Osteoarthritis - Standard Treatment Guidelines

Osteoarthritis (OA) also known as degenerative arthritis or degenerative joint disease is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. A variety of causes—hereditary, developmental, metabolic, and mechanical—may initiate processes leading to loss of cartilage, When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines Osteoarthritis. Following are the major recommendations :

Case Definition:

Osteoarthritis can be classified into either primary or secondary depending on whether or not there is an identifiable underlying cause.

Primary osteoarthritis is a chronic degenerative disorder related to aging. A number of studies have shown that there is a greater prevalence of the disease among siblings and especially identical twins, indicating a hereditary basis. Up to 60% of OA cases are thought to result from genetic factors

Secondary Osteoarthritis is caused by other factors such as

• Congenital disorders of joints


• Diabetes.


• Inflammatory diseases (such as Perthes' disease), (Lyme disease), and all chronic forms of arthritis (e.g. costochondritis, gout, and rheumatoid arthritis). In gout, uric acid crystals cause the cartilage to degenerate at a faster pace.


• Injury to joints, as a result of an accident


• Septic arthritis


• Ligamentous deterioration or instability may be a factor.


• Developmental disorder resulting into mal-alignment of extremities.

Incidence of Condition In Our Country

Osteoarthritis affects nearly 27 million people in the United States, accounting for 25% of visits to primary care physicians, and half of all NSAID prescriptions. It is estimated that 80% of the population have radiographic evidence of OA by age 65, although only 60% of those will have symptoms.

Prevention And Counselling

Life style modification , weight control, regular exercise Patient needs to be counselled regarding the nature of the disease and need for treatment, possible treatment options and chances of improvement.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

* SITUATION 1: At Secondary Hospital / Non Metro situation : Optimal standards of Treatment in situations where technology and resources are limited

Clinical diagnosis:

The main symptom is pain, causing loss of ability and often stiffness. "Pain" is generally described as a sharp ache, or a burning sensation in the associated muscles and tendons. OA can cause a crackling noise (called "crepitus") when the affected joint is moved. It commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel better with gentle use but worse with excessive or prolonged use. In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen.

Investigations:

X Ray - Particularly standing xrays for knees in which eccentric joint space reduction is the diagnostic crieterion as compared to inflammatory where there is concentric space reduction.

Treatment:

not applicable

Standard Operating Procedure

In Patient :

Surgery

• Arthroscopy joint debridement


• Joint Replacement

Out Patient :

1. Life style modification

2. Physical therapy

3. Analgesics

• Oral


• Topical

4 . Steroids

• Systemic


• Intra articular

5. Glucosamine (controversial)

Day Care

• Injectable medications


• Intra articular Steroid injection


• Intra articular hyaluronic acid injection

Referral criteria:

For further evaluation and management of cases not responding to conventional therapy.

SITUATION 2: At Super Specialty facility in Metro Location where higher end technology is available

Clinical diagnosis:

The main symptom is pain, causing loss of ability and often stiffness. "Pain" is generally described as a sharp ache, or a burning sensation in the associated muscles and tendons. OA can cause a crackling noise (called "crepitus") when the affected joint is moved. It commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips and knees, although in theory, any joint in the body can be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel better with gentle use but worse with excessive or prolonged use. In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit the movement of the fingers significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen.

Investigations:

X Ray - Particularly standing xrays for knees in which eccentric joint space reduction is the diagnostic crieterion as compared to inflammatory where there is concentric space reduction.

Treatment:

not applicable

Standard Operating Procedure

In Patient :

Surgery

• Arthroscopy joint debridement


• Joint Replacement

Out Patient :

1. Life style modification

2. Physical therapy

3. Analgesics

• Oral


• Topical

4 . Steroids

• Systemic


• Intra articular

5. Glucosamine (controversial)

Day Care

• Injectable medications


• Intra articular Steroid injection


• Intra articular hyaluronic acid injection

Referral criteria:

not applicable

WHO DOES WHAT? AND TIMELINES

Doctor

Early diagnosis and appropriate treatment. Counsel the patient for prevention and dietary advice.

Nurse

counseling the patient. Injectable treatment

Technician

Appropriate bracing manufacturing and application of braces Physiotherapy

Resources Required For One Patient / Procedure (Patient Weight 60 Kgs)

(Units to be specified for human resources, investigations, drugs and consumables and equipment. Quantity to also be specified)

Guidelines by The Ministry of Health and Family Welfare :

Dr. P.K. DAVE, Rockland Hospital, New Delhi, Dr. P.S. Maini, Fortis Jessa Ram Hospital, New Delhi

Reviewed By

Dr. V.K. SHARMA Professor Central Instiute of Orthopaedics Safdarjung Hospital New Delhi