Study Points

Osteoarthritis

Course #94953 - $50 • 10 Hours/Credits

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Of the following, secondary osteoarthritis occurs most often in the

    No support text associated with this question.Click to Review
  2. Which of the following systemic diseases may be associated with secondary osteoarthritis of the metacarpophalangeal (MCP) joints?

    OVERVIEW OF OSTEOARTHRITIS

    Osteoarthritis is classified as primary or secondary. The cause of primary osteoarthritis is idiopathic; no abnormality is the cause of changes in the joint [6]. Secondary osteoarthritis is the result of a known cause, most often trauma/injury or systemic diseases. Secondary osteoarthritis is most often found in the shoulder, elbow, and ankle and is more likely to become clinically apparent at a younger age than primary osteoarthritis [6,27,28,29]. A population-based study showed that secondary osteoarthritis related to trauma accounts for approximately 12% of the overall prevalence of symptomatic osteoarthritis of the knee, hip, or ankle [30]. Injuries sustained in sports activities comprise a large portion of post-traumatic osteoarthritis [31]. A wide variety of systemic diseases have been identified as frequent causes of secondary osteoarthritis; these conditions include metabolic diseases, endocrine disorders, bone dysplasias, and crystal deposition diseases (Table 1) [6,32].

    SYSTEMIC CONDITIONS ASSOCIATED WITH SECONDARY OSTEOARTHRITIS

    DiseaseJoint Affected
    Metabolic Diseases
    HemochromatosisKnee, hip, ankle
    Gaucher diseaseKnee, hip
    Hemoglobinopathies (e.g., sickle cell disease and thalassemia)Knee, hip
    Wilson disease (hepatolenticular degeneration)Knee, hip
    OchronosisKnee, hip
    Ehlers-Danlos syndrome (and other joint hypermobility)Knee, hip
    Avascular necrosisHip, ankle
    Endocrine Diseases
    AcromegalyKnee, hip
    Hypothyroidism (severe stages)Knee, hip
    HyperparathyroidismKnee, hip
    Bone Dysplasias
    Multiple epiphyseal dysplasiaKnee, hip
    Spondyloepiphyseal dysplasiaKnee, hip
    Progressive hereditary arthro-ophthalmopathy (Stickler syndrome)Knee, hip
    Osteo-onychodystrophy (nail-patella syndrome)Knee, hip
    Epiphyses-related conditionsKnee, hip
    Osteochondritis dissecansElbow, ankle
    Calcium Crystal Deposition Diseases
    Calcium pyrophosphate deposition diseaseKnee, hip, MCP joint (especially middle and index fingers)
    Apatite crystal deposition diseaseKnee, hip
    GoutHip
    Other Systemic Diseases
    Neuropathic arthropathy (Charcot joints)Knee, hip
    Paget disease (osteitis deformans)Knee, hip
    OsteopetrosisKnee, hip
    ChondrocalcinosisHip
    MCP = metacarpophalangeal.
    Click to Review
  3. According to the literature, the percentage of individuals who are asymptomatic but have structural changes indicative of osteoarthritis on radiographs is estimated to be

    OVERVIEW OF OSTEOARTHRITIS

    Research has shown that the symptoms of osteoarthritis do not correlate well with its radiographic evidence [16,36,37,38]. According to a systematic literature review, radiographic evidence of osteoarthritis is found in 15% to 76% of individuals with pain, and 15% to 81% of individuals with radiographic evidence of disease have pain [36]. An estimated 40% of individuals with structural changes on radiographs are asymptomatic [36,37]. In addition, many individuals have joint-related symptoms and no radiographic evidence [4,6]. As a result of this discordance, the disease is defined as either radiographic (evidence on imaging studies) or symptomatic (frequent pain in a joint plus radiographic evidence of osteoarthritis in that joint) [39]. Total joint replacement is used as a surrogate measure of symptomatic end-stage osteoarthritis, as the procedure is the option chosen when nonoperative measures have failed to manage pain and improve function and mobility.

    Click to Review
  4. The diagnosis of osteoarthritis is most likely to be made at the youngest age at which of the following joints?

    OVERVIEW OF OSTEOARTHRITIS

    Data on the age at the time of diagnosis of osteoarthritis at other joints are limited. However, studies have indicated a younger age at the time of clinical presentation of elbow osteoarthritis (approximately 50 years) and ankle osteoarthritis (43 to 58 years) [29,55].

    Click to Review
  5. According to population-based studies, the overall prevalence of symptomatic osteoarthritis of the knee is approximately

    OVERVIEW OF OSTEOARTHRITIS

    COMPARISON OF JOINT-SPECIFIC OSTEOARTHRITIS IN MEN AND WOMENa

    JointRadiographic OsteoarthritisbSymptomatic Osteoarthritis
    OverallWomenMenOverallWomenMen
    Knee0.9%1.2%0.4%12.1%13.6%10.0%
    Hip2.5%2.5%2.6%9.7%11.1%8.3%
    Hand7.3%9.5%4.8%8.0%8.9%6.7%
    aThe prevalence of knee and hand osteoarthritis was determined in adults 60 years of age and older, and the prevalence of hip osteoarthritis was determined in adults 55 years of age and older.
    bRadiographic osteoarthritis defined as evidence of moderate-to-severe changes.
    Click to Review
  6. The odds of radiographic osteoarthritis of the knee are highest for which racial/ethnic population?

    OVERVIEW OF OSTEOARTHRITIS

    Studies have consistently shown that osteoarthritis of the knee is more prevalent in the black population than the white population. Multivariable analysis of data from NHANES III showed significantly higher odds of radiographic knee osteoarthritis (Kellgren-Lawrence grade 2 or higher) among non-Hispanic black participants (52%) compared with white (36%) or Mexican-American (38%) participants [57,60]. Although the findings of the Johnston County Osteoarthritis Project also demonstrated that knee-related symptoms, radiographic knee osteoarthritis (mild), and symptomatic knee osteoarthritis were all more prevalent among black individuals than white individuals, the difference was slight. However, the prevalence of moderate-to-severe radiographic osteoarthritis was significantly greater for both men and women in the black population (11% vs. 5% for black vs. white men and 16% vs. 8% for black vs. white women) [42]. A study of more than 1,000 premenopausal and perimenopausal women demonstrated that early osteoarthritis changes were more prevalent in black women than white women (23% vs. 9%) [61]. The prevalence of knee osteoarthritis has also been found to be higher in the Chinese population than in the white population [62].

    Click to Review
  7. The primary component of normal adult articular cartilage is

    OVERVIEW OF OSTEOARTHRITIS

    Normal adult articular cartilage is made up of extracellular matrix (approximately 98% to 99%) and chondrocytes (1% to 2%) [70]. The chondrocytes secrete enzymes and cytokines that help regulate the normal cycle of degradation and repair of articular cartilage by inhibiting the production of proteoglycans and collagen, the two major components of the extracellular matrix [70]. Damage to the extracellular matrix interferes with its ability to bind or exclude water, resulting in edema and subsequent softening of the cartilage and expansion of the matrix, which makes the matrix vulnerable to further injury and breakdown of its components [71,72,73].

    Click to Review
  8. Which of the following is a characteristic of an osteoarthritic joint rather than an aging joint?

    OVERVIEW OF OSTEOARTHRITIS

    DIFFERENCES BETWEEN OSTEOARTHRITIC JOINTS AND AGING JOINTS

    FeatureOsteoarthritic JointAging Joint
    Fibrillation in cartilagePrimarily weight-bearing jointsNonweight-bearing joints
    Cartilage massHypertrophy, erosionNo change
    Water content of cartilageEdema (early stage)No change or dehydration
    Cell activityIncreased activity and proliferationReduced
    SynoviumMild focal superficial inflammationAtrophy
    Bone changesSubchondral bone remodelingOsteopenia
    Click to Review
  9. Preservation of the joint space is associated with primary osteoarthritis of which joint?

    OVERVIEW OF OSTEOARTHRITIS

    There is substantial heterogeneity in osteoarthritis across anatomic sites with regard to risk factors, clinical features, and outcomes, which has drawn some researchers to conclude that osteoarthritis of different joints are distinct clinical entities [79,80]. Some examples to support the concept of distinct disease entities include [28,29,33,81]:

    • Primary osteoarthritis of the knee is more common than secondary osteoarthritis, but primary osteoarthritis of the ankle is rare, with the disease at that joint occurring more often after trauma (e.g., fracture or ligamentous injury).

    • Overweight/obesity has been identified as the most common risk factor with knee osteoarthritis, but mechanical overuse is the primary predisposing factor for hand osteoarthritis.

    • Erosion of articular cartilage and narrowing of the joint space are hallmark characteristics of knee and hip osteoarthritis, but articular cartilage is relatively preserved. There is no joint space narrowing in primary osteoarthritis of the elbow.

    Click to Review
  10. Which of the following statements regarding genetic risk factors for osteoarthritis is TRUE?

    RISK FACTORS

    Studies have indicated that there may be a genetic factor to the development of osteoarthritis, and the familial risk factor for osteoarthritis of the knee, hip, and hand has ranged from 27% to 60% [32,54,79]. It is thought that most genes related to osteoarthritis affect the development of the disease at any joint but that specific genes may also be involved at specific joints [32,79]. Over the past several years, a candidate gene study and several genome-wide association studies have collectively established 15 loci associated with knee or hip osteoarthritis that have been replicated with genome-wide significance, providing further evidence of joint-specific effects in osteoarthritis [16,79,80,85,86,87,88,89]. In 2019, researchers performed a genome-wide association study with more than 77,000 participants and identified 64 loci, 52 of them being novel. Of these 64 loci, therapeutics are currently available or in clinical trials for 10 of the effector genes, making them a future prospect for effective treatment of osteoporosis [290].

    Click to Review
  11. Which of the following is the most important modifiable risk factor for severe osteoarthritis of the knee?

    RISK FACTORS

    Clinical studies have long demonstrated that the risk of osteoarthritis is higher for individuals who are overweight or obese, and obesity has been referred to as the most important modifiable risk factor for severe osteoarthritis of the knee [90,91,92]. In a meta-analysis, those who were obese or overweight were nearly three times as likely to report osteoarthritis of the knee [93]. Overweight as a risk factor is thought to be related to the increased load on weight-bearing joints; however, some studies have indicated an association between obesity and osteoarthritis of the hand and shoulder, which suggests factors other than joint overload [27,33,54]. Factors that have been proposed are a metabolic intermediary (such as diabetes or lipid abnormalities) or an increased production of humoral factors (produced by excess adipose tissue), which alters the metabolism of articular cartilage [94].

    Click to Review
  12. Which of the following statements regarding the relationship between overweight/obesity and osteoarthritis is NOT true?

    RISK FACTORS

    The data on osteoarthritis and overweight have been more consistent for osteoarthritis of the knee than for disease at other joint sites, and most studies have indicated that overweight/obesity is a greater risk factor for women [35,79,82,90,94,95,96,97,98]. In the Framingham Osteoarthritis Study, there was more than a 50% decrease in the risk among women who had a loss of approximately 11 pounds or a decrease in body mass index (BMI) of 2 or more [90]. Weight gain was also associated with an increased risk for osteoarthritis, but the difference was not significant [90]. In a population-based case-control study in England (525 men and women [45 years of age and older] with primary knee osteoarthritis and 525 matched controls), the risk of osteoarthritis increased progressively with higher BMI; compared with a BMI of 24.0–24.9, the risk was 0.1 for a BMI of less than 20 and 13.6 for a BMI of 36 or greater [92].

    Click to Review
  13. Which of the following is NOT among the general differential diagnosis of osteoarthritis?

    DIAGNOSIS

    The differential diagnosis of osteoarthritis varies according to the anatomic site as well as such patient-related factors as age, gender, and history (Table 5) [27,29,35,37,159,160,161]. In general, the differential diagnosis includes infection, traumatic injuries, bursitis, other types of arthritis, and overuse syndromes [37]. In addition, clinicians should consider secondary osteoarthritis in patients who have metabolic bone disorders, endocrine diseases, and other systemic conditions, as described earlier [37]. Ancillary testing should be done for patients who have joint pain at night, who have progressive joint pain, or who have a strong family history of inflammatory arthritis [74]. Many features on clinical evaluation and imaging studies are characteristic of osteoarthritis, and some features differ according to joint site (Table 6) [27,28,35,55,160].

    Click to Review
  14. Ancillary testing should be done for patients who have

    DIAGNOSIS

    The differential diagnosis of osteoarthritis varies according to the anatomic site as well as such patient-related factors as age, gender, and history (Table 5) [27,29,35,37,159,160,161]. In general, the differential diagnosis includes infection, traumatic injuries, bursitis, other types of arthritis, and overuse syndromes [37]. In addition, clinicians should consider secondary osteoarthritis in patients who have metabolic bone disorders, endocrine diseases, and other systemic conditions, as described earlier [37]. Ancillary testing should be done for patients who have joint pain at night, who have progressive joint pain, or who have a strong family history of inflammatory arthritis [74]. Many features on clinical evaluation and imaging studies are characteristic of osteoarthritis, and some features differ according to joint site (Table 6) [27,28,35,55,160].

    Click to Review
  15. Self-reports of severe pain are most frequent among which of the following racial/ethnic populations?

    DIAGNOSIS

    When considering patients' self-reports of pain and function, clinicians should understand that these self-reports can differ according to gender and race/ethnicity [45,170,171]. Self-reports of work or activity limitations or severe pain have been significantly more common among black, Hispanic, and mixed-race individuals than among white individuals with osteoarthritis; the rate of self-reports for Asian/Pacific Islander and Alaska Native/American Indian populations have been similar to those for the white population [45]. Among participants in the Johnston County Osteoarthritis Project, total scores on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and scores on the pain and function subscales were significantly worse for black individuals than for white individuals with knee osteoarthritis. The total WOMAC scores were similar for the two racial groups among individuals who had only hip osteoarthritis or hip and knee osteoarthritis [171]. The researchers hypothesized that high BMI and frequent depressive symptoms in the black population may have contributed to the racial/ethnic differences.

    Click to Review
  16. Which of the following is NOT one of the six symptoms and signs that together are diagnostic of knee osteoarthritis according to guidelines developed by the European League against Rheumatism (EULAR)?

    DIAGNOSIS

    According to the EULAR guidelines on the diagnosis of knee osteoarthritis, a diagnosis can be made with 99% confidence when three symptoms and three signs are present [162]:

    • Persistent knee pain

    • Limited morning stiffness

    • Reduced function

    • Crepitus

    • Restricted movement

    • Osseous enlargement

    Click to Review
  17. The strongest sign of hip osteoarthritis on physical examination is

    DIAGNOSIS

    The strongest sign of hip osteoarthritis on physical examination is pain that is exacerbated by internal or external rotation of the hip with the knee in full extension [35]. Other signs include crepitus and gait abnormalities (resulting from alterations in walking to avoid pain) [175]. Deformity and instability are late signs of severe osteoarthritis, but they are uncommon [175]. Both hips should be examined if osteoarthritis is suspected, as the disease occurs bilaterally in approximately 20% of individuals [35].

    Click to Review
  18. Which of the following statements about diagnosis of osteoarthritis of the hand is TRUE?

    DIAGNOSIS

    Osteoarthritis of the hand is characterized by pain with use, which affects one or a few joints at any one time, and mild stiffness in the morning and/or after a period of inactivity [167]. The severity of osteoarthritis-related pain varies, and the pain may be intermittent. The joints most often affected are the distal and proximal interphalangeal joints and the base of the thumb [165,167,166]. Individuals who have evidence of osteoarthritis at several joints in the hand are at increased risk for generalized osteoarthritis, and clinicians should evaluate such patients as appropriate [167].

    Hard tissue enlargements on the distal interphalangeal joints (Heberden and Bouchard nodes) are the clinical finding that is most characteristic of osteoarthritis of the hand [53,165,166]. Although radiographic findings are not an established diagnostic criterion, evidence of osteophytes is the only unique radiographic criterion for a diagnosis [165]. Other classic radiographic findings include joint space narrowing, subchondral bone sclerosis, or subchondral cysts [160,165]. The diagnosis of hand osteoarthritis does not require blood tests, but such tests may be helpful in excluding coexisting disease or in identifying an inflammatory arthritis [160].

    Click to Review
  19. Which of the following is most characteristic of later stage osteoarthritis of the elbow?

    DIAGNOSIS

    Individuals with osteoarthritis of the elbow typically have pain, stiffness, and weakness in the joint [28]. Later stage disease is associated with pain when carrying a heavy object at the side of the body with the elbow in extension. The history is important when evaluating symptoms related to the elbow because of the strong relationship between trauma or occupation with osteoarthritis, especially in individuals who are younger than 40 years of age [55]. Primary osteoarthritis of the elbow is often associated with osteoarthritis at another joint site, especially the second and third metacarpophalangeal joints, the knee, and the hip, and those joints should be evaluated as appropriate [179].

    Click to Review
  20. A hallmark feature of osteoarthritis of the ankle is

    DIAGNOSIS

    A history of ankle fracture or ligamentous injury is a hallmark feature of osteoarthritis of the ankle [29]. Diagnostic evaluation includes radiographs of the ankles made with the patient standing. MRI is also recommended, as it can provide evidence of osteonecrosis as well as indicate the amount of involvement, the extent of bone loss, and the size of subchondral cysts [29].

    Click to Review
  21. In its guideline for the treatment of osteoarthritis of the knee, the American Academy of Orthopaedic Surgeons recommends achieving and/or maintaining a BMI less than or equal to

    TREATMENT OPTIONS

    Given the strong correlation between overweight/obesity (defined as a BMI greater than 25) and osteoarthritis of the knee and hip, weight reduction and maintenance of a healthy weight are central to guidelines on the management of osteoarthritis at these sites [174,192,209,210,211]. A systematic review showed that a moderate weight-loss program (0.25% of body weight per week) can reduce pain and physical disability for individuals with osteoarthritis of the knee [212]. In its 2013 guideline for the treatment of osteoarthritis of the knee, the AAOS recommends weight reduction, specifically, achieving and/or maintaining a BMI ≤25 [211].

    Click to Review
  22. Which of the following is a contraindication to an exercise program for osteoarthritis?

    TREATMENT OPTIONS

    Some patients may fear that regular exercise will exacerbate pain, but a review of the literature has shown that moderate exercise does not increase the risk for progression of osteoarthritis, provided that care is taken to avoid injury [103,214]. The goal of an exercise program is to control pain, increase flexibility, and improve muscle strength and endurance [215]. The exercise program should be individualized to the patient, with consideration given to the patient's age, comorbidities, and mobility [216]. Guidelines suggest that exercise should be prescribed for all patients with osteoarthritis, regardless of age, severity of pain and disability, and comorbidity [186]. The AGS notes that absolute contraindications to an exercise program include uncontrolled arrhythmias, third-degree heart block, changes on recent electrocardiography, unstable angina, acute myocardial infarction, and acute congestive heart failure [215]. Relative contraindications include cardiomyopathy, valvular heart disease, poorly controlled blood pressure, and uncontrolled metabolic disease [215].

    Click to Review
  23. A physical therapy program is not routinely a treatment approach for osteoarthritis of the

    TREATMENT OPTIONS

    The AAOS found inconclusive evidence for physical therapy as an effective treatment option for osteoarthritis of the glenohumeral joint and is unable to recommend for or against physical therapy as part of initial treatment of the condition [184]. Similarly, a supervised physical therapy program is not routinely a treatment approach for osteoarthritis of the ankle [29]. Physical therapy should begin in the early stages of osteoarthritis of the elbow (mild pain and loss of less than 15 degrees of motion) [28]. Strategies may include gentle range-of-motion exercises to maintain mobility and strength [28].

    Click to Review
  24. Which of the following statements regarding the pharmacologic treatment of osteoarthritis is TRUE?

    TREATMENT OPTIONS

    Some guidelines recommended acetaminophen as the initial analgesic for the management of mild-to-moderate pain related to osteoarthritis, but this recommendation has since been shown to be questionable [180]. A comparative effectiveness study conducted by the AHRQ found good evidence that acetaminophen is modestly inferior in efficacy compared with NSAIDs but has a lower risk of gastrointestinal complications [230]. An update to this study found that no currently available analgesic offered a clear overall advantage compared with the others [187]. Its original findings on acetaminophen remained the same, with the addition that acetaminophen poses a higher risk of liver injury [187]. Other research has shown that NSAIDs are more effective than acetaminophen for relieving osteoarthritis-related pain, especially moderate-to-severe pain [231]. The AAOS working group noted that many physicians prefer to prescribe acetaminophen rather than NSAIDs (because of the side effect profile of NSAIDs), but that this practice is "unreasonable" because acetaminophen does not show a benefit over placebo [211]. For this same reason, the AAOS recommendation was downgraded from level B (moderate) in the 2008 guideline to inconclusive in the 2013 edition. NSAIDs should be prescribed at the lowest effective dose, and their long-term use should be avoided [180]. A COX-2 selective agent or an NSAID with a prescription for a gastroprotective agent (such as a proton-pump inhibitor) may be used for patients who have an increased risk for gastrointestinal complications [180].

    There is good evidence that nonselective NSAIDs and COX-2-selective NSAIDs have comparable efficacy and that COX-2-selective agents are comparable to each other [187,232]. Although COX-2-selective agents have better tolerability in general compared with NSAIDs, there is considerable variability across individual drugs in terms of protection against serious gastrointestinal events [232]. In addition, some COX-2 selective NSAIDs have been associated with an increased risk of myocardial infarction, and these drugs should be used with caution in patients with cardiovascular risk factors [187,232].

    Studies have found that opioids were more effective overall than control interventions with respect to pain relief and improved function, but the beneficial effects were small to moderate and were outweighed by a substantial increase in the risk of adverse events [233,234]. The authors of the review concluded that opioids should not be used routinely for individuals with osteoarthritis, even for severe pain. Some guidelines suggest the use of weak narcotics or opioids for pain that has been refractory to other pharmacologic agents; however, the guidelines note that strong opioids should be used sparingly [180]. The 2013 AAOS guideline on the treatment of knee osteoarthritis does not make a recommendation for or against the use of opioids, and the ACR guidelines similarly make no recommendations, aside from advising against their use for osteoarthritis of the hand (with the exception of certain patients) [174,211].

    There is good evidence that topical NSAIDs have efficacy comparable to oral NSAIDs, although most trials have involved knee osteoarthritis only, and head-to-head trials have not been large enough to evaluate the comparative risk of serious cardiovascular events and gastrointestinal effects [187]. There is also good evidence that topical NSAIDs are safer than oral NSAIDs, but a systematic literature review showed that systemic adverse events have occurred in a substantial proportion of older adults treated with topical NSAIDs [239]. Capsaicin has also been effective in relieving osteoarthritis-related pain, and some guidelines have suggested the use of this topical agent as an alternative treatment or an adjunct to treatment with oral analgesics [180]. The ACR guideline recommends the use of topical capsaicin for hand osteoarthritis and topical NSAIDs for hand and knee osteoarthritis [174]. The AHRQ comparative review found that topical capsaicin was superior to placebo but associated with increased local adverse events and withdrawals due to adverse events [187].

    Click to Review
  25. According to the American Academy of Orthopaedic Surgeons, there is insufficient evidence to recommend oral analgesics for osteoarthritis of the

    TREATMENT OPTIONS

    In reviewing the literature for its guidelines on the treatment of osteoarthritis of the glenohumeral joint, the AAOS was not able to find sufficient evidence to support several pharmacologic treatments, including acetaminophen, NSAIDs, opioids, or narcotics. As a result, the AAOS states it is unable to recommend for or against the use of any of these options for the initial treatment of patients with osteoarthritis of this joint [184].

    Click to Review
  26. Guidelines recommend intra-articular corticosteroids for hip and knee osteoarthritis, especially for patients with

    TREATMENT OPTIONS

    Certain guidelines conditionally recommend intra-articular injection of corticosteroids into the knee or hip, especially after aspiration of fluid in patients who have signs of local inflammation with joint effusion [6,174,192]. For example, the ACR recommends this therapy for knee and hip osteoarthritis if the patient does not have satisfactory response to acetaminophen and topical NSAIDs and if there is a contraindication to oral NSAIDs. The AAOS was unable to make a recommendation for or against corticosteroid injection based on a lack of compelling evidence [211]. Although the approach is otherwise widely recommended, it is acknowledged that intra-articular corticosteroids provide short-term relief only [32,242,243]. A meta-analysis of 28 trials (1,973 patients) of knee osteoarthritis showed a benefit of pain relief for two to four weeks, with no benefit in terms of functional improvement and no benefit in either pain or function beyond four weeks [242]. An update to the meta-analysis, which included 27 trials (1,767 patients), found that the overall quality of the evidence did not clearly support a benefit of intra-articular corticosteroid use after one to six weeks [243]. Despite the short-term benefit found in most studies, clinical experience has shown longer relief in many patients [32]. Because of the potential side effects of intra-articular injections, which include long-term damage to joint cartilage, flare after injection, and infection, most physicians do not recommend more than three to four injections per joint per year [6,32]. Intra-articular injection is more technically difficult in the hip joint than in the knee, and radiographic or ultrasonographic guidance has been suggested, although there are no comparative data to provide evidence that accuracy is increased with such guidance [6,209].

    Click to Review
  27. Studies have shown that intra-articular corticosteroids provide pain relief for up to

    TREATMENT OPTIONS

    Certain guidelines conditionally recommend intra-articular injection of corticosteroids into the knee or hip, especially after aspiration of fluid in patients who have signs of local inflammation with joint effusion [6,174,192]. For example, the ACR recommends this therapy for knee and hip osteoarthritis if the patient does not have satisfactory response to acetaminophen and topical NSAIDs and if there is a contraindication to oral NSAIDs. The AAOS was unable to make a recommendation for or against corticosteroid injection based on a lack of compelling evidence [211]. Although the approach is otherwise widely recommended, it is acknowledged that intra-articular corticosteroids provide short-term relief only [32,242,243]. A meta-analysis of 28 trials (1,973 patients) of knee osteoarthritis showed a benefit of pain relief for two to four weeks, with no benefit in terms of functional improvement and no benefit in either pain or function beyond four weeks [242]. An update to the meta-analysis, which included 27 trials (1,767 patients), found that the overall quality of the evidence did not clearly support a benefit of intra-articular corticosteroid use after one to six weeks [243]. Despite the short-term benefit found in most studies, clinical experience has shown longer relief in many patients [32]. Because of the potential side effects of intra-articular injections, which include long-term damage to joint cartilage, flare after injection, and infection, most physicians do not recommend more than three to four injections per joint per year [6,32]. Intra-articular injection is more technically difficult in the hip joint than in the knee, and radiographic or ultrasonographic guidance has been suggested, although there are no comparative data to provide evidence that accuracy is increased with such guidance [6,209].

    Click to Review
  28. According to the available research, hyaluronan

    TREATMENT OPTIONS

    It is difficult to determine the efficacy of hyaluronan because research evidence is confounded by different molecular weights of hyaluronan preparations, different dosing schedules, and poor trial design, and the level of evidence across studies has been low [209,244,245,248]. Most of the evidence available is related to osteoarthritis of the knee, with limited data available on use of the treatment for osteoarthritis of the hip, hand, or shoulder.

    Since the publication of the 2000 ACR guidelines, certain studies and analyses have supported the efficacy of hyaluronan/hylan derivatives for relieving pain and improving function in patients with symptomatic osteoarthritis of the knee (compared with placebo), with the greatest benefit found in conjunction with less severe pain and disability at 5 to 13 weeks after injection [192,245,249,250]. However, researchers have noted that the effect size is small compared with placebo and that the effect may be overestimated as a result of publication bias [244,245]. When compared with NSAIDs, hyaluronan takes longer to relieve knee symptoms; additionally, the dosing schedule necessitates more office visits than intra-articular corticosteroids, creating inconvenience and increasing costs [192,209]. Uncontrolled and small studies of hyaluronic acid for hip osteoarthritis have shown pain reduction after treatment, but intra-articular corticosteroids were more effective in one small study [209,248,251].

    Evidence of benefit of hyaluronan for osteoarthritis of other joints is limited. A small study (56 patients) showed that a single course of three injections of intra-articular sodium hyaluronate relieved pain and improved joint function in patients with osteoarthritis of the carpometacarpal joint of the thumb. Although the effects were achieved more slowly than treatment with triamcinolone, the duration of benefit was longer (up to six months) [253]. In another small study (16 men), intra-articular sodium hyaluronate (administered once weekly for five weeks) improved scores for pain (primarily at rest) related to osteoarthritis of the trapeziometacarpal joint [167].

    Click to Review
  29. Which of the following herbal products has proof of effectiveness in the treatment of osteoarthritis?

    TREATMENT OPTIONS

    In a systematic review undertaken to evaluate the effectiveness of 22 herbal medicinal products, there was some evidence of pain relief with topical capsaicin, avocado-soybean unsaponifiables, and SKI306X (a Chinese herbal mixture). However, none of the 22 products had proof of effectiveness beyond doubt [265]. According to a review of studies involving antioxidant and anti-inflammatory supplements, the following cannot be recommended for the treatment of osteoarthritis: vitamin E (alone); a combination of vitamins A, C, and E; ginger; turmeric; omega-3 fatty acids; or Zyflamend (an extract of 10 different herbs) [266]. Additional clinical trials are needed before alternative supplements can be recommended.

    Click to Review
  30. Which of the following statements regarding the surgical treatment of osteoarthritis is TRUE?

    TREATMENT OPTIONS

    Because there are anatomic differences in joint structure and size between men and women, a gender-specific knee prosthesis was designed specifically for women [275]. Researchers believed that the better fit would lead to improvements in recovery and outcomes for women who had total knee arthroplasty. In one study, 85 women who received a standard joint in one knee and the gender-specific joint in the other knee were followed up for two years after the surgery [275]. Patient satisfaction, range of motion while lying, and WOMAC scores were similar for both prostheses. The researchers did note that the standard prostheses appeared to fit at the distal part of the femur better than the gender-specific type; furthermore, the small size of the gender-specific prosthesis exposed more bone and resulted in more bleeding immediately after surgery. Although the study concluded that there were no benefits to the use of gender-specific prostheses in women undergoing total knee arthroplasty, research evaluating long-term effects is necessary.

    Total hip arthroplasty is also relatively common, with 522,825 procedures completed in 2014 [281]. This procedure is recommended for the treatment of osteoarthritis in older patients for whom nonsurgical interventions have been ineffective. Some data suggest that the benefit of arthroplasty of the hip is greater when done earlier in the course of disease [35]. According to one study, female gender, the presence of comorbidities, contralateral hip osteoarthritis, back pain, and poor preintervention health or mental health status were predictors of poorer outcomes and lesser improvements in quality-of-life measures after total hip arthroplasty [282].

    Other joint replacement procedures are not done as widely and are not associated with the same success as knee and hip arthroplasty. The AAOS guideline on the treatment of osteoarthritis of the glenohumeral joint includes a weak recommendation for total shoulder arthroplasty and hemiarthroplasty as options, with a moderate recommendation for total arthroplasty over hemiarthroplasty [184].

    The use of total elbow arthroplasty is limited by the high risk for instability and loosening and is rarely used to treat primary osteoarthritis [28,55]. When performed in younger patients, long-term success of the procedure has been limited because of high functional demands [28]. As a result, total replacement should be reserved for patients older than 65 years of age who are willing to accept low levels of activity [28,55].

    Click to Review

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.