Chapter 50 Osteoarthritis
Clinical Case Problem 1 An 80-Year-Old Woman with Painful Finger Joints
Clinical Case Problem 2 A 65-Year-Old Woman with an Arthritic Hip
4. Which of the following is not true?
5. Which of the following radiographic features is (are) usually seen in patients with osteoarthritis?
6. Which of the following treatment modalities is not useful in the treatment of her left knee pain?
7. Which of the following statements concerning osteoarthritis is (are) true?
8. Major goals of therapy in osteoarthritis include which of the following?
9. Which of the following statements regarding the use of NSAIDs given to an elderly patient with osteoarthritis is true?
10. What is the drug of first choice for the treatment of this patient’s osteoarthritis pain?
Answers
1. e. This patient has obvious osteoarthritis. However, the location of Bouchard nodes represents both overgrowth and significant osteoarthritic changes at the PIP joints (not the DIP joints), whereas Heberden nodes represent bone overgrowth and significant osteoarthritic changes at the DIP (not the PIP) joints. Synovial fluid analysis most likely will reveal a high (not low) viscosity and normal mucin clotting. The total leukocyte count in the synovial fluid is likely to be less than 1000 cells/mm3. A significantly elevated erythrocyte sedimentation rate is seldom seen with osteoarthritis except in the unusual cases in which there is a significant inflammatory component. Similarly, the rheumatoid factor should be negative in osteoarthritis.
2. e. The most common symptom in osteoarthritis is pain. The pain is described as dull, aching, aggravated by joint use, and relieved by joint rest. Joint stiffness in weight-bearing joints is common but usually a transient finding, especially in the morning. It also occurs after prolonged rest. Osteoarthritis pain is the result of movement of one joint surface against another, with both joint surfaces exhibiting characteristic articular cartilage damage, including fraying and ultimately complete lack of cartilage. In addition, there are subchondral bone microfractures, irritation of the periosteal nerve endings, ligamentous stress, muscle strain, and soft tissue inflammation such as bursitis and tendonitis. Bone crepitus is the most common physical finding in osteoarthritis. Osteophytes are a common radiologic finding, especially with advanced age. The diagnosis of osteoarthritis is clinical, however, and the mere presence of osteophytes on radiographic film, which can found in asymptomatic joints, is not sufficient for the diagnosis.
3. d. Joint space narrowing is common. It is almost always associated with osteoarthritis. The primary defect in primary osteoarthritis and secondary osteoarthritis is loss of articular cartilage. In primary osteoarthritis, this is the result of “normal” wear and tear. In secondary osteoarthritis, the loss is the result of acute or chronic trauma, congenital deformities, metabolic disorders, septic and tubercular arthritis, and endocrine disorders (such as acromegaly, obesity, or diabetes). The result is that the majority of people have evidence of osteoarthritis in weight-bearing joints by the age of 65 years, and 70% to 90% of people older than 75 years clinically have at least one affected joint.
Cartilage changes progress as follows: glistening appearance is lost; surface areas of the articular cartilage flake off; deeper layers of the articular cartilage develop longitudinal fissures (fibrillation); the cartilage becomes thin and eventually absent in some areas, leaving the underlying subchondral bone unprotected; the unprotected subchondral bone becomes sclerotic (dense and hard); cysts develop within the subchondral bone and communicate with the longitudinal fissures in the cartilage; pressure builds up in the cysts until the cystic contents are forced into the synovial cavity, breaking through the articular cartilage on the way; as the articular cartilage erodes, cartilage-coated osteophytes may grow outward from the underlying bone and alter the bone contours and joint anatomy; these spur-like bone projections enlarge until small pieces, called joint mice, break off into the synovial cavity; and the process of loss of articular cartilage probably takes place through the enzymatic breakdown of the cartilage matrix (the proteoglycans, glycosaminoglycans, and collagen are involved).
4. a. Exercise is important in the treatment of osteoarthritis. Painful joints need to be moved in full range of movement, and cartilage needs motion to stay healthy. Active isometric exercises and strengthening can reduce pain and make mobility easier and safer. Low-impact exercises are recommended (e.g., swimming and cycling) when knees, hips, and spine are effected.
5. e. Radiographic changes in osteoarthritis include narrowing of the joint space as a result of loss of articular cartilage, bone sclerosis as a result of thickening of subchondral bone, subchondral bone cysts, and osteophyte (bone spur) formation.
6. d. The treatments of osteoarthritis include both pharmacologic and nonpharmacologic measures.
Nonpharmacologic measures include the avoidance of overuse of the affected joint; walking aids, such as canes, crutches, and walkers; weight loss; heat application; exercises; and other physiotherapy techniques. Specifically, a cane should be used in the contralateral hand. Exercises should be mainly isometric (nonmovement, such as quadriceps strengthening), stretching, and range of motion maneuvers. Heat modalities such as hot packs, soaks, and warm pools for aerobic exercise may decrease discomfort and facilitate the exercise program.
Pharmacologic measures include simple analgesics such as acetaminophen, NSAIDs, and local steroid injections. Newer concepts in the treatment of osteoarthritis that are in various stages of use or study include chondroprotective agents, which may conserve cartilage or stimulate cartilage repair within the osteoarthritic joint. These agents include chondroitan sulfate, glucosamine, tetracyclines, and intraarticular hyaluronic acid. Topical preparations such as capsaicin, DMSO, methylsalicylate, and compounded NSAID gels can be used for relief of pain. Non-narcotic analgesics include acetaminophen, propoxyphene, and tramadol. Intraarticular corticosteroids can be used. Antiinflammatory agents such as NSAIDs are effective, with limiting factors being gastric side effects and problems with renal functions. Cyclooxygenase-2 (COX-2) inhibitors are effective and do not have the degree of gastric side effects shared by nonselective NSAIDs, although adding an acid-lowering medication or misoprostol to a nonselective NSAID may achieve the same purpose. The COX-2 inhibitors may also have renal side effects, and the possible increased risk of thrombotic cardiovascular events with both nonselective NSAIDs and COX-2 inhibitors should be taken into consideration.
Orthopedic surgery is used in severe cases. Joint replacement, especially of the knee and hip, is the treatment of choice when more conservative therapy has failed to control pain and to maintain function. Osteotomy may be considered for some patients who have not yet progressed to the degree of needing total joint replacement. Arthroscopic débridement and meniscus repair may be of some benefit, but arthroscopic lavage alone has not been shown to be an effective treatment of osteoarthritis. Some studies have shown no benefit of arthroscopic surgery of débridement and lavage over physical and medical therapy in pain control or progression to surgery.
7. e. At least 33% of adults between the ages of 25 and 75 years have radiographic findings commonly seen in osteoarthritis. Some studies suggest that osteoarthritis begins as early as 15 or 16 years of age. In the United States, 85% of the population has either clinical or radiographic evidence of osteoarthritis by the age of 75 years. The cartilaginous fraying that is associated with cartilage degeneration has been described. Associated with this may be a mild synovitis that develops in response to cartilaginous fragments (joint mice) in the joint space. The most common sites for osteoarthritis are the small joints of the hands, the small joints of the feet, the hips, the knees, and the vertebral column, where the cartilaginous degeneration is of a somewhat different type (the intervertebral disks) but nevertheless the same basic pathologic process. With the exception of the first carpometacarpal joint, the wrists and metacarpophalangeal joints are typically not osteoarthritic.
8. e. The goals for the patient with osteoarthritis are to minimize pain, to prevent disability, and to delay progression. Some argue that it is not possible to delay progression in osteoarthritis; however, this is false. Weight loss in an obese individual and decreased repetitive trauma or impact to a joint with osteoarthritis will delay progression.
9. d. The most common type of toxicity associated with NSAIDs in elderly patients is gastrointestinal. This may take the form of an acute or chronic gastritis, a peptic ulcer, or a perforated ulcer. This may result in secondary anemia and other complications. NSAID toxicity is more common in elderly individuals. The risk for development of reversible renal failure with use of an NSAID is greater for patients with renal disease and congestive heart failure.
10. a. NSAIDs, although a mainstay for treatment of osteoarthritis, have significant potential toxicity, especially in elderly patients with renal impairment or other diseases. Thus, ordinary acetaminophen is safer and must be considered a drug of first choice. If an NSAID is used for the treatment of osteoarthritis in elderly patients, it is suggested that (1) the dose be kept as low as possible and (2) the drug be given with food and preferably with a cytoprotective agent such as misoprostol or an acid-lowering medication. The use of a COX-2 inhibitor can be considered.
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