Updated: 11/30/2019

Osteoarthritis

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Questions
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Evidence
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Snapshot
  • A 60-year-old woman presents to her primary care physician with pain in her hands and knees. She reports to having this pain intermittently for at least 8 months and describes it being worse in the evening. On physical exam, there is bone deformity noted on the distal and proximal interphalangeal joints, swelling of the right knee, and 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
      • adverse effects
        • gastrointestinal side-effects such as ulcer formation
  • 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 (6)
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
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(M2.OR.17.4754) A 69-year-old man presents to his primary care physician for pain when he walks. He states that the pain is the worst in his left great toe but is also present in his hips and knees. He says that his symptoms are worse with activity and tend to improve with rest. His symptoms have progressively worsened over the past several years. He has a past medical history of obesity, type II diabetes mellitus, smoking, and hypertension. He drinks roughly ten beers per day. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient has a recent travel history to Bangkok where he admits to having unprotected sex. On physical exam, examination of the lower extremity results in pain. There is crepitus of the patient's hip when his thigh is flexed and extended. Which of the following is the most likely diagnosis? Review Topic | Tested Concept

QID: 108991
1

Osteoarthritis

65%

(33/51)

2

Rheumatoid arthritis

0%

(0/51)

3

Infectious arthritis

14%

(7/51)

4

Gout

20%

(10/51)

5

Pseudogout

2%

(1/51)

L 2 D

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(M2.OR.15.4672) A 64-year-old male presents to his primary care physician with a complaint of bilateral knee pain that has been present for the past several years but has worsened recently. He reports pain with climbing stairs and with extended walks of greater than 100 yards. The pain worsens with activity throughout the day and is alleviated by periods of rest. He states that he has minimal morning stiffness, lasting approximately 5-10 minutes after waking up most days. Physical examination reveals tenderness to palpation of the bony structures on the medial aspect of the bilateral knees as well as crepitus and a decreased range of motion, limited at the extremes of flexion and extension. Both knee joints are cool to touch and exhibit bony enlargement upon palpation of the medial joint line. Which of the following studies would be indicated for further work-up of this patient's presenting condition? Review Topic | Tested Concept

QID: 107191
1

Complete blood count (CBC)

4%

(1/25)

2

Erythrocyte sedimentation rate (ESR)

8%

(2/25)

3

Rheumatoid factor (RF)

0%

(0/25)

4

MRI of the knee

12%

(3/25)

5

No further work-up needed

72%

(18/25)

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(M2.OR.14.44) A 72-year-old woman with a past medical history of diabetes and obesity presents to the clinic with joint pain. She has severe pain in both of her knees for which she has been taking ibuprofen daily. Her temperature is 98.2°F (36.8°C), blood pressure is 177/109 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Radiography of the knee shows the finding in Figure B. Which of the following is the most likely diagnosis? Review Topic | Tested Concept

QID: 104586
FIGURES:
1

Osteoarthritis

29%

(2/7)

2

Reactive arthritis

14%

(1/7)

3

Rheumatoid arthritis

14%

(1/7)

4

Septic arthritis

43%

(3/7)

5

Systemic lupus erythematosus

0%

(0/7)

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