Rheumatology Book

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OsteoarthritisAka: Osteoarthrosis, Degenerative Joint Disease, DJD

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  1. See Also
    1. Knee Osteoarthritis
    2. Hand Osteoarthritis
  2. Epidemiology
    1. Most common form of arthritis
    2. Associated functional Impairment increases with age
    3. Prevalence directly increases with age
      1. Age over 40 years: 70% of U.S. population
      2. Age over 65 years: 80% of U.S. population
      3. See Rheumatologic Conditions in the Elderly
  3. Pathophysiology
    1. Primary lesion resides in the articular cartilage
      1. Abnormal cartilage repair and remodeling
      2. Chondrocytes produce proteolytic enzymes
      3. Proteolytic enzymes destroy cartilage
    2. End result
      1. Asymmetric joint cartilage loss
      2. Subchondral sclerosis (bone density increased)
      3. Subchondral cysts
      4. Marginal osteophytes
  4. Etiologies
    1. Primary
      1. Weight bearing joints
        1. Hands
        2. Hips, Knees, and feet
      2. Stressors
        1. Obesity (single most important factor)
        2. Overuse injuries
    2. Secondary
      1. Acute or Chronic trauma
      2. History of knee meniscectomy
      3. Congenital abnormalities
      4. Rheumatic Conditions
        1. Gout
        2. Rheumatoid Arthritis
        3. Calcium pyrophosphate deposition disease (CPPD)
      5. Endocrine Conditions
        1. Diabetes Mellitus
        2. Acromegaly
  5. Symptoms
    1. Morning stiffness of short duration (<30 minutes)
    2. Pain on motion that worsens with increasing joint usage
    3. Slowly progressive deformity and possibly pain
      1. Initial high-use joint pain relieved with rest
      2. Next, pain is constant on affected joint usage
      3. Eventually pain occurs at rest and at night
    4. No systemic manifestations
      1. No Fatigue
      2. No generalized weakness
    5. Associated muscle spasm, contractures and atrophy
    6. Symptoms uncommon before age 40
  6. Signs
    1. Joint Exam
      1. Joint Effusion
      2. Atrophy
      3. Joint instability
      4. Crepitation
      5. Limited range of motion
    2. Joints spared (Contrast with Rheumatoid Arthritis)
      1. Wrist spared
      2. Metacarpal-phalangeal joints spared (except thumb)
      3. Elbow spared
      4. Ankle spared
    3. Joints commonly involved
      1. See Knee Osteoarthritis
      2. See Hip Osteoarthritis
      3. Foot Osteoarthritis
      4. See Hand Osteoarthritis
        1. Distal interphalangeal joints (Heberden's Nodes)
        2. Proximal interphalangeal joints (Bouchard's Nodes)
        3. First carpometacarpal joint (thumb)
      5. Cervical and lumbar spine
        1. Mechanisms
          1. Apophyseal joint arthritis and Osteophytes
          2. Disc degeneration
        2. Secondary affects
          1. Local muscle spasm
          2. Nerve root impingement with radiculopathy
          3. Cervical stenosis
          4. Lumbar Stenosis (Pseudoclaudication)
  7. Labs: General (if indicated)
    1. Erythrocyte Sedimentation Rate
    2. Rheumatoid Factor negative
  8. Labs: Synovial Fluid (if indicated)
    1. Synovial Fluid appearance
      1. Clear fluid
      2. High viscosity and good mucin
    2. Synovial Fluid Crystals
      1. Basic Calcium Phosphate (BCP) Crystals
      2. Apatite crystals
    3. Synovial Fluid White Blood Cell Count
      1. Non-Inflammatory fluid: 200 - 2000 WBC/mm3
      2. WBC Count usually <500 cells (mostly mononuclear)
  9. Differential Diagnosis
    1. Bursitis or Tendonitis
    2. Mechanical intra-articular disorder
    3. Rheumatoid Arthritis
    4. Gout
    5. Lyme Disease
    6. Hemochromatosis
    7. Hyperparathyroidism
    8. Acromegaly
    9. Wilson's Disease
  10. Radiology
    1. Indicated if other diagnosis considered
      1. Joint trauma
      2. Joint pain at night
      3. Progressive joint pain
      4. Family History of other arthritic conditions
      5. Age under 18 years
    2. See Osteoarthritis XRay
    3. See Foot XRay in Osteoarthritis
    4. See Hand XRay in Osteoarthritis
    5. See Hip XRay in Osteoarthritis
    6. See Knee XRay in Osteoarthritis
    7. See Spine XRay in Osteoarthritis
  11. Management: Non-Pharmacologic Treatment
    1. See Knee Osteoarthritis for muscle strengthening
    2. Reduce Obesity
    3. Physical Therapy
    4. Physiotherapy (Heat, Cold, Contrast Baths or Ultrasound)
    5. Consider comorbidity
      1. See Depression in the Elderly
    6. Exercise Program (do not exacerbate symptoms)
      1. Stretching
      2. Mild aerobic, active, Isometric Exercise
      3. Swimming is single best Exercise
      4. Tai chi
        1. Song (2003) J Rheumatol 30:2039
    7. Joint protection
    8. Work and home modified in severe disease
      1. Limit weight bearing on affected joints
      2. Walk Aids (Canes and Walkers)
    9. Surgery
      1. Hip replacement or knee replacement in refractory cases
  12. Management: Pharmacologic Management
    1. Acetaminophen (Tylenol) 1 gram PO qid
    2. NSAIDs (cautious use in the elderly)
      1. Avoid Feldene - higher risk of GI toxicity
      2. Be cautious due to CNS effects (esp. Indomethacin)
    3. COX2 Inhibitors (no advantages to standard NSAIDs)
    4. Intra-articular Corticosteroid injection
      1. Avoid more than 3-4 times per year
    5. Sodium hyaluronate (Synvisc) in Knee Osteoarthritis
    6. Topical Capsaicin cream for refractory joint pain
  13. Management: Alternative Medications
    1. Effective agents (high quality studies)
      1. Glucosamine Sulfate 1500 mg once daily or 500 mg orally three times daily
        1. Towheed (2005) Cochrane Database Syst Rev ( 2):CD002946
        2. Richy (2003) Arch Intern Med 163(13):1514
      2. S-Adenosylmethionine (SAMe) 200 mg three times daily
        1. Methyl donor in proteoglycan synthesis
        2. More effective than Placebo for pain, stiffness
        3. Very expensive and unstable shelf life (Butanedisulfonate salt is most stable)
    2. Possibly effective agents (insufficient evidence to recommend)
      1. Methlsulfonylmethane (MSM) 500 mg three times daily
      2. Dimethyl Sulfoxide (DMSO) 25% applied topically
        1. Small, 3 week studies showed reduced pain
      3. Devil's Claw 2.4 grams daily
      4. Ginger Extract 510 mg daily
    3. Ineffective agents (avoid these based on high quality studies)
      1. Chondroitin sulfate 400 mg PO tid
      2. Tipi
      3. Reumalex
    4. Unknown benefit (anecdotal, inconclusive data or only small studies support)
      1. Avocado-soybean unsaponifiables 300 mg daily
      2. Boron supplementation
        1. Effects calcium metabolism in bones, joints
        2. Higher arthritis rates with low boron intake
      3. Cetyl Myristoleate (anti-inflammatory effects)
      4. Acupuncture
      5. FLUIDjoint
        1. Concentrated milk proteins from New Zealand
        2. Promoted as containing antibodies for immunity
        3. Not recommended due to $50/month and unproven
    5. References
      1. Morelli (2003) Am Fam Physician 67(2):339
      2. Gregory (2008) Am Fam Physician 77(2):177
  14. Prevention
    1. Maintain appropriate body weight
    2. Continued moderate joint activity is critical
      1. Normal joint use directs cartilage remodeling
      2. Decreased joint use risks abnormal cartilage repair
  15. Resources: Patient Education
    1. Information from your Family Doctor: Staying Active
      1. http://www.familydoctor.org/healthfacts/115/
  16. References
    1. Brandt (1995) Ann Intern Med 122:874
    2. Griffin (1995) Arch Fam Med 4:1049
    3. Hinton (2002) Am Fam Physician 65(5):841
    4. Manek (2000) Am Fam Physician 61:1795
    5. Swagerty (2001) Am Fam Physician 64(2):279
    6. Klippel (1997) Primer Rheumatic Diseases, AF

Arthropathies NOS (C0022408)

Definition (CSP)condition in which there is a deviation from or interruption of the normal structure or function of the joints.
Definition (NCI)Any disease of the joints.
ConceptsDisease or Syndrome (T047)
ICD9716.9, 716.9, 716.90, 719.9, 719.90
MSHD007592
Englisharthropathic, Arthropathy, Arthrosis, DISORDER JOINT, Disorder of joint, JOINT DIS, Joint Disease, Joint Diseases, joint disorder, Joint disorders, Osteoarthrosis, Unspecified disorder of joint
Spanishartropatia, enfermedad articular, trastorno articular
Parent ConceptsMusculoskeletal and connective tissue disorders (C0263660), Disorder of skeletal system (C0263661), Arthropathies NOS (C0022408), Musculoskeletal System (C0026860), Disorder of extremity (C1290877), Other and unspecified arthropathies (C1442831), Musculoskeletal Diseases (C0026857), Non-Neoplastic Connective and Soft Tissue Disorder (C1335003), Degenerative polyarthritis (C0029408), Mechanical joint disorder (C0409261), Joint finding (C0427210), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesAOD, COSTAR, CSP, CST, ICD9CM, MSH, MTH, MTHICD9, NCI, NDFRT, OMIM, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)


Degenerative polyarthritis (C0029408)

Definition (MSH)A progressive, degenerative joint disease, the most common form of arthritis, especially in older persons. The disease is thought to result not from the aging process but from biochemical changes and biomechanical stresses affecting articular cartilage. In the foreign literature it is often called osteoarthrosis deformans.
Definition (CSP)noninflammatory degenerative joint disease occurring chiefly in older persons, characterized by degeneration of the articular cartilage, hypertrophy of bone at the margins, and changes in the synovial membrane, accompanied by pain and stiffness.
Definition (NCI)A noninflammatory degenerative joint disease occurring chiefly in older persons, characterised by degeneration of the articular cartilage, hypertrophy of bone at the margins and changes in the synovial membrane. It is accompanied by pain and stiffness, particularly after prolonged activity.
ConceptsDisease or Syndrome (T047)
ICD9715.9
MSHD010003
EnglishDegenerative Arthritides, degenerative arthritis, Degenerative arthropathy, Degenerative joint disease, Degenerative polyarthritis, DJD, hypertrophic arthritis, Hypertrophic polyarthritis, Joint degeneration, OA, OA - Osteoarthritis, OA - Osteoarthrosis, Osteoarthritides, OSTEOARTHRITIS, Osteoarthritis and allied disorders, Osteoarthroses, Osteoarthrosis, primary OA
Spanishartritis degenerativa, artropatia, artropatia degenerativa, artrosis, enfermedad articular degenerativa, OA - Osteoartritis, OA - Osteoartrosis, osteoartritis, osteoartrosis, osteopatia degenerativa, poliartritis degenerativa
Parent ConceptsMechanical Arthritis (C0221567), Arthropathies NOS (C0022408), Degenerative polyarthritis (C0029408), Non-traumatic joint disorders (C0810350), Arthritis (C0003864), Osteoarthrosis and allied disorders (C0263742), Rheumatism (C0035435), Musculoskeletal Diseases (C0026857), Ambiguous concept (C1274012), [X]Inflammatory polyarthropathies (C1692324), Duplicate concept (C1274013)
SourcesAIR, AOD, CCS, COSTAR, CSP, DXP, ICD9CM, LCH, MEDLINEPLUS, MSH, MTH, NCI, NDFRT, OMIM, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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