10. Treatments for OA (Robson)

Question 1

What are the symptoms of OA?

Answer 1

Joint pain when in use 
Morning stiffness - lasting less than 30 minutes
Joint instability or joint buckling 
Loss of function of the joint
Crepitus on motion of the joint

Question 2

What are the signs of OA?

Answer 2

Bony enlargement at the affected joints - osteophyte formation 
Limited range of movement at the joint 
Crepitus on motion 
Malalignment and/or joint deformity 
Muscle atrophy/weakness

Question 3

What is the core treatment in the management of OA and why?

Answer 3

Exercise and change in diet:

Allows for local muscle strengthening to increase the stability of the joint

Allows for weight loss - decreased weight being placed on the joints

Question 4

What is TENS in the treatment of OA?

Answer 4

Transcutaneous electrical nerve stimulation - used as an adjunct for pain relief

Question 5

What non-pharmacological methods can be used to treat OA?

Answer 5

Exercise and diet change
TENS
Acupuncture
Aids and devices e.g. walking stick, orthopedic insoles

Question 6

What are neutriceuticals?

Give three neutriceuticals recommended for treatment of OA

Answer 6

Foods that can help to increase health

Omega-3 in diet
Chondroitin sulphate supplements
Glucosamine supplements

Question 7

Why should you increase omega-3 in the diet of someone with OA?

Answer 7

Omega-3 - releases natural pain-relieving chemicals

Question 8

How can doctors ensure that they are offering patient centred care?

Answer 8

Offer personalised plan
Carefully and explicitly outline to patients reasons for their medication prescribed
Should offer accurate verbal and written communication

Question 9

What is the first line pharmacological management for OA?

Answer 9

Oral analgesics - paracetamol and/or topical NSAIDs

Question 10

What oral analgesic can be prescribed to a patient if paracetamol/topical NSAID is ineffective and why?

Answer 10

Cox-2 inhibitor - should not cause the same side effects as cox 1 e.g. gastric ulcers

(cox-1 present all the time and cox-2 specific to inflammation)

Question 11

Why might paracetamol/topical NSAID not be effective for some patients with OA?

Answer 11

Cox 1 inhibitor - may result in comorbidities or adverse side effects

Cox - inhibitors should not be used in certain patients e.g. with gastric ulcers

Question 12

Why are topical NSAIDs particularly useful in relieving joint pain?

Answer 12

These target the specific joint and have very specific effects

These are absorbed through the skin directly into the synovial fluid - therefore the NSAID will be concentrated in and around the actual joint - does not pass first past metabolism

Question 13

What are the two main benefits of topical NSAIDs?

Answer 13

Increased concentration - does not pass first pass metabolism
Does not result in gastric ulcers forming

Question 14

What is the last line pharmacological management for OA?

Answer 14

Intra-articular injections - corticosteroids

Question 15

Why are corticosteroids the last line treatment for OA and how should they be used?

Answer 15

Can further aggregate the OA - should be used sparingly only as an adjunct to get them through a particularly bad moment

Question 16

When might a patient with OA be referred for surgery?

Answer 16

When pain stiffness and reduced function have a substantial impact on the quality of life of the patient e.g. waking up at night

Question 17

What are the six different surgical treatment options for OA?

Answer 17

Arthroscopic lavage 
Arthroscopic lavage plus debridement 
Microfracture 
Mosiacplasty (osteochondral transplant)
Chondrocyte grafts 
Joint replacement

Question 18

What is meant by arthroscopic lavage and which joints can this be done to?

Answer 18

This is an arthroscopic knee washout - cleaning of the joint

Can only be done to big joints e.g. knee, hip, shoulder - needs to be big enough to get all of the instruments in

Question 19

What is the purpose of an athroscopic knee lavage?

Answer 19

To clean the surfaces of the joint and to remove any cracked bits or loose hyaline cartilage from the joint - this may be causing the knee to lock or rub on the surface of the bone

Question 20

What is debridement?

Answer 20

This is done to tidy up the edges of damaged cartilage - remove any torn or loose bits of meniscus - tidy and neaten the edges of the cartilage

Question 21

Why is debridement commonly done with arthroscopic lavage?

Answer 21

Debridement aids with pain relief (also faster pain relief) compared to just lavage

Cleaning of the joint and then cleaning of the edges

Question 22

What is microfracture?

Answer 22

Take a probe and push it through the bone into the bone marrow
This results in stem cells coming up to the surface of the bone
These stem cells differentiate into chondroblasts and osteoblasts and produce cartilage to fill spaces from cracks

Question 23

Who does microfracture work best for?

Answer 23

People under the age of 40
Recent cartilage injury
People not overweight (too much stress on the joints)

Question 24

What is viscosuplementation?

Answer 24

This involves putting artificial synovial fluid into the joint - injected as liquid

Question 25

Why is viscosupplementation done?

Answer 25

Helps to support the joint whilst it is recovering

Gives pain relief for up to six months

Question 26

What is the advantage of viscosupplementation compared to other treatments for OA?

Answer 26

Can go into any joint types
Works well at all stages of OA
Long term effectiveness
No long term loss or damage

Question 27

What is the component injected in viscosupplementation?

Answer 27

Hyaluronic acid

Question 28

What are the disadvantages of viscosupplementation?

Answer 28

Severe OA may not respond well

Has some local adverse effects at the injection side

Question 29

How does viscosupplementation work?

Answer 29

Returns the synovial fluid back to normal viscosity so that the cartilages are no longer touching one another

Question 30

What is chondrocyte grafting?

Answer 30

Grafting of chondrocytes - inject into the site so that they take up residence and produce the required cartilage

Question 31

Where is the chondrocyte obtained for grafting?

Answer 31

Patients own costal cartilage e.g. rib OR from non-damaged part of the joint
Can buy off the shelf from companies

Question 32

Where are chondrocytes injected for grafting and why?

Answer 32

Injected underneath a periosteal patch to ensure that they do not float away and are present in the required site

Question 33

What is the main disadvantage of microfracture for the treatment of OA?

Answer 33

Microfracture tends to produce fibrocartilage rather than hyaline cartilage - less durable

Question 34

What is mosiacplasty?

Answer 34

Find the non-damaged regions of the joint

Take a biopsy of the articular cartilage and the subchondral bone and graft this into sites of damge

Question 35

What is osteotomy?

Answer 35

This is realigning the bones and the joint surfaces

Question 36

How does osteotomy work?

Answer 36

If there is damage to just one side of the joint e.g. the medial knee - can take a wedge out of the lateral tibia to realign the surfaces

Question 37

What is the final treatment option for OA?

Answer 37

Joint replacement

Question 38

What are the two types of joint replacement?

Answer 38

Cemented - use cement to hold it in place - less accurate

Non-cemented - more precision required

Question 39

Which components are replaced in a joint replacement?

Answer 39

Can replace the whole joint or may only replace parts

Question 40

Which knee joint type tends to last longer and why?

Answer 40

Non-cemented - the bone cells actually integrate into the surface of the prothesis