Age and Ageing Advance Access originally published online on December 2, 2008
Age and Ageing 2009 38(1):2-3; doi:10.1093/ageing/afn272
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The age of osteoarthritis
There are key reasons for those with an interest in the elderly to care about osteoarthritis right now.The first will be familiar: a demographic consequence of increasing age-related disease. Although the performance of over 140,000 hip and knee replacements in England & Wales in 2007 [1] may be a surprise, this was recently revised upwards from preliminary data, with 97% performed for osteoarthritis. We predicted three decades to elapse, not one, for this level of surgical activity to occur [2]. Population data from the United States suggest a lifetime risk of knee osteoarthritis by age 85 years of 45% although the rural obese population generating this estimate may have an extraordinarily high rate of disease [3].
The second relates to new clinical guidance, which includes the National Institute for Health and Clinical Excellence (NICE) clinical guideline for the care and management of adults with osteoarthritis (CG59) [4]; and those from the Osteoarthritis Research Society International (OARSI) [5] and the European League Against Rheumatism (EULAR) [6]. These are similar in advocating non-pharmacological therapies as central to osteoarthritis treatment, including education, aerobic and strengthening exercise and weight loss. However, evidence for widely used pharmacological therapies is more controversial, leading to differences in both scope and recommendations from these bodies.
The third reason is that novel data are challenging the dogma that structural change is not related to pain and function in osteoarthritis. Early epidemiological studies were limited to single views from plain radiography. However, even in the seminal observations from the Empire Rheumatism Council's Field Epidemiology Unit, 80% of women with advanced structural change (grades 3–4) from osteoarthritis had knee pain versus 20% with grades 0–1, compared to 81% and 60% respectively for rheumatoid arthritis, showing the structure–symptom relationship is as strong, or even stronger, than other conditions where this paradigm is established [7]. Studies with validated pain tools and multiple views from plain radiography [8] show a strong relationship of pain with x-ray evidence of osteoarthritis. Others using magnetic resonance imaging show that bone marrow lesions are strongly related to pain [9] and even to structural deterioration of the joint [10]. This may provide a pathogenic basis for the link and help us to explore effective treatment targeting disease progression, which is also strongly associated with bone marrow lesions.
Should clinicians and scientists change their practice and, if so, how?
Clinicians
Clinicians in geriatric medicine are experienced in managing those with multiple problems and in old age there is evidence that some degree of radiographic osteoarthritis is universal [11], so imaging should not be requested routinely. However, where joint pain affects function and participation, investigation or even a musculoskeletal opinion may be appropriate, especially if rheumatoid arthritis or other inflammatory forms of arthritis are suspected.
Non-pharmacological treatment options are important and there is no upper age limit on the advice for education, exercise and weight loss if obese. Therapies around the joint are effective, including certain topical NSAID preparations (particularly diclofenac in dimethyl sulfoxide); intra-articular steroid injection of hips or knees can give relief for up to 2 months [12], using ultrasound guidance for the hip, where expertise can be rapidly established [13]. Tablets have a role although the evidence of efficacy for paracetamol is surprisingly weak and glucosamine and chondroitin remain controversial. For those with severe pain, oral NSAIDs may be needed, but attention needs to be made to protecting the stomach from NSAID side-effects and consider the additional risk of coronary and cerebrovascular events from some non-selective NSAIDs and coxibs. Knee braces and patellar taping can be effective for pain relief in the setting of knee osteoarthritis. Trials of shoe orthotics have shown disappointing results, despite enthusiasm for this approach.
Scientists
We suggest that patients be included in trials of disease modifying strategies wherever available; the most promising strategies are listed below. However, surgery is one area where the science is improving and we must encourage both this trend and the early referral of those with severe osteoarthritis, which improves outcome in this group. While knee and hip replacement are effective for most persons, there is no controlled evidence of this intervention, whilst two controlled trials of the study of arthroscopic surgery for knee osteoarthritis showed no efficacy for this procedure [14, 15]. Further, there is evidence that newer operations like resurfacing are no better than total joint arthroplasty and some complications, like heterotopic ossification may be worse [16]. Ideally, we would like treatments that prevent joint failure and delay or prevent the need for surgery.
Preventing joint failure
The most important concept emerging from current research is that joint failure is the problem in osteoarthritis. This leads to three main strategies for slowing disease:
- Optimise the biomechanics.
- Prevent joint failure using agents shown to do so in other types of inflammatory arthritis (yes, osteoarthritis is inflammatory and inflammation predicts progression).
- Interventions targeted at specific points of the pathogenetic pathway: bone, cartilage, ligaments and synovium.
There are a number of pharmaceutical sponsored studies ongoing, mainly looking at targets in the final category, including bone (calcitonin, osteoprotegerin-1), cartilage (aggrecanase inhibition, piascledine: avocado soybean unsaponifiables), ligaments (FGF-18) and synovium (iNOS inhibition). However, there is little justification for industry to commit funds towards strategies (1) and (2); therefore, strategic investment is needed. The Arthritis Research Campaign has funded Clinical Studies Groups in important areas, including osteoarthritis; this should facilitate consensus and funding for the most promising studies.
In conclusion, for osteoarthritis this is the time to educate patients and physicians on progress and for scientists, to move on to the definitive demonstration of disease modification.
1 Northumbria Healthcare NHS Foundation Trust, Newcastle Hospitals NHS Foundation Trust, Musculoskeletal Research Group Newcastle University, Newcastle upon Tyne, UK
2 Boston University School of Medicine, Boston, USA and ARC Epidemiology Research Unit, University of Manchester Manchester, UK
* To whom correspondence should be addressed Email: Fraser.Birrell{at}ncl.ac.uk
References
- National Joint Registry. (2007) http://www.njrcentre.org.uk/njrcentre/Healthcareproviders/Accessingthedata/StatsOnline/NJRStatsOnline/tabid/179/Default.aspx (29 September 2008, date last accessed).
- Birrell F, Johnell O, Silman A. Projecting the need for hip replacement over the next three decades: influence of changing demography and threshold for surgery. Ann Rheum Dis (1999) 58:569–72.
[Abstract/Free Full Text] - Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum (2008) 59:1207–13.[CrossRef][Web of Science][Medline]
- NICE. Osteoarthritis: the care and management of osteoarthritis in adults. (2008) http://www.nice.org.uk/cg59 (29 Septemeber 2008, date last accessed).
- Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis: Part I. Critical appraisal of existing treatment guidelines and systematic review of current research evidence. Osteoarthritis Cartilage (2007) 15:981–1000.[CrossRef][Web of Science][Medline]
- Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the diagnosis of hand osteoarthritis—report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis (2008) [Epub ahead of print].
- Lawrence, Bremer & Bier, 1966. Osteo-arthrosis prevalence in the population and relationship between symptoms and X-ray changes. Ann Rheum Dis (1966) 25:1–24.[Web of Science][Medline]
- Duncan R, Peat G, Thomas E, et al. Symptoms and radiographic osteoarthritis: not as discordant as they are made out to be? Ann Rheum Dis (2007) 66:86–91.
[Abstract/Free Full Text] - Felson DT, Chaisson CE, Hill CL, et al. The association of bone marrow lesions with pain in knee osteoarthritis. Ann Intern Med (2001) 134:541–9.
[Abstract/Free Full Text] - Hunter DJ, Zhang Y, Niu J, et al. Increase in bone marrow lesions associated with cartilage loss: a longitudinal magnetic resonance imaging study of knee osteoarthritis. Arthritis Rheum (2006) 54:1529–35.[CrossRef][Web of Science][Medline]
- Davies B, Ottewell L, Francis RM, et al. Is radiographic osteoarthritis universal in the very elderly? The Northumberland 85 +Musculoskeletal study. Ann Rheum Dis (2008) 67:3186.
- Atchia I, Reed M, Kane D, et al. Efficacy of a single ultrasound guided injection in hip osteoarthritis. Osteoarthritis Cartilage (2008) 16(S4):S18.
- Atchia I, Birrell F, Kane D. A modular, flexible training strategy to achieve competence in diagnostic and interventional musculoskeletal ultrasound in patients with hip osteoarthritis. Rheumatology (Oxford) (2007) 46:1583–6.[CrossRef][Medline]
- Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med (2002) 347:81–8.
[Abstract/Free Full Text] - Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med (2008) 359:1097–107.
[Abstract/Free Full Text] - Rama KR, Vendittoli PA, Ganapathi M, et al. Incidence and severity of heterotopic ossification after surface replacement arthroplasty and total hip arthroplasty: a randomized study. J Arthroplasty (2008) [Epub ahead of print].
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