knee osteoarthritis

In the knee, primary osteoarthritis tends to particularly affect the posterior aspect of the patella and the medial compartment of the knee. Patients with this condition thus tend to develope a varus deformity. Secondary osteoarthritis may follow a variety of conditions such as ligament or meniscus injury, recurrent patella dislocation, osteochondritis dissecans, joint infection or other insult. According to Framingham Osteoarthritis Study, 33% of people age >65 years had radiographic evidence of knee OA, and 9.5% reported symptomatic knee OA (1).

Reference: 1. http://onlinelibrary.wiley.com/doi/10.1002/art.24543/full 0

clinical features
The patient with osteoarthritis of the knee is classically over 50 years of age, overweight, and may have a bow-leg deformity. There may be a progressive loss of movement and fixed flexion deformities. Pain is severe and is accentuated as the individual attempts to get moving after a period of inactivity. Swelling is common and locking may occur. On examination, the quadriceps muscle is often wasted, there is no effusion or warmth, and there may be patellofemoral crepitus. Applying force to the patella elicits pain. How do I diagnose knee osteoarthritis?

See also the section on diagnosing Knee osteoarthritis in the CKS topic on Osteoarthritis. Consider the possibility of knee osteoarthritis as the cause of knee pain if the person has one or more risk factors. Symptoms of knee osteoarthritis are often episodic or variable in severity, and slow to change. They include:

Use-related pain, often worse towards the end of the day and relieved by rest. More persistent rest pain and night pain may occur in advanced osteoarthritis. o A feeling of the knee giving way. o Stiffness in the morning or after inactivity lasting 30 minutes or less. o Impaired function. Physical examination findings may include: o Crepitus. o Painful or restricted movement. o Bony enlargement around the joint margins and absent or modest effusion (without warmth). o Varus (bowlegged) or, less commonly, valgus (knock-knee) deformity o Joint line tenderness. o Pain on patellofemoral compression. Make a working, clinical diagnosis of knee osteoarthritis, without the need for radiographic confirmation, if the person is 45 years of age or older, and has use-related knee pain with all of the following features: o Short-lived morning stiffness (lasting 30 minutes or less). o Functional limitation. o One or more of these examination findings: crepitus, restricted movement, or bony enlargement around the joint margins. o The absence of red flags (including those for inflammatory arthritis, such as redness, warmth, or a large effusion) or other conditions, such as meniscal or ligamentous lesions (see Scenario: Knee pain - history of trauma), or bursitis. (Note that a person with inflammatory arthritis may develop secondary osteoarthritis.) Consider offering an X-ray of both knees to aid diagnosis if there is any uncertainty. Features of knee osteoarthritis on X-ray may be absent or may include: o Joint space narrowing. o Osteophyte(s). o Subchondral bone sclerosis. o Subchondral cysts.
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Risk factors for knee osteoarthritis

Risk factors for knee osteoarthritis include: o Age older than 50 years. o Female sex. o Body mass index greater than 25 kg/m2. o Previous knee injury. o Joint laxity or hypermobility syndrome. o Occupational or recreational use. o Family history of osteoarthritis. o Presence of Heberden's nodes (bony posterolateral swelling of the distal interphalangeal joints of the fingers).

Basis for recommendation

These recommendations are based on evidence from variable levels of evidence (from meta-analysis of cohort studies to non-comparative descriptive studies) in European League Against Rheumatism (EULAR) evidence-based recommendations for the diagnosis of osteoarthritis [Zhang et al, 2010] and expert opinion in the full National Institute for Health and Clinical Excellence guideline (background document) on the care and management of adults with osteoarthritis [National Collaborating Centre for Chronic Conditions, 2008].

The stated risk factors were found by EULAR to be strongly associated with the incidence of knee osteoarthritis following a systematic review of the evidence [Zhang et al, 2010].

http://onlinelibrary.wiley.com/doi/10.1002/art.22088/full http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1471783/ http://www.nejm.org/doi/pdf/10.1056/nejmcp051726