Osteoarthritis Treatment & Management

The goals of osteoarthritis treatment include pain alleviation and the improvement of functional status.^[46]

Several treatment options are available for slowing or stopping the progression of this common disorder. Pharmacologic agents used in the treatment of osteoarthritis include the following:

• Corticosteroids
• Sodium Hyaluronate
• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Muscle relaxants
• Glucocorticoids

Nonpharmacologic interventions, which are the cornerstones of osteoarthritis therapy, include the following:

• Patient education
• Temperature-based modalities
• Weight loss^[47]
• Exercise
• Physical therapy
• Occupational therapy
• Unloading in certain joints (eg, knee, hip)

The American College of Rheumatology issued the following pharmacologic guidelines for the treatment of osteoarthritis of the hip and knee:^[48]

• Arthrocentesis with corticosteroid injection can be used only for knee osteoarthritis if effusion is present.
• Up to 4 g/d of acetaminophen can be administered. This is the preferred initial treatment for patients with osteoarthritis.
• Topical anti-inflammatory medications or capsaicin can be administered only for knee osteoarthritis.
• Low-dose nonsteroidal anti-inflammatory drugs (NSAIDs) (ie, analgesic doses) or nonacetylated salicylates may be indicated.
• Administer full-dose NSAIDs with misoprostol if risk factors for upper gastrointestinal bleeding are present.
• Narcotic analgesic use may be indicated in cases of severe pain.

Analgesics, NSAIDs, and COX-2 inhibitors

Begin treatment with acetaminophen for mild or moderate osteoarthritic pain without apparent inflammation. If the clinical response to acetaminophen is not satisfactory or if the clinical presentation of osteoarthritis is inflammatory, consider using nonsteroidal anti-inflammatory drugs (NSAIDs). Use the lowest effective dose or intermittent dosing if symptoms are intermittent and then try full doses if the patient's response is insufficient. In patients with highly resistant pain, consider the analgesic tramadol. Options in patients at an elevated risk for GI toxicity due to NSAIDs include the addition of a proton-pump inhibitor or misoprostol to the treatment regimen or the use of a selective cyclooxygenase (COX) inhibitor instead of the nonselective NSAID.

Corticosteroid injections

Intra-articular pharmacologic therapy includes corticosteroid injection and viscosupplementation, which may provide pain relief and have an anti-inflammatory effect on the affected joint.^{[49, 50]} Radiologists may aid in the treatment of osteoarthritis by administering image-guided intra-articular injections of steroids.

After the introduction of the needle into the joint and prior to steroid administration, aspiration of as much synovial fluid as possible should be attempted. This procedure often provides symptomatic relief for the patient and allows laboratory evaluation of the fluid, if necessary. Infected joint fluid and bacteremia are contraindications to steroid injection.

Steroid injections generally result in a clinically and statistically significant reduction in osteoarthritic knee pain as soon as 1 week after injection. The effect may last, on average, anywhere from 4-6 weeks per injection, but this benefit is unlikely to continue beyond that time frame.^[51]

One randomized, placebo-controlled study confirmed the effectiveness of corticosteroid injection in the treatment of hip osteoarthritis, with benefits often lasting as long as 3 months.^[52] Some controversial evidence exists regarding frequent steroid injections and subsequent damage to cartilage (chondrodegeneration). Therefore, usually no more than 3 injections are recommended per year in any 1 osteoarthritic joint. Systemic glucocorticoids have no role in the management of osteoarthritis.

To see complete information on Injection, Acromioclavicular Joint, please go to the main article by clicking here.

Additional pharmacologic agents

Muscle relaxants may benefit patients with evidence of muscle spasm. Judicious use of narcotics (eg, acetaminophen with codeine; oxycodone) is reserved for patients with severe osteoarthritis.

Glucosamine and chondroitin sulfate, which are being studied by the National Institutes of Health (NIH) in double-blind trials, have been used in Europe for many years. Another agent, S-adenosylmethionine (SAM-e [pronounced "sammy"]), is a European supplement receiving a lot of attention in the United States.

Chondroprotective drugs (ie, matrix metalloproteinase [MMP] inhibitors, growth factors) are being tested as disease-modifying drugs in the management of osteoarthritis.^[53]

Instruct the patient to avoid aggravating stress to the affected joint. Implement correction procedures if the patient illustrates poor posture. Lifestyle modification, particularly exercise and weight reduction, is a core component in the management of osteoarthritis (OA).^{[54, 55]} Weight reduction relieves stress on the affected knees or hips. The benefits of weight loss, whether obtained through regular exercise and diet or surgical interventions, may extend not only to symptom relief but also to a slowing in cartilage loss in weight-bearing joints such as knees with radiographic OA.^[56]

Osteoarthritis of the knee may result in disuse atrophy of the quadriceps. Because these muscles help to protect the articular cartilage from further stress, most research into osteoarthritis of the knee focuses on quadriceps strengthening in knee osteoarthritis. Stretching exercises are also important in the treatment of osteoarthritis, because they increase range of motion.

Some patients with osteoarthritis benefit from heat and capsaicin cream placed locally over the affected joint, and a minority of patients report relief with ice.^[57]

For more information, see Surgical Treatment of Patellofemoral Arthritis and Surgical Treatment of Interphalangeal Joint Arthritis.

In a study of patients with knee osteoarthritis, Jan et al found that, in most respects, non–weight-bearing exercise was as therapeutically effective as weight-bearing exercise.^[58] After an 8-week exercise program, patients in the weight-bearing and non–weight-bearing groups showed equally significant improvements in function, walking speed, and muscle torque. However, patients in the weight-bearing group demonstrated greater improvement in position sense, which may help patients with complex walking tasks, such as walking on a spongy surface.

Chaipinyo and Karoonsupcharoen found no significant difference between home-based strength training and home-based balance training for knee pain caused by osteoarthritis. However, more improvement was noted in the strength-training group in terms of knee-related quality of life.^[59]

The importance of aerobic conditioning, particularly low-impact exercises (if osteoarthritis affects weight-bearing joints), should be stressed as well. Swimming, especially aerobic aquatic programs through the Arthritis Foundation, can be helpful.

Results from a study by Wang et al suggested that tai chi is a potentially effective treatment for pain associated with osteoarthritis of the knee.^[60] In a prospective, single-blind, randomized, controlled trial, 40 patients with symptomatic tibiofemoral osteoarthritis who performed 60 minutes of tai chi twice weekly for 12 weeks experienced significantly greater pain reduction than did control subjects who underwent 12 weeks of wellness education and stretching. The mean difference in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores was -118.80 mm.

The tai chi cohort also had significantly better WOMAC physical function scores, patient and physician global visual analog scale scores, chair stand time, Center for Epidemiologic Studies Depression Scale scores, self-efficacy scores, and Short Form 36 physical component summaries.

In a review on patient adherence to exercise, Marks and Allegrante concluded that interventions to enhance self-efficacy, social support, and skills in the long-term monitoring of progress are necessary to foster exercise adherence in people with osteoarthritis.^[61]

Assistive devices

The use of assistive devices for ambulation and for activities of daily living may be indicated for patients with osteoarthritis. Braces and appropriate footwear may also be of some use. A cane can be used in the opposite hand for hip osteoarthritis, and a cane in the hand of comfort may be helpful for knee osteoarthritis. The patient can be taught joint-protection and energy-conservation techniques. Other physical therapy modalities include electrotherapy and thermotherapy.

Patients who undergo arthroscopy (see below for surgical treatment options) 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; range-of-motion and strengthening exercises are started within a few days after joint-replacement surgery and continued until the patient has good range of motion and strength. After resection arthroplasty of the hip, patients require instruction in the use of crutches or a walker, which are usually needed permanently.

Occupational therapy

Occupational adjustments may be necessary for some patients with osteoarthritis. Evaluation of how well the patient performs his/her activities of daily living, as well as retraining of the patient, can be assisted by an occupational therapist. Joint-protection techniques should be emphasized. Hand splinting, especially of the first carpometacarpal joint, may be indicated.

Sodium hyaluronate injections

In the United States, HAs are classified as medical devices rather than as drugs.^[62] Although the exact mechanisms of action through which they provide symptomatic relief are unknown, several possibilities exist, including direct binding to receptors (CD44 in particular) in the synovium and cartilage that can lead to several biologic activation pathways. These mechanisms of action can include the following:

• Increased endogenous production of hyaluronate and aggrecan by the joint
• A mechanical barrier to the activation of nociceptors
• The inhibition of pain mediators (eg, PGE, bradykinin)
• An anti-inflammatory effect (eg, inhibition of proinflammatory cytokine activity, inhibition of inflammatory cell function)
• A beneficial effect on immune cells
• An antioxidant effect
• Restoration of the synovial fluid's physical characteristics (viscoelasticity)

Intra-articular injection of sodium hyaluronate (ie, hyaluronic acid [HA], hyaluronan), also referred to as viscosupplementation, has been shown to be safe and effective for the symptomatic relief of knee osteoarthritis.^{[63, 64]}

Intra-articular HAs approved by the US Food and Drug Administration (FDA) for the treatment of osteoarthritic knee pain include the naturally extracted, non–cross-linked sodium hyaluronate products Hyalgan,^[65] Supartz, Orthovisc, and Euflexxa and the cross-linked sodium hyaluronate product known as hylan G-F 20 (Synvisc). Euflexxa is derived from a fermentation process (Streptococcus), while the source material for the other products listed is chicken combs. At present, no distinct advantage or disadvantage has been associated with either source of HA.

Some differences between the viscosupplements do exist in the FDA-approved prescribing information. For example, Hyalgan and Synvisc have been established as safe for repeat treatment, while the safety and efficacy of other products for repeat treatment has not been established.

The HA class in general has demonstrated a very favorable safety profile for the chronic pain management of knee osteoarthritis, with the most common adverse event being injection site pain. While any intra-articular injection (HA products and steroids) may elicit an inflammatory response and possible effusion, a clinically distinct acute inflammatory side effect (ie, severe acute inflammatory reaction [SAIR] or HA–associated intra-articular pseudosepsis) has been described. However, preclinical and clinical data provide compelling evidence that this reaction is limited only to the cross-linked hylan G-F 20 product and may have an immunologic mechanism of action. Molecular weight per se has not been found to correlate with efficacy (eg, higher or lower viscosity does not equate with better or worse clinical outcomes).

Interestingly, the duration of residence of an intra-articular injection (days) cannot explain the prolonged clinical benefit (months), and accordingly, subsequent biologic mechanisms have been proposed that may play an important role in the clinical benefit. The combination of quadriceps strengthening and HAs may have a synergistic effect on pain.^[66]

Viscosity can help to facilitate the cushioning and lubricating characteristics of the joint during slow movements, while elasticity blunts deforming forces (compression and resistance to shear forces) during rapid motions.

A study Waddell and colleagues hypothesized that hyaluronan inhibits interleukin-1beta–induced metalloproteinase production from osteoarthritic synovial tissue.^[67]

As reviewed by Goldberg and Buckwalter, preclinical support is available for most of the HAs, as well as clinical evidence (particularly for Hyalgan) using arthroscopy, microscopy, and blinded morphologic assessments and weight-bearing radiographs for assessing joint-space narrowing.^[20] Intra-articular HAs may also be chondroprotective early in the development of osteoarthritis. However, additional studies would seem to be warranted to further explore the ability of HAs to intervene in the disease processes associated with osteoarthritis. Certainly, a single product with symptomatic and disease-modifying characteristics, even if effective only in some patient populations, would be a valuable option in the management of knee osteoarthritis.

Electromagnetic field stimulation and TENS

A pulsed electromagnetic field stimulation device (Bionicare) has been FDA-approved for use in patients with knee osteoarthritis. Pulsed electromagnetic field stimulation is believed to act at the level of articular cartilage by maintaining proteoglycan composition of chondrocytes via down-regulation of its turnover.^[68] One published multicenter, double-blind, randomized, placebo-controlled, 4-week trial, utilizing 78 patients with knee osteoarthritis, found improved pain and function in patients who were treated with the device.^[69] Another randomized clinical trial demonstrated that pulsed shortwave treatment was effective in relieving pain and improving function and quality of life in women with knee osteoarthritis, on a short-term basis. Additional studies are needed to validate the 12-month follow-up.^[70]

Transcutaneous electrical nerve stimulation (TENS) may be another treatment option for pain relief, but so far there exists only limited evidence that this modality is beneficial.^[71]

Acupuncture

Acupuncture is becoming a more frequently used option in treating pain and physical dysfunction associated with osteoarthritis. Some evidence supports its use. For example, a significant decrease in pain after acupuncture, in comparison with the amount of pain persisting after control treatments, was reported in a review article of randomized, controlled trials.^[72]

Arthroscopy

A procedure of low invasiveness and morbidity, arthroscopy will not interfere with future surgery. It may help patients with osteoarthritis of the knee in whom imaging reveals specific structural damage. Arthroscopy is especially indicated for removal of meniscal tears and loose bodies.^[1]

Less predictable arthroscopic procedures include debridement of loose articular cartilage with a microfracture technique and cartilaginous implants in areas of eburnated subchondral bone. These treatments have varying success rates and should be performed only by surgeons experienced with arthroscopic surgical techniques.^{[1, 73, 74]}

Arthroscopic views are shown in the images below.

A study by Kirkley et al found that arthroscopic surgery for osteoarthritis of the knee provided no additional benefit to patients who underwent optimized physical and medical therapy.^[1] In an accompanying editorial, however, Marx stated that osteoarthritis is not a contraindication for arthroscopic surgery and that arthroscopic surgery remains appropriate, in specific situations, in patients with arthritis in whom osteoarthritis is not believed to be the primary cause of pain.^{[73, 74]}

Overall, arthroscopy is not recommended for nonspecific "cleaning of the knee" in osteoarthritis.

Osteotomy

Consider osteotomy in patients with a malaligned hip or knee joint. The procedure is usually recommended in younger patients with osteoarthritis. Osteotomy can lessen pain, although it can lead to more challenging surgery later if the patient requires arthroplasty.

Osteotomy is used in active patients younger than 60 years who want to continue with reasonable physical activity.^[75] 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. (The effectiveness of osteotomy for genu valgum is not highly predictable.) Osteotomy often can prevent individuals from requiring a total knee replacement until they are older.

Contraindications for osteotomy are knee flexion of 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 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 by bone ingrowth into a porous coating on the prosthesis. The use of cement relieves pain more quickly, but bone ingrowth may last longer; therefore, prostheses with a porous coating are used in younger patients.

Perform arthroplasty if all other modalities are ineffective and osteotomy is not viable, or if a patient cannot perform his or her daily activities despite maximal therapy.^{[76, 77]} This procedure alleviates pain and may improve function. Approximately 8-15 years of viability are expected from joint replacement in the absence of complications.

Examples of joint replacement are shown in the radiographs below.

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.

Infection is a particular postsurgical concern in cases of total joint replacement. This complication is now rare, however, 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 means available to prevent these complications, especially the initiation of early motion and ambulation when possible. The use of low-molecular-weight heparin or warfarin is also indicated.

For more information, see Total Knee Arthroplasty, Unicompartmental Knee Arthroplasty, Surgical Treatment of Patellofemoral Arthritis, and Surgical Treatment of Interphalangeal Joint Arthritis.

Resection arthroplasty

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

Fusion consists of the union of bones on either side of the joint. This procedure relieves pain but prevents motion and puts more stress on surrounding joints. Fusion is sometimes used after knee replacements fail or as a primary procedure for ankle or foot arthritis.

Joint lavage

Closed-needle joint lavage may benefit a small subgroup of patients with osteoarthritis.

A physiatrist may help in formulating a nonpharmacologic management plan for the patient with osteoarthritis, and a nutritionist may help the patient to lose weight. A referral to an orthopedic surgeon may be necessary if the osteoarthritis fails to respond to a medical management plan.