Osteoarthrosis

Published on 02/04/2015 by admin

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131 Osteoarthrosis

Instruction

Look at this patient’s hands.

Examine this patient’s joints.

Salient features

History

• Pain in the joints

• Stiffness after a period of inactivity

• Impairment of gait as a result of joint pain

• Knees: pain on activities such as climbing stairs, getting out of a chair, and walking long distances. Morning stiffness usually lasts <30 min. Ask the patient whether their knees ‘give way’, a so-called instability symptom

• Hip: morning stiffness and pain (lasting <30 min) and pain at rest or at night are common. However, nocturnal hip pain may reflect inflammatory arthritis, infection, tumours or crystal diseases.

Examination

• Heberden’s nodes (bony swellings) at the terminal interphalangeal joints

• Squaring of the hands as a result of subluxation of the first metacarpophalangeal joint.

Proceed as follows:

• Tell the examiner that you would like to examine the hips and knees as these joints are usually involved.

• Knee: feel for crepitus: it may be red, warm and tender, and have an effusion.

• Hip: the strongest clinical indicator of osteoarthritis of the hip is pain, exacerbated by internal or external rotation of the hip while the knee is in full extension. An assessment of the range of motion of the knee joint and lower lumbar spine may help to determine whether hip pain is referred from these other joint rather than the hip.

Diagnosis

This elderly patient has Heberden’s nodes and squaring of the hands with involvement of the interphalangeal joints of the hands (lesions) caused by osteoarthrosis (aetiology) and is unable to button his clothes (functional status).

Questions

Which other joints are frequently involved?

Spine, in particular cervical and lumbar spines.

What are Heberden’s nodes?

Bony swellings seen at the terminal interphalangeal joints in osteoarthrosis (Fig. 131.1).

Fig. 131.1 Heberden (distal interphalangeal) and Bouchard (proximal interphalangeal) nodes on both index fingers and thumbs. Note angular changes at distal joints as result of loss of joint cartilage and instability.

(With permission from Canale, Beaty 2007.)

What are Bouchard’s nodes?

Bony swellings at the proximal interphalangeal joints in osteoarthrosis (Fig. 131.1).

Advanced-level questions

What are the typical radiological features?

• Subchondral bone sclerosis and cysts

• Osteophytes (Fig. 131.2).

Fig. 131.2 Primary osteoarthritis of the fingers, with characteristic cartilage loss, deviations, and spurs of the proximal (Bouchard’s nodes) and distal (Heberden’s nodes) interphalangeal joints.

(With permission from Grainger, Allison 2001.)

Note: Radiological findings correlate poorly with the severity of pain.

What will the synovial aspirate show?

White blood cell count of <100 × 10³ cells/l.

What do you understand by the term nodal osteoarthrosis?

Nodal osteoarthrosis is a primary generalized osteoarthrosis with characteristic features. It occurs predominantly in middle-aged women and is autosomal dominant. It characteristically affects the terminal interphalangeal joints, with the development of Heberden’s nodes. The arthritis may be acute and, although there may be marked deformity, there is little disability. It can also affect the carpometacarpal joints of the thumbs, spinal apophyseal joints, knees and hips.

How would you manage a patient with osteoarthrosis?

• Change in lifestyle: maintain optimal weight, use appropriate footwear, encourage exercise to strengthen muscles (range-of-motion exercise that does not strengthen muscles is generally ineffective). An exercise programme of water aerobics or with a physical therapist at a frequency of twice a week for at least 2 months should improve muscle strength.

• Drugs: simple analgesics, rubifacients, NSAIDs and cyclooxygenase 2 (COX-2) inhibitors for acute flare-ups; intra-articular corticosteroid injections for acute flare-ups or patients unfit for surgery.

• The combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain (N Engl J Med 2006;354:795).

• Surgery: arthroscopic removal of loose body, arthroscopic washout or radioisotope synovectomy for persistent synovitis; joint replacement for hip and knee. A recent study suggests that arthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy (N Engl J Med 2008;359:1097).

What is the role of aggrecan in osteoarthritis?

In osteoarthritis, the degeneration of the cartilaginous extracellular matrix far exceeds its synthesis. The extracellular matrix of cartilage wears away, exposing articular cartilage and, eventually, bone. The two important components of this extracellular matrix are a type II collagen–rich collagenous network (which provides tensile strength) and a cartilage-specific proteoglycan called aggrecan (which is highly hydrated and thereby allows cartilage to resist a compressive load). Experimental studies suggest that the loss of aggrecan is the primary event leading to the destruction of cartilage. Three enzymes capable of degrading aggrecan have been identified: ADAMTS 1, ADAMTS 4, and ADAMTS 5. ADAMTS 5 is the main aggrecanase in mouse articular cartilage and is a possible pharmacologic target to prevent osteoarthritis.

William Heberden (1710–1801) was a London physician who described the nodes as ‘little hard knobs’ and this was first published posthumously in 1802.

JK Spender (1886), of Bath, introduced the term osteoarthritis. Archibald E Garrod from London, established the modern usage and clinical differentiation from rheumatoid arthritis in 1907.

In 1884, CJ Bouchard (1837–1915) described nodes adjacent to the proximal interphalangeal joints identical to those at the distal interphalangeal joints.

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