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Osteoarthritis
Dr. Angelo Smith M.D
WHPL
Osteoarthritis (OA)
• OA is the most common
form of arthritis and the most
common joint disease
• Most of the people who h...
•The repair mechanisms of tissue absorption and
synthesis get out of balance and result in
osteophyte formation (bone spur...
OA
OA is a disease of
joints that affects all
of the weight-bearing
components of the
joint:
•Articular
cartilage
•Menisci...
OA – Articular Cartilage
Articular cartilage is the main tissue affected
OA results in:
•Increased tissue swelling
•Change...
OA – Articular Cartilage
A) Normal articular
cartilage from 21-year
old adult (3000X)
B) Osteoarthritic
cartilage (3000X)
Commonly AffectsCommonly Affects
–Hips
–Knees
–Feet
–Spine
–Hands (Interphalangeal joints)
Uncommonly Affected Joints
• Shoulder
• Wrist
• Elbow
• Metacarpophalangeal joint
• TMJ
• SI
• Ankle
OA
Nodal osteoarthritis
Note bony
enlargement of distal
and proximal
interphalangeal
joints (Heberden's
nodes and
Bouchard...
Risk factors –
Conditions that contribute to
osteoarthritis
Age
• Ageisthestrongestrisk factorforOA.AlthoughOAcanstartinyoungadulthood,ifyouareover45yearsold,you
areathigherrisk.
Fem...
Hereditarygenedefect
• Adefectinoneofthe genesresponsibleforthecartilagecomponentcollagen cancausedeterioration ofcartilag...
Pathogenesis of Osteoarthritis
An Interplay of Factors
• Family history
of disease
• Increasing Age
• Being female
Risk factors you cannot change
• Overuse of the
joint
• Major injury
• Overweight
• Muscle
weakness
Risk factors you can change
Medical history
Physical exam
X-ray
Other tests
Diagnosing osteoarthritis
OA – Symptoms
• OA usually occurs slowly -
It may be many years before
the damage to the joint
becomes noticeable
• Only a...
Two Major Types of OA
• Primary or Idiopathic
– Most common type
– Diagnosed when there is no known cause for
the symptoms...
OA vs. Aging
Unlike aging, OA is progressive and a significantly
more active process
Osteoarthritis with lateral osteophyte, loss of articular cartilage and
some subchondral bony sclerosis- X-ray shows loss ...
Laboratory findings in OA
• THERE ARE NO DIAGNOSTIC LAB
TESTS FOR OSTEOARTHRITIS
• OA is not a systemic disease, therefore...
Synovial fluid analysis
• Severe, acute joint pain is an
uncommon manifestation of OA
• Clear fluidWBC <2000/mm3
• Normal ...
Differential Diagnosis
• Rheumatoid Arthritis
• Gout
• CPPD (Calcium pyrophosphate crystal
deposition disease)
• Septic Jo...
Asymmetrical joint space narrowing from loss of
articular cartilage
The medial (inside) part of the knee is most commonly ...
OA – Radiographic Diagnosis
•Asymmetrical
joint space
narrowing
•Periarticular
sclerosis
•Osteophytes
•Sub-chrondral
bone ...
OA – Arthroscopic Diagnosis
Normal Articular Cartilage
Ostearthritic degenerated cartilage
with exposed subchondral bone
A...
•OA is a condition which progresses slowly over a
period of many years and cannot be cured
•Treatment is directed at decre...
Management/Treatment of OA
• Goals
– Educate patient about disease and management
– Improve function
– Control pain
– Alte...
Management/Treatment of OA
• No known cure for OA
• HOWEVER
– Impaired muscle function
– Reduced fitness
• Affect pain and...
Management/Treatment of OA
• Pharmacologic
– Acetaminophen
– NSAIDS
• Cox-2 specific
inhibitors
• With PPI or
misoprostol
...
Treatment/Management of OA
• Pharmacologic
– Herbal therapy
• Avocado soybean unsaponifiables (ASU’s) with
promising resul...
Management/Treatment of OA
• Possible structure/disease modifying stuff
– Glucosamine
– Diacerein
– Cytokine inhibitors
– ...
Treatment/Management of OA
• Pharmacologic
– Glucosamine 20 studies with >2500 patients
• If only high quality studies eva...
Treatment/Management of OA
• Pharmacologic
– Diacerein
• Pain improved 5 points compared to placebo
• Over 3 years,
– Slow...
• I recommend in ALL patients with knee and
hip OA
– GS 1500 mg/ CS 800 mg
• 3 month trial, evaluate efficacy; continue if...
Management/Treatment of OA
• Non-pharmacologic
– Patient education
– Self-management
programs
– Weight loss
– PT/OT
– ROM ...
Summary
• Non-pharmacologic therapy is important in the
prevention and treatment of OA
• The best studied and most effecti...
OA – Arthroscopic Treatment
•In addition to being the most accurate way of determining how
advanced the osteoarthritis is:...
OA – Non-operative Treatments
•Pain medications
•Physical therapy
•Walking aids
•Shock absorption
•Re-alignment through
or...
•Osteoarthritis usually
affects the inside half
(medial compartment) of
the knee more often than
the outside (lateral
comp...
Proximal Tibial Osteotomy
•The result is that the weight bearing line of the lower
extremity moves more medially (towards ...
Proximal Tibial Osteotomy
•In the procedure to realign the
angles, a wedge of bone is
removed from the lateral side
of the...
The ultimate solution for osteoarthritis of the knee is to
replace the joint surfaces with an artificial knee joint:
•Usua...
•The ends of the femur, tibia, and patella are shaped to accept
the artificial surfaces.
•The end result is that all movin...
Total Knee Replacement
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
Osteoarthritis
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Osteoarthritis

Osteoarthritis - etiology and management simplified

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Osteoarthritis

  1. 1. Osteoarthritis Dr. Angelo Smith M.D WHPL
  2. 2. Osteoarthritis (OA) • OA is the most common form of arthritis and the most common joint disease • Most of the people who have OA are older than age 45, and women are more commonly affected than men. • OA most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.
  3. 3. •The repair mechanisms of tissue absorption and synthesis get out of balance and result in osteophyte formation (bone spurs) and bone cysts
  4. 4. OA OA is a disease of joints that affects all of the weight-bearing components of the joint: •Articular cartilage •Menisci •Bone
  5. 5. OA – Articular Cartilage Articular cartilage is the main tissue affected OA results in: •Increased tissue swelling •Change in color •Cartilage fibrillation •Cartilage erosion down to subchondral bone
  6. 6. OA – Articular Cartilage A) Normal articular cartilage from 21-year old adult (3000X) B) Osteoarthritic cartilage (3000X)
  7. 7. Commonly AffectsCommonly Affects –Hips –Knees –Feet –Spine –Hands (Interphalangeal joints)
  8. 8. Uncommonly Affected Joints • Shoulder • Wrist • Elbow • Metacarpophalangeal joint • TMJ • SI • Ankle
  9. 9. OA Nodal osteoarthritis Note bony enlargement of distal and proximal interphalangeal joints (Heberden's nodes and Bouchard's nodes, respectively).
  10. 10. Risk factors – Conditions that contribute to osteoarthritis
  11. 11. Age • Ageisthestrongestrisk factorforOA.AlthoughOAcanstartinyoungadulthood,ifyouareover45yearsold,you areathigherrisk. Femalegender • Ingeneral,arthritisoccursmorefrequentlyinwomenthaninmen.Beforeage45,OAoccursmorefrequently inmen; afterage45,OAismorecommonin women.OAofthehandisparticularlycommonamongwomen. Jointalignment • Peoplewithjointsthatmoveorfittogetherincorrectly,suchasbowlegs,adislocatedhip,ordouble-jointedness,are OA – Risk Factors
  12. 12. Hereditarygenedefect • Adefectinoneofthe genesresponsibleforthecartilagecomponentcollagen cancausedeterioration ofcartilage. Jointinjury oroverusecausedby physicallabororsports • Traumaticinjury(ex.Ligamentormeniscaltears)tothekneeorhipincreasesyourriskfordevelopingOAinthese joints.Jointsthatareusedrepeatedlyincertainjobsmay bemore likelytodevelopOAbecauseofinjuryoroveruse. Obesity • BeingoverweightduringmidlifeorthelateryearsisamongthestrongestriskfactorsforOAoftheknee.
  13. 13. Pathogenesis of Osteoarthritis An Interplay of Factors
  14. 14. • Family history of disease • Increasing Age • Being female Risk factors you cannot change
  15. 15. • Overuse of the joint • Major injury • Overweight • Muscle weakness Risk factors you can change
  16. 16. Medical history Physical exam X-ray Other tests Diagnosing osteoarthritis
  17. 17. OA – Symptoms • OA usually occurs slowly - It may be many years before the damage to the joint becomes noticeable • Only a third of people whose X-rays show OA report pain or other symptoms: – Steady or intermittent pain in a joint – Stiffness that tends to follow periods of inactivity, such as sleep or sitting – Swelling or tenderness in one or more joints [not necessarily occurring on both sides of the body at the same time] – Crunching feeling or sound of bone rubbing on bone (called crepitus) when the joint is used
  18. 18. Two Major Types of OA • Primary or Idiopathic – Most common type – Diagnosed when there is no known cause for the symptoms • Secondary – Diagnosed when there is an identifiable cause • Trauma or Underlying joint disorder • Each of these major types has subtypes
  19. 19. OA vs. Aging Unlike aging, OA is progressive and a significantly more active process
  20. 20. Osteoarthritis with lateral osteophyte, loss of articular cartilage and some subchondral bony sclerosis- X-ray shows loss of joint space OA – Overall Changes
  21. 21. Laboratory findings in OA • THERE ARE NO DIAGNOSTIC LAB TESTS FOR OSTEOARTHRITIS • OA is not a systemic disease, therefore: – ESR, Chem 7, CBC, and UA all WNL • Synovial fluid • Mild leukocytosis (<2000 WBC/microliter) • Can be used to exclude gout, CPPD, or septic arthritis if diagnosis is in doubt
  22. 22. Synovial fluid analysis • Severe, acute joint pain is an uncommon manifestation of OA • Clear fluidWBC <2000/mm3 • Normal viscosity
  23. 23. Differential Diagnosis • Rheumatoid Arthritis • Gout • CPPD (Calcium pyrophosphate crystal deposition disease) • Septic Joint • Polymyalgia Rheumatica
  24. 24. Asymmetrical joint space narrowing from loss of articular cartilage The medial (inside) part of the knee is most commonly affected by osteoarthritis. OA – Radiographic Diagnosis
  25. 25. OA – Radiographic Diagnosis •Asymmetrical joint space narrowing •Periarticular sclerosis •Osteophytes •Sub-chrondral bone cysts
  26. 26. OA – Arthroscopic Diagnosis Normal Articular Cartilage Ostearthritic degenerated cartilage with exposed subchondral bone Arthroscopy allows earlier diagnosis by demonstrating the more subtle cartilage changes that are not visible on x-ray
  27. 27. •OA is a condition which progresses slowly over a period of many years and cannot be cured •Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition •Functional treatment goals: •Limit pain •Increase range of motion •Increase muscle strength OA – Disease Management
  28. 28. Management/Treatment of OA • Goals – Educate patient about disease and management – Improve function – Control pain – Alter disease process and its consequences
  29. 29. Management/Treatment of OA • No known cure for OA • HOWEVER – Impaired muscle function – Reduced fitness • Affect pain and dysfunction • Are amenable to therapeutic exercise
  30. 30. Management/Treatment of OA • Pharmacologic – Acetaminophen – NSAIDS • Cox-2 specific inhibitors • With PPI or misoprostol – Nonacetylated salicylate – Tramadol – Opioids • Topical – Capsaicin – Methylsalicylate – NSAIDS • Intra-articular – Corticosteroids – Hyaluronic acid
  31. 31. Treatment/Management of OA • Pharmacologic – Herbal therapy • Avocado soybean unsaponifiables (ASU’s) with promising results in 2 studies on: – Functional index, pain, NSAID use, and global evaluation • Reumalex (willow bark preparation) inconclusive • Tipi tea inconclusive
  32. 32. Management/Treatment of OA • Possible structure/disease modifying stuff – Glucosamine – Diacerein – Cytokine inhibitors – Cartilage repair – Bisphosphonates – Degradative enzyme inhibitors • Tetracyclines, metalloproteinase inhibitors
  33. 33. Treatment/Management of OA • Pharmacologic – Glucosamine 20 studies with >2500 patients • If only high quality studies evaluated: – No benefit over placebo on pain • If all studies included: – Pain may improve by as much as 13 points • 2 RCT’s using Rotta preparation: – Demonstrated slowing of radiological progression of OA over a 3 year period
  34. 34. Treatment/Management of OA • Pharmacologic – Diacerein • Pain improved 5 points compared to placebo • Over 3 years, – Slowed progress of OA in the hip compared to placebo – Did not slow progress of OA in the knee • Diarrhea is most common side effect – 42 out of 100 had diarrhea in the first 2 weeks – 18 discontinued because of side effects (13 in placebo)
  35. 35. • I recommend in ALL patients with knee and hip OA – GS 1500 mg/ CS 800 mg • 3 month trial, evaluate efficacy; continue if helping • Consider indefinite use even if no pain relief for joint space preservation Glucosamine/Chondroitin--My Take
  36. 36. Management/Treatment of OA • Non-pharmacologic – Patient education – Self-management programs – Weight loss – PT/OT – ROM exercises – Muscle strengthening • Non-pharmacologic – Assistive devices – Patellar taping – Appropriate footwear – Lateral-wedged insoles – Bracing – Joint protection and energy conservation
  37. 37. Summary • Non-pharmacologic therapy is important in the prevention and treatment of OA • The best studied and most effective non- pharmacologic therapy is EXERCISE • Exercise helps control weight, increase strength, improve and maintain function and decrease pain • Traditional belief - patients concerned that joint use will “wear out” a damaged joint that is already “worn out” - NOT true for moderate intensity exercises
  38. 38. OA – Arthroscopic Treatment •In addition to being the most accurate way of determining how advanced the osteoarthritis is: •Arthroscopy also allows the surgeon to debride the knee joint •Debridement essentially consists of cleaning out the joint of all debris and loose fragments. During the debridment any loose fragments of cartilage are removed and the knee is washed with a saline solution. •The areas of the knee joint which are badly worn may be roughened with a burr to promote the growth of new cartilage - a fibrocartilage material that is similar scar tissue. •Debridement of the knee using the arthroscope is not 100% successful. If successful, it usually affords temporary relief of symptoms for somewhere between 6 months - 2 years. •Arthroscopy also allows access for surgical treatment of articular cartilage: graft-transplantation, micro-fracture techniques, sub- chondral drilling
  39. 39. OA – Non-operative Treatments •Pain medications •Physical therapy •Walking aids •Shock absorption •Re-alignment through orthotics •Limit strain to affected areas
  40. 40. •Osteoarthritis usually affects the inside half (medial compartment) of the knee more often than the outside (lateral compartment). •This can lead to the lower extremity becoming slightly bowlegged, or in medical terms, a genu varum deformity Proximal Tibial Osteotomy
  41. 41. Proximal Tibial Osteotomy •The result is that the weight bearing line of the lower extremity moves more medially (towards the medial compartment of the knee). •The end result is that there is more pressure on the medial joint surfaces, which leads to more pain and faster degeneration. •In some cases, re-aligning the angles in the lower extremity can result in shifting the weight-bearing line to the lateral compartment of the knee. This, presumably, places the majority of the weight-bearing force into a healthier compartment. The result is to reduce the pain and delay the progression of the degeneration of the medial compartment.
  42. 42. Proximal Tibial Osteotomy •In the procedure to realign the angles, a wedge of bone is removed from the lateral side of the upper tibia. •A staple or plate and screws are used to hold the bone in place until it heals. •This converts the extremity from being bow-legged to knock-kneed. •The Proximal Tibial Osteotomy buys some time before ultimately needing to perform a total knee replacement. The operation probably lasts for 5-7 years if successful.
  43. 43. The ultimate solution for osteoarthritis of the knee is to replace the joint surfaces with an artificial knee joint: •Usually only considered in people over the age of 60 •Artificial knee joints last about 12 years in an elderly population •Not recommended in younger patients because: •The younger the patient, the more likely the artificial joint will fail •Replacing the knee the second and third time is much harder and much less likely to succeed. •Younger patients are more active and place more stress on the artificial joint, that can lead to loosening and failure earlier •Younger patients are also more likely to outlive their artificial joint, and will almost surely require a revision at some point down the road. •Younger patients sometimes require the surgery (simply because no other acceptable solution is available to treat their condition) Total Knee Replacement
  44. 44. •The ends of the femur, tibia, and patella are shaped to accept the artificial surfaces. •The end result is that all moving surfaces of the knee are metal against plastic Total Knee Replacement
  45. 45. Total Knee Replacement

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