Updated: 9/18/2017

Osteoarthritis

Topic
Review Topic
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Questions
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Evidence
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Snapshot
  • A 56-year-old woman presents to her primary care physician with pain in her hands. The pain began approximately 1 year prior to presentation and has progressively worsened. She describes the pain being worse in the evening and improves in the morning. She has also noticed swelling in her knuckles. On physical exam, there is bone deformity noted on the distal and proximal interphalangeal joints, as well as tenderness upon palpation of the affected joints.
Introduction
  • Clinical definition 
    • a degenerative disorder affecting the articular cartilage
  • Epidemiology
    • incidence
      • most common articular disease
    • demographics
      • more common in women and the elderly
    • risk factors
      • modifiable
        • obesity
        • trauma
        • repetitive use (e.g., heavy labor)
      • non-modifiable
        • age
        • female gender
        • family history
  • Pathogenesis
    • not completely understood but is more complex than "wear and tear" of the joint and inflammation appears to be involved
      • chondrocytes attempt to proliferate and synthesize proteoglycans when it is injured
        • however, degradation exceeds synthesis, thus compromising the extracellular matrix
      • inflammatory processes appear to promote proteolytic articular degeneration mediated by chondrocytes
        • e.g., transforming growth factor-β (TGF-β) induces chondrocytes to secrete matrix metalloproteinase (MMPs) to degrade type II collagen
    • eventually portions of the articular cartilage and subchondral bone is sloughed off into the joint space (synovial space)
      • forming loose bodies (joint mice)
    • subchondral bone becomes exposed and rubs on the adjacent bone, resulting in
      • bone eburnation (polished ivory)
    • osteophytes (bony outgrowths) develop due to bone remodeling
      • can be appreciated in the
        • distal interphalangeal joint as Herberden nodes
        • proximal interphalangeal joint as Bouchard nodes
    • late stage osteoarthritis is characterized by loss of chondrocytes and degraded extracellular matrix
  • Prognosis
    • favorable with joint replacement
Biology and Anatomy
  • Articular cartilage greatly decreases friction with movement and resists tension and compressive forces
    • composed of type II collagen and proteoglycans which are synthesized and secreted by chondrocytes
      • chondrocytes maintain cartilage with its anabolic and catabolic activities
Presentation
  • Symptoms
    • pain
      • worsens with use and improves with rest
      • commonly involves the hands, hips, and knees
  • Physical exam
    • joint tenderness
    • decreased range of motion
    • bony swelling
      • swelling of the distal interphalangeal (Herberden nodes)
      • swelling of the proximal interphalangeal (Bouchard nodes)
Imaging
  • Radiography
    • indication
      • may be used to confirm the diagnosis and determine disease progression and severity
    • findings
      • joint space narrowing
      • osteophytes
      • joint mice
      • subchondral sclerosis
Studies
  • Labs
    • c-reative protein (CRP) and erythrocyte sedimentation rate (ESR) levels are normal
  • Diagnostic criteria
    • typically a clinical diagnosis
Differential
  • Rheumatoid arthritis
  • Arthralgia
  • Bursitis
  • Tendonitis
Treatment
  • Conservative
    • exercise and weight loss
      • indication
        • first-line in the management of osteoarthritis
  • Medical
    • topical or oral nonsteroidal antiinflammatory drugs (NSAIDs)
      • indication
        • for the symptomatic management of osteoarthritis in patients who do not adequately respond to conservative treatment
  • Operative
    • orthopedic surgery
      • indication
        • in patients with advanced pain who are unresponsive to conservative and pharmacologic therapy
Complications
  • Pain
  • Bone deformity
  • Functional impairment

 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.MK.41) A 72-year-old man presents to his primary care physician for his annual exam. He has a very stoic personality and says that he is generally very healthy and has "the normal aches and pains of old age." On further probing, you learn that he does have pretty significant back and hip pain that worsens throughout the day. On physical exam you note bony enlargement of the distal interphalangeal joints bilaterally. Which of the following is the likely cause of his symptoms? Review Topic

QID: 106264
FIGURES:
1

Gout

7%

(1/14)

2

Pseudogout

0%

(0/14)

3

Rheumatoid arthritis

7%

(1/14)

4

Osteoarthritis

86%

(12/14)

5

Osteopaenia

0%

(0/14)

M1

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