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Osteoarthritis

Based on
Malaysian CPG
2013

Epidemiology
Osteoarthritis is a progressive joint disease due to
failure in repair of joint damage
Hand OA:
>58 years old, more erosive and symptomatic in women

Hip OA:
>45 years old

Knee OA:
lifetime risk of 44.7% by 85 years old, higher in history of
knee injury and increased BMI

Risk factors
Non-modifiable
Advancing age
Female
Family history influence
risk for hand and knee
OA
Presence of Heberdens
nodes in hand OA
increase the risk for
future knee OA

Modifiable
BMI (>25kg/m2)
Previous knee injury
Malalignment
(contributes to
progression)

Classification
Primary
Generalised OA, associated with Heberdens nodes and
polyarticular disease

Secondary
Metabolic eg acromegaly, haemachromatosis
Anatomic eg SUFE, Perthes disease, congenital hip
dislocation, avascular necrosis
Trauma eg joint injury and fracture through a joint or
osteonecrosis
Inflammatory eg rheumatoid arthritis, psoriatic arthropathy,
septic arthritis

Symptoms
Joint pain increased by joint use and impact and relieved by rest
Stiffness occurs after inactivity, lasts <30 minutes
Swelling fullness and swelling with or without warmth and loss of function
Gait disturbance if involves weight-bearing joints, may have muscle
spasm
Bony swelling reduced dexterity and fine movements if involves the hand
Loss of muscle bulk due to inactivity secondary to pain
Limb deformity enlargement of joins resulting in valgus/varus
Clicking or grinding sensation occurs with joint motion
Instability requires walking aids if involves the weight-bearing joints

Signs
Altered gait if involved weight bearing joints
Tenderness of soft tissues eg synovium, capsule,
periarticular muscles
Joint swelling due to synovitis/synovial effusion/bone
enlargement
Crepitus
Loss of function with reduced motion
Deformity subluxation of IPJ, varus/valgus knees,
shortening in hip OA

Diagnosis: Hand OA

Diagnosis: Hip OA

Diagnosis: Knee OA

Investigations
Diagnosis is clinical
Blood investigations and synovial fluid
analysis seldom required except to exclude
other diagnosis
Plain radiography of the joint is the standard
imaging for assessing OA
Should be done in the weight bearing position
for knee and hip OA.
Classical features include narrowed joint space,
osteophytes, subchondral bone sclerosis,

Synovial fluid assessment

Imaging

Imaging

Grading

Management: Non-Pharmacological
Patient education
Information of the diagnosis, nature of disease, therapeutic options
and importance of ongoing patient participation in the disease
management
Lifestyle modification
Weight reduction to reduce pain and improve function
Physical activity low-impact aerobic exercises (walking),
strengthening exercises
Physiotherapy
To improve muscle strength, balance, coordination, mobility
Transcutaneous electrostimulation, thermotherapy
Occupational therapy
To improve health, prevent disability and help achieve optimum
functional level and ADL independence

Management: Pharmacological (Oral)


Simple analgesics paracetamol
for mild to moderate pain

Weak opioid analgesics tramadol


May be used alone or in combination with paracetamol
Use with caution in elderly

Analgesics with anti-inflammatory properties NSAIDs and COX-2


inhibitors
Increased risk of thrombotic cardiovascular events
Use with caution in elderly, hypertensive, renal/hepatic impairment

Nutraceutical glucosamine, chondroitin, diacerein


Evaluation should be done at 3 months after initiation of treatment before
deciding its continuation

Management: Pharmacological (Nonoral)


Intra-articular corticosteroids eg
Hydrocortisone
For short-term pain relief in acute exacerbation

Intra-articular viscosupplementation by
hyaluronic acid
Controversial

Topical NSAIDs eg diclofenac, capsaicin


Adjunct therapy in mild to moderate pain

Management: Surgical
Assess need for surgery
Pain causing sleep interruption and present
while resting
Limitations to ADL (walking and self-care)
Psychosocial well-being
Economic impact
Recent deterioration

Types of surgery
Arthroscopic lavage with or without debridement only in patients with
loose bodies or flaps of meniscus/cartilage in the joint
High tibial osteotomy if <50 years old and has minimum 120o of knee
flexion
Total joint replacement requiring patient to avoid jogging and highimpact sports for the rest of their life following surgery to ensure
implant longevity
Partial joint replacement for patients with knee OA affecting a single
compartment
Arthrodesis to fuse the diseased joint in an optimal position if there is
pain and significant ligamentous instability in an unreconstructable
knee following an infection at the site of a knee arthroplasty

Management: Recent Advances on Trial


Intra-articular stem cells to boost reparative
process and limit destructive process
Autologous chondrocyte implantation to
treat symptomatic knee cartilage defects by
recruitment of progenitor cells as potential
cartilage precursors
Platelet rich plasma to enhance tissue
regeneration

Referral
Referral to rheumatology or orthopaedic clinic if
Arthritis with unclear diagnosis
Patient does not experience satisfactory improvement in
terms of pain, stability or function despite adequate
pharmacological and non-pharmacological treatment

Referrals should provide information on


Diagnosis
Severity and impact on ADL
Co-morbidities
Relevant investigation results and current medications