Elsevier

The Lancet

Volume 393, Issue 10182, 27 April–3 May 2019, Pages 1745-1759
The Lancet

Seminar
Osteoarthritis

https://doi.org/10.1016/S0140-6736(19)30417-9Get rights and content

Summary

Osteoarthritis is a leading cause of disability and source of societal cost in older adults. With an ageing and increasingly obese population, this syndrome is becoming even more prevalent than in previous decades. In recent years, we have gained important insights into the cause and pathogenesis of pain in osteoarthritis. The diagnosis of osteoarthritis is clinically based despite the widespread overuse of imaging methods. Management should be tailored to the presenting individual and focus on core treatments, including self-management and education, exercise, and weight loss as relevant. Surgery should be reserved for those that have not responded appropriately to less invasive methods. Prevention and disease modification are areas being targeted by various research endeavours, which have indicated great potential thus far. This narrative Seminar provides an update on the pathogenesis, diagnosis, management, and future research on osteoarthritis for a clinical audience.

Introduction

Osteoarthritis is a common and disabling condition that represents a substantial and increasing health burden with notable implications for the individuals affected, health-care systems, and wider socioeconomic costs.1, 2 With the combined effects of ageing and increasing obesity in the global population, along with increasing numbers of joint injuries, this already burdensome syndrome is becoming more prevalent, with worldwide estimates suggesting that 250 million people are currently affected.

In this context of substantive burden, the majority of patients with osteoarthritis do not receive appropriate management therapies.3 Osteoarthritis is a complex chronic disease, frequently compounded by the presence of multimorbidity. Typical management is best characterised as palliative and reactive, rather than focused on shared decision making or coordinated and proactive and preventive actions. However, considering the increasing individual and societal burden of osteoarthritis, the approach towards management should change towards individualised patient care that is based on their specific needs, which could be achieved through a biopsychosocial and medical framework.4

The overview we present here is timely given recent changes in conceptions of osteoarthritis pathogenesis and pain aetiology, and as such, the newly apparent inappropriate management, which needs redressing. Osteoarthritis is a disease of the whole joint, involving structural alterations in the articular cartilage, subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles.5 Pain is the dominant symptom and is a major driver of clinical decision making and health service use, and is best framed within a biopsychosocial model.6 Surgery should be reserved for cases in which all appropriate, less invasive options that have been delivered for a reasonable period have not provided adequate symptom relief. These topics are the focus of this narrative Seminar, along with recent promising research on prevention and disease modification.

Section snippets

Prevalence

Clinically, the knee is the most common site of osteoarthritis, followed by the hand and hip.1, 7, 8 A systematic review9 showed that the reported prevalence of osteoarthritis in individual studies depended on the definition of osteoarthritis used, as well as on the age categories, countries of origin, and sex distribution of the study population. In table 1, we show the prevalence data according to these variables for the population-based studies (not the hospital-based) used in that review.

New insights on pathogenesis

Osteoarthritis is a whole joint disease, involving structural alterations in the hyaline articular cartilage, subchondral bone, ligaments, capsule, synovium, and periarticular muscles.5, 39 The complex pathogenesis of osteoarthritis involves mechanical, inflammatory, and metabolic factors, which ultimately lead to structural destruction and failure of the synovial joint. The disease is an active dynamic alteration arising from an imbalance between the repair and destruction of joint tissues,

Causes of osteoarthritis pain

Patients with osteoarthritis experience pain as the most disabling symptom. Pain is a major driver of clinical decision making and health service use, and is best framed within a biopsychosocial model (figure 3).6 Morning stiffness, reduced range of motion, crepitus, joint instability (buckling or giving-way), swelling, muscle weakness, fatigue, and pain-related psychological distress are also seen frequently in patients with osteoarthritis.50

The pain in knee osteoarthritis is typically an

The diagnosis of osteoarthritis and the role of imaging

Clinical diagnosis is the standard for confirming osteoarthritis, made on the basis of symptoms (pain, brief morning stiffness, and functional limitations) and a brief physical examination (crepitus, restricted or painful movement, joint tenderness, and bony enlargement). Appropriate use of diagnostic criteria (such as those from the American College of Rheumatology or the European League Against Rheumatism for knee osteoarthritis; figure 4) is recommended,67, 68 although the need for early

Management

Overall, the key management strategies for knee and hip osteoarthritis are in broad agreement across the guidelines of the various stakeholder organisations,73, 74 which include large professional societies, research societies, and governmental organisations.

Joint replacement surgery

Joint replacement surgery is a clinically relevant and cost-effective treatment for end-stage osteoarthritis.116, 117 Joint replacement, however, can only be considered cost-effective if the procedure is restricted to patients with more severely affected functional status.118 The lifetime risk of undergoing total joint replacement is substantially less than the risk of developing symptomatic hip or knee osteoarthritis; the mortality-adjusted lifetime risk of total hip replacement at age 50

Prevention

Although osteoarthritis is one of the most common diseases, primary prevention is still in its infancy. Some of the risk factors for osteoarthritis are not modifiable and only define a high-risk group; others can either be prevented or modified. Factors that make knee osteoarthritis a high risk and for which overwhelming evidence exists are obesity and previous knee injury.19 The relevance of a risk factor for prevention can be established by the population attributable fraction (PAF), which

Overall conclusion and future perspectives

Health-care providers and policy makers should realise that the global population will be confronted with an increase in osteoarthritis in the coming decades, to that degree that it will become one of the most frequent diseases. Although several evidence-based guidelines are available for hip and knee osteoarthritis, the evidence for non-surgical treatment efficacy in hip osteoarthritis compared with in knee osteoarthritis is insufficient, and for other forms of peripheral osteoarthritis it is

Search strategy and selection criteria

We searched PubMed with the search term “osteoarthritis” in combination with the terms “incidence”; “prevalence”; “burden”; “economic”; “costs”; “comorbidity”; “mortality”; “pain mechanisms”; “etiology”; “diagnosis”; “guidelines”; “recommendation”; “management”; “surgery”, “replacement”, or “arthroplasty”; “disease modification”; and “prevention”. We focused on publications from the past 5 years (Jan 31, 2014, to Jan 31, 2019), published in English on meta-analyses or systematic reviews, and on

References (150)

  • PS Hsu et al.

    Increased risk of stroke in patients with osteoarthritis: a population-based cohort study

    Osteoarthritis Cartilage

    (2017)
  • P Calders et al.

    Presence of comorbidities and prognosis of clinical symptoms in knee and/or hip osteoarthritis: a systematic review and meta-analysis

    Semin Arthritis Rheum

    (2018)
  • S Glyn-Jones et al.

    Osteoarthritis

    Lancet

    (2015)
  • DJ Hunter et al.

    The symptoms of osteoarthritis and the genesis of pain

    Med Clin North Am

    (2009)
  • A Liu et al.

    The relationship between knee pain characteristics and symptom state acceptability in people with knee osteoarthritis

    Osteoarthritis Cartilage

    (2014)
  • D Schiphof et al.

    Sensitivity and associations with pain and body weight of an MRI definition of knee osteoarthritis compared with radiographic Kellgren and Lawrence criteria: a population-based study in middle-aged females

    Osteoarthritis Cartilage

    (2014)
  • T Dimitroulas et al.

    Neuropathic pain in osteoarthritis: a review of pathophysiological mechanisms and implications for treatment

    Semin Arthritis Rheum

    (2014)
  • C Fingleton et al.

    Pain sensitization in people with knee osteoarthritis: a systematic review and meta-analysis

    Osteoarthritis Cartilage

    (2015)
  • HP French et al.

    Prevalence of neuropathic pain in knee or hip osteoarthritis: a systematic review and meta-analysis

    Semin Arthritis Rheum

    (2017)
  • JR Hochman et al.

    Neuropathic pain symptoms on the modified painDETECT correlate with signs of central sensitization in knee osteoarthritis

    Osteoarthritis Cartilage

    (2013)
  • FP Luyten et al.

    Toward classification criteria for early osteoarthritis of the knee

    Semin Arthritis Rheum

    (2018)
  • AE Nelson et al.

    A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the US bone and joint initiative

    Semin Arthritis Rheum

    (2014)
  • P Christensen et al.

    Long-term weight-loss maintenance in obese patients with knee osteoarthritis: a randomized trial

    Am J Clin Nutr

    (2017)
  • BR da Costa et al.

    Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis

    Lancet

    (2017)
  • M van Middelkoop et al.

    The OA Trial Bank: meta-analysis of individual patient data from knee and hip osteoarthritis trials show that patients with severe pain exhibit greater benefit from intra-articular glucocorticoids

    Osteoarthritis Cartilage

    (2016)
  • G Wang et al.

    Efficacy and safety of duloxetine in Chinese patients with chronic pain due to osteoarthritis: a randomized, double-blind, placebo-controlled study

    Osteoarthritis Cartilage

    (2017)
  • LA Deveza et al.

    Too much opioid, too much harm

    Osteoarthritis Cartilage

    (2018)
  • IN Ackerman et al.

    Forecasting the future burden of opioids for osteoarthritis

    Osteoarthritis Cartilage

    (2018)
  • MCS Inacio et al.

    Prevalence and changes in analgesic medication utilisation 1 year prior to total joint replacement in an older cohort of patients

    Osteoarthritis Cartilage

    (2018)
  • M Johansen et al.

    Exploring reasons for the observed inconsistent trial reports on intra-articular injections with hyaluronic acid in the treatment of osteoarthritis: meta-regression analyses of randomized trials

    Semin Arthritis Rheum

    (2016)
  • D Prieto-Alhambra et al.

    Incidence and risk factors for clinically diagnosed knee, hip and hand osteoarthritis: influences of age, gender and osteoarthritis affecting other joints

    Ann Rheum Dis

    (2014)
  • DJ Hunter et al.

    The individual and socioeconomic impact of osteoarthritis

    Nat Rev Rheumatol

    (2014)
  • WB Runciman et al.

    CareTrack: assessing the appropriateness of health care delivery in Australia

    Med J Aust

    (2012)
  • DJ Hunter et al.

    Therapy: are you managing osteoarthritis appropriately?

    Nat Rev Rheumatol

    (2017)
  • KD Brandt et al.

    Yet more evidence that osteoarthritis is not a cartilage disease

    Ann Rheum Dis

    (2006)
  • N Zorgregistraties

    Zorg door de huisarts; jaarcijfers 2016 en trendcijfers 2011–2016

  • Public Health Foresight Study 2018 (VTV-2018): diseases

  • D Yu et al.

    Annual consultation incidence of osteoarthritis estimated from population-based health care data in England

    Rheumatology (Oxford)

    (2015)
  • Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015

    Lancet

    (2016)
  • AD Woolf et al.

    Burden of major musculoskeletal conditions

    Bull World Health Organ

    (2003)
  • DJ Hunter et al.

    The individual and socioeconomic impact of osteoarthritis

    Nat Rev Rheumatol

    (2014)
  • S Gupta et al.

    The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition

    Rheumatology (Oxford)

    (2005)
  • D Schofield et al.

    The long-term economic impacts of arthritis through lost productive life years: results from an Australian microsimulation model

    BMC Public Health

    (2018)
  • DJ Schofield et al.

    The personal and national costs of lost labour force participation due to arthritis: an economic study

    BMC Public Health

    (2013)
  • Y Zhang et al.

    Epidemiology of osteoarthritis

    Rheum Dis Clin North Am

    (2008)
  • GM Brouwer et al.

    Association between valgus and varus alignment and the development and progression of radiographic osteoarthritis of the knee

    Arthritis Rheum

    (2007)
  • J Runhaar et al.

    Malalignment: a possible target for prevention of incident knee osteoarthritis in overweight and obese women

    Rheumatology (Oxford)

    (2014)
  • F Saberi Hosnijeh et al.

    Cam deformity and acetabular dysplasia as risk factors for hip osteoarthritis

    Arthritis Rheumatol

    (2017)
  • L Gala et al.

    Hip dysplasia in the young adult

    J Bone Joint Surg Am

    (2016)
  • AM Ezzat et al.

    Occupational physical loading tasks and knee osteoarthritis: a review of the evidence

    Physiother Can

    (2014)
  • Cited by (2287)

    View all citing articles on Scopus
    View full text