x
x

OSTEOARTHRITIS - GENERAL

Introduction

Osteoarthritis (OA) is a degenerative disease characterized by progressive destruction of the extracellular matrix (ECM) of articular cartilage, synovial inflammation, subchondral bone sclerosis and osteophyte formation. OA is most common in the knee and hip and fingers also are frequently affected. In general, weight-bearing joints are the most severely affected. OA is one of the most common chronic diseases in the elderly. There are no approved disease-modifying drugs for OA; pain and inflammation are managed using analgesics, corticosteroids and NSAIDs.

Pathophysiology

Structural damage, even minor injury, to cartilage manifests as an inability to heal. Aging also leads to changes in ECM composition and alters chondrocyte activity. Compared with normal aging chondrocytes, those isolated from OA cartilage show different patterns of protein expression (Table). After cartilage in OA-affected joints begins to degenerate, ECM degradation products are released into the synovial fluid, which in turn, stimulates the release of pro-inflammatory cytokines. These molecules increase the expression of various catabolic enzymes, including matrix metalloproteinases (MMPs).

Table. Changes in cartilage properties with aging versus osteoarthritis
Property

Aging

Osteoarthritis

Water content

Decreased

Increased

Collagen

Relatively unchanged
(some increased in type VI)

Relative concentration increased Content decreased in severe cases

Matrix becomes disordered

Proteoglycan concentration

Decreased

Decreased

Proteoglycan synthesis

Unchanged

Increased

Proteoglycan degradation

Decreased

Increased

Total chondroitin sulfate concentration

Decreased

Increased

Chondroitin-4-sulfate concentration

Decreased

Increased

Keratin sulfate concentration

Increased

Decreased

Chondrocyte size

Increased

Unchanged

Chondrocyte number

Decreased

Unchanged

Modulus of elasticity

Increased

Decreased

Incidence and Related Conditions

  • OA is the most prevalent joint disorder in the United States.
  • The knee is the most frequently affected joint and occurs in 10% of men and 13% of women aged ≥60 years.
  • The incidence and prevalence of OA is likely to increase owing to the aging population and the prevalence of obesity.
  • Risk factors include advancing age, gender, genetics, poor nutrition, joint injury and/or instability

Differential Diagnosis

  • Gout
  • Rheumatoid arthritis
  • Infection
ICD-10 Codes

  • OSTEOARTHRITIS - GENERAL

    Diagnostic Guide Name

    OSTEOARTHRITIS - GENERAL

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    OSTEOARTHRITIS - GENERALIZED, MULTIPLE SITESM15.0   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Arthritic wrist secondary to scapholunate advanced collapse (SLAC Wrist)
    Arthritic wrist secondary to scapholunate advanced collapse (SLAC Wrist)
  • Arthritic thumb CMC joint with swelling and subluxation
    Arthritic thumb CMC joint with swelling and subluxation
Basic Science Photos and Related Diagrams
Basic Science Pics
  • Normal and abnormal cartilage histology; A = Superficial zone; B = Transitional zone; C = Radial zone; D = Calcified zone; E = Cancellous bone; F = Cartilage matrix; G = Necrotic tissue with clustered chondrocytes
    Normal and abnormal cartilage histology; A = Superficial zone; B = Transitional zone; C = Radial zone; D = Calcified zone; E = Cancellous bone; F = Cartilage matrix; G = Necrotic tissue with clustered chondrocytes
Symptoms
Joint pain and swelling
Joint stiffness; difficulty making a fist
Limited mobility
Pain with pinch and grasp
Typical History
  • A patient typically presents with insidious onset and progression of joint pain and stiffness.  Patients with osteoarthritis are usually older and frequently have a history of overuse, diabetes, excessive alcohol use, obesity and/or previous joint trauma. In the upper extremity the most frequently involved joints are the DIP joints of the fingers, the thumb CMC joint and the wrist. 
Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Normal wrist and arthritic wrist
    Normal wrist and arthritic wrist
  • Normal and arthritic thumb
    Normal and arthritic thumb
  • Normal and arthritic DIP joints
    Normal and arthritic DIP joints
Treatment Options
Conservative
  • Modification of activity
  • Placement of orthosis
  • NSAIDs or corticosteroid injections
Operative

Thumb CMC Osteoarthritis:

In a recent Cochrane Systematic review,1 11 randomized/quasi-randomized trials of surgery for thumb OA were included (N=670 patients), and 7 surgical procedures were identified:

  • Trapeziectomy
  • Trapeziectomy with interpositional arthroplasty
  • Trapeziectomy with ligament reconstruction
  • Trapeziectomy with ligament reconstruction and tendon interposition (LRTI)
  • Artelon joint resurfacing
  • Arthrodesis
  • Swanson joint replacement

DIP Osteoarthritis of the Finger:

  • Although rarely needed, DIP arthrodesis can solve severe DIP arthritic pain 

Wrist osteoarthritis such as sccapholunate advanced collapse (SLAC) wrist:

  • Proximal row carpectomy
  • Partial wrist fusion
  • Complete wrist fusion
  • Rarely wrist arthroplasty
CPT Codes for Treatment Options

Per an agreement between Hand Surgery Resource, LLC and the American Medical Association (AMA) users are required to accept the following End User Point and Click Agreement in order to view CPT content on this website.  Please read and then click "Accept" at the bottom to indicate your acceptance of the agreement.

End User Point and Click Agreement

CPT codes, descriptions and other data only are copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. The AMA reserves all rights to approve any license with any Federal agency.

You, as an individual, are authorized to use CPT only as contained in Hand Surgery Resource solely for your own personal information and only within the United States for non-commercial, educational use for the purpose of education relating to the fundamental principles of hand surgery and the common diseases, disorders and injuries affecting the human hand. You agree to take all necessary steps to ensure your compliance with the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 330 N. Wabash Avenue, Chicago, IL 60611. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt.

Common Procedure Name
Wrist fusion complete
CPT Description
Arthrodesis, wrist, complete, with iliac or other autograft (includes obtaining graft)
CPT Code Number
25810
Common Procedure Name
Extensor tendon transfer
CPT Description
Tendon transfer or transplant, CM area or dorsum of hand single w/o free graft
CPT Code Number
26480
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

CPT 2021 Professional Edition: Spiralbound

Complications
  • As reported in the Cochrane review, the AE rate was 10% after trapeziectomy and 19% after trapeziectomy with LRTI, corresponding to a risk increase of 9% (95% CI 0%, 28%).    
  • As reported in the Cochrane review, trapeziectomy with LRTI may not confer additional benefits or result in more adverse events (AEs) versus trapeziectomy.
Outcomes
  • On a visual analog scale (VAS) from 0 (no pain) to 100 mm, mean pain was 26 mm for trapeziectomy; trapeziectomy with LRTI reduced pain by 2.8 mm (95% confidence interval [CI] -9.8, 4.2).
  • On a scale of 0 (no disability) to 100, physical function was 31.1 after trapeziectomy; trapeziectomy with LRTI resulted a worsening in physical function of 0.2 points (95% CI −5.8, 6.1).k increase of 9% (95% CI 0%, 28%).
Key Educational Points
  • The 3 major components of extracellular matrix (ECM) are water, collagen and proteoglycans
  • The primary cell in hyaline cartilage is the chondrocytye 
  • Cartilage is composed of 4 layers:1. Tangential layer (zone 1, superficial disease); 2. Transitional layer (zone 2, middle); 3. Deep (zone 3, radial); 4. Calcified cartilage layer attached to subchondral bone (zone 4)
  • Cartilage is composed of extracellular matrix (95%) and chondrocytes (5%)
  • Cartilage changes seen in osteoarthritis include loss of proteoglycans, disorganized collagen with decreased modulus of elasticity, dying chondrocytes, increased water content and increased proteolytic enzymes activated enhanced by cytokines
References

Cited

  1. Wajon A, Vinycomb T, Carr E, et al. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane database Syst Rev 2015:CD004631. PMID: 25702783

New articles

  1. Burke J, Hunter M, Kolhe R, et al. Therapeutic potential of mesenchymal stem cell based therapy for osteoarthritis. Clin Transl Med 2016;5:Epub. PMID: 27510262
  2. Kulkarni P, Deshpande S, Koppikar S, et al. Glycosaminoglycan measured from synovial fluid serves as a useful indicator for progression of osteoarthritis and complements Kellgren-Lawrence Score. BBA Clin 2016;6:1-4. PMID: 27331021

Reviews

  1. Berenbaum F, Meng QJ. The brain-joint axis in osteoarthritis: nerves, circadian clocks and beyond. Nat Rev Rheumatol 2016;12:508-16. PMID: 27305851
  2. Berger AJ, Meals RA. Management of osteoarthritis of the thumb joints. J Hand Surg Am 2015;40:843-50. PMID: 25754790

Classics

  1. Stecher, RM. Heberden’s notes: the importance of osteoarthritis of the fingers to the practicing physician. Practitioner 1948;161(963):176-9. PMID: 18879550
  2. Spender, JK. On some hitherto undescribed symptoms in the early history of osteoarthritis: the so-called rheumatoid arthritis. Br Med J 1888;1(1424):781-3. PMID: 20752255
Subscribe to OSTEOARTHRITIS - GENERAL
⇡