Osteoarthritis

Assessment

History

The patient presents with knee pain and the radiographs have shown degenerative changes which suggest degenerative joint disease-osteoarthritis. Osteoarthritis is the most common clinical presentation in orthopaedics. Although the most probable causes of the patients symptoms is osteoarthritis, a full history and examination is required to exclude other possible causes such as inflammatory arthritis and trauma. In addition to the site of the pain the patient presents with it is important to elicit; the severity, periodicity (if continuous or intermittent), exacerbating and alleviating factors and if night pain is present. Instead of talking about what to elicit, talk about the clinical features and symptoms. The onset of the pain is of importance particularly when the pain is at its worse, what time of day and what the patient was doing at this time. Morning stiffness may be present. In inflammatory joint disease such as rheumatoid arthritis this often lasts longer that an hour and is alleviated by joint use. In osteoarthritis of the knee, this morning stiffness lasts for less than 15 minutes and is exacerbated by movement. The pain is usually aching and burning, worse after activity and relieved by rest. It is also worth noting if the patient's complaint causes deformity, weakness which may be localised or generalised, if the joint gives way, if there is numbness or locking. The effect of the patient's symptoms on Activities of Daily Living (ADL) such washing, dressing, climbing the stairs is important to assess the extent of disability.

In the medical history it is important to establish if certain co-morbidities associated with degenerative changes are present. Studies have suggested that a history of hypercholesterolemia and hypertension may predispose to osteoarthritis. Previous trauma and surgery often predisposes secondary osteoarthritis. Congenital joint conditions may also predispose to osteoarthritis. Primary osteoarthritis occurs in 90% of cases and there is an unknown aetiology. Secondary osteoarthritis makes up the remaining cases and has a known aetiology, it often occurs in weight bearing joints. The causes of secondary osteoarthritis are; obesity, abnormal cartilage surfaces, joint instability, genetic abnormalities such dysplasia of the hip, osteonecrosis, metabolic bone disease, inflammatory arthritis, and neuropathies.

The family and social history may provide a cause of the pain. Studies have suggested that there may be genetic components to osteoarthritis as a fifth of sufferers have a positive family history. Studies have suggested that genetic factors may contribute from 35-65% of the aetiology. A social history including an occupational history is relevant. Studies have suggested that certain occupations are more likely to result in osteoarthritis than others. Studies have also suggested that smoking increases the risk of osteoarthritis. Demographic factors such as the patients age (48); gender (male) and occupation are important clues in the diagnosis. Osteoarthritis is more common in women than men, and its incidence increases with age. However, under 45 years of age osteoarthritis is more common in men and usually involves one or two joints. Osteoarthritis affects all racial groups but there are differences in the presentation. In Chinese and Asian groups, hip osteoarthritis is more common whereas in the Afro-Caribbean population, knee osteoarthritis s more common.

Obesity is believed to be causal in osteoarthritis, but this has a greater impact on women and commonly affects the knee. Obesity is associated with the progression of osteoarthritis. Studies have suggested that losing weight can halve the progression of osteoarthritis.

The patient was a former amateur footballer and studies on the effect of exercise on the development of osteoarthritis are conflicted. The general consensus is that the duration of exercise is more important than the intensity of the exercise in current and former athletes that have developed osteoarthritis.

Examination

On examination, the pain may be exacerbated by movement and localised. There may be a loss of movement, swelling, deformity, crepitus and weakness. In inflammatory arthritis, the pain is often relieved by movement and worse during rest. The joints are hot and swollen and there is often a symmetrical involvement unlike in osteoarthritis. There may be an altered function of the joint and as discussed before, it is important to observe how the patient adjusts to this to determine the extent of disability. Muscle wasting may be seen as some patients become immobile due to the pain caused by movement. A full neurovascular examination is important to rule out neuropathic changes and vasculitis.

Talk about pathology mention anatomy of knee joint

Investigations

Plain antero-posterior and Lateral radiographs are indicated in order to achieve a complete visualisation of the joint. In this patient degenerative changes can be seen. Other radiographic features include a narrowed joint space which is often asymmetric. This is often symmetrical in inflammatory disease. Subchondral sclerosis and cysts can be seen in advanced disease as bone attempts to remodel itself in response to the cartilage damage. Marginal osteophytes may also be seen in advanced disease. However, it is important to note that only half of patients with degenerative changes on radiology are symptomatic.

Blood tests are mainly performed to rule out the inflammatory arthropathies. The C-reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) are often normal although studies have suggested that these may be raised in early disease and is a predictor of disease progression. Rheumatoid factor and antinuclear antibodies are tested for and are negative.

Arthroscopy may be carried out and may reveal early fissuring of the cartilage surface.

Management

The management of osteoarthritis requires a multidisciplinary approach as the stresses on the affected individual manifest themselves not only physically but also psychologically and socially. The therapeutic aims of treatment are; Pain control, Improvement in function, Improvement of the Quality of Life and the Minimization of toxic side-effects.

Conservative Management and Non-Pharmacological Management

The initial management of osteoarthritis is non-pharmacological and involves interventions such as; patient education, advice on weight loss and physiotherapy. Studies have reported that patients who were given information from doctors and leaflets about their condition