osteoarthrosis
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Osteoarthritis (OA) is a type of degenerative
joint disease An arthropathy is a disease of a joint. Types Arthritis is a form of arthropathy that involves inflammation of one or more joints, while the term arthropathy may be used regardless of whether there is inflammation or not. Joint diseases can be cla ...
that results from breakdown of joint cartilage and underlying
bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...
which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the world. The most common symptoms are
joint pain Arthralgia (from Greek ''arthro-'', joint + ''-algos'', pain) literally means ''joint pain''. Specifically, arthralgia is a symptom of injury, infection, illness (in particular arthritis), or an allergic reaction to medication. According to MeSH, ...
and stiffness. Usually the symptoms progress slowly over years. Initially they may occur only after exercise but can become constant over time. Other symptoms may include joint swelling, decreased range of motion, and, when the back is affected, weakness or numbness of the arms and legs. The most commonly involved joints are the two near the ends of the fingers and the joint at the base of the thumbs; the knee and hip joints; and the joints of the neck and lower back. Joints on one side of the body are often more affected than those on the other. The symptoms can interfere with work and normal daily activities. Unlike some other types of arthritis, only the joints, not internal organs, are affected. Causes include previous joint injury, abnormal joint or limb development, and inherited factors. Risk is greater in those who are overweight, have legs of different lengths, or have jobs that result in high levels of joint stress. Osteoarthritis is believed to be caused by mechanical stress on the joint and low grade inflammatory processes. It develops as cartilage is lost and the underlying bone becomes affected. As pain may make it difficult to exercise, muscle loss may occur. Diagnosis is typically based on signs and symptoms, with medical imaging and other tests used to support or rule out other problems. In contrast to
rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are invol ...
, in osteoarthritis the joints do not become hot or red. Treatment includes exercise, decreasing joint stress such as by rest or use of a
cane Cane or caning may refer to: *Walking stick or walking cane, a device used primarily to aid walking * Assistive cane, a walking stick used as a mobility aid for better balance *White cane, a mobility or safety device used by many people who are ...
, support groups, and pain medications. Weight loss may help in those who are overweight. Pain medications may include paracetamol (acetaminophen) as well as
NSAID Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
s such as
naproxen Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, menstrual cramps, inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It is available in immediate and delayed release formulat ...
or ibuprofen. Long-term
opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...
use is not recommended due to lack of information on benefits as well as risks of
addiction Addiction is a neuropsychological disorder characterized by a persistent and intense urge to engage in certain behaviors, one of which is the usage of a drug, despite substantial harm and other negative consequences. Repetitive drug use o ...
and other side effects.
Joint replacement Replacement arthroplasty (from Greek ''arthron'', joint, limb, articulate, + ''plassein'', to form, mould, forge, feign, make an image of), or joint replacement surgery, is a procedure of orthopedic surgery in which an arthritic or dysfunctional ...
surgery may be an option if there is ongoing disability despite other treatments. An artificial joint typically lasts 10 to 15 years. Another alternative therapy for osteoarthritis is stem cell transplantation where allogenic mesenchymal stem cells or autologous chondrocyte injected to the patients. Osteoarthritis is the most common form of arthritis, affecting about 237million people or 3.3% of the world's population. It becomes more common as people become older. Among those over 60 years old, about 10% of males and 18% of females are affected. Osteoarthritis is the cause of about 2% of years lived with disability.


Signs and symptoms

The main symptom is pain, causing loss of ability and often stiffness. The pain is typically made worse by prolonged activity and relieved by rest. Stiffness is most common in the morning, and typically lasts less than thirty minutes after beginning daily activities, but may return after periods of inactivity. Osteoarthritis can cause a crackling noise (called "
crepitus Crepitus is "a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone". Various types of crepitus that can be heard in joint pathologies are: *Bone crepitus: This can be heard when two fragme ...
") when the affected joint is moved, especially shoulder and knee joint. A person may also complain of joint locking and joint instability. These symptoms would affect their daily activities due to pain and stiffness. Some people report increased pain associated with cold temperature, high humidity, or a drop in barometric pressure, but studies have had mixed results. Osteoarthritis commonly affects the hands, feet, spine, and the large
weight-bearing In orthopedics, weight-bearing is the amount of weight In science and engineering, the weight of an object is the force acting on the object due to gravity. Some standard textbooks define weight as a vector quantity, the gravitational force act ...
joints, such as the
hips In vertebrate anatomy, hip (or "coxa"Latin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) in medical terminology) refers to either an anatomical region or a joint. The hip region ...
and knees, although in theory, any joint in the body can be affected. As osteoarthritis progresses, movement patterns (such as gait), are typically affected. Osteoarthritis is the most common cause of a
joint effusion A joint effusion is the presence of increased intra-articular fluid. It may affect any joint. Commonly it involves the knee. Diagnostic approach The approach to diagnosis depends on the joint involved. While aspiration of the joint is conside ...
of the knee. In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) or
Bouchard's nodes Bouchard's nodes are hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes). They are seen in osteoarthritis, where they are caused by formation of calcific spurs of the articular ( ...
(on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. Osteoarthritis of the toes may be a factor causing formation of
bunion A bunion, also known as hallux valgus, is a deformity of the joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is typically gradual. Complicatio ...
s, rendering them red or swollen.


Causes

Damage from mechanical stress with insufficient self repair by joints is believed to be the primary cause of osteoarthritis. Sources of this stress may include misalignments of bones caused by congenital or pathogenic causes; mechanical injury; excess body weight; loss of strength in the muscles supporting a joint; and impairment of peripheral nerves, leading to sudden or uncoordinated movements. However exercise, including running in the absence of injury, has not been found to increase the risk of knee osteoarthritis. Nor has cracking one's knuckles been found to play a role. The risk of osteoarthritis increases with ageing.


Primary

The development of osteoarthritis is correlated with a history of previous joint injury and with obesity, especially with respect to knees. Changes in sex hormone levels may play a role in the development of osteoarthritis, as it is more prevalent among post-menopausal women than among men of the same age. Conflicting evidence exists for the differences in hip and knee osteoarthritis in African Americans and Caucasians.


Occupational

Increased risk of developing knee and hip osteoarthritis was found among those who work with manual handling (e.g. lifting), have physically demanding work, walk at work, and have climbing tasks at work (e.g. climb stairs or ladders). With hip osteoarthritis, in particular, increased risk of development over time was found among those who work in bent or twisted positions. For knee osteoarthritis, in particular, increased risk was found among those who work in a kneeling or
squatting position Squatting is a versatile posture where the weight of the body is on the feet but the knees and hips are bent. In contrast, sitting involves taking the weight of the body, at least in part, on the buttocks against the ground or a horizontal object. ...
, experience heavy lifting in combination with a kneeling or squatting posture, and work standing up. Women and men have similar occupational risks for the development of osteoarthritis.


Secondary

This type of osteoarthritis is caused by other factors but the resulting pathology is the same as for primary osteoarthritis: *
Alkaptonuria Alkaptonuria is a rare inherited genetic disease which is caused by a mutation in the ''HGD'' gene for the enzyme homogentisate 1,2-dioxygenase (); if a person inherits an abnormal copy from both parents (it is a recessive condition), the body ac ...
* Congenital disorders of joints *
Diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
doubles the risk of having a joint replacement due to osteoarthritis and people with diabetes have joint replacements at a younger age than those without diabetes. * Ehlers-Danlos syndrome *
Hemochromatosis Iron overload or hemochromatosis (also spelled ''haemochromatosis'' in British English) indicates increased total accumulation of iron in the body from any cause and resulting organ damage. The most important causes are hereditary haemochromatos ...
and
Wilson's disease Wilson's disease is a genetic disorder in which excess copper builds up in the body. Symptoms are typically related to the brain and liver. Liver-related symptoms include vomiting, weakness, fluid build up in the abdomen, swelling of the legs, ...
* Inflammatory diseases (such as Perthes' disease), (
Lyme disease Lyme disease, also known as Lyme borreliosis, is a vector-borne disease caused by the ''Borrelia'' bacterium, which is spread by ticks in the genus ''Ixodes''. The most common sign of infection is an expanding red rash, known as erythema migran ...
), and all chronic forms of arthritis (e.g.,
costochondritis Costochondritis, also known as chest wall pain syndrome or costosternal syndrome, is a benign inflammation of the upper costochondral (rib to cartilage) and sternocostal (cartilage to sternum) joints. 90% of patients are affected in multiple ri ...
,
gout Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot and swollen joint, caused by deposition of monosodium urate monohydrate crystals. Pain typically comes on rapidly, reaching maximal intens ...
, and
rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are invol ...
). In gout,
uric acid Uric acid is a heterocyclic compound of carbon, nitrogen, oxygen, and hydrogen with the formula C5H4N4O3. It forms ions and salts known as urates and acid urates, such as ammonium acid urate. Uric acid is a product of the metabolic breakdown ...
crystals cause the cartilage to degenerate at a faster pace. * Injury to joints or ligaments (such as the ACL) as a result of an accident or orthopedic operations. * Ligamentous deterioration or instability may be a factor. * Marfan syndrome *
Obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's ...
* Joint infection


Pathophysiology

While osteoarthritis is a degenerative joint disease that may cause gross cartilage loss and morphological damage to other joint tissues, more subtle biochemical changes occur in the earliest stages of osteoarthritis progression. The water content of healthy cartilage is finely balanced by compressive force driving water out and
hydrostatic Fluid statics or hydrostatics is the branch of fluid mechanics that studies the condition of the equilibrium of a floating body and submerged body "fluids at hydrostatic equilibrium and the pressure in a fluid, or exerted by a fluid, on an imme ...
and osmotic pressure drawing water in. Collagen fibres exert the compressive force, whereas the
Gibbs–Donnan effect The Gibbs–Donnan effect (also known as the Donnan's effect, Donnan law, Donnan equilibrium, or Gibbs–Donnan equilibrium) is a name for the behaviour of charged particles near a semi-permeable membrane that sometimes fail to distribute evenly ...
and cartilage
proteoglycans Proteoglycans are proteins that are heavily glycosylated. The basic proteoglycan unit consists of a "core protein" with one or more covalently attached glycosaminoglycan (GAG) chain(s). The point of attachment is a serine (Ser) residue to which ...
create osmotic pressure which tends to draw water in. However, during onset of osteoarthritis, the collagen matrix becomes more disorganized and there is a decrease in proteoglycan content within cartilage. The breakdown of collagen fibers results in a net increase in water content. This increase occurs because whilst there is an overall loss of proteoglycans (and thus a decreased osmotic pull), it is outweighed by a loss of collagen. Other structures within the joint can also be affected. The ligaments within the joint become thickened and
fibrotic Fibrosis, also known as fibrotic scarring, is a pathological wound healing in which connective tissue replaces normal parenchymal tissue to the extent that it goes unchecked, leading to considerable tissue remodelling and the formation of perma ...
, and the menisci can become damaged and wear away. Menisci can be completely absent by the time a person undergoes a
joint replacement Replacement arthroplasty (from Greek ''arthron'', joint, limb, articulate, + ''plassein'', to form, mould, forge, feign, make an image of), or joint replacement surgery, is a procedure of orthopedic surgery in which an arthritic or dysfunctional ...
. New bone outgrowths, called "spurs" or
osteophyte Osteophytes are exostoses (bony projections) that form along joint margins. They should not be confused with enthesophytes, which are bony projections that form at the attachment of a tendon or ligament. Osteophytes are not always distinguished ...
s, can form on the margins of the joints, possibly in an attempt to improve the congruence of the
articular cartilage Hyaline cartilage is the glass-like (hyaline) and translucent cartilage found on many joint surfaces. It is also most commonly found in the ribs, nose, larynx, and trachea. Hyaline cartilage is pearl-gray in color, with a firm consistency and has ...
surfaces in the absence of the menisci. The subchondral bone volume increases and becomes less mineralized (hypomineralization). All these changes can cause problems functioning. The pain in an osteoarthritic joint has been related to thickened synovium and to subchondral bone lesions.


Diagnosis

Diagnosis is made with reasonable certainty based on history and clinical examination.
X-ray An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10  picometers to 10  nanometers, corresponding to frequencies in the range 30&nb ...
s may confirm the diagnosis. The typical changes seen on X-ray include:
joint A joint or articulation (or articular surface) is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole.Saladin, Ken. Anatomy & Physiology. 7th ed. McGraw- ...
space narrowing, subchondral sclerosis (increased bone formation around the joint), subchondral
cyst A cyst is a closed sac, having a distinct envelope and division compared with the nearby tissue. Hence, it is a cluster of cells that have grouped together to form a sac (like the manner in which water molecules group together to form a bubble) ...
formation, and
osteophytes Osteophytes are exostoses (bony projections) that form along joint margins. They should not be confused with enthesophytes, which are bony projections that form at the attachment of a tendon or ligament. Osteophytes are not always distinguished ...
. Plain films may not correlate with the findings on physical examination or with the degree of pain. In 1990, the
American College of Rheumatology The American College of Rheumatology (ACR; until 1985 called American Rheumatism Association) is an organization of and for physicians, health professionals, and scientists that advances rheumatology through programs of education, research, advocacy ...
, using data from a multi-center study, developed a set of criteria for the diagnosis of hand osteoarthritis based on hard tissue enlargement and swelling of certain joints. These criteria were found to be 92% sensitive and 98%
specific Specific may refer to: * Specificity (disambiguation) * Specific, a cure or therapy for a specific illness Law * Specific deterrence, focussed on an individual * Specific finding, intermediate verdict used by a jury in determining the fina ...
for hand osteoarthritis versus other entities such as rheumatoid arthritis and
spondyloarthropathies Spondyloarthropathy or spondyloarthrosis refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra ...
. File:Osteo of the hand.jpg, Severe osteoarthritis and
osteopenia Osteopenia, known as "low bone mass" or "low bone density", is a condition in which bone mineral density is low. Because their bones are weaker, people with osteopenia may have a higher risk of fractures, and some people may go on to develop osteop ...
of the carpal joint and 1st carpometacarpal joint File:Gonarthrose-Knorpelaufbrauch.jpg, MRI of osteoarthritis in the knee, with characteristic narrowing of the joint space File:Osteoarthritis left knee.jpg, Primary osteoarthritis of the left knee. Note the
osteophytes Osteophytes are exostoses (bony projections) that form along joint margins. They should not be confused with enthesophytes, which are bony projections that form at the attachment of a tendon or ligament. Osteophytes are not always distinguished ...
, narrowing of the joint space (arrow), and increased subchondral bone density (arrow). File:Damaged cartilage Danish sow.png, Damaged cartilage from sows. (a) cartilage erosion (b)cartilage ulceration (c)cartilage repair (d)osteophyte (bone spur) formation. File:Primary osteoarthrosis (2) at knee joint.jpg, Histopathology of osteoarthrosis of a knee joint in an elderly female File:Primary osteoarthrosis (5) at knee joint.jpg, Histopathology of osteoarthrosis of a knee joint in an elderly female File:Health joint.png, In a healthy joint, the ends of bones are encased in smooth cartilage. Together, they are protected by a joint capsule lined with a synovial membrane that produces synovial fluid. The capsule and fluid protect the cartilage, muscles, and connective tissues. File:Joint with severe osteoathritis.png, With osteoarthritis, the cartilage becomes worn away. Spurs grow out from the edge of the bone, and synovial fluid increases. Altogether, the joint feels stiff and sore. File:Osteoarthritis.png, Osteoarthritis File:Osteoarthritis -- Smart-Servier (cropped).jpg, Bone (left) and clinical (right) changes of the hand in osteoarthritis


Classification

A number of classification systems are used for gradation of osteoarthritis: * WOMAC scale, taking into account pain, stiffness and functional limitation. * Kellgren-Lawrence grading scale for osteoarthritis of the knee. It uses only
projectional radiography Projectional radiography, also known as conventional radiography, is a form of radiography and medical imaging that produces two-dimensional images by x-ray radiation. The image acquisition is generally performed by radiographers, and the images a ...
features. * Tönnis classification for osteoarthritis of the
hip joint In vertebrate anatomy, hip (or "coxa"Latin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) in medical terminology) refers to either an anatomical region or a joint. The hip region is ...
, also using only projectional radiography features. Both primary generalized nodal osteoarthritis and erosive osteoarthritis (EOA, also called inflammatory osteoarthritis) are sub-sets of primary osteoarthritis. EOA is a much less common, and more aggressive inflammatory form of osteoarthritis which often affects the distal interphalangeal joints of the hand and has characteristic articular erosive changes on X-ray.


Management

Lifestyle modification (such as weight loss and exercise) and pain medications are the mainstays of treatment. Acetaminophen (also known as paracetamol) is recommended first line with NSAIDs being used as add on therapy only if pain relief is not sufficient. Medications that alter the course of the disease have not been found as of 2018. Recommendations include modification of risk factors through targeted interventions including 1) obesity and overweight, 2) physical activity, 3) dietary exposures, 4) comorbidity, 5) biomechanical factors, 6) occupational factors. Successful management of the condition is often made more difficult by differing priorities and poor communication between clinicians and people with osteoarthritis. Realistic treatment goals can be achieved by developing a shared understanding of the condition, actively listening to patient concerns, avoiding medical
jargon Jargon is the specialized terminology associated with a particular field or area of activity. Jargon is normally employed in a particular communicative context and may not be well understood outside that context. The context is usually a partic ...
and tailoring treatment plans to the patient's needs.


Lifestyle changes

For overweight people,
weight loss Weight loss, in the context of medicine, health, or physical fitness, refers to a reduction of the total body mass, by a mean loss of fluid, body fat ( adipose tissue), or lean mass (namely bone mineral deposits, muscle, tendon, and other co ...
may be an important factor. Weight loss and exercise provides long-term treatment and advocated in patients with OA. As an adjunct to these lifestyle changes, use of analgesia, intra-articular cortisone injection and consideration of hyaluronic acids and platelet-rich plasma are recommended for pain relief in patients with knee osteoarthritis. Patient education has been shown to be helpful in the self-management of arthritis. It decreases pain, improves function, reduces stiffness and fatigue, and reduces medical usage. Patient education can provide on average 20% more pain relief when compared to NSAIDs alone.


Physical measures

Moderate exercise may be beneficial with respect to pain and function in those with osteoarthritis of the knee and hip. These exercises should occur at least three times per week. While some evidence supports certain physical therapies, evidence for a combined program is limited. Providing clear advice, making exercises enjoyable, and reassuring people about the importance of doing exercises may lead to greater benefit and more participation. Limited evidence suggests that supervised exercise therapy may improve exercise adherence. There is not enough evidence to determine the effectiveness of
massage therapy Massage is the manipulation of the body's soft tissues. Massage techniques are commonly applied with hands, fingers, elbows, knees, forearms, feet or a device. The purpose of massage is generally for the treatment of body stress or pain. In Eu ...
. The evidence for
manual therapy Manual therapy, or manipulative therapy, is a physical treatment primarily used by physical therapists, physiotherapists, occupational therapists to treat musculoskeletal pain and disability; it mostly includes kneading and manipulation of mu ...
is inconclusive. A 2015 review indicated that aquatic therapy is safe, effective, and can be an adjunct therapy for knee osteoarthritis. Functional, gait, and balance training have been recommended to address impairments of position sense, balance, and strength in individuals with lower extremity arthritis, as these can contribute to a higher rate of falls in older individuals. For people with hand osteoarthritis, exercises may provide small benefits for improving hand function, reducing pain, and relieving finger joint stiffness. Lateral wedge insoles and neutral insoles do not appear to be useful in osteoarthritis of the knee. Knee braces may help but their usefulness has also been disputed. For pain management heat can be used to relieve stiffness, and cold can relieve muscle spasms and pain. Among people with hip and knee osteoarthritis, exercise in water may reduce pain and disability, and increase quality of life in the short term. Also therapeutic exercise programs such as aerobics and walking reduce pain and improve physical functioning for up to 6 months after the end of the program for people with knee osteoarthritis. Hydrotherapy might also be an advantage on the management of pain, disability and quality of life reported by people with osteoarthritis.


Medication


By mouth

The
pain medication An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...
paracetamol (acetaminophen) is the first line treatment for osteoarthritis. Pain relief does not differ according to dosage. However, a 2015 review found acetaminophen to have only a small short-term benefit with some laboratory concerns of liver inflammation. For mild to moderate symptoms effectiveness of acetaminophen is similar to
non-steroidal anti-inflammatory drug Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
s (NSAIDs) such as
naproxen Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, menstrual cramps, inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It is available in immediate and delayed release formulat ...
, though for more severe symptoms NSAIDs may be more effective. NSAIDs are associated with greater side effects such as
gastrointestinal bleeding Gastrointestinal bleeding (GI bleed), also called gastrointestinal hemorrhage (GIB), is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is significant blood loss over a short time, symptoms may include ...
. Another class of NSAIDs, COX-2 selective inhibitors (such as
celecoxib Celecoxib, sold under the brand name Celebrex among others, is a COX-2 inhibitor and nonsteroidal anti-inflammatory drug (NSAID). It is used to treat the pain and inflammation in osteoarthritis, acute pain in adults, rheumatoid arthritis, ankyl ...
) are equally effective when compared to nonselective NSAIDs, and have lower rates of adverse gastrointestinal effects, but higher rates of cardiovascular disease such as
myocardial infarction A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may ...
. They are also more expensive than non-specific NSAIDs. Benefits and risks vary in individuals and need consideration when making treatment decisions, and further unbiased research comparing NSAIDS and COX-2 selective inhibitors is needed. NSAIDS applied topically are effective for a small number of people. The COX-2 selective inhibitor
rofecoxib Rofecoxib is a COX-2 selective nonsteroidal anti-inflammatory drug (NSAID). It was marketed by Merck & Co. to treat osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, acute pain conditions, migraine, and dysmenorrhea. Rofecoxib ...
was removed from the market in 2004, as cardiovascular events were associated with long term use. Failure to achieve desired pain relief in osteoarthritis after two weeks should trigger reassessment of dosage and pain medication. Opioids by mouth, including both weak opioids such as
tramadol Tramadol, sold under the brand name Ultram among others, is an opioid pain medication used to treat moderate to moderately severe pain. When taken by mouth in an immediate-release formulation, the onset of pain relief usually begins within an ...
and stronger opioids, are also often prescribed. Their appropriateness is uncertain, and opioids are often recommended only when first line therapies have failed or are contraindicated. This is due to their small benefit and relatively large risk of side effects. The use of tramadol likely does not improve pain or physical function and likely increases the incidence of adverse side effects. Oral steroids are not recommended in the treatment of osteoarthritis. Use of the antibiotic doxycycline orally for treating osteoarthritis is not associated with clinical improvements in function or joint pain. Any small benefit related to the potential for doxycycline therapy to address the narrowing of the joint space is not clear, and any benefit is outweighed by the potential harm from side effects.


Topical

There are several NSAIDs available for
topical A topical medication is a medication that is applied to a particular place on or in the body. Most often topical medication means application to body surfaces such as the skin or mucous membranes to treat ailments via a large range of classes ...
use, including
diclofenac Diclofenac, sold under the brand name Voltaren, among others, is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammatory diseases such as gout. It is taken by mouth or rectally in a suppository, used by injection, or ...
. A Cochrane review from 2016 concluded that reasonably reliable evidence is available only for use of topical diclofenac and ketoprofen in people aged over 40 years with painful knee arthritis. Transdermal opioid pain medications are not typically recommended in the treatment of osteoarthritis. The use of
topical A topical medication is a medication that is applied to a particular place on or in the body. Most often topical medication means application to body surfaces such as the skin or mucous membranes to treat ailments via a large range of classes ...
capsaicin Capsaicin (8-methyl-''N''-vanillyl-6-nonenamide) ( or ) is an active component of chili peppers, which are plants belonging to the genus ''Capsicum''. It is a chemical irritant for mammals, including humans, and produces a sensation of burnin ...
to treat osteoarthritis is controversial, as some reviews found benefit while others did not.


Joint injections

Local drug delivery by intra-articular (IA) injection may be more effective and safer in terms of increased bioavailability, less systemic exposure and reduced adverse events. Several intra-articular medications for symptomatic are available on the market as follow.


= Steroids

=
Joint injection In medicine, a joint injection (intra-articular injection) is a procedure used in the treatment of inflammatory joint conditions, such as rheumatoid arthritis, psoriatic arthritis, gout, tendinitis, bursitis, Carpal Tunnel Syndrome, and occasiona ...
of glucocorticoids (such as
hydrocortisone Hydrocortisone is the name for the hormone cortisol when supplied as a medication. Uses include conditions such as adrenocortical insufficiency, adrenogenital syndrome, high blood calcium, thyroiditis, rheumatoid arthritis, dermatitis, asthm ...
) leads to short-term pain relief that may last between a few weeks and a few months. A 2015 Cochrane review found that intra-articular corticosteroid injections of the knee did not benefit quality of life and had no effect on knee joint space; clinical effects one to six weeks after injection could not be determined clearly due to poor study quality. Another 2015 study reported negative effects of intra-articular corticosteroid injections at higher doses, and a 2017 trial showed reduction in cartilage thickness with intra-articular
triamcinolone Triamcinolone is a glucocorticoid used to treat certain skin diseases, allergies, and rheumatic disorders among others. It is also used to prevent worsening of asthma and COPD. It can be taken in various ways including by mouth, injection i ...
every 12 weeks for 2 years compared to placebo. A 2018 study found that intra-articular triamcinolone is associated with an increase in
intraocular pressure Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine this. IOP is an important aspect in the evaluation of patients at risk of glaucoma. Most tonometers are calibrated t ...
.


= Hyaluronic acid

= Injections of hyaluronic acid have not produced improvement compared to placebo for knee arthritis, but did increase risk of further pain. In ankle osteoarthritis, evidence is unclear.


= Platelet-rich plasma

= The effectiveness of injections of
platelet-rich plasma Platelet-rich plasma (PRP), also known as autologous conditioned plasma, is a concentrate of platelet-rich plasma protein derived from whole blood, centrifuged to remove red blood cells. Though promoted to treat an array of medical problems, evid ...
(PRP) is unclear; there are suggestions that such injections improve function but not pain, and are associated with increased risk. A Cochrane review of studies involving PRP found the evidence to be insufficient.


Surgery


Bone fusion

Arthrodesis Arthrodesis, also known as artificial ankylosis or syndesis, is the artificial induction of joint ossification between two bones by surgery. This is done to relieve intractable pain in a joint which cannot be managed by pain medication, spli ...
(fusion) of the bones may be an option in some types of osteoarthritis. An example is ankle osteoarthritis, in which ankle fusion is considered to be the gold standard treatment in end-stage cases.


Joint replacement

If the impact of symptoms of osteoarthritis on quality of life is significant and more conservative management is ineffective, joint replacement surgery or resurfacing may be recommended. Evidence supports joint replacement for both knees and hips as it is both clinically effective and cost-effective. People who underwent total knee replacement had improved SF-12 quality of life scores, were feeling better compared to those who did not have surgery, and may have short- and long-term benefits for quality of life in terms of pain and function. The beneficial effects of these surgeries may be time-limited due to various environmental factors, comorbidities, and pain in other regions of the body. For people who have shoulder osteoarthritis and do not respond to medications, surgical options include a shoulder hemiarthroplasty (replacing a part of the joint), and total shoulder arthroplasty (replacing the joint). Biological joint replacement involves replacing the diseased tissues with new ones. This can either be from the person (autograft) or from a donor (allograft). People undergoing a joint transplant (osteochondral allograft) do not need to take immunosuppressants as bone and cartilage tissues have limited immune responses. Autologous articular cartilage transfer from a non-weight-bearing area to the damaged area, called osteochondral autograft transfer system, is one possible procedure that is being studied. When the missing cartilage is a focal defect, autologous chondrocyte implantation is also an option.


Shoulder replacement

For those with osteoarthritis in the shoulder, a complete shoulder replacement is sometimes suggested to improve pain and function. Demand for this treatment is expected to increase by 750% by the year 2030. There are different options for shoulder replacement surgeries, however, there is a lack of evidence in the form of high-quality randomized controlled trials, to determine which type of shoulder replacement surgery is most effective in different situations, what are the risks involved with different approaches, or how the procedure compares to other treatment options. There is some low-quality evidence that indicates that when comparing total shoulder arthroplasty over hemiarthroplasty, no large clinical benefit was detected in the short term. It is not clear if the risk of harm differs between total shoulder arthroplasty or a hemiarthroplasty approach.


Other surgical options

Osteotomy An osteotomy is a surgical operation whereby a bone is cut to shorten or lengthen it or to change its alignment. It is sometimes performed to correct a hallux valgus, or to straighten a bone that has healed crookedly following a fracture. It is ...
may be useful in people with knee osteoarthritis, but has not been well studied and it is unclear whether it is more effective than non-surgical treatments or other types of surgery.
Arthroscopic surgery Arthroscopy (also called arthroscopic or keyhole surgery) is a minimally invasive surgical procedure on a joint in which an examination and sometimes treatment of damage is performed using an arthroscope, an endoscope that is inserted into the ...
is largely not recommended, as it does not improve outcomes in knee osteoarthritis, and may result in harm. It is unclear whether surgery is beneficial in people with mild to moderate knee osteoarthritis.


Alternative medicine


Glucosamine and chondroitin

The effectiveness of
glucosamine Glucosamine (C6H13NO5) is an amino sugar and a prominent precursor in the biochemical synthesis of glycosylated proteins and lipids. Glucosamine is part of the structure of two polysaccharides, chitosan and chitin. Glucosamine is one of the most ...
is controversial. Reviews have found it to be equal to or slightly better than
placebo A placebo ( ) is a substance or treatment which is designed to have no therapeutic value. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. In general, placebos can af ...
. A difference may exist between glucosamine sulfate and glucosamine hydrochloride, with glucosamine sulfate showing a benefit and glucosamine hydrochloride not. The evidence for glucosamine sulfate having an effect on osteoarthritis progression is somewhat unclear and if present likely modest. The Osteoarthritis Research Society International recommends that glucosamine be discontinued if no effect is observed after six months and the
National Institute for Health and Care Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care in England that publishes guidelines in four areas: * the use of health technologies withi ...
no longer recommends its use. Despite the difficulty in determining the efficacy of glucosamine, it remains a treatment option. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) recommends glucosamine sulfate and chondroitin sulfate for knee osteoarthritis. Its use as a therapy for osteoarthritis is usually safe. A 2015 Cochrane review of clinical trials of
chondroitin A chondroitin is a chondrin derivative. Types include: * Chondroitin sulfate * Dermatan sulfate Chondroitin as a supplement is now commonly used (often in combination with glucosamine) in treating the joint disease of osteoarthritis. In contrast ...
found that most were of low quality, but that there was some evidence of short-term improvement in pain and few side effects; it does not appear to improve or maintain the health of affected joints.


Other remedies

Avocado–soybean unsaponifiables (ASU) is an extract made from
avocado oil Avocado oil is an edible oil extracted from the pulp of avocados, the fruit of ''Persea americana''. It is used as an edible oil both raw and for cooking, where it is noted for its high smoke point. It is also used for lubrication and in cosmetics ...
and
soybean oil Soybean oil (British English: soyabean oil) is a vegetable oil extracted from the seeds of the soybean (''Glycine max''). It is one of the most widely consumed cooking oils and the second most consumed vegetable oil. As a drying oil, processed s ...
sold under many
brand name A brand is a name, term, design, symbol or any other feature that distinguishes one seller's good or service from those of other sellers. Brands are used in business, marketing, and advertising for recognition and, importantly, to create an ...
s worldwide as a dietary supplement and as a prescription drug in France. A 2014 Cochrane review found that while ASU might help relieve pain in the short term for some people with osteoarthritis, it does not appear to improve or maintain the health of affected joints. The review noted a high-quality, two-year clinical trial comparing ASU to
chondroitin A chondroitin is a chondrin derivative. Types include: * Chondroitin sulfate * Dermatan sulfate Chondroitin as a supplement is now commonly used (often in combination with glucosamine) in treating the joint disease of osteoarthritis. In contrast ...
which has uncertain efficacy in osteoarthritis with no difference between the two agents. The review also found there is insufficient evidence of ASU safety. A few high-quality studies of '' Boswellia serrata'' show consistent, but small, improvements in pain and function.
Curcumin Curcumin is a bright yellow chemical produced by plants of the ''Curcuma longa'' species. It is the principal curcuminoid of turmeric (''Curcuma longa''), a member of the ginger family, Zingiberaceae. It is sold as a herbal supplement, cosmet ...
, phytodolor, and
s-adenosyl methionine ''S''-Adenosyl methionine (SAM), also known under the commercial names of SAMe, SAM-e, or AdoMet, is a common cosubstrate involved in methyl group transfers, transsulfuration, and aminopropylation. Although these anabolic reactions occur throug ...
(SAMe) may be effective in improving pain. A 2009 Cochrane review recommended against the routine use of SAMe, as there has not been sufficient high-quality
clinical research Clinical research is a branch of healthcare science that determines the safety and effectiveness ( efficacy) of medications, devices, diagnostic products and treatment regimens intended for human use. These may be used for prevention, treatm ...
to prove its effect. A 2021 review found that
hydroxychloroquine Hydroxychloroquine, sold under the brand name Plaquenil among others, is a medication used to prevent and treat malaria in areas where malaria remains sensitive to chloroquine. Other uses include treatment of rheumatoid arthritis, lupus, an ...
(HCQ) had no benefit in reducing pain and improving physical function in hand or knee osteoarthritis, and the off-label use of HCQ for people with osteoarthritis should be discouraged. There is no evidence for the use of
colchicine Colchicine is a medication used to treat gout and Behçet's disease. In gout, it is less preferred to NSAIDs or steroids. Other uses for colchicine include the management of pericarditis and familial Mediterranean fever. Colchicine is taken b ...
for treating the pain of hand or knee arthritis. There is limited evidence to support the use of hyaluronan, methylsulfonylmethane,
rose hip The rose hip or rosehip, also called rose haw and rose hep, is the accessory fruit of the various species of rose plant. It is typically red to orange, but ranges from dark purple to black in some species. Rose hips begin to form after pollina ...
,
capsaicin Capsaicin (8-methyl-''N''-vanillyl-6-nonenamide) ( or ) is an active component of chili peppers, which are plants belonging to the genus ''Capsicum''. It is a chemical irritant for mammals, including humans, and produces a sensation of burnin ...
, or
vitamin D Vitamin D is a group of fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group are vitamin D3 (c ...
.


Acupuncture and other interventions

While
acupuncture Acupuncture is a form of alternative medicine and a component of traditional Chinese medicine (TCM) in which thin needles are inserted into the body. Acupuncture is a pseudoscience; the theories and practices of TCM are not based on scientif ...
leads to improvements in pain relief, this improvement is small and may be of questionable importance. Waiting list–controlled trials for peripheral joint osteoarthritis do show clinically relevant benefits, but these may be due to placebo effects. Acupuncture does not seem to produce long-term benefits. Electrostimulation techniques such as
TENS Transcutaneous electrical nerve stimulation (TENS or TNS) is the use of electric current produced by a device to stimulate the nerves for therapeutic purposes. TENS, by definition, covers the complete range of transcutaneously applied currents ...
have been used for twenty years to treat osteoarthritis in the knee. However, there is no conclusive evidence to show that it reduces pain or disability. A
Cochrane review Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health profes ...
of
low-level laser therapy Low-level laser therapy (LLLT), cold laser therapy, or photobiomodulation (PBM) is a form of medicine that applies low-level (low-power) lasers or light-emitting diodes (LEDs) to the surface of the body. Whereas high-power lasers are used in la ...
found unclear evidence of benefit, whereas another review found short-term pain relief for osteoarthritic knees. Further research is needed to determine if balnotherapy for osteoarthritis ( mineral baths or
spa treatment A spa is a location where mineral-rich spring water (and sometimes seawater) is used to give medicinal baths. Spa towns or spa resorts (including hot springs resorts) typically offer various health treatments, which are also known as balneothe ...
s) improves a person's
quality of life Quality of life (QOL) is defined by the World Health Organization as "an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards ...
or ability to function. The use of ice or cold packs may be beneficial; however, further research is needed. There is no evidence of benefit from placing hot packs on joints. There is low quality evidence that
therapeutic ultrasound Therapeutic ultrasound refers generally to any type of ultrasonic procedure that uses ultrasound for therapeutic benefit. Physiotherapeutic ultrasound was introduced into clinical practice in the 1950s, with lithotripsy introduced in the 1980s. ...
may be beneficial for people with osteoarthritis of the knee; however, further research is needed to confirm and determine the degree and significance of this potential benefit. Therapeutic ultrasound may relieve pain compared to conventional non-drug ultrasound however phonopheresis does not produce additional benefits to functional improvement. It is safe treatment to relieve pain and improve physical function in patients with knee osteoarthritis. Continuous and pulsed ultrasound modes (especially 1 MHz, 2.5 W/cm2, 15min/ session, 3 session/ week, during 8 weeks protocol) can be effective in improving patients physical function and pain. There is weak evidence suggesting that electromagnetic field treatment may result in moderate pain relief; however, further research is necessary and it is not known if electromagnetic field treatment can improve quality of life or function. Viscosupplementation for osteoarthritis of the knee may have positive effects on pain and function at 5 to 13 weeks post-injection.


Epidemiology

Globally, , approximately 250million people had osteoarthritis of the knee (3.6% of the population). Hip osteoarthritis affects about 0.85% of the population. , osteoarthritis globally causes moderate to severe disability in 43.4 million people. Together, knee and hip osteoarthritis had a ranking for disability globally of 11th among 291 disease conditions assessed. , osteoarthritis affected 52.5million people in the United States, approximately 50% of whom were 65 years or older. It is estimated that 80% of the population have
radiograph Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...
ic evidence of osteoarthritis by age 65, although only 60% of those will have symptoms. The rate of osteoarthritis in the United States is forecast to be 78million (26%) adults by 2040. In the United States, there were approximately 964,000 hospitalizations for osteoarthritis in 2011, a rate of 31 stays per 10,000 population. With an aggregate cost of $14.8billion ($15,400 per stay), it was the second-most expensive condition seen in U.S. hospital stays in 2011. By payer, it was the second-most costly condition billed to Medicare and private insurance.


History


Etymology

Osteoarthritis is derived from the prefix '' osteo-'' (from grc, ὀστέον, ostéon, bone) combined with ''arthritis'' (from , , ), which is itself derived from '' arthr-'' (from , , ) and '' -itis'' (from , , ), the latter suffix having come to be associated with
inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...
. The ''-itis'' of osteoarthritis could be considered misleading as inflammation is not a conspicuous feature. Some clinicians refer to this condition as ''osteoarthrosis'' to signify the lack of inflammatory response, the suffix ''
-osis OSIS or ''variant'' may refer to: ;OSIS * Open Source Information System * Open Scripture Information Standard * ''Organisasi Siswa Intra Sekolah'', Indonesian for Intra-school students organization ;-osis The suffix '' -osis'' is used for form ...
'' (from , , ) simply referring to the pathosis itself.


Other animals

Osteoarthritis has been reported in fossils of the large carnivorous dinosaur ''
Allosaurus ''Allosaurus'' () is a genus of large carnosaurian theropod dinosaur that lived 155 to 145 million years ago during the Late Jurassic epoch ( Kimmeridgian to late Tithonian). The name "''Allosaurus''" means "different lizard" alludin ...
fragilis''.


Research


Therapies

Pharmaceutical agents that will alter the natural history of disease progression by arresting joint structural change and ameliorating symptoms are termed as disease modifying therapy (DMOAD). Therapies under investigation include the following: *
Strontium ranelate Strontium ranelate, a strontium(II) salt of ranelic acid, is a medication for osteoporosis marketed as Protelos or Protos by Servier. Studies indicate it can also slow the course of osteoarthritis of the knee. The drug is unusual in that it bo ...
– may decrease degeneration in osteoarthritis and improve outcomes * Gene therapy – Gene transfer strategies aim to target the disease process rather than the symptoms. Cell-mediated gene therapy is also being studied. One version was approved in
South Korea South Korea, officially the Republic of Korea (ROK), is a country in East Asia, constituting the southern part of the Korean Peninsula and sharing a land border with North Korea. Its western border is formed by the Yellow Sea, while its eas ...
for the treatment of moderate knee osteoarthritis, but later revoked for the mislabeling and the false reporting of an ingredient used. The drug was administered intra-articularly. * Autologous chondrocyte implantation (ACI) is approved cell therapy by FDA for the treatment of osteoarthritis.


Cause

As well as attempting to find disease-modifying agents for osteoarthritis, there is emerging evidence that a system-based approach is necessary to find the causes of osteoarthritis.


Diagnostic biomarkers

Guidelines outlining requirements for inclusion of soluble
biomarker In biomedical contexts, a biomarker, or biological marker, is a measurable indicator of some biological state or condition. Biomarkers are often measured and evaluated using blood, urine, or soft tissues to examine normal biological processes, p ...
s in osteoarthritis clinical trials were published in 2015, but there are no validated biomarkers used clinically to detect osteoarthritis, as of 2021. A 2015 systematic review of biomarkers for osteoarthritis looking for molecules that could be used for risk assessments found 37 different biochemical markers of
bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...
and cartilage turnover in 25 publications. The strongest evidence was for urinary C-terminal telopeptide of
type II collagen Type II collagen is the basis for hyaline cartilage, including the articular cartilages at joint surfaces. It is formed by homotrimers of collagen, type II, alpha 1 chains. It makes up 50% of all protein in cartilage and 85–90% of collagen of ...
(uCTX-II) as a prognostic marker for knee osteoarthritis progression, and serum
cartilage oligomeric matrix protein Cartilage oligomeric matrix protein (COMP), also known as thrombospondin-5, is an extracellular matrix (ECM) protein primarily present in cartilage. In humans it is encoded by the ''COMP'' gene. Function The protein encoded by this gene is a ...
(COMP) levels as a prognostic marker for incidence of both knee and hip osteoarthritis. A review of biomarkers in hip osteoarthritis also found associations with uCTX-II. Procollagen type II C-terminal propeptide (PIICP) levels reflect type II collagen synthesis in body and within joint fluid PIICP levels can be used as a prognostic marker for early osteoarthritis.


References


External links

* {{Authority control Arthritis Skeletal disorders Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate