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Diagnosis and Treatment of Hip and Knee OsteoarthritisA Review

Educational Objective
To review the clinical management of patients with osteoarthritis of the hip or knee.
1 Credit CME
Abstract

Importance  Osteoarthritis (OA) is the most common joint disease, affecting an estimated more than 240 million people worldwide, including an estimated more than 32 million in the US. Osteoarthritis is the most frequent reason for activity limitation in adults. This Review focuses on hip and knee OA.

Observations  Osteoarthritis can involve almost any joint but typically affects the hands, knees, hips, and feet. It is characterized by pathologic changes in cartilage, bone, synovium, ligament, muscle, and periarticular fat, leading to joint dysfunction, pain, stiffness, functional limitation, and loss of valued activities, such as walking for exercise and dancing. Risk factors include age (33% of individuals older than 75 years have symptomatic and radiographic knee OA), female sex, obesity, genetics, and major joint injury. Persons with OA have more comorbidities and are more sedentary than those without OA. The reduced physical activity leads to a 20% higher age-adjusted mortality. Several physical examination findings are useful diagnostically, including bony enlargement in knee OA and pain elicited with internal hip rotation in hip OA. Radiographic indicators include marginal osteophytes and joint space narrowing. The cornerstones of OA management include exercises, weight loss if appropriate, and education—complemented by topical or oral nonsteroidal anti-inflammatory drugs (NSAIDs) in those without contraindications. Intra-articular steroid injections provide short-term pain relief and duloxetine has demonstrated efficacy. Opiates should be avoided. Clinical trials have shown promising results for compounds that arrest structural progression (eg, cathepsin K inhibitors, Wnt inhibitors, anabolic growth factors) or reduce OA pain (eg, nerve growth factor inhibitors). Persons with advanced symptoms and structural damage are candidates for total joint replacement. Racial and ethnic disparities persist in the use and outcomes of joint replacement.

Conclusions and Relevance  Hip and knee OA are highly prevalent and disabling. Education, exercise and weight loss are cornerstones of management, complemented by NSAIDs (for patients who are candidates), corticosteroid injections, and several adjunctive medications. For persons with advanced symptoms and structural damage, total joint replacement effectively relieves pain.

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Article Information

Corresponding Author: Jeffrey N. Katz, MD, MSc, Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women’s Hospital, 75 Francis St, Hale 5016, Boston, MA 02115 (jnkatz@bwh.harvard.edu).

Accepted for Publication: October 23, 2020.

Author Contributions: Dr Katz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Katz, Loeser.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: Arant, Loeser.

Conflict of Interest Disclosures: Dr Katz reported receipt of research funding for a cohort study of patients with OA from Samumed and for a qualitative study of patients with OA from Flexion Therapeutics. Dr Loeser reported receipt of research funding for a preclinical study in OA from Bioventus and consulting fees from Unity Biotechnology. No other disclosures were reported.

Funding/Support: This work was supported by National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases grants P30AR072577 and P30 AR072520.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

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