Osteoarthritis is a common degenerative disorder of the articular cartilage associated with hypertrophie bone changes. Risk factors include genetics, female sex, past trauma, advancing age, and obesity. The diagnosis is based on a history of joint pain worsened by movement, which can lead to disability in activities of daily living. Plain radiography may help in the diagnosis, but laboratory testing usually does not. Pharmacologic treatment should begin with acetaminophen and step up to nonsteroidal anti-inflammatory drugs. Exercise is a useful adjunct to treatment and has been shown to reduce pain and disability. The supplements glucosamine and chondroitin can be used for moderate to severe osteoarthritis when taken in combination. Corticosteroid injections provide inexpensive, short-term (four to eight weeks) relief of osteoarthritic flare-ups of the knee, whereas hyaluronic acid injections are more expensive but can maintain symptom improvement for longer periods. Total joint replacement of the hip, knee, or shoulder is recommended for patients with chronic pain and disability despite maximal medical therapy
- Signs and Symptoms of Osteoarthritis
Pain on range of motion Hypertrophic changes at distal and proximal interphalangeal joints (Heberden nodes and Bouchard nodes; Figure 1) Tenderness over metacarpophalangeal joint of thumb |
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Physical therapy using land-based or water-based exercise can help reduce pain and improve function in patients with osteoarthritis | B | [10] , [11] ,[12] |
| Acetaminophen should be used as first-line therapy for mild osteoarthritis. | A | 16 |
| Nonsteroidal anti-inflammatory drugs are superior to acetaminophen for treating moderate to severe osteoarthritis | A | 16 |
| Intra-articular corticosteroid injections can be beneficial for short-term (i.e., less than eight weeks) relief of osteoarthritis pain of the knee. | A | [21] , [22] |
| Compared with intra-articular corticosteroids, intra-articular hyaluronic acid njections of the knee are less effective in the short term, equivalent in the ntermediate term (i.e., four to eight weeks), and superior in the long term | B | [26] , [27] |
| The combination of glucosamine and chondroitin may decrease pain in patients with moderate to severe knee osteoarthritis, although the evidence for this effect is limited and inconsistent. | B | 30 |
| Patients who have continued pain and disability from osteoarthritis of the hip, knee, or shoulder despite maximal medical therapy are candidates for total joint replacement. |
Complementary and Alternative Medicine
A meta-analysis on the effectiveness of acupuncture for osteoarthritis of the knee found only short-term benefit, which the authors described as clinically irrelevant.[28] Acupuncture can be of benefit in chronic low back pain, but studies do not differentiate the etiology of the back pain.[29]
The most widely used supplements for osteoarthritis are glucosamine and chondroitin. The literature consisted of small clinical trials until the release of the Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), which included more than 1,500 patients. The trial had five arms comparing glucosamine alone, chondroitin alone, a combination of glucosamine and chondroitin, celecoxib, and placebo. The results were favorable only for the combination of glucosamine and chondroitin, which appeared to be effective for moderate to severe osteoarthritis of the knee.[30] Chondroitin alone did not show benefit for osteoarthritis of the knee or hip in a meta-analysis.[31]
Balneotherapy is a heterogeneous group of treatments also known as spa therapy or mineral baths. A Cochrane review concluded that mineral baths were of some benefit to patients with osteoarthritis, but the authors addressed methodologic flaws in the studies and urged caution in interpreting the findings.[32] Capsaicin cream is a topical analgesic derived from chili peppers. It has been found to be superior to placebo in treating osteoarthritis pain. It is widely available, is relatively inexpensive, and can be used as an adjunct to standard osteoarthritis treatments.[33] There also is evidence supporting the use of the supplement S-adenosylmethionine (SAM-e) to reduce functional limitation, but not compared with placebo in patients with osteoarthritis pain. The effectiveness of SAM-e is comparable to that of NSAIDs in some studies but with fewer adverse effects.[34]
Surgical
Surgery should be reserved for patients whose symptoms have not responded to other treatments. The well-accepted indication for surgery is continued pain and disability despite conservative treatment. The most effective surgical intervention is total joint replacement, with excellent patient outcomes following total joint replacement of the hip, knee, and shoulder. [1] , [35] Many different prosthetic devices are available; however, controlled trials comparing the various devices are lacking. Patients can expect that most current joint prostheses will function well for 15 to 20 years.[35]
There are other surgical approaches to osteoarthritis treatment, but they have not equaled the success of total joint replacement. Randomized trials of arthroscopic debridement for osteoarthritis of the knee have consistently failed to show an advantage over maximal medical therapy combined with physical therapy.[36]
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