Osteoarthritis: Difference between revisions

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==Diagnosis==
===Signs and symptoms===
====Knee osteoarthritis====
Osteoarthritis of the knees is associated with buckling, or sudden giving way, of the knees.<ref name="pmidpending">Felson, David T., Jingbo Niu, Christine McClennan, Burton Sack, Piran Aliabadi, David J. Hunter, et al. 2007. Knee Buckling: Prevalence, Risk Factors, and Associated Limitations in Function. Ann Intern Med 147, no. 8 (October 16): 534-540. http://www.annals.org/cgi/content/abstract/147/8/534 (accessed October 16, 2007). </ref> This is more likely if the [[quadriceps]] muscle is weak.
A screening survey is positive if any one of the following is answered yes:<ref name="pmidpending">Christian H Roux et al., “Screening for hip and knee osteoarthritis in the general population: predictive value of a questionnaire and prevalence estimates,” Ann Rheum Dis (December 12, 2007), http://ard.bmj.com/cgi/content/abstract/ard.2007.075952v1 (accessed December 13, 2007).</ref>
* During the last 4 weeks, have you had knee pain on most days?
* During the last 4 weeks, have you had knee pain while climbing down stairs or walking down slopes?
* During the last 4 weeks, have you had swelling in one or both knees?
* Do you have knee OA? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)
* [[sensitivity (tests)|sensitivity]] = 87%
* [[specificity (tests)|specificity]] = 92%
Using the prevalence of disease in this study (5% to 8%), the predictive values are:
* [[positive predictive value]] = 51%
* [[negative predictive value]] = 98%
====Hip osteoarthritis====
A screening survey is positive if any one of the following is answered yes:<ref name="pmidpending">Christian H Roux et al., “Screening for hip and knee osteoarthritis in the general population: predictive value of a questionnaire and prevalence estimates,” Ann Rheum Dis (December 12, 2007), http://ard.bmj.com/cgi/content/abstract/ard.2007.075952v1 (accessed December 13, 2007).</ref>
* During the last 4 weeks, have you had hip pain (groin or upper thigh) on most days?
* During the last 4 weeks, have you had hip pain while climbing down stairs or walking down slopes?
* During the last 4 weeks, have you noticed any limitation in the range of motion of one or both hips?
* Do you have hip osteoarthritis? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)
* [[sensitivity (tests)|sensitivity]] = 93%
* [[specificity (tests)|specificity]] = 95%
Using the prevalence of disease in this study (5% to 8%), the predictive values are:
* [[positive predictive value]] = 56%
* [[negative predictive value]] = 99%
==Treatment==
===Medications===
====Acetaminophen====
A [[randomized controlled trial]] comparing [[acetaminophen]] to [[ibuprofen]] in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.<ref name="pmid2052056">{{cite journal |author=Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI |title=Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=325 |issue=2 |pages=87-91 |year=1991 |pmid=2052056 |doi=}}</ref> However, [[acetaminophen]] at a dose of 4 grams per day can increase [[liver function test]]s.<ref name="pmid16820551">{{cite journal |author=Watkins PB, Kaplowitz N, Slattery JT, ''et al'' |title=Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial |journal=JAMA |volume=296 |issue=1 |pages=87-93 |year=2006 |pmid=16820551 |doi=10.1001/jama.296.1.87}}</ref>
===Supplements===
[[Dietary supplement]]s have been studied.
====Chondroitin====
====Chondroitin====
A [[meta-analysis]] of [[randomized controlled trial]]s found no benefit from [[chondroitin]].<ref name="pmid17438317">{{cite journal |author=Reichenbach S, Sterchi R, Scherer M, ''et al'' |title=Meta-analysis: chondroitin for osteoarthritis of the knee or hip |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=580-90 |year=2007 |pmid=17438317 |doi=}}</ref> This [[meta-analysis]] included the large [[randomized controlled trial]] of Clegg.<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392&promo=ONFLNS19 |issn=}}</ref>
A [[meta-analysis]] of [[randomized controlled trial]]s found no benefit from [[chondroitin]].<ref name="pmid17438317">{{cite journal |author=Reichenbach S, Sterchi R, Scherer M, ''et al'' |title=Meta-analysis: chondroitin for osteoarthritis of the knee or hip |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=580-90 |year=2007 |pmid=17438317 |doi=}}</ref> This [[meta-analysis]] included the large [[randomized controlled trial]] of Clegg.<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392&promo=ONFLNS19 |issn=}}</ref>
====Glucosamine====
Neither glucosamine sulfate<ref name="pmid18283204">{{cite journal |author=Rozendaal RM, Koes BW, van Osch GJ, ''et al'' |title=Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial |journal=Ann. Intern. Med. |volume=148 |issue=4 |pages=268–77 |year=2008 |month=February |pmid=18283204 |doi= |url= |issn=}}</ref> nor glucosamine hydrochloride<ref name="pmid16495392">{{cite journal |author=Clegg DO, Reda DJ, Harris CL, ''et al'' |title=Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis |journal=N. Engl. J. Med. |volume=354 |issue=8 |pages=795–808 |year=2006 |month=February |pmid=16495392 |doi=10.1056/NEJMoa052771 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16495392&promo=ONFLNS19 |issn=}}</ref> is effective for osteoarthritis.
A molecule derived from [[glucosamine]] is used by the body to make some of the components of cartilage and synovial fluid.  An initial [[meta-analysis]] found that supplemental glucosamine may improve symptoms of OA and delay its progression.<ref name="pmid15855241">{{cite journal |author=Poolsup N, Suthisisang C, Channark P, Kittikulsuth W |title=Glucosamine long-term treatment and the progression of knee osteoarthritis: systematic review of randomized controlled trials |journal=The Annals of pharmacotherapy |volume=39 |issue=6 |pages=1080-7 |year=2005 |pmid=15855241 |doi=10.1345/aph.1E576}}</ref> However, a large study suggests that glucosamine is not effective in treating OA of the knee.<ref name="pmid15501201">{{cite journal |author=McAlindon T, Formica M, LaValley M, Lehmer M, Kabbara K |title=Effectiveness of glucosamine for symptoms of knee osteoarthritis: results from an internet-based randomized double-blind controlled trial |journal=Am. J. Med. |volume=117 |issue=9 |pages=643–9 |year=2004 |pmid=15501201 |doi=10.1016/j.amjmed.2004.06.023}}</ref> A subsequent [[meta-analysis]] that includes this trial concluded that glucosamine hydrochloride is not effective and that the effect of glucosamine sulfate is uncertain.<ref name="pmid17599746">{{cite journal |author=Vlad SC, Lavalley MP, McAlindon TE, Felson DT |title=Glucosamine for pain in osteoarthritis: Why do trial results differ? |journal=Arthritis Rheum |volume=56 |issue=7 |pages=2267-2277 |year=2007 |pmid=17599746 |doi=10.1002/art.22728}}</ref> This meta-analysis was followed by a [[randomized controlled trial]] that found no benefit from glucosamine sulfate.<ref name="pmid18283204">{{cite journal |author=Rozendaal RM, Koes BW, van Osch GJ, ''et al'' |title=Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial |journal=Ann. Intern. Med. |volume=148 |issue=4 |pages=268–77 |year=2008 |month=February |pmid=18283204 |doi= |url= |issn=}}</ref>
===Injections===
Injections of the [[hip]] joint for labral tears may not be effective.<ref name="pmid18760208">{{cite journal |author=Martin RL, Irrgang JJ, Sekiya JK |title=The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates |journal=Arthroscopy |volume=24 |issue=9 |pages=1013–8 |year=2008 |month=September |pmid=18760208 |doi=10.1016/j.arthro.2008.04.075 |url=http://linkinghub.elsevier.com/retrieve/pii/S0749-8063(08)00358-7 |issn=}}</ref>
===Surgery===
[[Arthroscopic surgery]] for osteoarthritis of the knee is not effective according among patients with moderate or severe disease to two [[randomized controlled trial]]s. However, a number of patients including those with severe disease of two or more compartments of the knee, were excluded.<ref name="pmid18784099">{{cite journal |author=Kirkley A, Birmingham TB, Litchfield RB, ''et al'' |title=A randomized trial of arthroscopic surgery for osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=359 |issue=11 |pages=1097–107 |year=2008 |month=September |pmid=18784099 |doi=10.1056/NEJMoa0708333 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=18784099&promo=ONFLNS19 |issn=}}</ref><ref name="pmid12110735">{{cite journal |author=Moseley JB, O'Malley K, Petersen NJ, ''et al'' |title=A controlled trial of arthroscopic surgery for osteoarthritis of the knee |journal=N. Engl. J. Med. |volume=347 |issue=2 |pages=81–8 |year=2002 |pmid=12110735 |doi=10.1056/NEJMoa013259}}</ref>
==Prognosis==
===Knee===
The strongest predictors of poor functional outcome are age, body mass index, anxiety and pain severity.<ref>Elaine Thomas et al., “Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators?,” Ann Rheum Dis (February 4, 2008): ard.2007.080945. </ref>
===Hip===
Among patients presenting with hip pain to their general practitioner, the rates of total hip replacement are:<ref name="pmid18050175">{{cite journal |author=Lievense AM, Koes BW, Verhaar JA, Bohnen AM, Bierma-Zeinstra SM |title=Prognosis of hip pain in general practice: A prospective followup study |journal=Arthritis Rheum |volume=57 |issue=8 |pages=1368–1374 |year=2007 |pmid=18050175 |doi=10.1002/art.23094}}</ref>
* 12% of patients at 3 years
* 22% after 6 years
Predictors of the need for a total hip replacement are:<ref name="pmid18050175"/>
* age >/=60 years, morning stiffness
* pain in the groin/medial thigh
* decreased extension/adduction
* painful internal rotation
* body mass index </=30 kg/m(2)
* Kellgren/Lawrence grade of 2 or higher
==References==
<references/>

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Diagnosis

Signs and symptoms

Knee osteoarthritis

Osteoarthritis of the knees is associated with buckling, or sudden giving way, of the knees.[1] This is more likely if the quadriceps muscle is weak.

A screening survey is positive if any one of the following is answered yes:[1]

  • During the last 4 weeks, have you had knee pain on most days?
  • During the last 4 weeks, have you had knee pain while climbing down stairs or walking down slopes?
  • During the last 4 weeks, have you had swelling in one or both knees?
  • Do you have knee OA? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)

Using the prevalence of disease in this study (5% to 8%), the predictive values are:

Hip osteoarthritis

A screening survey is positive if any one of the following is answered yes:[1]

  • During the last 4 weeks, have you had hip pain (groin or upper thigh) on most days?
  • During the last 4 weeks, have you had hip pain while climbing down stairs or walking down slopes?
  • During the last 4 weeks, have you noticed any limitation in the range of motion of one or both hips?
  • Do you have hip osteoarthritis? (If you do, was the diagnosis made by a rheumatologist or a general practitioner?)

Using the prevalence of disease in this study (5% to 8%), the predictive values are:

Treatment

Medications

Acetaminophen

A randomized controlled trial comparing acetaminophen to ibuprofen in x-ray proven mild to moderate osteoarthritis of the hip or knee found that equal benefit.[2] However, acetaminophen at a dose of 4 grams per day can increase liver function tests.[3]

Supplements

Dietary supplements have been studied.

Chondroitin

A meta-analysis of randomized controlled trials found no benefit from chondroitin.[4] This meta-analysis included the large randomized controlled trial of Clegg.[5]

Glucosamine

Neither glucosamine sulfate[6] nor glucosamine hydrochloride[5] is effective for osteoarthritis.

A molecule derived from glucosamine is used by the body to make some of the components of cartilage and synovial fluid. An initial meta-analysis found that supplemental glucosamine may improve symptoms of OA and delay its progression.[7] However, a large study suggests that glucosamine is not effective in treating OA of the knee.[8] A subsequent meta-analysis that includes this trial concluded that glucosamine hydrochloride is not effective and that the effect of glucosamine sulfate is uncertain.[9] This meta-analysis was followed by a randomized controlled trial that found no benefit from glucosamine sulfate.[6]

Injections

Injections of the hip joint for labral tears may not be effective.[10]

Surgery

Arthroscopic surgery for osteoarthritis of the knee is not effective according among patients with moderate or severe disease to two randomized controlled trials. However, a number of patients including those with severe disease of two or more compartments of the knee, were excluded.[11][12]

Prognosis

Knee

The strongest predictors of poor functional outcome are age, body mass index, anxiety and pain severity.[13]

Hip

Among patients presenting with hip pain to their general practitioner, the rates of total hip replacement are:[14]

  • 12% of patients at 3 years
  • 22% after 6 years

Predictors of the need for a total hip replacement are:[14]

  • age >/=60 years, morning stiffness
  • pain in the groin/medial thigh
  • decreased extension/adduction
  • painful internal rotation
  • body mass index </=30 kg/m(2)
  • Kellgren/Lawrence grade of 2 or higher

References

  1. ↑ 1.0 1.1 1.2 Felson, David T., Jingbo Niu, Christine McClennan, Burton Sack, Piran Aliabadi, David J. Hunter, et al. 2007. Knee Buckling: Prevalence, Risk Factors, and Associated Limitations in Function. Ann Intern Med 147, no. 8 (October 16): 534-540. http://www.annals.org/cgi/content/abstract/147/8/534 (accessed October 16, 2007). Cite error: Invalid <ref> tag; name "pmidpending" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmidpending" defined multiple times with different content
  2. ↑ Bradley JD, Brandt KD, Katz BP, Kalasinski LA, Ryan SI (1991). "Comparison of an antiinflammatory dose of ibuprofen, an analgesic dose of ibuprofen, and acetaminophen in the treatment of patients with osteoarthritis of the knee". N. Engl. J. Med. 325 (2): 87-91. PMID 2052056. [e]
  3. ↑ Watkins PB, Kaplowitz N, Slattery JT, et al (2006). "Aminotransferase elevations in healthy adults receiving 4 grams of acetaminophen daily: a randomized controlled trial". JAMA 296 (1): 87-93. DOI:10.1001/jama.296.1.87. PMID 16820551. Research Blogging.
  4. ↑ Reichenbach S, Sterchi R, Scherer M, et al (2007). "Meta-analysis: chondroitin for osteoarthritis of the knee or hip". Ann. Intern. Med. 146 (8): 580-90. PMID 17438317. [e]
  5. ↑ 5.0 5.1 Clegg DO, Reda DJ, Harris CL, et al (February 2006). "Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis". N. Engl. J. Med. 354 (8): 795–808. DOI:10.1056/NEJMoa052771. PMID 16495392. Research Blogging.
  6. ↑ 6.0 6.1 Rozendaal RM, Koes BW, van Osch GJ, et al (February 2008). "Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial". Ann. Intern. Med. 148 (4): 268–77. PMID 18283204. [e]
  7. ↑ Poolsup N, Suthisisang C, Channark P, Kittikulsuth W (2005). "Glucosamine long-term treatment and the progression of knee osteoarthritis: systematic review of randomized controlled trials". The Annals of pharmacotherapy 39 (6): 1080-7. DOI:10.1345/aph.1E576. PMID 15855241. Research Blogging.
  8. ↑ McAlindon T, Formica M, LaValley M, Lehmer M, Kabbara K (2004). "Effectiveness of glucosamine for symptoms of knee osteoarthritis: results from an internet-based randomized double-blind controlled trial". Am. J. Med. 117 (9): 643–9. DOI:10.1016/j.amjmed.2004.06.023. PMID 15501201. Research Blogging.
  9. ↑ Vlad SC, Lavalley MP, McAlindon TE, Felson DT (2007). "Glucosamine for pain in osteoarthritis: Why do trial results differ?". Arthritis Rheum 56 (7): 2267-2277. DOI:10.1002/art.22728. PMID 17599746. Research Blogging.
  10. ↑ Martin RL, Irrgang JJ, Sekiya JK (September 2008). "The diagnostic accuracy of a clinical examination in determining intra-articular hip pain for potential hip arthroscopy candidates". Arthroscopy 24 (9): 1013–8. DOI:10.1016/j.arthro.2008.04.075. PMID 18760208. Research Blogging.
  11. ↑ Kirkley A, Birmingham TB, Litchfield RB, et al (September 2008). "A randomized trial of arthroscopic surgery for osteoarthritis of the knee". N. Engl. J. Med. 359 (11): 1097–107. DOI:10.1056/NEJMoa0708333. PMID 18784099. Research Blogging.
  12. ↑ Moseley JB, O'Malley K, Petersen NJ, et al (2002). "A controlled trial of arthroscopic surgery for osteoarthritis of the knee". N. Engl. J. Med. 347 (2): 81–8. DOI:10.1056/NEJMoa013259. PMID 12110735. Research Blogging.
  13. ↑ Elaine Thomas et al., “Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators?,” Ann Rheum Dis (February 4, 2008): ard.2007.080945.
  14. ↑ 14.0 14.1 Lievense AM, Koes BW, Verhaar JA, Bohnen AM, Bierma-Zeinstra SM (2007). "Prognosis of hip pain in general practice: A prospective followup study". Arthritis Rheum 57 (8): 1368–1374. DOI:10.1002/art.23094. PMID 18050175. Research Blogging.
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