X-ray changes of osteoarthritis

• decrease of joint space
• subchondral sclerosis
• subchondral cysts
• osteophytes forming at joint margins

NICE recommend that we can diagnose osteoarthritis clinically without the need for investigations if:

• patient is > 45 years
• has exercise related pain
• no morning stiffness or morning stiffness lasting > 30 minutes

*it is sometimes better to use the term 'wear & repair' to patients

NICE published guidelines on the management of osteoarthritis (OA) in 2014

• all patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness
• paracetamol and topical NSAIDs are first-line analgesics. Topical NSAIDs are indicated only for OA of the knee or hand
• second-line treatment is oral NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids. A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors. These drugs should be avoided if the patient takes aspirin
• non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes
• if conservative methods fail then refer for consideration of joint replacement

Joint replacement

Joint replacement (arthroplasty) remains the most effective treatment for osteoarthritis patients who experience significant pain.

Selection criteria

• around 25% of patients are now younger than 60-years-old
• whilst obesity is often thought to be a barrier to joint replacement there is only a slight increase in short-term complications. There is no difference in long-term joint replacement survival

Surgical techniques

• for hips the most common type of operation is a cemented hip replacement. A metal femoral component is cemented into the femoral shaft. This is accompanied by a cemented acetabular polyethylene cup
• uncemented hip replacements are becoming increasingly popular, particularly in younger more active patients. They are more expensive than conventional cemented hip replacements
• hip resurfacing is also sometimes used where a metal cap is attached over the femoral head. This is often used in younger patients and has the advantage that the femoral neck is preserved which may be useful if conventional arthroplasty is needed later in life

Post-operative recovery

• patients receive both physiotherapy and a course of home-exercises
• walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery

Patients who have had a hip replacement operation should receive basic advice to minimise the risk of dislocation:

• avoiding flexing the hip > 90 degrees
• avoid low chairs
• do not cross your legs
• sleep on your back for the first 6 weeks

Complications

• wound and joint infection
• thromboembolism: NICE recommends patients receive low-molecular-weight heparin for 4 weeks following a hip replacement
• dislocation

What is the role of glucosamine?

• normal constituent of glycosaminoglycans in cartilage and synovial fluid
• a systematic review of several double blind RCTs of glucosamine in knee osteoarthritis reported significant short-term symptomatic benefits including significantly reduced joint space narrowing and improved pain scores
• more recent studies have however been mixed
• the 2008 NICE guidelines suggest it is not recommended
• a 2008 Drug and Therapeutics Bulletin review advised that whilst glucosamine provides modest pain relief in knee osteoarthritis it should not be prescribed on the NHS due to limited evidence of cost-effectiveness