I. Background
On January 13, 2000, the World Health Organization (WHO) launched the Bone and Joint Decade, a global initiative to raise awareness of bone diseases among governments, medical research institutions, the public and society at large. This includes Osteoarthritis (OA), a common disease with increasing health consequences and medical costs. On October 12, 2001, the Ministry of Health (MOH) organized a campaign to raise awareness of World Arthritis Day and decided to establish the MOH Arthritis Prevention and Control Education Program Fund.
With the support of this fund, a draft guideline for the diagnosis and treatment of osteoarthritis was drafted by domestic orthopedic and rheumatologic experts, which provides standardized guidance for the diagnosis and treatment of OA by physicians nationwide. However, it has been more than 4 years since the publication of the draft guideline, especially in recent years, with the in-depth understanding of the occurrence and development mechanism of OA, there are many urgent updates in the guideline, therefore, based on foreign OA guidelines 1-12 and literature 19-23, combined with the specific situation in China, the previous version of the guideline has been revised. This guideline is only an academic guideline, and its implementation must still depend on the patient and the specific medical situation. Before taking any preventive and therapeutic measures, you should refer to the relevant product descriptions.
II. Overview
OA refers to a joint disease caused by a variety of factors that lead to fibrosis, cracking, ulceration, and loss of articular cartilage. The cause is not clear, its occurrence is related to age, obesity, inflammation, trauma and genetic factors. Its pathology is characterized by degenerative destruction of articular cartilage, subchondral osteosclerosis or cystic changes, osteophytes at the joint edges, synovial hyperplasia, joint capsule contracture, ligamentous laxity or contracture, and muscle atrophy and weakness.
OA is more common in middle-aged and elderly patients, with more women than men, and the prevalence can reach 50% in people over 60 years of age and 80% in those aged 75 years. OA occurs in joints with high load and high activity, such as the knee, spine (cervical and lumbar spine), hip, ankle, hand and other joints.
Third, the classification
OA can be divided into two categories: primary and secondary. Primary OA occurs mostly in the middle-aged and elderly, no clear systemic or local causes, and genetic and physical factors have a certain relationship. Secondary OA can occur in young adults, can be secondary to trauma, inflammation, joint instability, chronic and repeated cumulative strain or congenital diseases.
IV. Clinical manifestations
(A) symptoms and signs
1. Joint pain and pressure pain: Initially, it is mild or moderate intermittent hidden pain, which improves at rest and worsens after activity, and the pain is often related to weather changes. In the late stage, there may be persistent pain or nocturnal pain. There is localized pressure pain in the joints, which is especially obvious when accompanied by joint swelling.
2. Joint stiffness: stiffness and tightness of the joints when waking up in the morning, also known as morning stiffness, can be relieved after activity. Joint stiffness is aggravated when air pressure decreases or air humidity increases, and the duration is usually short, often a few minutes to ten minutes, rarely more than 30 minutes.
3. Enlarged joints: The joints of the hands are obviously enlarged and deformed, and Heberden’s nodes and Bouchard’s nodes may appear. Some of the knee joints may also be enlarged due to the formation of osteoid or joint effusion.
4. Bone rubbing sound (sensation): Due to the destruction of articular cartilage and uneven joint surface, bone rubbing sound (sensation) appears when the joint moves, mostly in the knee joint.
5, joint weakness, activity disorders: joint pain, decreased mobility, muscle atrophy, soft tissue contracture can cause joint weakness, walking with soft legs or joint strangulation, can not be fully straightened or activity disorders.
(B) Laboratory tests: blood routine, protein electrophoresis, immune complexes and serum complement are generally within normal limits. Patients with concomitant synovitis may have mildly elevated C-reactive protein (CRP) and hematocrit (ESR). Patients with secondary OA may have abnormal laboratory tests of the primary disease.
(C) X-ray examination: asymmetric joint space narrowing, subchondral bone sclerosis and/or cystic changes, joint edge hyperplasia and bone superfluous formation or with varying degrees of joint effusion, and free bodies or joint deformation visible in some joints.
V. Diagnostic points
It is generally not difficult to diagnose OA based on the patient’s symptoms, physical signs, X-ray manifestations and laboratory tests. This guideline proposes diagnostic criteria for OA of the knee and hip for reference (Table 1, 2). The diagnostic criteria are basically based on those established by Altman and discussed by some orthopedic specialists.
The criteria developed by Altman and discussed by some orthopedic experts.
VI. Treatment
The goal of treatment for OA is to reduce or eliminate pain, correct deformity, improve or restore joint function, and improve quality of life.
The overall treatment principle of OA is a combination of non-pharmacological and pharmacological treatment, surgical treatment when necessary, and treatment should be individualized. Combine the patient’s own situation, such as age, gender, weight, own risk factors, lesion site and degree, etc. to choose the appropriate treatment plan.
(i) Non-pharmacological treatment: It is the basis of pharmacological treatment and surgical treatment, etc.
For first-time patients with OA who are not heavily symptomatic, non-pharmacological treatment is the preferred treatment modality, aiming to reduce pain, improve function and enable patients to have a good understanding of the nature and prognosis of the disease.
1, patient education: self-behavioral therapy (reduce unreasonable exercise, moderate activity, avoid poor posture, avoid prolonged running, jumping, squatting, reduce or avoid climbing stairs), weight loss, aerobic exercise (such as swimming, bicycling, etc.), joint functional training (such as knee flexion and extension activities in the non-weight-bearing position to maintain maximum joint mobility), muscle training (such as hip OA should pay attention to the training of the abductor muscle group) etc.
2. Physical therapy: mainly to increase local blood circulation and reduce inflammation, including heat therapy, hydrotherapy, ultrasound, acupuncture, massage, traction, transcutaneous electrical nerve stimulation (TENS), etc.
3., Mobility support: mainly reduce the weight-bearing of the affected joint, cane, crutches, walkers, etc. can be used.
4., change the line of negative gravity: according to the inversion or valgus deformity accompanying OA, use the corresponding orthopedic brace or orthopedic shoes to balance the load on each joint surface.
(B) Drug treatment: If non-drug treatment is ineffective, drug treatment can be selected according to the joint pain.
1.Local drug therapy: For hand and knee OA, it is recommended to choose local drug therapy first before using oral drugs. Local drug therapy can be used non-steroidal anti-inflammatory drugs (NSAIDs) emulsions, creams, patches and non-NSAIDs rubs (capsaicin, etc.). Topical topical agents can be effective in relieving mild to moderate joint pain with mild adverse effects. For moderate to severe pain, topical drugs can be used in combination with oral NSAIDs.
2. Systemic analgesic drugs: according to the route of administration, they are divided into oral drugs, injections and suppositories.
(1) Medication principles.
① Conduct risk assessment before drug administration and pay attention to the risk of potential medical diseases.
(2) Individualize the dose according to the individual patient’s condition.
(3) Use the lowest effective dose possible and avoid overdose and repeated or superimposed use of similar drugs.
④ Use the drug for 3 months and check blood and stool routine, fecal occult blood and liver and kidney function according to the condition of choice.
(2) Drug administration method.
① Patients with OA generally choose acetaminophen, with the maximum daily dose not exceeding 4000 mg.
(2) In patients with OA who are not well treated with acetaminophen, NSAIDs may be used on a case-by-case basis after weighing the patient’s risk of gastrointestinal, hepatic, renal, and cardiovascular disease (Table 3). The efficacy and adverse effects of oral NSAIDs are not identical in individual patients, and selective dosing should be performed after referring to the drug insert and assessing the risk factors for NSAIDs (Table 4). If patients are at high risk for gastrointestinal adverse reactions, non-selective NSAIDs plus gastric mucosal protectors such as H2 receptor antagonists, proton pump inhibitors or misoprostol, or selective COX-2 inhibitors may be used.
③Other analgesic drugs. patients with OA who are ineffective or intolerant to NSAIDs treatment can use tramadol, opioid analgesics, or a combination of acetaminophen and opioids.
3.Joint cavity injection.
①Sodium hyaluronate, if oral drug therapy is not effective, joint cavity injection of sodium hyaluronate-like viscoelastic supplements can be combined with injection of chilblains in the aspiration of joint fluid.
②Glucocorticoids, intra-articular cavity injection of glucocorticoids is feasible for severe OA that is not effective with NSAIDs drug therapy for 4-6 weeks or those who cannot tolerate NSAIDs drug therapy, persistent pain and obvious inflammation. However, if used for a long time, it can aggravate the damage of joint cartilage and aggravate the symptoms. Therefore, intra-articular glucocorticosteroid injections are not recommended, and repeated use is not recommended, generally no more than 3 to 4 times a year.
4, improve the condition of drugs and chondroprotective agents: including diacetin, glucosamine, avocado soybean unsaponifiables (ASU), doxycycline, etc.. These drugs can slow down the course of the disease and improve the patient’s symptoms to some extent. Diacerein has structural modulating effects.
(iii) Surgical treatment
The aims of surgical treatment of OA are to.
(1) further assist in the diagnosis;
(2) To reduce or eliminate pain;
(3) prevent or correct deformities;
(4) prevent further joint damage;
(5) To improve joint function;
(6) As part of a comprehensive treatment.
The main methods of surgical treatment for OA are.
(1) free-body removal;
(2) joint debridement;
(3) Osteotomy;
(4) Joint fusion;
(5) Arthroplasty (artificial joint replacement), etc.
Surgical treatment is mainly through arthroscopy (speculum) and open surgery.