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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
knee. One should not confuse environmental factors as causes of OA. cartilage volume. or excessive kneeling. sex hormones. This effect underscores the need for continued muscle toning exercises in all individuals to prevent muscle dysfunction. This is especially true of individuals whose lifestyles require squatting. ankle. leading to increased joint motion. trauma. climbing stairs. of the hips. Pathophysiology . a gene for OA has been identified and plays an important role. or menisci lead to abnormal biomechanics in the joints and enhance their premature degeneration. resulting in OA. to a lesser extent. The hereditary component has long been recognized.The daily stresses applied to the joints. ligaments. However. Muscle dysfunction compromises the body's neuromuscular protective mechanisms. particularly with generalized OA. obesity. especially the weight-bearing joints (eg. It has been strongly linked to OA of the knees and. estrogen replacement therapy lowers the expected rate of radiographic and clinical findings in the knees and hips. Potential risk factors include age. however. proteoglycan content.6 and environment. biochemical and pathophysiologic findings support the notion that age alone is an insufficient cause of OA. hip). Obesity increases the mechanical stress in a weight-bearing joint. play an important role in causing osteoarthritis (OA). because these factors actually cause traumatic arthritis on a macrotraumatic or microtraumatic basis. genetics.8 Old joints and osteoarthritic joints differ. Traumatic insults to the articular cartilage. and cartilage perfusion are reduced and may result in certain characteristic radiologic features that include joint-space narrowing and marginal osteophytes. muscle weakness.7. cartilage vascularization. With advancing age. Menopause often increases the progression of OA.
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). Compression of the exposed trabecular bone can cause a fracture. . and cartilaginous vertical clefts develop (fibrillation). As a result. which reflect an effort by the chondrocytes to repair the damage sustained. which leads to its softening. In addition to the articular cartilage. and new bone formation (bony eburnation) can take place. Presentation Pain is the most important symptom of osteoarthritis (OA). and neuromuscular apparatus may also show pathophysiologic changes. Changes resulting from repetitive microtrauma are usually seen in the load-bearing areas of the articular cartilage. ligaments. As the disease progresses. When pain occurs at rest. Simultaneously. However. the synovium. is mild to moderate in intensity. loss of joint surface integrity occurs. subchondral bone. usually occurs after joint activity. deeper lesions expose the subchondral bone. OA usually begins with the swelling of the cartilage due to the increased synthesis of proteoglycans.The pathology of osteoarthritis (OA) is the result of both the combined effect of tissue damage and an immune reaction to that damage. The exposed bony surface can have necrotic lesions that lead to the formation of bone cysts. it is indicative of severe OA. and it is characterized by hypertrophic repair of the articular cartilage. This stage may last for years or decades. causing a loss of elasticity in the cartilage. the level of proteoglycans is remarkably diminished. and is relieved with rest. It begins early in the course of the disease. the thickness of the joint surface is reduced.
Spinal stenosis is caused by facet arthritic changes that result in compression of the nerve roots. Symptoms include pain. Stiffness after a period of inactivity and gradual improvement after a short period of movement is known as the "gel phenomenon. and occasional radicular pain from spinal stenosis. When an osteoarthritic knee or ankle joint is examined. Frequently. but a loss of extension also occurs. Excessive pain causes a loss of full joint extension and limited range of motion (ROM) during ambulation. Heberden nodes occur around the distal interphalangeal joints. with the duration usually being less than 30 minutes.When the spine is involved in OA. its risk-to-benefit ratio must be carefully evaluated. . whereas the duration is much longer in inflammatory rheumatoid arthritis. especially in young patients with OA that is secondary to trauma or sportsrelated injuries. The tenderness experienced by osteoarthritic patients usually emanates from arthritis changes in the hip. and a loss of motion and a crepitant feeling are detected. Localized tenderness. certain general aspects are important to consider—for instance. The occurrence of an acquired spondylolisthesis is a common denominator of arthritis of the lumbar spine. this pain is difficult to mask and is accompanied by a hip flexion contracture. Indications Before any surgical procedure is considered. causing ambulatory episodes of giving way or buckling to occur." Muscle activity in patients with OA is lessened because of pain and increased symptomatology. is often present. and Bouchard nodes are seen at the proximal interphalangeal joints.Morning stiffness in OA is brief and localized. especially in superficial joints. especially the lumbar spine. Not only is there loss of hip motion.9 Although no surgical procedure is absolutely indicated or contraindicated for osteoarthritis (OA). such as the knee or ankle. bony enlargement due to proliferative change is often noted. Secondary genu varum or valgum deformity may be present when patients ambulate. the associated changes are very commonly seen from L3 through L5. stiffness. as evidenced by the hip flexion contracture. leading to inevitable joint deformity and a loss of function. in affected osteoarthritic hands.
Relevant Anatomy See Treatment. consider a magnetic resonance image (MRI) study. 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. especially if osteonecrosis of the hip. This procedure also relieves the pain . which would provide the most information about what is occurring in the affected area. it is also expensive and should never be the primary imaging study. radiographic evaluation is often needed. Imaging Studies The diagnosis of osteoarthritis (OA) is usually made based on the history and physical examination findings. dental. Local and remote (eg. in the absence of other bony changes such as subchondral cysts or sclerosis. The patient's vascular status may need to be evaluated. however.11. These factors must be integrated into an overall evaluation in selecting the appropriate surgical procedure. and the cell count is slightly increased but always less than 1000/mm3. When radiographic findings are normal but the pain is persistent. Synovial fluid: The viscosity is good. Another important aspect in selecting a surgical procedure is its long-term functional outcome in patients. Also. Computed tomography (CT) scanning has no advantage in the primary diagnosis of OA. Radiographic evidence of osteophytes. Conventional radiographs are sensitive and cost-effective and should be the initial imaging study in the routine evaluation of OA10. may be a manifestation of aging and not OA. Diagnostic Procedures Arthrocentesis is often performed for osteoarthritis (OA) to assist with the differential diagnosis of a septic or crystal-induced arthritis. except in those patients with the erosive inflammatory or generalized forms of the disease. Surgical therapy. Patients may need to be medically cleared for surgery by their primary care physician. Characteristic findings of degenerative arthritis are osteophytes and joint-space narrowing. or ankle may be occurring. knee. urinary) infections must be ruled out or cured. Contraindications Patients with osteoarthritis (OA) must be evaluated for contraindications to surgery. Laboratory Studies Hematologic findings: Generally.14 . MRI is very sensitive and is useful at times. The erythrocyte sedimentation rate (ESR) is normal.12. however. no abnormal hematologic findings are seen in patients with osteoarthritis (OA). An MRI could confirm the diagnosis of such conditions as avascular necrosis and/or soft-tissue meniscal changes or tearing. The main indication for this imaging modality is the detection of the small intraarticular bodies seen in advanced cases of OA.pain at rest that requires narcotics for control.13. MRI is indicated whenever there is confusion regarding the diagnosis.
Samples of the joint fluid may be sent for analysis.15 Physical therapy Physical therapy has an important role in the management of OA. and they are costly. including physical therapy to increase muscle tone and joint motion. Italy).5 inches Grade IV . Arthroscopy is also used for visual inspection for pathology. flexibility.Erosion down to the subchondral bone Treatment Medical Therapy Currently. avoidance of certain activities (eg. 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 . squatting). 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. including aspirin and nonsteroidal antiinflammatory drugs (NSAIDs). including muscle strengthening and improving ROM. Genzyme Biosurgery. and aerobic conditioning.Fragmentation and fissuring of less than 0. Fidia Farmaceutici SpA. such as Synvisc (Hylan G-F 20. along with the injection of hyaluronic acid medications. If steroids are overutilized.associated with the effusion. Modification of the patient's lifestyle is also important. measures may include weight reduction. and pharmacotherapy. Padua. Arthroscopy is indicated after all conservative treatments have failed. Ridgefield. NJ) and Hyalgan (sodium hyaluronate. . The procedure supplies a direct vision of what is going on and is often all that is necessary to relieve the patient's pain. products containing these agents have not been proven to work (although they may). especially if a crystalline arthritis or an infection is suspected. Glucosamine and chondroitin sulfate may also have a role in the treatment of OA. Abano Terme. weight loss.Softening and swelling Grade II . Prior to using the hyaluronic injections.16 Exercise programs can be designed to achieve various goals. restriction of vigorous activities.5 inches Grade III . the various treatments of osteoarthritis (OA) are aimed at controlling the symptoms of pain. one should aspirate the knee and instill steroids. kneeling. Topical analgesic creams may be appropriate early on. medications.Fragmentation and fissuring of greater than 0. and use of supportive devices.
Physical modalities that can reduce OA pain include cold application in the acute phase. weight control. However. the use of superficial heat in the subacute phase.17 Nonpharmacologic modalities Nonpharmacologic modalities should be considered as initial management in the early stages of OA disease. superficial-heat application in the subacute phase. walker) and/or orthoses (eg. methylsalicylate or capsaicin cream) is appropriate in cases of knee OA with mild to moderate pain. hand splint. cane. New York. Pfizer Inc. NSAID-treated patients had significantly greater improvement in both pain at rest and pain during motion. and avoiding activities such as kneeling and squatting that increase stress to weightbearing joints. COX-2 inhibitors have a more specific anti-inflammatory effect with fewer . either as an adjunctive treatment or as monotherapy. and NSAIDs. and deep-heat application in the chronic phase. and the use of deep heat in the chronic phase of the disease. and the use of gait aids (eg.Physical modalities may include the application of cold to affected areas to decrease pain during the acute inflammation phase. Patients should be educated about OA. 5-28] than in the balance group. Muscle strengthening. NY) have been studied in patients with OA. knee brace) may be useful as well. aerobic conditioning. Other alternative or additional pharmacologic agents should be considered in patients in whom symptomatic relief is inadequate. In a recent meta-analysis of trials comparing simple analgesics with NSAIDs in patients with knee OA. greater improvement was noted in the strength group regarding knee-related quality of life (improved 17 points out of 100 [95% confidence interval (CI). A topical analgesic cream (eg. Range-of-motion (ROM) exercises and stretching may be helpful. inhibitors such as celecoxib (Celebrex. Pain relief can be achieved with low-to-moderate doses of simple analgesics and anti-inflammatory medications such as acetaminophen. Chaipinyo et al found no significant difference between home-based strength training and home-based balance training for knee pain caused by osteoarthritis. aspirin. The agent should be carefully selected after risk factors such as serious gastrointestinal and renal toxicity are evaluated. Pharmacotherapy Nonpharmacologic strategies should be considered as adjuncts to pharmacologic measures. Cyclooxygenase 2 (COX-2)–specific inhibitors.
Pfizer Inc) were withdrawn from the US market on September 30. Vioxx was withdrawn from the world market. and April 7. Whitehouse Station. these procedures have varying success rates and should only be used by those surgeons experienced with arthroscopic surgical techniques. occasional intra-articular injections of corticosteroids may provide temporary benefit in flare-ups and in the relief of symptoms. compared with that of placebo. 2005.18. Fusion of a joint (eg. Surgical Therapy Surgery is indicated in those patients who have significant symptoms that have not responded to conservative therapy.15 NSAIDs and topical creams containing an NSAID or capsaicin may have a role as well. Merck & Co. whether it is treatment by oral or injected medications or the supportive role of physical therapy. NJ) and valdecoxib (Bextra. Inc. Additionally.21 Arthroscopic view of a torn meniscus before (top) and after (bottom) removal of loose meniscal fragments. Paracetamol (acetaminophen) is the drug of choice in the management of OA. respectively. Oral corticosteroids have no place in the management of OA. Less predictable arthroscopic procedures include debridement of loose articular cartilage with a microfracture technique. but this procedure may be the only one that will work in a patient with infection following one of the other procedures. or an arthroplasty such as the Genzyme procedure. Severe dermatologic toxicities resulting in death have occurred with Bextra. The COX-2 inhibitors rofecoxib (Vioxx. valgus osteotomy for significant genu varum. ankle) is rarely done today. . This procedure is especially indicated for removal of meniscal tears and of any loose bodies that can occur. 2004. because of their association with an increased rate of cardiovascular events (including heart attacks and strokes). knee. hip. or total knee arthroplasty. cartilaginous implants in areas of eburnated subchondral bone.19. The lower extremity surgical procedures include arthroscopy with debridement. Oral glucosamine may have a role in the treatment of OA. and it may exert its effect by providing physical cushioning or viscosupplementation of the joint. Hyaluronic acid therapy consists of a series of injections.20. Arthroscopy Arthroscopy is a procedure of low invasiveness and morbidity and will not interfere with future surgery. Celecoxib is more effective than placebo and has an efficacy comparable to that of naproxen in patients with hip or knee OA. However.adverse effects.
"18 In an accompanying editorial. Contraindications for an osteotomy are knee flexion less than 90°. Arthroplasty Arthroplasty (total joint replacement) is an excellent treatment in individuals with moderate to severe OA."20 Osteotomy Osteotomy is used in active patients younger than 60 years who want to continue with reasonable physical activity.Arthroscopic view of an arthritic knee. The rate of revision for arthroplasty has decreased with advances in the technique and prosthesis . 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 "). 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. a flexion-extension contracture of more than 15°. "However. can significantly improve the patient's quality of life."19 Also see the Medscape article "Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis. it was found that "arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.) Osteotomy often can save individuals from having a total knee replacement until they are older. and a significant amount of varus over 15°-20°. severe arterial insufficiency. and bicompartmental involvement are also contraindications. Marx stated. and has results that last the longest. Arthroscopic view of a knee after the removal of loose fragments of articular and meniscal cartilage. Osteotomy is most beneficial for significant genu varum or bowleg deformity. osteoarthritis is not a contraindication to arthroscopic surgery.23 This procedure is the most reliable. Arthroscopic view of the removal of cartilaginous loose body.9.10.22 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. (Note: The osteotomy for genu valgum is not a procedure of high predictability regarding its effectiveness. Instability due to previous trauma or surgery.
Anteroposterior radiograph obtained after knee replacement (see Image below). Lateral radiograph obtained after knee replacement (same patient as in Image above). The prosthesis is held in place by cement or bone ingrowth into the porous coating. Arthroplasty consists of the surgical removal of joint surface and the insertion of a metal and plastic prosthesis. with medial joint-space narrowing and subchondral sclerosis. The use of cement relieves pain more quickly. a porous coating is used in younger patients. Candidates are preferably older than 60 years. Intraoperative Details . so that they are less likely to need a repeat procedure. therefore.design. Anteroposterior radiograph shows knee replacement in 1 knee and arthritis in the other. Anteroposterior radiograph of the pelvis and hips shows an arthritic hip not treated surgically and a total hip replacement. Resection arthroplasty consists of the removal of the joint and allowing the scar to separate the bones and to help in reducing pain. Preoperative Details See Contraindications. 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. 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. Fusion is sometimes used after knee replacements fail or as a primary procedure for ankle or foot arthritis. but a porous coating may last longer. This procedure relieves the pain but prevents motion and puts more stress on the surrounding joints.
Younger and more active patients will require revisions. especially initiating early motion and ambulation when possible. ROM and strengthening exercises are started within a few days after joint-replacement surgery and continued until the patient has good ROM and strength. they are examined at least yearly. Afterward. After joint replacement. Postoperative Details Postoperative care for the lower extremities may vary depending on the treatment used. whereas the majority of older patients do not require revision. This complication is now rare. Surgical therapy. After resection arthroplasty of the hip. Patients who undergo arthroscopy usually require a period of crutch use and/or exercise therapy. above. The longevity of the prosthetic implant depends upon the patient's activity. Follow-up Patients are monitored regularly until they have recovered from surgery. The surgeon must use all of the material available to prevent these complications.See Treatment. especially in cases of total joint replacement. . The use of lowmolecular-weight heparin or warfarin is also indicated. especially with the use of perioperative antibiotics. which progresses to full weight bearing in 1-3 months. 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. Outcome and Prognosis Success rates with hip and knee arthroplasty are generally more than 90%. this typically lasts days or sometimes weeks. exercise is indicated. The prevention of thrombophlebitis and resultant pulmonary embolism is important in patients who undergo lower extremity arthroplasty procedures for osteoarthritis. patients require partial weight bearing. Those patients undergoing osteotomy and fusion require partial weight bearing until bony healing occurs. which is usually needed permanently. afterward. Complications Infection is the most feared postsurgical complication. patients require instruction in the use of crutches or a walker.