Osteoarthritis

Question 1

Definition

Answer 1

• TEAR, FLARE & REPAIR

	○ TEAR = INJURY: MICROTRAUMA/PHYSICAL TRAUMA & MECHANICAL IMBALANCE
	○ FLARE = INFLAMMATORY RESPONSE & PAIN
	○ REPAIR = DOESN’T RETURN TO NORMAL LVLS - leading to JOINT DEGENERATION

Question 2

Presentation

Answer 2

• 45yrs +
  
  • WORSENING PAIN + STIFFNESS + LOSS of FUNCTION○ ACTIVITY RELATED JOINT PAIN +○ EITHER NO MORNING JOINT RELATED STIFFNESS/MORNING STIFFNESS LASTING ≤ 30 MINS = 1ST FEW STEPS are PAINFUL + UNCOMFORTABLE, but this WEARS OFF

      § If JOINT IMMOBILE for a WHILE = SYNOVIAL FLUID bwtn JOINTS PUSHED AWAY = TAKES a FEW MOVEMENTS to LUBRICATE JOINTS AGAIN
    
      § PAIN is due to INCREASED SYNOVIAL FLUID causing PRESSURE (+ MOVEMENTS that INCREASE PRESSURE e.g. flexing the knee) or DAMAGE to UNDERLYING STRUCTURES
    
      § PROLONGED PAIN = THINK of OTHER ARTHRITIDES e.g. RA
    
      § PAIN due to MOVEMENT, so they STOP MOVING = STIFFNESS + WEAKER + LOSS of FUNCTION

Question 3

Investigations

Answer 3

ON/E: SWELLING + REDUCED ROM

IMAGING: X-RAYS of affected joint

• Try to CONFIRM CLINICAL DIAGNOSIS + get WGT.-BEARING X-RAYS
• 2 X-RAYS at 90°
• WGT.-BEARING X-RAYS = show ANY NARROWED JOINT SPACE, VARUS/VALGUS DEFORMITY
• L = LOSS of JOINT SPACE (cartilage worn away = bon-bone contact - bone rubs against each other)
• O = OSTEOPHYTES (excess bone at edge of joints, increases no. of joint contacts)
• S = SUBCHONDRAL SCLEROSIS
• S = SUBCHONDRAL CYSTS

Question 4

Management

Answer 4

MDT:

• PT. = mostly managed by pt. using ANALGESIA. RESTRICTING PAINFUL ACTIVITIES
• GP
• PHYSICIAN
• NURSES
• PHYSIOTHERAPIST
• DIETICIAN
• OT
• ORTHOPAEDIC SURGEON

1. Holistic approach + self-management:

social - effect on life e.g. daily activities, family duties, hobbies, lifestyle expectations

health beliefs incl. ICE and knowledge of OA

occupational - ability to perform job, adjustments to home/work

mood - depression, other stresses

sleep quality

support network - ICE of main carer, how carer coping, isolation

other MSK pain - chronic pain syndrome, other treatable source of pain

exercise attitudes

influence of co-morbidities - falls, interactions of morbidities, assessment of appropriate drug therapy, fitness for surgery, understanding surgical options

pain assessment - self-help strategies, analgesics e.g. side effects, drugs, doses, freq., timing

2. Core Rx = INFORMATION, EXERCISE, WGT. LOSS = can WORSEN PAIN, but if wgt. is lost = WILL IMPROVE SYMPTOMS + MAKES SURGICAL TREATMENT SAFER
3. Non-pharmacological Rx:

• THERMOTHERAPY = HEAT PACKS
• ELECTROTHERAPY = TENS MACHINE, UNCOMMON in SCOTLAND for OA
• AIDS & DEVICES = e.g. GRABBERS, AIDS to PUT ON CLOTHING, WALKING STICKS - for ARTHRITIS in LOWER LIMBS esp. for HIP○ WALKING STICKS = HOLD IN OPP. HAND TO AFFECTED LEG (REDUCES JOINT REACTION FORCE IN THAT SIDE)

• MANUAL THERAPY/PHYSIOTHERAPY = STRENGTHEN MUSCLES in AFFECTED SIDE

○ PAIN → LOSS of FUNCTION → DISUSE → ATROPHY → PRONE to FALLS + KNEE GIVES WAY

• NICE DO NOT RECOMMEND = ACUPUNCTURE, NUTRACEUTICALS (GLUCOSAMINE, CHONDROITIN)

4. Pharmacological rx:

• ORAL ANALGESIA = PARACETAMOL, NSAIDs (SYNERGISTIC EFFECT)
• TOPICAL TREATMENTS (GELS) = NSAIDs, CAPSAICIN (LOCALISED HEAT REACTION that DULLS PAIN - KNEE, HAND)
• INTRA-ARTICULAR INJECTIONS = STEROIDS, HYALURONIC ACID○ STEROIDS = esp. for BIG JOINTS e.g. HIP = done in OPERATING THEATRE/RADIOLOGY CLINIC; KNEE = done in CLINIC○ HYALURONIC ACID = LUBRICANT, used in SCOTLAND, EXPENSIVE, NOT RECOMMENDED by NICE, for EARLY OA - may AVOID PT. NEEDING SURGERY

5. Operative Rx: JOINT REPLACEMENT SURGERY

• WHEN TO REFER: EXHAUSTED ALL NONOPERATIVE OPTIONS + PAIN AFFECTING QoL

* SUBSTANTIAL IMPACT ON QoL
* REFRACTORY to NON-SURGICAL TREATMENT

Question 5

Red flags for other diseases + DDx

Answer 5

• OA = DETERIORATES GRADUALLY ∴ DOESN’T CHANGE IN 1 DAY (i.e. get better & then worse the next day)

* TRAUMA
* PROLONGED MORNING-RELATED STIFFNESS
* RAPID DETERIORATION of SYMPTOMS
* HOT, SWOLLEN JOINT esp. If ACUTE e.g. SEPTIC ARTHRITIS

DDx:

* GOUT
* OTHER INFLAMMATORY ARTHRITIDES
* SEPTIC ARTHRITIS = SYSTEMIC SYMPTOMS e.g. MALAISE
* MALIGNANCY

Question 6

Pathogenesis

Answer 6

Primary OA:

W/O OBVIOUS CAUSE, GENETIC, AGE-RELATED, OBESITY can EXACERBATE PRESSURE ON JOINT + INSTABILITY

Secondary OA:

Due to SOME SPECIFIC CAUSE e.g. INFECTION, TRAUMA, SURGERY, MECHANICAL IMBALANCE (like shallow acetabulum)

Question 7

Biomechanical factors

Answer 7

• ABNORMAL ANATOMY e.g. DDH
  
  • INTRA-ARTICULAR # = COLLAGEN HEALS IMPROPERLY (type 2 collagen isn’t laid down, type 1 is - weak spots)
  • LIGAMENT RUPTURE
  • MENISCAL INJURY
  • OCCUPATION = FARMERS, FOOTBALL PLAYERS - BEYOND MODERATE EXERCISE = GREATLY INCREASES RISK of OA

    ○ Exercise is good for joints, but not too much/too hard

  • PERSISTENT HEAVY PHYSICAL ACTIVITY
  • ELITE RUNNING
  • OBESITY