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
SeminarOsteoarthritis
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
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