Osteoarthritis

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Osteoarthritis is the most common form of arthritis. It is "a progressive, degenerative joint disease, the most common form of arthritis, especially in older persons. The disease is thought to result not from the aging process but from biochemical changes and biomechanical stresses affecting articular cartilage. In the foreign literature it is often called osteoarthrosis deformans."[1]

Cause / etiology

Obesity may contribute to osteoarthritis of the knee.[2][3][4]

Leg-length inequality > 1 cm is associated with osteoarthritis of the knee.[5]

Diagnosis

Signs and symptoms

Knee osteoarthritis

Osteoarthritis of the knees is associated with buckling, or sudden giving way, of the knees.[6] This is more likely if the quadriceps muscle is weak.

A screening survey is positive if any one of the following is answered yes:[6]

  • During the last 4 weeks, have you had knee pain on most days?
  • During the last 4 weeks, have you had knee pain while climbing down stairs or walking down slopes?
  • During the last 4 weeks, have you had swelling in one or both knees?
  • Do you have knee OA? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)

Using the prevalence of disease in this study (5% to 8%), the predictive values are:

Hip osteoarthritis

A screening survey is positive if any one of the following is answered yes:[6]

  • During the last 4 weeks, have you had hip pain (groin or upper thigh) on most days?
  • During the last 4 weeks, have you had hip pain while climbing down stairs or walking down slopes?
  • During the last 4 weeks, have you noticed any limitation in the range of motion of one or both hips?
  • Do you have hip osteoarthritis? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)

Using the prevalence of disease in this study (5% to 8%), the predictive values are:

Treatment

Treatment with combined weight loss and exercise is better than either treatment alone.[7]

Analgesic medications

The World Health Organization recognizes a "pain ladder" of increasingly potent analgesics to deal with the pain of osteoarthritis. These may be supplemented with adjuvants.

The Disease-Modifying Anti-Rheumatic Drugs (DMARD) used in rheumatoid arthritis and other autoimmune disorders are not indicated in the essentially mechanical wear involved in osteoarthritis.

Analgesics

Acetaminophen

A randomized controlled trial comparing acetaminophen to ibuprofen in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.[8] However, acetaminophen at a dose of 4 grams per day can increase liver function tests.[9]

NSAIDs
Monoclonal antibodies

Adalimumab did not help in a randomized controlled trial.[10]

Opioids

Tramadol

Adjuvants for pain medications

Dietary supplements

Various dietary supplements and complementary and alternative medicine approaches may help.[11] There is no benefit from glucosamine and chondroitin according to a network meta-analysis.[12]

A combination of glucosamine and chondroitin dietary supplements may help moderate to severe osteoarthritis according to the GAIT study while neither supplement seems effective alone.[13] However, longer follow-up of the GAIT study showed the combination group tended to have the most loss of joint space.[14]

Chondroitin

For more information, see: chondroitin.

A meta-analysis of randomized controlled trials found no benefit from chondroitin as monotherapy.[15]

Glucosamine

For more information, see: glucosamine.


A molecule derived from glucosamine is used by the body to make some of the components of cartilage and synovial fluid.

Neither glucosamine sulfate[16] nor glucosamine hydrochloride[13][14] is effective as monotherapy for osteoarthritis.

S-adenosylmethionine

For more information, see: S-adenosylmethionine.


Acupuncture

For more information, see: Acupuncture.

Acupuncture is probably not effective according to a meta-analysis that concluded "sham-controlled trials show clinically irrelevant short-term benefits of acupuncture for treating knee osteoarthritis. Waiting list-controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation effects."[17]


Arthroscopic surgery and joint lavage

Joint lavage, with or without corticosteroids, does not help.[18][19][20] However, a number of patients including those with severe disease of two or more compartments of the knee, were excluded from one trial.[20]

Intra-articular injections

Single intraarticular corticosteroids of the knee may reduce pain for one week after the injection according to a systematic review.[21]

One trial that compared corticosteroid injections every three months to placebo for two years[22] found improvements in outcomes ranging from none to small for the WOMAC pain score[23]

Intraarticular viscosupplementation of the knee with hyaluronic acid is "associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events."[21]

Intra-articular injections of the hip joint for labral tears may not be effective.[24]

Physical therapy

Some types of physical therapy may help according to a systematic review of trials.[25]

Knee bracing and shoe prosthesis

Laterally wedged insoles may (with valgus bracing)[26] or may not (without bracing)[27][28] benefit some patients with arthritis of the medial knee according to randomized controlled trials.

Prognosis

Knee

The strongest predictors of poor functional outcome are age, body mass index, anxiety and pain severity.[29]

Hip

Among patients presenting with hip pain to their general practitioner, the rates of total hip replacement are:[30]

  • 12% of patients at 3 years
  • 22% after 6 years

Predictors of the need for a total hip replacement are:[30]

  • age >/=60 years, morning stiffness
  • pain in the groin/medial thigh
  • decreased extension/adduction
  • painful internal rotation
  • body mass index </=30 kg/m(2)
  • Kellgren/Lawrence grade of 2 or higher

References

  1. Anonymous (2015), Osteoarthritis (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT (2011). "Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data.". Ann Intern Med 155 (11): 725-32. DOI:10.1059/0003-4819-155-11-201112060-00004. PMID 22147711. PMC PMC3408027. Research Blogging.
  3. McAlindon TE, Wilson PW, Aliabadi P, Weissman B, Felson DT (1999). "Level of physical activity and the risk of radiographic and symptomatic knee osteoarthritis in the elderly: the Framingham study.". Am J Med 106 (2): 151-7. PMID 10230743[e]
  4. Hart DJ, Doyle DV, Spector TD (1999). "Incidence and risk factors for radiographic knee osteoarthritis in middle-aged women: the Chingford Study.". Arthritis Rheum 42 (1): 17-24. DOI:<17::AID-ANR2>3.0.CO;2-E 10.1002/1529-0131(199901)42:1<17::AID-ANR2>3.0.CO;2-E. PMID 9920009. <17::AID-ANR2>3.0.CO;2-E Research Blogging.
  5. Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, Lewis CE et al. (2010). "Association of leg-length inequality with knee osteoarthritis: a cohort study.". Ann Intern Med 152 (5): 287-95. DOI:10.1059/0003-4819-152-5-201003020-00006. PMID 20194234. Research Blogging.
  6. 6.0 6.1 6.2 Felson, David T., Jingbo Niu, Christine McClennan, Burton Sack, Piran Aliabadi, David J. Hunter, et al. 2007. Knee Buckling: Prevalence, Risk Factors, and Associated Limitations in Function. Ann Intern Med 147, no. 8 (October 16): 534-540. http://www.annals.org/cgi/content/abstract/147/8/534 (accessed October 16, 2007).
  7. Messier SP, Mihalko SL, Legault C, Miller GD, Nicklas BJ, DeVita P, Beavers DP, Hunter DJ, Lyles MF, Eckstein F, Williamson JD, Carr JJ, Guermazi A, Loeser RF. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. JAMA. 2013 Sep 25;310(12):1263-73. doi: 10.1001/jama.2013.277669. PMID: http://pubmed.gov/24065013.
  8. Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI (1991). "Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee". N. Engl. J. Med. 325 (2): 87-91. PMID 2052056[e]
  9. Watkins PB, Kaplowitz N, Slattery JT, et al (2006). "Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial". JAMA 296 (1): 87-93. DOI:10.1001/jama.296.1.87. PMID 16820551. Research Blogging.
  10. Chevalier X, Ravaud P, Maheu E, Baron G, Rialland A, Vergnaud P et al. (2014). "Adalimumab in patients with hand osteoarthritis refractory to analgesics and NSAIDs: a randomised, multicentre, double-blind, placebo-controlled trial.". Ann Rheum Dis. DOI:10.1136/annrheumdis-2014-205348. PMID 24817417. Research Blogging.
  11. De Silva V, El-Metwally A, Ernst E, Lewith G, Macfarlane GJ, Arthritis Research UK Working Group on Complementary and Alternative Medicines (2011). "Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review.". Rheumatology (Oxford) 50 (5): 911-20. DOI:10.1093/rheumatology/keq379. PMID 21169345. Research Blogging.
  12. Wandel S, Jüni P, Tendal B, Nüesch E, Villiger PM, Welton NJ et al. (2010). "Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis.". BMJ 341: c4675. DOI:10.1136/bmj.c4675. PMID 20847017. PMC PMC2941572. Research Blogging.
  13. 13.0 13.1 Clegg DO, Reda DJ, Harris CL, et al (February 2006). "Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis". N. Engl. J. Med. 354 (8): 795–808. DOI:10.1056/NEJMoa052771. PMID 16495392. Research Blogging.
  14. 14.0 14.1 Sawitzke AD, Shi H, Finco MF, et al (October 2008). "The effect of glucosamine and/or chondroitin sulfate on the progression of knee osteoarthritis: a report from the glucosamine/chondroitin arthritis intervention trial". Arthritis Rheum. 58 (10): 3183–91. DOI:10.1002/art.23973. PMID 18821708. Research Blogging.
  15. Reichenbach S, Sterchi R, Scherer M, et al (2007). "Meta-analysis: chondroitin for osteoarthritis of the knee or hip". Ann. Intern. Med. 146 (8): 580-90. PMID 17438317[e]
  16. Rozendaal RM, Koes BW, van Osch GJ, et al (February 2008). "Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial". Ann. Intern. Med. 148 (4): 268–77. PMID 18283204[e]
  17. Manheimer E, Linde K, Lao L, Bouter LM, Berman BM (June 2007). "Meta-analysis: acupuncture for osteoarthritis of the knee". Ann. Intern. Med. 146 (12): 868–77. PMID 17577006[e]
  18. Avouac J, Vicaut E, Bardin T, Richette P (2010). "Efficacy of joint lavage in knee osteoarthritis: meta-analysis of randomized controlled studies.". Rheumatology (Oxford) 49 (2): 334-40. DOI:10.1093/rheumatology/kep382. PMID 19955221. Research Blogging.
  19. Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH et al. (2002). "A controlled trial of arthroscopic surgery for osteoarthritis of the knee.". N Engl J Med 347 (2): 81-8. DOI:10.1056/NEJMoa013259. PMID 12110735. Research Blogging. Review in: ACP J Club. 2003 Mar-Apr;138(2):49 Review in: J Fam Pract. 2002 Oct;51(10):813
  20. 20.0 20.1 Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ et al. (2008). "A randomized trial of arthroscopic surgery for osteoarthritis of the knee.". N Engl J Med 359 (11): 1097-107. DOI:10.1056/NEJMoa0708333. PMID 18784099. Research Blogging. Review in: Ann Intern Med. 2009 Jan 20;150(2):JC1-15
  21. 21.0 21.1 Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G (2006). "Intraarticular corticosteroid for treatment of osteoarthritis of the knee.". Cochrane Database Syst Rev (2): CD005328. DOI:10.1002/14651858.CD005328.pub2. PMID 16625636. Research Blogging.
  22. Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J et al. (2003). "Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial.". Arthritis Rheum 48 (2): 370-7. DOI:10.1002/art.10777. PMID 12571845. Research Blogging.
  23. Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (December 1988). "Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee". J. Rheumatol. 15 (12): 1833–40. PMID 3068365[e]
  24. Martin RL, Irrgang JJ, Sekiya JK (September 2008). "The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates". Arthroscopy 24 (9): 1013–8. DOI:10.1016/j.arthro.2008.04.075. PMID 18760208. Research Blogging.
  25. Wang SY, Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL (2012). "Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review.". Ann Intern Med 157 (9): 632-44. DOI:10.7326/0003-4819-157-9-201211060-00007. PMID 23128863. Research Blogging.
  26. van Raaij TM, Reijman M, Brouwer RW, Bierma-Zeinstra SM, Verhaar JA (2010). "Medial knee osteoarthritis treated by insoles or braces: a randomized trial.". Clin Orthop Relat Res 468 (7): 1926-32. DOI:10.1007/s11999-010-1274-z. PMID 20177839. PMC PMC2881986. Research Blogging.
  27. Baker K, Goggins J, Xie H, Szumowski K, LaValley M, Hunter DJ et al. (2007). "A randomized crossover trial of a wedged insole for treatment of knee osteoarthritis.". Arthritis Rheum 56 (4): 1198-203. DOI:10.1002/art.22516. PMID 17393448. Research Blogging.
  28. Bennell KL, Bowles KA, Payne C, Cicuttini F, Williamson E, Forbes A et al. (2011). "Lateral wedge insoles for medial knee osteoarthritis: 12 month randomised controlled trial.". BMJ 342: d2912. DOI:10.1136/bmj.d2912. PMID 21593096. PMC PMC3100910. Research Blogging.
  29. Elaine Thomas et al., “Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators?,” Ann Rheum Dis (February 4, 2008): ard.2007.080945.
  30. 30.0 30.1 Lievense AM, Koes BW, Verhaar JA, Bohnen AM, Bierma-Zeinstra SM (2007). "Prognosis of hip pain in general practice: A prospective followup study". Arthritis Rheum 57 (8): 1368–1374. DOI:10.1002/art.23094. PMID 18050175. Research Blogging.