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Osteoarthritis: A Nursing Perspective

1 Contact Hour including 1 advanced Pharmacology Hour
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Sunday, March 21, 2027

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥92% of participants will understand how to assess and manage osteoarthritis (OA).

Objectives

After completing this continuing education course, the learner will be able to:

  1. Summarize the burden of osteoarthritis (OA).
  2. Outline national goals for improving the care of OA.
  3. Identify causes of OA.
  4. Describe symptoms of OA.
  5. List interventions that relieve symptoms of OA.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Osteoarthritis: A Nursing Perspective
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Author:    Raymond Lengel (MSN, FNP-BC, RN)

Introduction

Osteoarthritis (OA) is the most common cause of disability in the older population, and it is also known as degenerative arthritis or degenerative joint disease. It affects 23.7% or 58.5 million American adults and is more common as people age (Centers for Disease Control and Prevention [CDC], 2021b). In addition, women's prevalence is greater than men's, and OA is more common in patients with poor health (CDC, 2021b). Managing arthritis improves mobility, decreases falls and death rates, and improves the quality of life.

OA is a joint disease with deterioration of the joint and abnormal bone formation. OA is present when the endings of the bones - called cartilage, which normally cushion the bones - no longer does its job. The ends of the bones rub together, and the cartilage wears away.

Rheumatoid arthritis (RA), another form of arthritis, is a chronic destructive, sometimes deforming disease that attacks the collagen in the body, especially in the joints. RA is associated with widespread symptoms such as fatigue, fever, poor appetite, neuropathy, splenomegaly, and adenopathy. Other diseases that affect the joints include gout, lupus, scleroderma, and fibromyalgia.

Immobility, a significant complication of arthritis, leads to less activity which is associated with many complications, including worsening of joint stiffness, increased blood pressure and blood glucose, and weight gain. Immobility leads to decreased physical activity - resulting in deconditioning. Lack of physical activity is detrimental to the body and increases the risk of many fatal diseases, such as diabetes, high cholesterol, hypertension, and heart disease. As deconditioning sets in, weakness and functional decline follow. Arthritis is associated with a decreased quality of life.

Osteoarthritis: A Poorly Understood Disease

OA is associated with significant morbidity and a significant burden to the health care system. Unfortunately, it is underdiagnosed and undertreated. Optimal management of OA could lead to improved function, reduced morbidity, and possibly improvement in many co-morbid conditions such as diabetes and heart disease (Cunningham et al., 2021).

OA management could be improved by implementing specific programs to manage OA. A recent analysis suggested nurses' confidence in knowledge and skills regarding OA management was lower than other clinicians' (Briggs et al., 2019). Barriers to managing OA include a lack of program access, lack of provider time, lack of patient educational material, lack of provider trust, limited reimbursement, and lack of financing for nursing intervention and nurse-managed care (Cunningham et al., 2021; Wallis et al., 2020). Strategies to improve nursing knowledge and the ability to disseminate this knowledge could profoundly impact the management of this disease.

A significant gap exists among primary care providers between what is believed should be done and what is actually performed. A recent analysis suggested that over 55% of general practitioners thought OA should be monitored. Still, only 15.2% routinely monitored their patients, and 45% did not monitor their patients at all (Clarson et al., 2013). Another recent analysis showed a significant gap between what practices nurses feel confident in and what ideally should be performed according to the National Institute of Health and Care Excellence (NICE) OA guidelines (Healey et al., 2016). Properly educated care providers could lead clinics that significantly benefit patients with OA.

National Goals

Multiple organizations have goals to reduce the burden and help manage OA. Organizations working to lessen the burden of OA include the Centers for Disease Control and Prevention (CDC), the Arthritis Foundation, Healthy People 2030, and many state government organizations. The goal of the CDC is to help people with arthritis live life to the fullest and help them pursue activities they value with minimal pain (CDC, n.d.). The main goals of the National Arthritis Action Plan, A Public Health Strategy, are to(CDC, n.d.):

  • Prevent arthritis
  • Increase public awareness
  • Assist in early diagnosis and treatment
  • Reduce pain and disability
  • Help people develop self-management techniques to manage arthritis physically, psychologically, and occupationally
  • Support patients and family members with arthritis

Healthy People 2030 provides objectives for the nation to reach to improve the national state of arthritis. Its primary focus is to minimize pain, disability, and limitations from arthritis. Specific goals of Healthy People 2030 include(Healthy People 2030, n.d.):

  • Reduce the mean level of joint pain among adults with diagnosed arthritis
  • Reduce the proportion of adults with arthritis who experience a limitation in work and activity because of arthritis or joint symptoms
  • Increase the number of arthritic adults who get counseling regarding physical activity

The national goals are set to improve arthritis care, and the first step in reaching these goals is improving provider and patient knowledge. In addition to the programs on the national level, many state health departments are working to improve the care of arthritis by increasing public awareness of the disease and improving the care of arthritis.

Causes of Arthritis

OA affects the whole joint and is characterized by osteophyte formation, changes in the subchondral bone, cartilage damage, inflammation of the synovial tissue, and tendon and muscle weakness. Changes to the articular cartilage are the first signs noted in OA, leading to irregular surfaces and focal erosions. Osteophytes form as the disease progresses. Synovial inflammation and hypertrophy are not as pronounced as in inflammatory arthritis. Joint destruction is mediated by proteases and pro-inflammatory markers (Sen & Hurley, 2022).

OA is not only a disorder of the articular cartilage but also the subchondral bone. It is characterized by subchondral bone sclerosis and damaged cartilage. Subchondral bone is hypomineralized secondary to abnormal bone remodeling. In addition, the subchondral bone may have microdamage, bone cysts, and bone marrow edema-like lesions (Li et al., 2013).

Multiple factors contribute to OA (Lozada, 2022). Age is an important risk factor for the disease, with older individuals at greater risk than younger people. Females have a higher incidence of OA than males. Obesity is a strong risk factor due to the excess stress that extra body weight puts on the weight-bearing joints. Repetitive stresses, such as with carpet layers or assembly-line workers, increase the risk of OA. Weak muscles in the legs also contribute to OA. Trauma contributes to the development of OA – individuals with a history of trauma or a broken bone near a joint are at increased risk for OA. While no specific genetic marker is known in OA, there is a strong family connection. Defective cartilage or poorly structured joints commonly run in families and can increase the risk of OA.

Osteoarthritis Risk Factors
  1. Obesity
  2. Age
  3. Heredity
  4. Trauma
  5. Repetitive stress, such as in those who have played a lot of sports
  6. Occupations that have a lot of repetitive movements, e.g., assembly line workers, carpet installers

Signs and Symptoms

The hallmark symptom of OA is pain. Typical OA pain is worse with movements and improves with rest. Pain at night is common, especially as the disease progresses, and is usually worse after a more active day. OA commonly affects the weight-bearing joints, such as knees and hips, but other joints commonly affected include the fingers (distal interphalangeal [DIP] and carpometacarpal [CMC]) and the neck. Stiffness after prolonged rest is common with this disease. For example, getting out of bed in the morning or getting up after watching a movie often elicits pain and stiffness.

A physical exam reveals specific characteristics typical of OA—moving the joint results in a crackling/crunching noise called crepitus that sounds like Rice Krispies cereal. Arthritic joints sometimes cannot move through a full range of motion (ROM). For example, a person with OA of the knee may be unable to straighten the leg fully. Misalignment of the joints may be present and accompanied by enlargement of the bones surrounding the joint. An effusion may be noted, but rarely is there erythema over the affected joint.

Features of Osteoarthritis
  1. Pain in the joints worsens with movement and improves with rest.
  2. Typical joints affected: knees, hips, fingers, neck, and the spine. Usually, only one to a few joints are affected.
  3. Stiffness after prolonged rest, such as watching a movie or waking up in the morning.
  4. Crepitus.
  5. Decreased ROM.
  6. Swollen joints.

Diagnosis

The diagnosis of OA is typically made with a history and physical exam. If in doubt, an X-ray is ordered. Diagnosis is specific to the joint affected (John Hopkins Arthritis Center, n. d.).

  1. Knee – knee pain plus three of the following:
    1. Bony enlargement of the knee
    2. Bony tenderness of the knee
    3. Over age 50
    4. Crepitus
    5. Morning stiffness lasting less than 30 minutes
    6. No warmth over the joint
  2. Hip – hip pain plus two of the following:
    1. Osteophytes on X-ray
    2. Joint space narrowing on X-ray
    3. Normal erythrocyte sedimentation rate (ESR)
    4. Reduced hip ROM
    5. Over age 50
    6. Morning stiffness lasting less than 60 minutes
  3. Hand–hand pain plus three of the following:
    1. Bony enlargement of two or more DIP joints
    2. Bony enlargement of three or more of the ten selected joints (2nd and 3rd DIP and proximal interphalangeal (PIP) joints of both hands and 1st CMC of both hands)
    3. Less than three swollen metacarpophalangeal joints
    4. Deformity in at least one of the joints

Laboratory tests alone do not diagnose OA but assist in the diagnosis and help rule out any other disease processes. Fluid in the joint may be removed, and this procedure can help relieve some of the pressure associated with the excess fluid. The fluid is typically examined under a microscope to help rule out other diseases that mimic arthritis, such as gout.

Case Study - Hand Osteoarthritis

Mr. Farmer is a 62-year-old white male who reports significant hand pain. He describes the pain as most severe in both thumbs and the distal joints of digits two through five of both hands. He has been having increasing difficulty using his screwdriver to fix things around the house, playing tennis and golf, and gripping his utensils to eat.

The physical exam shows an enlargement of the DIP joints (Heberden's nodes) and the CMC joints of both hands. An X-ray demonstrates arthritis at the CMC joints of both hands and the DIP joints of all fingers, as evidenced by cyst formation, sclerosis, and joint space narrowing.

The most common joint of the hand affected by OA is the DIP joint, and the second most commonly affected joint is the CMC. The PIP and metacarpophalangeal joints are more commonly affected by RA.

The goal for Mr. Farmer will be to reduce pain and help restore function. Treatment options for this patient include using finger or wrist splints, heat treatment, topical medications, occupational therapy to provide exercises, pain medications, steroid injections, or surgery (joint fusion or joint reconstruction).

Treatment

Treatment of OA focuses on pain control and maintaining function. Soon there may be treatments available to reverse or even cure the disease process, but symptom control is currently the only option. Treatment focuses on means of controlling pain and minimizing disability. Implementing interventions to target modifiable risk factors contributing to the disease, such as body weight, depression, muscle weakness or imbalance, or joint malalignment, can be helpful.

Non-Pharmacological Treatment

Non-pharmacological treatment is first-line management as it bypasses drugs' negative effects on the body. Non-drug treatments include exercise, nutrition, physical and occupational therapy, heat and cold treatments, ultrasound, weight loss, magnets, and patient education.

Weight loss can significantly reduce the pain and disability from OA by reducing the load that excess weight puts on the joints. Weight loss is accomplished through a combination of diet and exercise. Rehabilitative services such as Physical Therapists (PTs), Occupational Therapists (OTs), Athletic Trainers (Ats), as well as other exercise specialists, teach how to exercise safely, while a dietitian aids with dietary interventions for weight loss.

Exercise can help OA in a variety of ways. Exercise decreases pain and improves functioning. It enhances the strength of the muscles around the arthritic joint, reducing strain on the joint and resulting in pain control and improved function. Exercise can also aid in weight loss, a key element in reducing symptoms of OA. Exercise must be tailored to those suffering from OA, and exercise that does not overly tax the arthritic joints is recommended. Exercises that limit strain placed on the joints commonly affected by OA include water exercises, such as water aerobics, bicycling, especially recumbent biking, and elliptical exercise equipment, which can be found at many gyms. Exercises that strain the joints, such as running and high-impact aerobics, are not recommended as they can damage the joints and cause more pain. However, recent research shows comparable effects between land-based and water-based exercise for treating knee OA (Dong et al., 2018).

Different types of exercises are important in the treatment of OA. Aerobic exercises - such as biking, swimming, walking, and water aerobics - are essential not only for the treatment of OA but also for general health. Flexibility training or stretching exercises reduce stiffness and help improve function, and strength training keeps the muscles strong to support the joints. In a recent meta-analysis, overweight individuals over 55 with OA demonstrated a positive effect of physical activity and dietary restriction on reducing body weight and improving patient function (Alrushud et al., 2017).

Good nutrition is valuable in OA, and weight loss is critical to preventing and treating the disease. While there is much media buzz about certain foods being beneficial in OA, little research backs this up. A diet low in saturated fats and high in fruits and vegetables is recommended. Omega-3 fatty acids, found in fish such as mackerel, herring, salmon, and rainbow trout, are theorized to be helpful in OA (Thomas et al., 2018). One meta-analysis showed that fish oil in 3 of 4 clinical trials positively affected at least one clinical marker of OA (Akbar et al., 2017). In addition, there is likely some benefit of the Mediterranean diet for individuals with OA (Morales-Ivorra et al., 2018). Another meta-analysis showed that some supplements (passion fruit peel extract, curcumin, L-carnitine, undenatured type II collagen, methylsulfonylmethane, glucosamine, and chondroitin) demonstrate short-term benefits but not as much benefit was noted in the long term (Liu et al., 2018). More research is needed to define the role of supplements in OA management.

PTs and OTs, as well as ATs, can be crucial in treating OA. They can assist in strengthening the muscles, improving flexibility, and providing non-drug means of pain control, such as ultrasound or heat/cold treatments. OA profoundly contributes to disability, and improving the home environment promotes function and safety. OTs provide home assessments that help maximize the home's safety while implementing interventions to make the home safer. Bars in the bathroom, next to the toilet, and in the shower or bathtub are examples of home interventions carried out by OTs. As OA progresses, mobility becomes increasingly impaired. Reliance on mobility aids – such as canes and walkers - becomes essential to ambulate. PTs can help teach patients how to use canes, walkers, and other mobility devices.

ATs are uniquely positioned to identify and treat the early, middle, and late stages of OA in the physically active population. The early onset of OA in younger than what is believed to be the average population is due to acute traumatic joint injuries. Increasing evidence demonstrates that young and middle-aged adults suffer from OA. Over half of the adults with symptomatic knee OA are younger than 65 (Palmieri-Smith et al., 2017).

Heat and cold treatments are helpful for patients with OA. Cold treatment decreases inflammation and reduces pain. It is best to apply cold in a moldable form, such as a bag of frozen peas, for no more than twenty minutes. Watch for any complications associated with the cold treatment, such as red or white patches on the skin or if the area becomes completely numb.

Heat is another common modality in the treatment of OA. Heat increases the blood flow to the area, aids in healing, and relaxes muscles. It should be used no longer than 30 minutes per application and should not be applied directly to the skin. While neither heat nor cold will modify the course of the disease, either is acceptable for symptom relief. Many patients find heat more soothing for their aching joints than cold. It is recommended that patients experiment to determine which intervention provides the greatest relief to their symptoms.

Utilizing ultrasound may have the potential to reduce pain in those with OA. Research has shown that long-duration, low-intensity ultrasound improves the joint's function and lessens pain in those with moderate to severe knee OA (Draper et al., 2018). A meta-analysis looked at the effect of ultrasound on patients with knee OA, concluding that it is a safe and effective method to reduce pain and improve function (Huang et al., 2020).

Magnets are a popular therapy for OA because they can decrease pain. Scientific data to prove their effectiveness is lacking, but magnets do not have significant side effects and are considered safe for use. Magnets are sold in various places, including pharmacies, grocery stores, online, and on TV. Current research does not support using static magnets for pain relief (Richmond, 2008). More research is needed before their use in OA is completely disregarded.

Drug Therapy

Medications treat OA when non-drug methods do not provide adequate relief. Previous guidelines touted acetaminophen (Tylenol) as a first-line agent, primarily due to its lack of negative side effects (compared to nonsteroidal anti-inflammatory medications [NSAIDs]). However, more recent guidelines refute this recommendation.

Acetaminophen has fallen out of favor as an agent in OA due to its minimal effectiveness. A recent systematic review showed that acetaminophen is slightly better than a placebo in treating (managing pain and improving function) knee or hip OA. Still, the improvement is not clinically significant (Leopoldino et al., 2019). The research also suggested that acetaminophen is more likely to lead to liver function abnormalities. Liver injury is more common with prolonged use of acetaminophen in higher than recommended doses or when combined with alcohol or certain medicines such as statins (e.g., atorvastatin, simvastatin).

The American Academy of Orthopaedic Surgeons (AAOS) recommends using acetaminophen if it improves pain and function. Caution should be used in patients who are on warfarin. Combining acetaminophen and warfarin can increase the international normalized ratio (INR). Absolute contraindications to acetaminophen include liver failure, while relative contraindications include chronic alcohol abuse or hepatic insufficiency (AAOS, 2021).

Others recommend acetaminophen as the least effective option compared to NSAIDs or the combination of glucosamine and chondroitin (Zhu et al., 2018). Research acknowledges that acetaminophen's side effect profile is less toxic than NSAIDs. NSAIDs are considered more effective than acetaminophen in relieving hip and knee pain in OA (Lozada, 2022). Like acetaminophen, NSAIDs act synergistically with opioids.

NSAIDs, such as ibuprofen (Motrin, Advil), naproxen sodium (Aleve, Naprosyn), choline and magnesium salicylates (Trilisate), diclofenac sodium (Voltaren, Voltaren XR), celecoxib (Celebrex), meloxicam (Mobic), and nabumetone (Relafen), are recommended over acetaminophen (Kolasinski et al., 2020). These medications have more side effects than acetaminophen, including hypertension, edema, gastrointestinal bleeding, dyspepsia, headaches, constipation, mental status changes, and renal insufficiency/kidney failure.

Absolute contraindications to NSAIDs include chronic kidney disease, an active peptic ulcer, and heart failure. Relative contraindications include a Helicobacter pylori infection, a history of peptic ulcer disease, hypertension, or concomitant use of selective serotonin receptor inhibitors or corticosteroids. NSAIDs may interact with aspirin, warfarin, antihypertensive medications, selective serotonin reuptake inhibitors, and corticosteroids.

Risk factors for gastric ulceration include older age, current use of corticosteroids, bleeding problems, or a history of gastric ulceration. These individuals should likely not use NSAIDs. The use of a proton pump inhibitor or misoprostol reduces the risk of gastric ulceration with the use of NSAIDs.

Another option for those with a risk for gastric ulceration is using celecoxib. Celecoxib is the only available selective inhibitor of cyclooxygenase-2 (COX-2), and COX-2 inhibitors are less likely to lead to gastric irritation. A COX-2 agent and a proton pump inhibitor can be used in those at high risk of gastrointestinal bleeding. Monitoring for and eradicating Helicobacter pylori reduces the risk of NSAID-induced gastrointestinal injury.

NSAIDs can potentially cause nephrotoxicity because they inhibit prostaglandin synthesis, which is associated with vasoconstriction of the afferent arteriole in the kidney and may lead to renal impairment. Compared to traditional NSAIDs, celecoxib has a lower risk of GI bleeding (Shin, 2018).

NSAIDs are associated with cardiovascular complications. They interfere with the cardioprotective effect of aspirin, elevate blood pressure, and may precipitate or aggravate heart failure. NSAIDs may also amplify the risk of clotting and should be used cautiously in those with a history of venous thrombosis. They should also be avoided in those with thrombocytopenia.

Generally, NSAIDs are equally effective. However, if one agent is ineffective, another NSAID may be effective, as there is individual variation in response to different NSAIDs. A recent meta-analysis showed that etoricoxib 60 mg/day and diclofenac 150 mg/day reduce pain and improve function in OA more than other agents but are associated with more adverse events (Da Costa et al., 2021).

Topical NSAIDs should be first-line agents as they demonstrate similar effectiveness to oral NSAIDs without systemic side effects (Klinge & Sawyer, 2013). They are especially helpful if the disease is localized to one area. In the United States, diclofenac sodium topical gel and diclofenac sodium topical solution are available to manage OA.

Other topical agents can provide significant relief for patients with OA. Capsaicin (Zostrix) decreases the neurotransmitter called substance P, which transmits pain. Capsaicin is applied three to four times a day, and it takes capsaicin a few weeks before it provides significant pain relief. Hands should be washed after contact with the substance. Kolasinski et al. (2020) suggest topical capsaicin be conditionally recommended in those with OA of the knee but not recommended in those with hand OA. The use of capsaicin in the hip is not likely to be helpful.

Another topical agent sometimes used to treat localized pain is the lidocaine patch. The Food and Drug Administration does not approve this patch for use in OA, but it is often used. It is a small patch applied to the skin around the painful joint and worn for no more than 12 hours daily.

The central nervous system (CNS) is involved in the pain of OA, so some medications address pain originating from the CNS. CNS medications that may be useful in treating OA include gabapentin and duloxetine. Gabapentin demonstrates limited efficacy in those with knee OA (Katz et al., 2021). Duloxetine is sometimes tried in those who do not respond to or have contraindications to NSAIDs. Research has shown that these agents improve function and reduce pain but are associated with significant side effects, including fatigue, dry mouth, constipation, decreased appetite, and nausea (Osani & Bannuru, 2019).

Tramadol (Ultram®, Ultram® ER) is dosed 50-100 mg every 4-6 hours for the immediate-release form and 100 mg daily for the extended-release form. For individuals suffering from chronic arthritic pain, the immediate release is initiated at 25 mg in the morning and increased by 25-50 mg daily every three days. The maximum dose for the immediate-release form is 400 mg per day. The extended-release form starts at 100 mg once a day and increases by 100 mg every five days with a maximum dose of 300 mg daily. Side effects include constipation, dizziness, nausea, vomiting, euphoria, headache, itching, agitation, somnolence, hallucinations, and anxiety.

Tramadol interacts with narcotic medications and many antidepressants. It should be used carefully for those with moderate to severe renal or liver insufficiency. Tramadol lowers the seizure threshold and should be used cautiously in those with a history of seizures. Caution must be used with tramadol as it has abuse potential.

Narcotic medicines are used when pain cannot be controlled by other means. They should only be used on a time-limited basis in those with disabling symptoms or severe pain who have not responded to other treatment modalities. Before starting opioid therapy, it is important to determine the pain's effect on the patient's life, including functional ability and psychological impact. Narcotics are more powerful pain medications but have side effects. Narcotics have side effects of sedation, respiratory depression, dizziness, falls, constipation, addiction, and dependence. Narcotic medications include codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, and morphine.

Injectable Therapy

Intra-articular steroid injections can be used for painful joints. The injection involves placing a needle directly into the arthritic joint and injecting a steroid and a numbing agent. These can be effective treatments, but their length of effect is variable from weeks to months. Reduction in pain may be felt within hours, but usually, it takes a few days to notice an impact. Corticosteroid injections can potentially damage hyaline cartilage and may advance OA (Kompel et al., 2019).

Intra-articular hyaluronic acid is sometimes used to mimic the joint lubricant, which is often reduced in those with OA that naturally occurs in the knee. It is classified as a medical device and not a drug. Hyaluronic acid is of uncertain benefit and is not recommended for routine use of knee OA (AAOS, 2021). In addition, the cost can be prohibitive, and side effects include pain and possibly joint infection.

Platelet-rich plasma (PRP) is a newer treatment option for OA, and it involves intra-articular injections. A review of the literature on PRP suggested that it is more effective than other intra-articular options for improving pain for up to 12 months. Still, the results are not definitive (Gato-Calvo et al., 2019). Those individuals with severe diseases and younger age respond better to treatment. Many questions remain, including how many injections it takes to be effective, the time between injections, and the volume needed to be injected. Evidence regarding this treatment is limited, and more research is needed before it is routinely used. In addition, insurance companies may not pay, and it tends to be an expensive treatment.

Surgery

When medical treatment fails, surgery is the next option. Surgical options include arthroscopy, osteotomy, total joint arthroplasty, or joint fusion. Success rates are variable after surgery. Partial meniscectomy using an arthroscopic technique is useful for those with a meniscal tear and OA who have failed non-surgical options (AAOS, 2021). The high tibial osteotomy improves function and pain in those with unicompartmental arthritis of the knee. When the surgeon removes a wedge of bone, an osteotomy may be used to delay joint replacement in younger patients. It can be used for misaligned hip or knee conditions such as genu varum or genu valgum.

Joint replacement surgery replaces the damaged joint with an artificial one. Even under the best circumstances, surgery cannot return the joint to its normal state (artificial joints do not have all the motion of a normal joint). However, an artificial joint will very likely diminish pain and improve function. Typically, the artificial joint is viable for 15-20 years. The two most commonly replaced are the hip and knee joints. Complications after surgery include infection, thrombophlebitis, and pulmonary embolism.

A joint fusion is the joining of the bones on each side of the joint. The ROM is significantly reduced, but the pain is improved. Fusions are typically not a first-line procedure for knee or hip OA but are sometimes used when a joint arthroplasty fails.

Case Study

Mr. Xavier is a 66-year-old carpet installer who has been retired for ten years. He has been experiencing progressive bilateral knee pain, but the right knee is more bothersome than the left. Over the last two months, the pain has been less responsive to over-the-counter pain medications. He complains of his knees being stiff for approximately 30 minutes when waking in the morning and about five minutes after getting up from a seated position during the day. Walking for more than 30 minutes is difficult due to pain. Pain is increased with squatting, kneeling, and going downstairs. He mentions more severe symptoms on cold or very humid days. He decides to visit his nurse practitioner.

The patient is 5'9" and 225 pounds with a body mass index of 33.2. He was noted to walk with a slightly antalgic gait. The clinical exam shows bony enlargement and tenderness of both knees, and he cannot fully extend his right knee but can fully extend the left knee. A slight genu varum of both knees suggests that the medial compartments of the knees are involved. Crepitus is noted in both knees, and tenderness is noted over the joint line in the right knee. An X-ray shows joint space narrowing and medial osteophytes.

The nurse practitioner recommends weight loss, prescribes meloxicam, and refers the patient to an orthopedic surgeon who recommends a total right knee replacement. Mr. Xavier only gets moderate relief with the meloxicam, but he does not want to proceed with the total knee replacement, so he asks what other options are available. The orthopedic surgeon discusses other treatment options, including lifestyle changes (exercise and weight loss), joint injections (corticosteroids and intra-articular hyaluronic acid), and topical medications.

Conclusion

Osteoarthritis is a common condition, particularly in the older population, characterized by pain and disability. Diagnosis is typically based on signs and symptoms, but diagnostic testing such as X-rays may be done when the clinician is uncertain. Multiple treatment options are available, ranging from lifestyle changes like weight loss to total joint replacements.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

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  • Alrushud, A. S., Rushton, A. B., Kanavaki, A. M., & Greig, C. A. (2017). Effect of physical activity and dietary restriction interventions on weight loss and the musculoskeletal function of overweight and obese older adults with knee osteoarthritis: a systematic review and mixed method data synthesis. BMJ Open, 7(6), e014537. Visit Source.
  • American Academy of Orthopaedic Surgeons. (2021). Management of Osteoarthritis (OA) in the Knee (Non-Arthoplasty). American Academy of Orthopaedic Surgeons. Visit Source.
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