Osteoarthritis Overview

Osteoarthritis (OA)

• Prevalence: Very common joint condition, affecting over 10% of people aged 60+.
• Types: Typically primary (generalized), but often secondary to other conditions like haemochromatosis or obesity.
• Signs and Symptoms (Localized): Pain, creaking (crepitus) during movement, persistent ache, worsening with prolonged activity, brief stiffness ("gel phenomenon" - typically 10-15 minutes after rest), perceived joint instability/lack of power due to pain.
• Signs and Symptoms (Generalized): "Nodal OA" predominantly affects DIP, PIP, CMC joints and knees in post-menopausal women. Characterized by joint tenderness, damage, swelling (Heberden's and Bouchard's nodes), limited movement, and mild synovitis.
• Assessment: Evaluate impact of symptoms on daily life (work, family, hobbies, and lifestyle).
• Diagnosis: X-rays show loss of joint space, osteophytes (bone spurs), subarticular sclerosis and subchondral cysts. CRP may be slightly elevated.
• Treatment (Core): Exercise (improving muscle strength and aerobic fitness), weight loss (if applicable), regular paracetamol plus topical NSAIDs (first-line medications). If these are ineffective, codeine or short-term oral NSAID use is considered, along with potential topical capsaicin.
• Treatment (Severe Symptoms): Intra-articular steroid injections and hyaluronic acid injections can temporarily alleviate symptoms, but hyaluronic acid is not currently approved for use by NICE.
• Treatment (Non-Pharmacological): Multidisciplinary approach involving physiotherapy, occupational therapy, heat/cold packs, walking aids, stretching, manipulation, TENS (Transcutaneous Electrical Nerve Stimulation).
• Treatment (Advanced): Joint replacement is a beneficial option for severe outcomes significantly impacting quality of life (hips, knees).
• Glucosamine/Chondroitin: Not recommended and considered as over-the-counter options.

Septic Arthritis

• Definition: Acute inflammation of a joint.
• Severity: Potential for rapid, severe joint destruction within 24 hours.
• Mortality: Mortality rates can be as high as 11%.
• Symptoms: Inflammation may be less obvious with immune compromise and underlying joint issues.
• Affected Joint: Knee is the most impacted area in over 50% of cases.
• Risk Factors: pre-existing joint disease (like rheumatoid arthritis), diabetes, immunosuppression, chronic renal failure, recent joint surgery, prosthetic joints, intravenous drug abuse, and age above 80 years.
• Diagnosis: Urgent joint aspiration (fluid removal) for synovial fluid analysis and culture is essential. X-rays and CRP may not always indicate the condition initially. Blood cultures are necessary (before starting antibiotics).
• Investigation: Investigate the infection source (e.g., immunocompromised state, IV lines, skin infection, pneumonia - ~50% of cases involving pneumococcal bacteria).
• Treatment: Empirical IV antibiotics (started after aspiration) until causative agents and sensitivities are determined. Common pathogens including Staphylococcus aureus, streptococci, Neisseria gonorrhoeae and Gram-negative bacilli are possible culprits. Local protocols/guidelines and microbiology support are necessary for optimal approach, especially for complex/immunocompromised cases (e.g., HIV).
• Treatment (Specific Antibiotics):
  • Flucloxacillin (2g QDS IV) or Clindamycin (if penicillin allergy)
  • Vancomycin (IV) plus 2nd or 3rd generation cephalosporin (e.g., cefuroxime, if a risk of MRSA infections.
  • Ceftriaxone for possible gonorrhoea or meningococcal infections.
• Duration: Prolonged antibiotic treatment, typically 2 weeks IV followed by 2-4 weeks oral treatment in improving patients. Surgical intervention for joint arthrocentesis, washout, and debridement is possible. Urgent considerations if the affected joint is a prosthetic.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• General Effect: Effective analgesics.
• Response: Around 60% of patients respond to NSAIDs with variable efficacy and tolerance.
• Risk-Benefit Analysis: Individualized risk-benefit assessment is critical, considering dosage, duration, indication, and co-morbidities.
• Side Effects (Serious): GI bleeding (including ulcers and perforation), cardiovascular events (MI and stroke), and kidney injury. Risk factors that increase side effects include higher age, multiple medications, peptic ulcer history and pre-existing kidney issues.
• Use Recommendations: The lowest possible dose and shortest period are crucial.
• GI Protection: NICE recommends proton pump inhibitors (PPIs) for those aged >45 plus other GI risk factors.
• Interactions: Drug interactions can increase bleeding risk. Avoid concomitant use with anticoagulants, antiplatelets, SSRIs, spironolactone, steroids, and bisphosphonates.
• Coxibs: Slightly lower GI risk compared to traditional non-selective NSAIDs.
• Cardiovascular Risk: Associated with a slight increased risk of MI and stroke; high-risk groups include patients with a history of cardiovascular issues; Coxibs and diclofenac pose increased concern in patients with previous MI, stroke or heart failure.
• Renal Risk: Higher in patients on diuretics, ACE inhibitors, or ARBs; increased risks in the elderly and those with hypertension or T2DM.

Rheumatology - Other Assessment Parameters

• Rheumatoid arthritis (RA) markers:
  • Negative Rheumatoid Factor (RF) and negative Anti-CCP antibodies = 0 points.
  • Low positive RF or low positive Anti-CCP = 2 points.
  • High positive RF or high positive Anti-CCP = 3 points.
• Inflammatory markers:
  • Normal C-Reactive Protein (CRP) and normal Erythrocyte Sedimentation Rate (ESR) = 0 points.
  • Abnormal CRP or ESR = 1 point.
• Symptom duration: Information on the number of days or weeks the symptoms have persisted is important for a complete evaluation.

Explore the key aspects of Osteoarthritis (OA), a common joint condition affecting many aged 60 and above. This quiz covers types, signs and symptoms, assessment, and diagnosis related to OA. Test your understanding of how this condition impacts daily life and how it can be identified.