Osteoarthritis 143

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Degenerative condition of joint characterised by progressive loss of articular cartilage, pain and stiffness.

Can be classified according to distribution of joint sites involved. Primary: Unknown. Likely to be multifactorial; 'wear-and-tear' concept proposed in the past.

Secondary: Other diseases can cause altered joint architecture and stability. Commonly associated diseases include:

(1) Developmental abnormalities (e.g. hip dysplasia, slipped femoral epiphysis).

(2) Trauma (e.g. previous fractures).

(3) Inflammatory (e.g. rheumatoid arthritis, gout, septic arthritis).

(4) Metabolic (e.g. alkaptonuria, haemochromatosis, acromegaly).

A/R: Age, previous joint injury, strenuous physical occupation.

E: Common, with 25% of > 60 years symptomatic (70% have radiographic changes).

H: Joint pain or discomfort, stiffness after inactivity.

Difficulty with certain movements or feelings of instability. Restriction to walking, climbing stairs and manual tasks.

E: Bone swelling at joint margins, e.g. Heberden's nodes (distal interphalangeal joints), Bouchard's nodes (at proximal interphalangeal joints). Crepitus and pain during joint movement. Restriction of range of joint movement.

P: Synovial joint cartilage fissuring and fibrillation. There is progressive loss of articular cartilage due to altered chondrocyte activity, subchondral sclerosis, bone cysts, osteophyte formation, patchy chronic synovial inflammation and fibrotic thickening of the joint capsules.

I: Joint X-ray: Radiographs of involved joints typically show four classic features:

(1) Joint space narrowing (due to cartilage loss);

(2) Subchondral cysts;

(3) Subchondral sclerosis; and

(4) Osteophytes.

Severity of radiological changes is not a good indicator of symptom severity. Synovial fluid analysis: Not indicated in most cases. Clear synovial fluid, viscous with low cell count and possibly cartilage fragments.

M: Treatment goals include symptom relief, optimising joint function, minimising disease progression and limiting disability.

Medical: Analgesia with paracetamol, codeine, NSAIDs, COX-2 inhibitors or quinine. Topical capsaicin may provide some benefit. Intra-articular injection of steroids and hyaluronic acid provides good but transient symptomatic relief. Supportive: Patient education. Encourage lifestyle changes (e.g. weight loss, exercise). Physiotherapy, occupational therapy, and psychosocial support. Surgical: Various techniques can provide benefits like arthroscopic irrigation, osteophyte removal, joint replacement and joint fusion.

Rehabilitation: Requires concerted effort from clinicians, physiotherapists, occupational therapists and patient to encourage return to normal physical activity.

C: Pain, disability, nerve entrapment syndromes and falls from reduced mobility.

P: Although symptoms may improve or worsen in phases, disease evolution is usually slow, with the natural history depending on the joint site involved.

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