IM MINI REVALIDA

CASE: Osteoarthritis
Prepared by: CC (Pensotes, Darryl Van) & CC (Perez, Cristine)

DEFINITION

Osteoarthritis (OA).is a disabling joint disease characterized by a noninflammatory degeneration of the joint complex
(articular cartilage, subchondral bone, and synovium) that occurs with old age or from overuse. It mainly affects the
weight-bearing and high-use joints, such as the hip, knee, hands, and vertebrae.

EPIDEMIOLOGY

According to the Philippine Rheumatology Association, OA is the most common joint disease worldwide. In the
Philippines, it ranks second to soft tissue rheumatism as the most common musculoskeletal condition seen in an urban
Filipino population and in the rural population. Its prevalence is 0.5% in individuals aged 20 years and above and
increases to 11% in the population aged 60 years and above. Therefore, we are looking at roughly 10 million Filipinos
with the disease and this number is expected to double in the next 25 years.

Sex: female > male

Specific joints: knee > hip > hand

ETIOLOGY/RISK FACTORS

Nonmodifiable risk factors

● Age (> 55 years)
● Sex
● Family history
● History of joint injury or trauma
● Anatomic factors causing asymmetrical joint stress
○ Varus (Bow-legged) knees - stress on medial knee compartment
○ Valgus (Knock- kneed) knees - stress on lateral knee compartment
● Hemophilic hemarthroses and deposition diseases that stiffen cartilage

Modifiable risk factors

● Obesity
● Excessive joint loading or overuse (mechanical stress)

PATHOPHYSIOLOGY

Chronic mechanical stress on the joints and age-related decrease in proteoglycans → cartilage loses elasticity and
becomes friable → degeneration and inflammation of cartilage → joint space narrowing and thickening and sclerosis of
the subchondral bone

CLINICAL MANIFESTATIONS

(include pertinent PE findings for the diagnosis and how to elicit)

Early clinical findings
● Pain during or after exertion (e.g., at the end of the day) that is relieved with rest
● Pain in both complete flexion and extension
● Crepitus on joint movement
● Joint stiffness and restricted range of motion
● Radiating or referred pain (e.g., coxarthrosis may lead to knee pain)
● Possible varus formation if the knee is affected
○ loss of cartilage usually begins medially
 ● Joints are usually asymmetrically involved
○ opposed to rheumatoid arthritis
Late clinical findings
● Constant pain (including at night)
● Morning joint stiffness usually lasting < 30 minutes
● More severely restricted range of motion

Subtypes and variants

● Heberden's nodes: pain and nodular thickening on the dorsal sides of the distal interphalangeal joints (DIP)
● Bouchard's nodes: pain and nodular thickening on the dorsal sides of the proximal interphalangeal joints (PIP)
● Rhizarthrosis: osteoarthritis of the first carpometacarpal joint (base of the thumb)
○ between the trapezoid and the first metacarpal bone
● Hallux rigidus: arthrosis of the first metatarsophalangeal joint
○ between the first metatarsal and the first proximal phalanx
○ characterized by hypertrophy of the sesamoid bones
● Coxarthrosis - OA of the hip
● Gonarthrosis - OA of the knee

DIFFERENTIAL DIAGNOSIS

Rheumatoid Arthritis
● OA in the middle-aged or older adult patient is most commonly confused with rheumatoid arthritis (RA) when it
involves the hand joints.
● Nodal OA of the hands typically affects the distal interphalangeal (DIP) joints and is frequently associated with
the highly characteristic Heberden nodes. By contrast, RA typically targets the metacarpophalangeal (MCP)
and proximal interphalangeal (PIP) joints, and Heberden nodes are absent. The carpometacarpal (CMC) joint of
the thumb is typically involved in OA, rather than the PIP joint in RA. Swelling of the joints is hard and bony in
OA; by comparison, soft, warm, and tender joint swelling is typical of RA.
● Stiffness of the joint is a very common feature of RA, but it is a relatively rare feature of OA. Furthermore, the
stiffness of RA is characteristically worse after resting the joint (eg, morning stiffness), while the stiffness of OA
(if present) is typically worse after any effort and is often described as evening stiffness. Early morning or
inactivity-related stiffness lasts for at least 30 minutes in RA, while early morning or inactivity-related stiffness
lasts for only a few minutes in people with OA.
Psoriatic Arthritis
● Psoriatic arthritis targets the DIP joints of the hands, which can be observed in hand OA. However, unlike hand
OA, psoriatic arthritis may target just one finger, often as dactylitis, and characteristic nail changes are usually
present.

Summary:
 DIAGNOSTIC PLAN

(Bases of each test, expected findings with normal/reference values)

Osteoarthritis is usually diagnosed on the basis of clinical features.
1. Radiography: evidence of joint degeneration supports the diagnosis of OA
a. Indications
i. Chronic hand and hip pain thought to be due to OA
- Since diagnosis if often unclear without confirming radiograph
ii. Symptoms and signs are not typical of knee OA
iii. Knee pain persists after inauguration of effective treatment
b. Radiological signs of osteoarthritis
i. Irregular joint space narrowing
ii. Subchondral sclerosis
- dense area of bone just below the cartilage zone of a joint, formed due to a
compressive load on the joint
iii. Osteophytes (bone spurs)
- bony projections that develop on joint surfaces as spurs or densifications
- develop on the edges of the joint and thereby increase the joint surface
iv. Subchondral cyst
- fluid-filled cyst that develops at the surface of a joint due to local bone necrosis
induced by the joint stress

Other possible tests

1. Synovial Fluid Analysis: can help identify between causes of arthritis
a. American Rheumatologic Association guidelines
i. Non-inflammatory <200 to 2000 WBC/mm^3
1. osteoarthritis or meniscal tears
ii. Inflammatory >2000 to 50,000 WBC/mm^3
1. RA, psoriatic arthritis, gout, pseudogout, infection, or spondyloarthritis
iii. Infectious > 50,000 WBC/mm^3
1. acute septic arthropathy, subacute or chronic septic arthropathy, or periprosthetic joint
infection
2. Arthroscopy: thickened capsule, synovial hypertrophy, and/or ulcerated cartilage

MANAGEMENT

PHARMACOLOGIC (include Dosage, Route of Administration)

● Paracetamol
○ First line for reduction of mild knee OA pain
○ Maximum dose of 4g daily
○ Close monitoring for upper GI adverse events for doses greater than 2g/day
● Tramadol
○ Control of moderate pain and improvement of function in knee OA
○ It is further recommended that patients be warned of AEs like dizziness and vomiting
● Oral NSAIDs and COXIBs up to 2 weeks duration
○ Recommended for their small to moderate effect in reducing exacerbations of knee OA pain and
improving function
○ Caution using these drugs in the elderly or those at high risk for renal, CV, and GI complications
○ Topical NSAIDs recommended for control of symptomatic or acute exacerbation of knee OA and
improvement of function (less systemic side effects compared to oral)
● Intra-articular (IA) steroids
○ For moderate symptomatic exacerbations of knee OA and improvement of function, with effects of up to
1-3 weeks
○ To demonstrate long term benefit (16-24 weeks), a dose equivalent to 50 mg of prednisone is
recommended.
○ Further injections in case of recurrence should not exceed 3 times per year in the same joint
○ No data to support role of oral steroids in the treatment of knee OA
● Intra-articular hyaluronic acid (IAHA)
 ○ Administered by experts in 3-5 weekly injections
○ Moderate pain reduction and improvement of function in patients with moderate knee OA
○ More effective than IA steroids for its longer duration of pain control and improved function of up to 5-13
weeks
○ May be considered for subsets of patients with moderate knee OA while awaiting more definitive
treatment (surgery).
● Glucosamine
○ Use of pharmaceutical grade of glucosamine sulfate is recommended for its small benefit on pain
reduction and improvement of function in patients with knee OA
○ Use of glucosamine hydrochloride is not recommended for knee OA
● Chondroitin
○ Chondroitin sulfate is not recommended for knee osteoarthritis.
○ In general, the combination of glucosamine hydrochloride and chondroitin sulfate is not recommended
for knee osteoarthritis.

NON-PHARMACOLOGIC (include Diet)

● Ways of lessening focal load across the joint
○ Avoiding activities that overload the joint, as evidenced by their causing pain
○ Improving the strength and conditioning of muscles that bridge the joint
○ Unloading the joint:
■ by redistributing load within the joint with a brace or splint
■ during weight bearing with a cane or crutch in the hand opposite to the affected joint
● Weight loss is recommended as a core treatment for obese and overweight adults with knee OA.
○ Each pound of weight increases the loading across the knee three- to sixfold.
○ Five percent weight loss significantly improves pain and function in knee OA.
● Exercise lessens pain and improves physical function
○ Aerobic and/or resistance training to strengthen muscles across the joint
○ Low impact exercises including water aerobics and water resistance training
● Manual or electroacupuncture is recommended as additional therapy to achieve pain relief and improvement of
function lasting a few weeks among patients with moderate pain due to knee osteoarthritis.
● The use of concentrated standardized ginger preparation is recommended for its moderate effect in the control
of pain and improvement of function in knee OA.
● Total joint replacement
○ Highly effective in patients with advanced knee and hip OA when conservative therapies have failed to
provide adequate pain relief

TREATMENT RESPONSE AND COMPLICATIONS (State anticipated treatment response and complications)
● Courses of pain and physical functioning have been found to be predominantly stable, without substantial
improvement or deterioration of symptoms over time.
● Patients with osteoarthritis who have undergone joint replacement have a good prognosis, with success rates
for hip and knee arthroplasty generally exceeding 90%.

PREVENTIVE
● Patient education on the pathogenesis of the disease; emphasis on adherence to therapy to prevent joint pains
and further debilitation
● Reevaluate the patient every 3 months
● Manage occupational risks
● Exercise
● Maintain a healthy weight - Excess weight is one of the biggest risk factors of OA, as it puts extra stress on the
joints, which can speed up the deterioration of joint cartilage.
● Maintain a healthy diet

PROGNOSIS

OA causes chronic knee pain and results in lack of activity (interfering with daily activities) and poor mobility. The
inactivity can result in increased risk of cardiovascular disease and obesity. Muscles surrounding the joint can develop
atrophy if the patient does not exercise.

Links to References:
- Include links to sample cases/case vignettes
- Include links to videos for History/PE
- THE PHILIPPINE RHEUMATOLOGY ASSOCIATION CLINICAL PRACTICE GUIDELINES FOR THE
MEDICAL MANAGEMENT OF KNEE OSTEOARTHRITIS (OA)
- Philippine Clinical Practice Guidelines on the Medical Management of Osteoarthritis of the Knee