rav reumatology osteoarthritis

* Osteoarthritis most commonly affects the weight-bearing joints as well as the distal and proximal interphalangeal and first carpometacarpal joints of the hand.

* Osteoarthritis is characterized by pain with activity that is relieved with rest and morning stiffness that lasts for less than 30 minutes daily.

* Secondary osteoarthritis involves joints not typically affected by primary osteoarthritis and develops due to conditions such as trauma, previous inflammatory arthritis, or metabolic disorders such as hemochromatosis or calcium pyrophosphate deposition disease.
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Radiographs of patients with diffuse idiopathic skeletal hyperostosis and degenerative spondylosis and ankylosing spondylitis are similar except that patients with diffuse idiopathic skeletal hyperostosis do not develop disk-space narrowing or syndesmophytes.
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Osteoarthritis of the knee can be diagnosed if knee pain is accompanied by at least three of the following features: age greater than 50 years, stiffness lasting less than 30 minutes, crepitus, bony tenderness, bony enlargement, and no palpable warmth.
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Osteoarthritis of the hand may manifest as swelling of the proximal and distal interphalangeal joints and hard bony enlargement, whereas rheumatoid arthritis of the hand presents with only proximal interphalangeal and metacarpophalangeal joint swelling and soft synovial proliferation.
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Compared with radiography, clinical examination is more sensitive and specific for the diagnosis of osteoarthritis of the hand.
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There is a poor correlation between radiographic evidence of osteoarthritis and symptoms.
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Weight loss and physical therapy benefit patients with osteoarthritis of the hip and knee.

* NSAIDs have been shown to be more effective in the treatment of osteoarthritis than acetaminophen but may increase cardiovascular risk.
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Tramadol and opioid analgesics are effective second-line agents in the treatment of osteoarthritis.
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Intra-articular corticosteroid injection therapy is warranted in patients with osteoarthritis of the knee or hip in whom NSAIDs are either contraindicated or do not provide adequate pain relief.
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Patients with signs of inflammation should not undergo intra-articular corticosteroid therapy until synovial fluid analysis excludes infection.

Diagnose secondary osteoarthritis.
Key Point

* Secondary osteoarthritis usually involves joints not affected by primary osteoarthritis and develops because of another condition, such as trauma, previous inflammatory arthritis, or metabolic disorders such as hemochromatosis or chondrocalcinosis.

This patient most likely has secondary

primary osteoarthritis usually affects patients with advanced age or who have occupations involving repetitive bending or manual labor.

Secondary osteoarthritis usually involves joints not affected by primary osteoarthritis. Secondary arthritis develops because of another condition, such as trauma, previous inflammatory arthritis, or metabolic disorders such as hemochromatosis or chondrocalcinosis. In this patient, the presence of skin hyperpigmentation and diabetes mellitus raises strong suspicion for hemochromatosis, which is particularly associated with involvement of the metacarpophalangeal joints in patients without primary osteoarthritis.

Symptoms of osteoarthritis that involve the second and third metacarpophalangeal joints also may be caused by calcium pyrophosphate deposition disease. However, radiographs of patients with this condition would typically reveal chondrocalcinosis, which occurs most frequently in the knees, symphysis pubis, and triangular fibrocartilage of the wrist.

Diabetic cheiroarthropathy (stiff hand syndrome) more commonly occurs in patients with long-standing diabetes. This condition manifests as joint stiffness, limited range of motion in the absence of pain, and skin thickening of the fingers, which is not compatible with this patient’s presentation or radiographic findings.

Rheumatoid arthritis may involve the metacarpophalangeal joints in a symmetric pattern and may be present in patients without rheumatoid factor. This condition also may manifest as rheumatoid nodules (subcutaneous nodules that develop over bony prominences at sites such as the extensor surfaces of the hand) that may resemble the bony enlargement associated with osteoarthritis. However, rheumatoid arthritis is unlikely in the absence of morning stiffness and joint swelling.

The presence of symmetric pain and bony enlargement of the joints accompanied by radiographic findings of joint-space narrowing and osteophytes is consistent with osteoarthritis. However, primary osteoarthritis does not typically involve the metacarpophalangeal joints; if this occurs, suspicion should be raised for secondary osteoarthritis. Similarly, radiographs of the metacarpophalangeal joints may reveal hook-shaped osteophytes that are significantly different from radiographs of patients with primary osteoarthritis.

Hemochromatosis arthropathy also may involve the proximal interphalangeal joints and, less frequently, the shoulders, hips, knees, and ankles. Finally, primary osteoarthritis usually affects patients with advanced age or who have occupations involving repetitive bending or manual labor.

Arthroscopy and MRI of the knee would most likely reveal abnormalities of the articular cartilage not visible on plain radiography but are not needed to establish the diagnosis of osteoarthritis. Similarly, aspiration of the knee joint would be warranted in patients with an effusion to obtain a synovial fluid leukocyte count but is not needed to establish a diagnosis;

Manage osteoarthritis of the knee in an elderly patient.
Key Point

* Hyaluronan injections may be considered in patients with osteoarthritis of the knee in whom NSAIDs are either contraindicated or do not provide adequate pain relief.

NSAIDs have been shown to be more effective than acetaminophen in relieving pain associated with osteoarthritis. However, neither selective nor nonselective NSAIDs would be indicated for an elderly patient with chronic kidney disease. These agents also should be used with caution in patients with heart failure and hypertension.

Like hyaluronan injections, narcotic analgesics may benefit patients in whom NSAIDs are contraindicated or for whom NSAIDs do not sufficiently relieve pain. However, a narcotic analgesic is not appropriate in a patient with a history of severe constipation caused by previous narcotic treatment

Total knee arthroplasty is warranted only when no further medical therapy is available and the patient decides that the impairment caused by his or her condition warrants this intervention.

Tramadol is an appropriate second-line agent in the treatment of osteoarthritis and is particularly useful in patients with osteoarthritis of the knee or hip who are intolerant of or who do not achieve adequate pain control using NSAIDs.

Arthroscopic lavage and/or débridement is not indicated for osteoarthritis of the knee. A randomized controlled trial comparing arthroscopic lavage and arthroscopic lavage plus débridement compared with a sham procedure for knee osteoarthritis showed no benefit of the intervention compared with sham arthroscopy.

Patients with hip and knee osteoarthritis who have not responded to conservative therapy and who have functional limitations should be referred to an orthopedic surgeon for consideration of arthroplasty. However, this patient is not severely incapacitated, and other medical options are available to manage his knee pain.

Use of an NSAID such as celecoxib or ibuprofen would be appropriate in a patient with moderate to severe osteoarthritis or a patient with osteoarthritis in whom acetaminophen did not provide sufficient pain relief. However, both selective and nonselective NSAIDs are associated with an increased risk of cardiovascular disease and should be avoided in patients with cardiovascular conditions. Finally, coadministration of an NSAID with aspirin also may inhibit the antiplatelet effects of aspirin.

tramadol as a second-line agent in the treatment of osteoarthritis. This medication is considered particularly useful in patients with osteoarthritis of the hip or knee who are intolerant of or who do not achieve adequate pain control using acetaminophen and/or NSAIDs. Tramadol is a centrally acting analgesic, and the most common adverse effects associated with this agent are nausea and dizziness.

NSAIDs such as celecoxib, ibuprofen, or sulindac are indicated for patients with osteoarthritis who have moderate-to-severe disease or who have achieved inadequate pain relief with acetaminophen. However, this patient has chronic kidney disease. In patients with compromised renal function, prostaglandin inhibition associated with ibuprofen can lead to frank renal failure, particularly in patients already taking an angiotensin-converting enzyme inhibitor.

Pain associated with osteoarthritis of the hip is often referred to the groin and medial thigh and, less frequently, the knee and/or buttocks. Patients with this condition also often experience pain on passive range of motion of the hip joint at the extremes of flexion, extension, or internal and external rotation.