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Oligoarticular (2 4 joints) Polyarticular ( 5 joints) Site of joint involvement Distal interphalangeal Metacarpophalangeal, wrists First metatarsal phalangeal
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Osteoarthritis, the most common form of joint disease, is chiefly a disease of aging Ninety percent of all people have radiographic features of osteoarthritis in weight-bearing joints by age 40 Symptomatic disease also increases with age This arthropathy is characterized by degeneration of cartilage and by hypertrophy of bone at the articular margins Inflammation is usually minimal Hereditary and mechanical factors may be involved in the pathogenesis Obesity is a risk factor for osteoarthritis of the knee and probably of the hip Recreational running does not increase the incidence of osteoarthritis, but participation in compet-
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B Laboratory Findings
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Osteoarthritis does not cause elevation of the erythrocyte sedimentation rate (ESR) or other laboratory signs of inflammation
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Radiographs may reveal narrowing of the joint space; sharpened articular margins; osteophyte formation and lipping of marginal bone; and thickened, dense subchondral bone Bone cysts may also be present
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Table 20 2 Examination of joint fluid
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Measure Volume (mL) (knee) Clarity Color WBC (per mcL) Polymorphonuclear leukocytes Culture
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(Normal) < 35 Transparent Clear < 200 < 25% Negative
Group I (Noninflammatory) Often > 35 Transparent Yellow 200 300 < 25% Negative
Group II (Inflammatory) Often > 35 Translucent to opaque Yellow to opalescent 2000 75,0001 50% or more Negative
Group III (Purulent) Often > 35 Opaque Yellow to green > 100,0002 75% or more Usually positive2
Gout, rheumatoid arthritis, and other inflammatory conditions occasionally have synovial fluid WBC counts > 75,000/mcL and < 100,000/mcL Most purulent effusions are due to septic arthritis Septic arthritis, however, can present with group II synovial fluid, particularly if infection is caused by organisms of low virulence (eg, Neisseria gonorrhoeae) or if antibiotic therapy has been started WBC, white blood cell count
Arthritis & Musculoskeletal Disorders
CMDT 2008
Table 20 3 Differential diagnosis by joint fluid groups
Group I (Noninflammatory) (< 2000 white cells/mcL) Degenerative joint disease Group II (Inflammatory) (2000 75,000 white cells/mcL) Rheumatoid arthritis Acute crystal-induced synovitis (gout and pseudogout) Reiter s syndrome Trauma
Group III (Purulent)(> 100,000 white cells/mcL) Pyogenic bacterial infections
Hemorrhagic Hemophilia or other hemorrhagic diathesis Trauma with or without fracture Neuropathic arthropathy Pigmented villonodular synovitis Synovioma Hemangioma and other benign neoplasms Trauma with or without fracture Neuropathic arthropathy
Ankylosing spondylitis Rheumatic fever2 Tuberculosis
Osteochondritis dissecans Osteochondromatosis Neuropathic arthropathy
Ankylosing spondylitis Rheumatic fever2 Tuberculosis
Subsiding or early inflammation Hypertrophic osteoarthropathy
Pigmented villonodular synovitis
Ankylosing spondylitis
May be hemorrhagic 2 Noninflammatory or inflammatory group Reproduced, with permission, from Rodnan GP (editor) Primer on the rheumatic diseases, 7th ed JAMA 1973;224(Suppl):662
Differential Diagnosis
Because articular inflammation is minimal and systemic manifestations are absent, degenerative joint disease should seldom be confused with other arthritides The distribution of joint involvement in the hands also helps distinguish osteoarthritis from rheumatoid arthritis Osteoarthritis chiefly affects the DIP and PIP joints and spares the wrist and metacarpophalangeal (MCP) joints; rheumatoid arthritis involves the wrists and MCP joints and spares the DIP joints Furthermore, the joint enlargement is bony-hard and cool in osteoarthritis but spongy and warm in rheumatoid arthritis Skeletal symptoms due to degenerative changes in joints especially in the spine may cause coexistent metastatic neoplasia, osteoporosis, multiple myeloma, or other bone disease to be overlooked
Prevention
Weight reduction reduces the risk of developing symptomatic knee osteoarthritis Maintaining normal vitamin D levels may reduce the occurrence and progression of osteoarthritis, in addition to being important for bone health
Treatment
A General Measures
For patients with mild to moderate osteoarthritis of weightbearing joints, a supervised walking program may result in clinical improvement of functional status without aggravating the joint pain Weight loss can also improve the symptoms
for osteoarthritis of the knee or hip Their superiority is most convincing in persons with severe disease Patients with mild disease should start with acetaminophen (26 4 g/d) NSAIDs should be considered for patients who do not respond to acetaminophen (See discussion of NSAID toxicity in the section on treatment of rheumatoid arthritis) High doses of NSAIDs, as used in more inflammatory arthritides, are unnecessary Results of a randomized controlled trial indicate that chondroitin sulfate and glucosamine, alone or in combination, are no better than placebo in reducing pain in patients with knee osteoarthritis For many patients, it is possible eventually to reduce the dosage or limit use of drugs to periods of exacerbation For patients with knee osteoarthritis and effusion, intra-articular injection of triamcinolone (20 40 mg) may obviate the need for analgesics or NSAIDs Corticosteroid injections up to four times a year appear to be safe Intra-articular injections of sodium hyaluronate reduce symptoms moderately in some patients Capsaicin cream 0025% applied twice daily can also reduce knee pain without NSAIDs Doxycycline, though not approved by the US Food and Drug Administration (FDA) for treating osteoarthritis, has shown promise in slowing the progression of knee osteoarthritis
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