Basics
Description
- Degenerative arthritis or osteoarthritis (OA) is the most common progressive joint disease, with 20-30 million cases in the US
- Found almost exclusively in the elderly
Etiology
- Mechanism
- Repetitive stress to synovial joints associated with age
- May be seen in younger patients secondary to joint trauma
- Articular cartilage destruction:
- Reactive changes in joint margin bone and subchondral sclerosis
- Risk factors include age, obesity, trauma, genetics, sex, and environment.
Diagnosis
Signs and Symptoms
- Chronic progressive joint pain:
- Worse with weight bearing, improved with rest
- Asymmetric joint involvement:
- Involves hand, foot, knee, hip, and spine joints
- Morning joint stiffness usually <30 min
- Joint deformity late in presentation with limited range of motion
- Heberden nodes at the distal interphalangeal joints
- Bouchard nodes at the proximal interphalangeal joints
- Absence of systemic symptoms
- Crepitus common
Essential Workup
- Thorough joint exam with assessment of range of motion and functional ability
- Radiographic exam: Typical findings in OA are decreased joint space, irregular bone at the joint margin, and osteophytes.
- Synovial fluid analysis in the setting of effusion may be therapeutic and diagnostic (see below), but is absolutely necessary if presents with warmth and erythema so as to rule out a septic joint or gout.
- ESR, CRP, and CBC if infection is in the differential as arthrocentesis may be indicated if a more superficial infection cannot be ruled out (e.g., septic bursitis, cellulitis, etc.).
Diagnosis Tests & Interpretation
Lab
Synovial fluid exam typically reveals the following:
- Clear
- Elevated leukocyte cell count, but <4,000/mm3
- <25% polymorphonuclear leukocytes
- Glucose level similar to blood levels (95-100%)
Imaging
- Radiographs
- Joint space narrowing
- Osteophyte formation
- Marginal bone erosion
- Subchondral sclerosis
Differential Diagnosis
- Gout or pseudogout
- Septic arthritis
- Rheumatoid arthritis
- Charcot joint
- Hemarthrosis
- Overlying bursitis or soft tissue infection
Treatment
The general goal of treatment is to provide relief from symptoms. A patient may have significant radiographic evidence of disease but have very few symptoms. Therefore the treatment regimen is tailored to the patients symptomatology.
Pre-Hospital
Immobilization of affected joint may be indicated until fracture is excluded.
Initial Stabilization/Therapy
- Pain management acutely
- Begin a daily medication that can be managed on follow-up with primary care physician.
- Instructions for gentle strengthening exercises
- Avoidance of unnecessary joint immobilization
Ed Treatment/Procedures
Intra-articular (IA) arthrocentesis and injection:
- Ultrasound (US) guidance is recommended when expertise and instrument is available
- Shown to be an effective low-risk intervention for OA with or without effusion
- Though relatively rare in larger joints, dry tap is a possible finding due to anatomic features of joint and periarticular soft tissue (e.g., fat pad).
- US very useful in this case
- Careful attention must be given to aseptic technique while joint is in proper position to reduce muscle tension, exposing joint space.
- Vapor coolant or lidocaine 1% or 2% can be used for local anesthesia.
- Usually 1.5 in or greater 22G or 18G hypodermic needle should be used with 1 syringe for arthrocentesis and another for IA corticosteroid injection.
- If septic joint cannot be ruled out, corticosteroids should not be administered after arthrocentesis.
Corticosteroid dosing equivalents:
- Small joints-wrist and foot:
- Methylprednisolone 10-20 mg, triamcinolone 10 mg, betamethasone 0.75-1.5 mg
- Medium-sized joints-elbow and ankle:
- Methylprednisolone 40-80 mg, triamcinolone 20 mg, betamethasone 3-6 mg
- Large joints-knee and shoulder:
- Methylprednisolone 80-120 mg, triamcinolone 40 mg; betamethasone 6-9 mg
- Some studies show triamcinolone to be more efficacious than other corticosteroids; the author recommends this, if available.
Medication
General guidelines:
- Acetaminophen is drug of choice initially as it has a safer medication profile compared with NSAIDs and has been shown to be as efficacious in some patients.
- If one class fails, consider another class (e.g., salicylates vs. COX-2 inhibitors).
- The 2 alternative medications below have been shown to have a small but positive effect by meta-analysis of recent studies and can be considered adjuncts.
- Postprandial administration is recommended for all these. Patients at increased risk for GI bleeding (e.g., history of peptic ulcer disease, etc.) should be placed on COX-2 inhibitors or alternatively a proton pump inhibitor can be given with a nonselective COX inhibitor.
- NSAIDs:
- Celecoxib (reversible COX-2-selective) 400 mg PO mg PO q24:
- Note: Contraindicated in sulfonamide allergy
- Ibuprofen (reversible nonselective COX): 400-600 mg PO q6h
- Naprosyn (reversible nonselective COX): 500 mg PO q12h
- Meloxicam (reversible nonselective COX): 7.5 mg PO q12h or 7.5-15 mg PO q24h
- Analgesics:
- Acetaminophen: 500 mg (peds: 10-15 mg/kg, do not exceed 5 doses/24 h) PO q4-6h, do not exceed 4 g/24 h
- Tramadol: 50 mg PO q4-6h:
- Note: Use cautiously in elderly, patients with seizure disorders, concurrently using antidepressants, or in hepatic or renal dysfunction.
- Other opioid narcotics rarely used
- Alternative therapies (separate or in combination):
- Glucosamine: 500 mg PO q8h
- Chondroitin: 1200 mg PO q24h
- Lifestyle modification:
- Weight loss for the obese
- Strengthening exercises
Follow-Up
Disposition
Admission Criteria
Rarely indicated in the absence of fracture
Discharge Criteria
- Ambulatory and capable of activities of daily living
- Improvement in symptoms (i.e., pain)
Sports Medicine Follow-up
- Consider referral to sports medicine clinic for definitive management
Additional Reading
- Hepper CT, Halvorson JJ, Duncan ST, et al. The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: A systematic review of level I studies. J Am Acad Orthop Surg. 2009;17(10):638-646.
- National Center for Complimentary and Alternative Medicine. The NIH Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT). J Pain Palliat Care Pharmacother. 2008;22(1):39-43.
- Sconfienza LM, Serafini G, Silvestri E, eds. Ultrasound-guided Musculoskeletal Procedures. Springer. 2012. 1-9.
- Stephens MB, Beutler Al, O'Connor FG. Musculoskeletal injections: A review of the evidence. Am Fam Physician. 2008;78(8):971-976.
- Vangsness CT Jr, Spiker W, Erickson J. A review of evidence-based medicine for glucosamine and chondroitin sulfate use in knee osteoarthritis. Arthroscopy. 2009;25(1):86-94.
Codes
ICD9
- 715.90 Osteoarthrosis, unspecified whether generalized or localized, involving unspecified site
- 715.94 Osteoarthrosis, unspecified whether generalized or localized, hand
- 715.97 Osteoarthrosis, unspecified whether generalized or localized, ankle and foot
- 715.95 Osteoarthrosis, unspecified whether generalized or localized, pelvic region and thigh
- 715.96 Osteoarthrosis, unspecified whether generalized or localized, lower leg
ICD10
- M19.049 Primary osteoarthritis, unspecified hand
- M19.079 Primary osteoarthritis, unspecified ankle and foot
- M19.90 Unspecified osteoarthritis, unspecified site
- M16.10 Unilateral primary osteoarthritis, unspecified hip
- M17.9 Osteoarthritis of knee, unspecified
SNOMED
- 396275006 Osteoarthritis (disorder)
- 22193007 Degenerative joint disease of hand
- 82300000 Degenerative joint disease of ankle AND/OR foot (disorder)
- 445478004 Degenerative joint disease of pelvis (disorder)
- 239873007 Osteoarthritis of knee (disorder)