Treatment
Medical Therapy
Currently, the various treatments of osteoarthritis (OA) are aimed at controlling the symptoms of pain, including physical therapy to increase muscle tone and joint motion; medications; weight loss; avoidance of certain activities (eg, kneeling, squatting); and pharmacotherapy, including aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
Topical analgesic creams may be appropriate early on, along with the injection of hyaluronic acid medications, such as Synvisc (Hylan G-F 20; Genzyme Biosurgery, Ridgefield, NJ) and Hyalgan (sodium hyaluronate; Fidia Farmaceutici SpA, Abano Terme, Padua, Italy). Prior to using the hyaluronic injections, one should aspirate the knee and instill steroids. If steroids are overutilized, one has to be careful of infection and/or increased deformity of the knee due to the microfractures that occur from the use of the steroids.
Glucosamine and chondroitin sulfate may also have a role in the treatment of OA; products containing these agents have not been proven to work (although they may), and they are costly.15
Physical therapy
Physical therapy has an important role in the management of OA.16 Exercise programs can be designed to achieve various goals, including muscle strengthening and improving ROM, flexibility, and aerobic conditioning. Modification of the patient's lifestyle is also important; measures may include weight reduction, restriction of vigorous activities, and use of supportive devices.
Physical modalities may include the application of cold to affected areas to decrease pain during the acute inflammation phase, the use of superficial heat in the subacute phase, and the use of deep heat in the chronic phase of the disease.
Chaipinyo et al found no significant difference between home-based strength training and home-based balance training for knee pain caused by osteoarthritis. However, greater improvement was noted in the strength group regarding knee-related quality of life (improved 17 points out of 100 [95% confidence interval (CI), 5-28] than in the balance group.17
Nonpharmacologic modalities
Nonpharmacologic modalities should be considered as initial management in the early stages of OA disease. Patients should be educated about OA, weight control, and avoiding activities such as kneeling and squatting that increase stress to weight-bearing joints.
Physical modalities that can reduce OA pain include cold application in the acute phase, superficial-heat application in the subacute phase, and deep-heat application in the chronic phase.
Range-of-motion (ROM) exercises and stretching may be helpful. Muscle strengthening, aerobic conditioning, and the use of gait aids (eg, cane, walker) and/or orthoses (eg, hand splint, knee brace) may be useful as well.
Pharmacotherapy
Nonpharmacologic strategies should be considered as adjuncts to pharmacologic measures. Pain relief can be achieved with low-to-moderate doses of simple analgesics and anti-inflammatory medications such as acetaminophen, aspirin, and NSAIDs. In a recent meta-analysis of trials comparing simple analgesics with NSAIDs in patients with knee OA, NSAID-treated patients had significantly greater improvement in both pain at rest and pain during motion. Other alternative or additional pharmacologic agents should be considered in patients in whom symptomatic relief is inadequate. The agent should be carefully selected after risk factors such as serious gastrointestinal and renal toxicity are evaluated.
A topical analgesic cream (eg, methylsalicylate or capsaicin cream) is appropriate in cases of knee OA with mild to moderate pain, either as an adjunctive treatment or as monotherapy. Cyclooxygenase 2 (COX-2)–specific inhibitors, inhibitors such as celecoxib (Celebrex; Pfizer Inc, New York, NY) have been studied in patients with OA. COX-2 inhibitors have a more specific anti-inflammatory effect with fewer adverse effects. Celecoxib is more effective than placebo and has an efficacy comparable to that of naproxen in patients with hip or knee OA.
The COX-2 inhibitors rofecoxib (Vioxx; Merck & Co, Inc, Whitehouse Station, NJ) and valdecoxib (Bextra; Pfizer Inc) were withdrawn from the US market on September 30, 2004, and April 7, 2005, respectively, because of their association with an increased rate of cardiovascular events (including heart attacks and strokes), compared with that of placebo. Additionally, Vioxx was withdrawn from the world market. Severe dermatologic toxicities resulting in death have occurred with Bextra.
Oral corticosteroids have no place in the management of OA. However, occasional intra-articular injections of corticosteroids may provide temporary benefit in flare-ups and in the relief of symptoms.
Paracetamol (acetaminophen) is the drug of choice in the management of OA. Hyaluronic acid therapy consists of a series of injections, and it may exert its effect by providing physical cushioning or viscosupplementation of the joint. Oral glucosamine may have a role in the treatment of OA.15 NSAIDs and topical creams containing an NSAID or capsaicin may have a role as well.
Surgical Therapy
Surgery is indicated in those patients who have significant symptoms that have not responded to conservative therapy, whether it is treatment by oral or injected medications or the supportive role of physical therapy. The lower extremity surgical procedures include arthroscopy with debridement, valgus osteotomy for significant genu varum, or total knee arthroplasty. Fusion of a joint (eg, hip, knee, ankle) is rarely done today, but this procedure may be the only one that will work in a patient with infection following one of the other procedures.Arthroscopy
Arthroscopy is a procedure of low invasiveness and morbidity and will not interfere with future surgery. This procedure is especially indicated for removal of meniscal tears and of any loose bodies that can occur. Less predictable arthroscopic procedures include debridement of loose articular cartilage with a microfracture technique, cartilaginous implants in areas of eburnated subchondral bone, or an arthroplasty such as the Genzyme procedure; these procedures have varying success rates and should only be used by those surgeons experienced with arthroscopic surgical techniques.18,19,20,21
Arthroscopic view of a torn meniscus before (top) and after (bottom) removal of loose meniscal fragments.
Arthroscopic view of an arthritic knee.
Arthroscopic view of a knee after the removal of loose fragments of articular and meniscal cartilage.
Arthroscopic view of the removal of cartilaginous loose body.
In a study by Kirkley et al published in the New England Journal of Medicine in September 2008 ("A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee"), it was found that "arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy."18 In an accompanying editorial, Marx stated, "However, osteoarthritis is not a contraindication to arthroscopic surgery, and arthroscopic surgery remains appropriate in patients with arthritis in specific situations in which osteoarthritis is not believed to be the primary cause of pain."19 Also see the Medscape article "Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis."20
Osteotomy
Osteotomy is used in active patients younger than 60 years who want to continue with reasonable physical activity.22 The principle underlying this procedure is to shift weight from the damaged cartilage on the medial aspect of the knee to the healthy lateral aspect of the knee. Osteotomy is most beneficial for significant genu varum or bowleg deformity. (Note: The osteotomy for genu valgum is not a procedure of high predictability regarding its effectiveness.) Osteotomy often can save individuals from having a total knee replacement until they are older.
Contraindications for an osteotomy are knee flexion less than 90°, a flexion-extension contracture of more than 15°, and a significant amount of varus over 15°-20°. Instability due to previous trauma or surgery, severe arterial insufficiency, and bicompartmental involvement are also contraindications.
Arthroplasty
Arthroplasty (total joint replacement) is an excellent treatment in individuals with moderate to severe OA.10,9,23 This procedure is the most reliable, can significantly improve the patient's quality of life, and has results that last the longest. The rate of revision for arthroplasty has decreased with advances in the technique and prosthesis design. Candidates are preferably older than 60 years, so that they are less likely to need a repeat procedure.
Anteroposterior radiograph shows knee replacement in 1 knee and arthritis in the other, with medial joint-space narrowing and subchondral sclerosis.
Anteroposterior radiograph of the pelvis and hips shows an arthritic hip not treated surgically and a total hip replacement.
Anteroposterior radiograph obtained after knee replacement (see Image below).
Lateral radiograph obtained after knee replacement (same patient as in Image above).
Arthroplasty consists of the surgical removal of joint surface and the insertion of a metal and plastic prosthesis. The prosthesis is held in place by cement or bone ingrowth into the porous coating. The use of cement relieves pain more quickly, but a porous coating may last longer; therefore, a porous coating is used in younger patients.
Resection arthroplasty and fusion
Older procedures that were used in major joints are now used in small joints and in large joints in which there is extensive bone destruction and/or persistent infection.
Resection arthroplasty consists of the removal of the joint and allowing the scar to separate the bones and to help in reducing pain. This procedure is sometimes used after the failure of hip replacements if there is extensive bone destruction or persistent infection.
Fusion consists of the union of bones on either side of the joint. This procedure relieves the pain but prevents motion and puts more stress on the surrounding joints. Fusion is sometimes used after knee replacements fail or as a primary procedure for ankle or foot arthritis.
Preoperative Details
See Contraindications.
Intraoperative Details
See Treatment, Surgical therapy, above.
Postoperative Details
Postoperative care for the lower extremities may vary depending on the treatment used. Patients who undergo arthroscopy usually require a period of crutch use and/or exercise therapy; this typically lasts days or sometimes weeks. Those patients undergoing osteotomy and fusion require partial weight bearing until bony healing occurs; afterward, exercise is indicated. After joint replacement, patients require partial weight bearing, which progresses to full weight bearing in 1-3 months; ROM and strengthening exercises are started within a few days after joint-replacement surgery and continued until the patient has good ROM and strength. After resection arthroplasty of the hip, patients require instruction in the use of crutches or a walker, which is usually needed permanently.
Follow-up
Patients are monitored regularly until they have recovered from surgery. Afterward, they are examined at least yearly.
Complications
Infection is the most feared postsurgical complication, especially in cases of total joint replacement. This complication is now rare, especially with the use of perioperative antibiotics.
The prevention of thrombophlebitis and resultant pulmonary embolism is important in patients who undergo lower extremity arthroplasty procedures for osteoarthritis. The surgeon must use all of the material available to prevent these complications, especially initiating early motion and ambulation when possible. The use of low-molecular-weight heparin or warfarin is also indicated.
More on Osteoarthritis |
| Overview: Osteoarthritis |
| Workup: Osteoarthritis |
 Treatment: Osteoarthritis |
| Follow-up: Osteoarthritis |
| Multimedia: Osteoarthritis |
| References |
| Further Reading |
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References
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum. Sep 2000;43(9):1905-15. [Medline].
Creamer P, Hochberg MC. Osteoarthritis. Lancet. Aug 16 1997;350(9076):503-8. [Medline].
Dutkowsky JP. Miscellaneous nontraumatic disorders. In: Crenshaw AH, ed: Campbell's Operative Orthopedics. 8th ed. St Louis, Mo: Mosby-Year Book; 1992:1957-2058.
Schumacher HR. Osteoarthritis. In: Primer on the Rheumatic Diseases. 10th ed. Atlanta, Ga: Arthritis Foundation;1993:184-90.
Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum. May 1998;41(5):778-99. [Medline].
Hurley MV. The role of muscle weakness in the pathogenesis of osteoarthritis. Rheum Dis Clin North Am. May 1999;25(2):283-98, vi. [Medline].
Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br. Nov 1961;43-B:752-7. [Medline]. [Full Text].
Zgoda M, Paczek L, Bartlomiejczyk I, et al. Age-related decrease in the activity of collagenase in the femoral head in patients with hip osteoarthritis. Clin Rheumatol. Feb 2007;26(2):240-1. [Medline].
Daras M, Macaulay W. Total hip arthroplasty in young patients with osteoarthritis. Am J Orthop. Mar 2009;38(3):125-9. [Medline].
Bellamy N, Bell MJ, Pericak D, et al. BLISS index for analyzing knee osteoarthritis trials data. J Clin Epidemiol. Feb 2007;60(2):124-32. [Medline].
Boniatis I, Costaridou L, Cavouras D, et al. Assessing hip osteoarthritis severity utilizing a probabilistic neural network based classification scheme. Med Eng Phys. Mar 2007;29(2):227-37. [Medline].
Gabriel SE, Crowson CS, Campion ME, O'Fallon WM. Indirect and nonmedical costs among people with rheumatoid arthritis and osteoarthritis compared with nonarthritic controls. J Rheumatol. Jan 1997;24(1):43-8. [Medline].
Lanes SF, Lanza LL, Radensky PW, et al. Resource utilization and cost of care for rheumatoid arthritis and osteoarthritis in a managed care setting: the importance of drug and surgery costs. Arthritis Rheum. Aug 1997;40(8):1475-81. [Medline].
Keen HI, Wakefield RJ, Conaghan PG. A systematic review of ultrasonography in osteoarthritis. Ann Rheum Dis. May 2009;68(5):611-9. [Medline].
Hathcock JN, Shao A. Risk assessment for glucosamine and chondroitin sulfate. Regul Toxicol Pharmacol. Feb 2007;47(1):78-83. [Medline].
Cibulka MT, White DM, Woehrle J, Harris-Hayes M, Enseki KR, Fagerson TL, et al. Hip pain and mobility deficits-hip osteoarthritis. J Orthop Sports Phys Ther. Apr 2009;39(4):A1-A25. [Medline].
[Best Evidence] Chaipinyo K, Karoonsupcharoen O. No difference between home-based strength training and home-based balance training on pain in patients with knee osteoarthritis: a randomised trial. Aust J Physiother. 2009;55(1):25-30. [Medline].
Kirkley A, Birmingham TB, Litchfield RB, et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. New England Journal of Medicine. Available at http://content.nejm.org/cgi/content/short/359/11/1097?query=TOC. Accessed September 11, 2008.
Marx RG. Arthroscopic Surgery for Osteoarthritis of the Knee?. New England Journal of Medicine. Available at http://content.nejm.org/cgi/content/short/359/11/1169?query=TOC. Accessed September 11, 2008.
Barclay L, Nghiem HT. Arthroscopic Surgery May Not Be Helpful for Knee Osteoarthritis. Medscape. Available at http://www.medscape.com/viewarticle/580300. Accessed September 11, 2008.
Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. Sep 11 2008;359(11):1097-107. [Medline].
Pagenstert G, Knupp M, Valderrabano V, Hintermann B. Realignment surgery for valgus ankle osteoarthritis. Oper Orthop Traumatol. Mar 2009;21(1):77-87. [Medline].
Kuo A, Ezzet KA, Patil S, Colwell CW Jr. Total Hip Arthroplasty in Rapidly Destructive Osteoarthritis of the Hip: A Case Series. HSS J. Mar 24 2009;[Medline].
Nemirovskiy OV, Dufield DR, Sunyer T, et al. Discovery and development of a type II collagen neoepitope (TIINE) biomarker for matrix metalloproteinase activity: from in vitro to in vivo. Anal Biochem. Feb 1 2007;361(1):93-101. [Medline].
Weiker GG, Villis JD. The degenerative knee. In: Garrett WE Jr, Speer KP, Kirkendall DT, eds. Principles and Practice of Orthopaedic Sports Medicine. Phladelphia, Pa: Lippincott Williams & Wilkins;2000:845-62.
Further Reading
Related eMedicine topics
Osteoarthritis (Physical Medicine and Rehabilitation)
Osteoarthritis, Primary (Radiology)
Osteoarthritis (Rheumatology)
Clinical guidelines
Total knee replacement. National Institutes of Health (NIH) Consensus Development Panel on Total Knee Replacement - Independent Expert Panel. 2004 Feb 17. 18 pages. NGC:003622
ACR Appropriateness Criteria® imaging after total hip arthroplasty (THA). American College of Radiology - Medical Specialty Society. 1998 (revised 2005). 8 pages. NGC:004649
Treatment of Osteoarthritis (OA) of the Knee Guideline (American Academy of Orthopaedic Surgeons, Dec 2008)
Clinical trials
Using Ultrasound to Predict Response to Intraarticular Corticosteroids in Knee Osteoarthritis
MR Imaging of Knee Osteoarthritis and Acute Knee Injuries
The Effect of Perioperative Neuromuscular Training on the Outcome of Total Knee Arthroplasty
Comparison of Hip Resurfacing and Cementless Metal-on-Metal Total Hip Arthroplasty
Effectiveness of Minimally Invasive Total Knee Replacement in Improving Rehabilitation and Function
Minimally Invasive Knee Replacement Outcomes (MIKRO) Study
A Clinical Evaluation of Metal Ion Release From Metal-on-Metal Cementless Total Hip Arthroplasty
Serum Metal Ion Concentration After Total Knee Arthroplasty (TKA)
Keywords
osteoarthritis, OA, degenerative joint disease, degenerative arthritis, osteoarthrosis, arthritis
