treatment option for pain relief.
To date, however, there is only limited evidence that TENS is beneficial in this setting. A systematic
review could not confirm that TENS is effective for pain relief in knee osteoarthritis.
[100]
A randomized
controlled trial found that TENS applied in conjunction with therapeutic exercise and daily activities
increased quadriceps activation and function in patients with tibiofemoral osteoarthritis.
[101]

Acupuncture
Acupuncture is becoming a more frequently used option for treatment of the pain and physical
dysfunction associated with osteoarthritis. Some evidence supports its use. For example, a review
article of randomized, controlled trials reported that the level of pain persisting after acupuncture was
significantly lower than the level of pain persisting after control treatments.
[102]

Several groups have issued guidelines regarding acupuncture for knee osteoarthritis. The AAOS
neither recommends nor opposes the use of acupuncture for pain relief in knee osteoarthritis, citing
inconclusive evidence.
[103]
OARSI suggests that acupuncture may yield symptomatic benefit in these
patients.
[65]
The ACR recommends traditional Chinese acupuncture for patients with chronic moderate-
to-severe pain who would be candidates for total knee arthroplasty but who either do not want it or
have contraindications to it.
[87]

Arthroscopy
A procedure of low invasiveness and morbidity, arthroscopy will not interfere with future surgery.
However, a randomized, controlled trial in patients with moderate-to-severe osteoarthritis found that
arthroscopic surgery for osteoarthritis of the knee provided no additional benefit beyond that afforded
by optimized physical and medical therapy.
[10]

Arthroscopy is indicated for removal of meniscal tears and loose bodies; less predictable arthroscopic
procedures include debridement of loose articular cartilage with a microfracture technique and
cartilaginous implants in areas of eburnated subchondral bone (see the images below). These
treatments have varying success rates and should be performed only by surgeons experienced in
arthroscopic surgical techniques.
[10, 104, 105]
Overall, arthroscopy is not recommended for nonspecific
cleaning of the knee in osteoarthritis.
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.
Patients who undergo arthroscopy usually require a period of crutch use or exercise therapy. This
period typically lasts days but sometimes extends for weeks.
Osteotomy
Osteotomy is used in active patients younger than 60 years who have a malaligned hip or knee joint
and want to continue with reasonable physical activity.
[106]
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. (The
effectiveness of osteotomy for genu valgum is not highly predictable.)
Osteotomy often can help individuals avoid requiring a total knee replacement until they are older. It
can lessen pain, but it can also lead to more challenging surgery if the patient later requires
arthroplasty.
Contraindications for osteotomy are as follows:
Knee flexion of less than 90
A flexion-extension contracture of more than 15
Varus over 15-20
Instability from previous trauma or surgery
Severe arterial insufficiency
Bicompartmental involvement
Patients undergoing osteotomy require partial weight-bearing until bony healing occurs. Afterward,
exercise is indicated.
Arthroplasty
Arthroplasty consists of the surgical removal of joint surface and the insertion of a metal and plastic
prosthesis (see the images below). The prosthesis is held in place by cement or by bone ingrowth into
a porous coating on the prosthesis. The use of cement results in faster pain relief, but bone ingrowth
may provide a more durable bond; accordingly, prostheses with a porous coating are used in younger
patients.
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.
Lateral radiograph obtained after knee replacement (same patient as in the above image).
Arthroplasty is performed if all other modalities are ineffective and osteotomy is not appropriate or if a
patient cannot perform ADLs despite maximal therapy.
[107, 108]
This procedure alleviates pain and may
improve function. At a minimum, 10-15 years of viability are expected from joint replacement in the
absence of complications.
Infection is a particular postoperative concern in cases of total joint replacement. This complication is
now rare, however, especially with the use of perioperative antibiotics.
Prevention of thrombophlebitis and resultant pulmonary embolism is important in patients who
undergo lower-extremity arthroplasty procedures for osteoarthritis. The surgeon must use all means
available to prevent these complications. Early motion and ambulation, when possible, are of
particular importance. The use of low-molecular-weight heparin or warfarin is also indicated.
After joint replacement, patients require partial weight-bearing, which progresses to full weight-bearing
in 1-3 months; range-of-motion and strengthening exercises are started within a few days after joint-
replacement surgery and continued until the patient has good range of motion and strength. After
resection arthroplasty of the hip, patients require instruction in the use of crutches or a walker, which
are usually needed permanently.
For more information, see the following articles:
Total Knee Arthroplasty
Unicompartmental Knee Arthroplasty
Surgical Treatment of Interphalangeal Joint Arthritis
Minimally Invasive Total Hip Arthroplasty
Fusion and Joint Lavage
Fusion consists of the union of bones on either side of the joint. This procedure relieves pain but
prevents motion and puts more stress on surrounding joints. Fusion is sometimes used after knee
replacements fail or as a primary procedure for ankle or foot arthritis.
Observational studies suggested a benefit for joint lavage. However, sham-controlled trials yielded
conflicting results, and a meta-analysis concluded that joint lavage does not result in pain relief or
improvement of function in patients with knee osteoarthritis.
[109]

Prevention
Overweight patients who have early signs of osteoarthritis or who are at high risk should be
encouraged to lose weight. Recommend quadriceps-strengthening exercises in patients with
osteoarthritis of the knees, except in those with pronounced valgus or varus deformity at the knees.
(See Lifestyle Modification, Physical/Occupational Therapy, and Other Nonpharmacologic Measures.)
It has been proposed that low vitamin D levels may play a role in the development and progression of
osteoarthritis; however, studies of vitamin D status and osteoarthritis have produced conflicting
results.
[110, 111]

A systematic review found no convincing evidence that selenium, vitamin A, or vitamin C is effective
for the treatment of osteoarthritis.
[112]
A prospective cohort study also found no evidence that vitamin C
supplementation slowed the progression of knee osteoarthritis; however, it did find that patients who
reported taking vitamin C were 11% less likely to develop knee osteoarthritis.
[113]

Medication Summary
The goals of pharmacotherapy in osteoarthritis are to reduce morbidity and to prevent complications.
To date, no disease-modifying or structure-modifying intervention has been proved effective in
osteoarthritis. Pay careful attention to a particular pharmacologic regimens adverse-event profile.
Pharmacologic agents used in the treatment of osteoarthritis include the following:
Acetaminophen
Nonsteroidal anti-inflammatory drugs (NSAIDs), oral and topical
Intra-articular corticosteroids
Intra-articular sodium hyaluronate
Opioids
Duloxetine
Muscle relaxants
Nutriceuticals (eg, glucosamine/chondroitin sulfate)
Analgesics, Other
Class Summary
Pain control is essential to the management of osteoarthritis. The goals of treatment include pain
alleviation and improvement of functional status.
View full drug information
Acetaminophen (Tylenol, Panadol, Aspirin-Free Anacin)

An initial trial with acetaminophen is warranted in patients with mild-to-moderate osteoarthritis
symptoms who do not derive sufficient relief from nonpharmacologic measures. Acetaminophen is the
drug of choice for patients who have a documented hypersensitivity to aspirin or NSAIDs, who have a
history of upper gastrointestinal (GI) tract disease, or who are on anticoagulants.
NSAIDs
Class Summary
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. They are used to relieve
osteoarthritis pain when the clinical response to acetaminophen is unsatisfactory. The mechanism of
action is nonselective inhibition of cyclooxygenase (COX)-1 and COX-2, resulting in reduced
synthesis of prostaglandins and thromboxanes. Other mechanisms may also exist, such as inhibition
of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation,
and various cell-membrane functions.
In more inflammatory presentations of osteoarthritis, such as knee involvement with effusion, these
agents may be used as first-line pharmacologic therapy. Use the lowest effective dose or intermittent
therapy if symptoms are intermittent. All of these medications increase the risk for GI ulcers and have
been associated with increased risk of cardiovascular disease. Patients at high risk for GI toxicity may
consider adding misoprostol or a proton-pump inhibitor to the regimen or substituting a COX-2
specific inhibitor for the NSAID.
Ketoprofen (Orudis, Oruvail)

Ketoprofen is indicated for relief of mild-to-moderate pain and inflammation. Small dosages are
initially indicated in small and elderly patients and in those with renal or liver disease. Doses higher
than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely
observe the patient for response.
Piroxicam (Feldene)

Piroxicam decreases the activity of cyclooxygenase, which in turn inhibits prostaglandin synthesis.
These effects decrease formation of inflammatory mediators.
Ibuprofen (Ibuprin, Advil, Motrin)

Ibuprofen relieves pain and inflammation. It is widely available and is relatively inexpensive as a
generic drug. After the very early stages of osteoarthritis, inflammation begins to play a role in the
disease. Thus, medications with a combination of analgesic and anti-inflammatory properties become
more desirable, at least in theory.
Meloxicam (Mobic)

To some extent, meloxicam is more selective for COX-2 receptors than traditional NSAIDs are. It
decreases the activity of cyclooxygenase, thereby, in turn, inhibiting prostaglandin synthesis. These
effects decrease the formation of inflammatory mediators.
Diclofenac (Voltaren, Arthrotec, Cataflam)

Diclofenac is one of a series of phenylacetic acids that have demonstrated anti-inflammatory and
analgesic properties in pharmacologic studies. It is believed to inhibit cyclooxygenase, which is
essential in the biosynthesis of prostaglandins. Diclofenac can cause hepatotoxicity; hence, liver
enzymes should be monitored in the first 8 weeks of treatment.
Diclofenac is rapidly absorbed; metabolism occurs in the liver by demethylation, deacetylation, and
glucuronide conjugation. The delayed-release, enteric-coated form is diclofenac sodium, and the
immediate-release form is diclofenac potassium. It poses a relatively low risk for bleeding GI ulcers.
Naproxen (Aleve, Anaprox, Anaprox DS, Naprelan, Naprosyn)

Naproxen is used for relief of mild to moderate pain. It inhibits inflammatory reactions and pain by
decreasing the activity of cyclooxygenase, which is responsible for prostaglandin synthesis. NSAIDs
decrease intraglomerular pressure and decrease proteinuria.
Celecoxib (Celebrex)

Celecoxib is a COX-2specific inhibitor. At therapeutic concentrations, COX-2 (inducible by cytokines
at sites of inflammation, such as the joints) is inhibited, and COX-1 isoenzyme (present in platelets
and the GI tract) is spared; therefore, in nonaspirin users, the incidence of GI toxicity (eg, endoscopic
peptic ulcers, bleeding ulcers, perforations, and obstructions) is decreased in comparison with that
seen in patients taking nonselective NSAIDs.
COX-2 is expressed in the kidney; however, the renal safety profile of celecoxib is not significantly
superior to that of nonselective NSAIDs. Selective COX-2 inhibitors may increase the risk of cardiac
disease; 1 drug in this class, rofecoxib, has already been removed from the market for this reason.
Celecoxib is currently under investigation for a possible associated risk of accelerated cardiac
disease.
Antidepressants, SNRIs
Class Summary
The selective serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine may be effective for
reducing osteoarthritis pain.
Duloxetine (Cymbalta)

Potent inhibitor of neuronal serotonin and norepinephrine reuptake. Indicated for chronic
musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain.
Analgesic, Topical
Class Summary
Topical analgesics are used for osteoarthritis involving relatively superficial joints, such as the knee
joint and the joints of the hands. They are much less effective for deeper joints, such as the hip joint.
Capsaicin (Dolorac, Capsin, Zostrix, Civamide)

Capsaicin is a topical analgesic of choice in osteoarthritis. Derived from plants of the Solanaceae
family, it may render skin and joints insensitive to pain by depleting substance P in peripheral sensory
neurons. Capsaicin must be used for at least 2 weeks for the full effects to be appreciated.
Opioid Analgesics
Class Summary
Opioid analgesics are used in patients whose pain has not been controlled with weaker analgesic
medications. They are a particularly reasonable choice in patients who do not want joint-replacement
surgery, are too medically ill for joint replacement, are not candidates for joint replacement for other
reasons, or are trying to buy time for subsequent joint-replacement surgery.
Elderly patients (aged 65 years and older) with arthritis are more likely to incur a fracture when
initiating opioid therapy as opposed to NSAID therapy. A higher opioid dose is associated with a
greater risk of fracture; this risk is due to an increased risk of falls. During the first 2 weeks after
initiation of opioid treatment, short-acting opioids are associated with a greater fracture risk than long-
acting opioids are.
[114]

Tramadol (Ultram, Ultram ER)

Tramadol inhibits ascending pain pathways, altering perception of and response to pain. This agent
also inhibits the reuptake of norepinephrine and serotonin.
Oxycodone (OxyContin, Roxicodone)

Pure narcotic analgesics, such as oxycodone, might be the initial drug of choice. Eventually, this
short-acting narcotic can be replaced with a long-acting transdermal preparation, such as fentanyl
(Duragesic patch).
Corticosteroids
Class Summary
Intra-articular pharmacologic therapy includes corticosteroid injection and viscosupplementation.
Steroid injections generally result in a clinically and statistically significant reduction in osteoarthritic
knee pain as soon as 1 week after injection. The effect may last, on average, anywhere from 4 to 6
weeks per injection, but the benefit is unlikely to continue beyond that time frame.
Methylprednisolone (Depo-Medrol, Medrol, Solu-Medrol)

Methylprednisolone decreases inflammation by suppressing migration of polymorphonuclear
leukocytes (PMNs) and reversing increased capillary permeability.
Betamethasone (Celestone Soluspan)

Betamethasone decreases inflammation by suppressing migration of PMNs and reversing increased
capillary permeability. It affects the production of lymphokines and has an inhibitory effect on
Langerhans cells.
Triamcinolone (Aristospan Intra-Articular)

Triamcinolone decreases inflammation by suppressing migration of PMNs and reversing capillary
permeability.
Intra-articular Agents
Class Summary
Intra-articular injections of these agents are used to treat patients with osteoarthritic knee pain that is
unresponsive to conservative nonpharmacologic therapy and simple analgesics (eg, acetaminophen).
Sodium hyaluronate (Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc, Synvisc-One)

Sodium hyaluronate is a hyaluronic acid derivative that supports the lubricating and shock-absorbing
properties of articular cartilage.
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Definisi
Osteoarthritis genu adalah suatu penyakit sendi degeneratif yang berkaitan dengan kerusakan kartilago
sendi lutut, merupakan suatu penyakit kerusakan tulang rawan sendi yang berkembang lambat dan
tidak diketahui penyebabnya, meskipun terdapat beberapa faktor resiko yang berperan. Keadaan ini
berkaitan dengan usia lanjut.

Anatomi
Sendi lutut merupakan gabungan dari tiga sendi yaitu patelofemoral, tibiofemoral medial dan
tibiofemoral lateral. Pada sendi tibiofemoral, terdapat meniskus lateralis dan medial. Meniskus
merupakan diskus fibrokartilago pipih atau segitiga atau irreguler yang melekat pada kapsul fibrosa dan
selalu pada salah satu tulang yang berdekatan. Meniskus mengandung kolagen tipe I sampai 60-90%
sedangkan proteoglikan hanya 10%. Konstituen glikosaminoglikan yang terbanyak adalah kondroitin
sulfat dan dermatan sulfat sedangkan keratan sulfat sangat sedikit. Selain itu fibrokartilago meniskus
juga lebih mudah membaik bila rusak. Sendi lutut diperkuat oleh kapsul sendi yang kuat, ligamen
kolateral dan medial yang menjaga kestabilan lutut agar tidak bergerak ke lateral dan medial dan
ligamentum krusiatum anterior dan posterior yang menjaga agar tidak terjadi hiperfleksi dan
hiperekstensi sendi lutut. Fleksi lutut akan diikuti rotasi internatibia, sedangkan ekstensi lutut akan
diikuti rotasi untuk memperbesar momen gaya pada waktu lutut ekstensi sehingga kerja otot quadriceps
femoris tidak terlalu kuat.

Patofisiologi
Terdapat dua perubahan morfologi utama yang mewarnai osteoartritis yaitu kerusakan tulang rawan
sendi yang progresif dan pembentukan tulang baru pada dasar lesi tulang rawan sendi dan tepi sendi
(osteofit). Perubahan yang lebih dulu timbul, sampai sekarang belum dimengerti. Penelitian-penelitian
menunjukan bahwa perubahan-perubahan metabolisme tulang rawan sendi telah timbul sejak proses
patologis osteoartritis. Perubahan tersebut berupa peningkatan aktivitas enzim-enzim yang merusak
makromolekul matriks tulang rawan sendi (proteoglikan dan kolagen). Hal ini menyebabkan penurunan
kadar proteoglikan, perubahan sifat-sifat kolagen dan berkurangnya kadar air tulang rawan sendi. Saat
ini osteoartritis tidak dipandang hanya sebagai proses degeneratif saja, tetapi juga merupakan suatu
penyakit dengan proses aktif. Dengan adanya perubahan-perubahan pada makromolekul tulang rawan
tersebut, sifat-sifat biomekanis tulang rawan sendi akan berubah. Hal ini akan menyebabkan tulang
rawan sendi rentan terhadap beban biasa. Permukaan tulang rawan sendi menjadi tidak homogen,
terpecah belah dengan robekan-robekan dan timbul ulserasi. Dengan berkembangnya penyakit, tulang
rawan sendi dapat hilang seluruhnya sehingga tulang dibawahnya menjadi terbuka. Pembentukan tulang
baru (osteofit) dipandang oleh beberapa ahli sebagai suatu proses perbaikan untuk membentuk kembali
persendian atau tepi sendi. Dengan menambah luas permukaan sendi yang dapat menerima beban,
osteofot mungkin dapat memperbaiki perubahan-perubahan awal tulang rawan sendi pada osteoartritis,
akan tetapi kaitan yang sebenarnya antara osteofit dengan kerusakan tulang rawan sendi belum jelas,
oleh karena osteofit dapat timbul pada saat tulang rawan sendi masih kelihatan normal.

Faktor Resiko
Ada beberapa faktor risiko yang diketahui berhubungan erat dengan terjadinya osteoartritis genu :

1. Umur
Dari semua faktor risiko timbulnya osteoartritis, faktor ketuaan adalah yang terpenting. Prevalensi dan
beratnya penyakit osteoartritis semakin meningkat dengan bertambahnya umur. Osteoartritis hampir
tidak pernah ditemukan pada anak, jarang pada umur dibawah 40 tahun dan sering pada umur diatas
60 tahun. Penderita osteoartritis genu meningkat pada usia lebih dari 65 tahun, baik secara klinik,
maupun radiologik. Gambaran radiologik yang berat (grade III dan IV menurut kriteria Kell-green-
Lawrence) makin meningkat dengan bertambahnya umur, yaitu 11,5% pada usia kurang dari 70 tahun,
17,8% pada umur 70-79 tahun dan 19,4% pada usia lebih dari 80 tahun, wanita yang mempunyai
gambaran radiologik oestoartritis berat 10,6% pada umur kurang dari 70 tahun, 17,6% pada umur 70-
79 tahun dan 21,1% pada umur lebih dari 80 tahun; sedangkan pada laki-laki 12,8% pada umur kurang
dari 70 tahun, 18,2 % pda umur 70-79 tahun dan 17,9% pada umur lebih dari 80 tahun. Prevalensi
radiologik osetoartritis akan meningkat sesuai dengan umur. Pada umur dibawah 45 tahun jarang
didapatkan gambaran radiologik yang berat. Pada usia tua gambaran radiologik osteoartritis genu yang
berat mencapai 20%. Pada penelitian lain didapatkan bahwa dengan makin meningkatnya umur, maka
beratnya osteoartritis secara radiologik akan meningkatkan secara esksponensial.

2. Jenis kelamin
Wanita lebih sering terkena osteoartritis genu dan laki-laki labih sering terkena osteoartritis paha,
pergelangan tangan dan leher. Secara keseluruhan, dibawah usia 45 tahun frekuensi osteoartritis
kurang lebih sama pada laki-laki dan wanita, tetapi diatas usia 50 tahun setelah menopause frekuensi
osteoartritis lebih banyak pada wanita dibanding pria. Hal ini menunjukkan adanya peran hormonal. Dari
500 pasien dengan osteoartritis pada anggota badan, ternyata 41,9% adalah penderita osteoartritis
genu dan jumlah wanita lebih banyak dari laki-laki (1,3 : 1)

3. Pekerjaan
Pekerjaan berat maupun pemakaian satu sendi yang terus-menerus berkaitan dengan peningkatan
resiko osteoartritis. Pekerjaan dan olahraga juga merupakan faktor predisposisiosteoantrosis sendi lutut.
Penelitian HANES I mendapatkan bahwa pekerja yang banyak membebani sendi lutut akan mempunyai
resiko terserang osteoartritis genu lebih besar dibandingkan pekerja yang tidak banyak membebani
lutut.

4. kegemukan
Berat badan yang berlebihan nyata berkaitan dengan meningkatnya risiko untuk timbul osteoartritis
pada wanita maupun pria. Maquet berusaha menjelaskan secara biomekanika beban yang diterima lutut
pada obesitas. Pada keadaan normal, gaya berat badan akan melalui medial sendi lutut dan akan
diimbangi oleh otot-otot paha bagian lateral sehingga resultannya akan jatuh pada bagian sentral sendi
lutut. Pada keadaan obesitas, resultan gaya tersebut akan bergeser ke medial sehingga beban yang
diterima sendi lutut tidak seimbang. Pada keadaan yang berat dapat timbul perubahan bentuk sendi
menjadi varus yang akan makin menggeser resultan gaya tersebut ke medial.
5. suku bangsa
prevalensi dan pola terkenanya sendi pada osteoartritis tampak berbeda diantara masing-masing suku
bangsa. osteoartritis genu lebih sering ditemukan pada orang Asia, sedangkan osteoartritis panggul
lebih sering pada orang Kaukasia. osteoartritis paha lebih jarang pada kulit hitam dan asia dibanding
kaukasia. Hal ini mungkin berkaitan dengan perbedaan cara hidup maupun perbedaan pada frekuensi
kelainan kongenital dan pertumbuhan. Frekuensi osteoartritis genu pada wanita kulit hitam lebih tinggi
dibandingkan dengan pada wanita kulit putih, sedangkan pada laki-laki, frekuensi pada kulit hitam sama
dengan pada kulit putih.
6. genetik
adanya mutasi pada gen prokolagen II atau gen-gen struktural lain untuk unsur-unsur tulang rawan
seperti kolagen tipe IX dan XII, protein pengikat atau proteoglikan dikatakan berperan dalam timbulnya
kecenderungan familial pada osteoartritis.
7. faktor lain
tingginya kepadatan tulang dikatakan dapat meningkatkan risiko timbulnya osteoartritis.
Hal ini mungkin timbul karena tulang yang lebih padat (keras) tidak membantu mengurangi benturan
beban pada sendi. Akibatnya tulang rawan sendi menjadi lebih mudah robek. Faktor ini diduga berperan
pada tingginya osteoartritis pada orang gemuk dan pelari
(yang umumnya mempunyai tulang yang lebih padat).
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