Nov 02, 2014
Chronic disorder Degenerative joint disease result in progressive erosion
of articular cartilage
Epidemiology
Starts at 50 years of age Female > male (2: 1) 10% of general population
*OA increases in frequency with age. Not because of ageing but OA takes many years to develop.
Classification
Primary OA – idiopathic and appear insidiously arises without obvious predisposing
influences ( majority of cases) Oligo-articular
AgeGenetic – familial tendency
Obesity – OA knee
Secondary OA – presence of other predisposing factor Previous trauma and mechanical problem –
intrarticular # (stepping >1cm),recurrent dislocation
Infection – septic arthritis Congenital deformity of a joint- Perthe’s ds,
SUFE Inflammatory – RA Underlying systemic diseases
DM, Haemochromatosis, Obesity Knees & hands in women, Hips in men
Pathology
The cardinal features are: Progressive loss of cartilage thickness Subarticular cyst formation and sclerosis Remodelling of the bone ends and
osteophyte formation Synovial irritation Capsular fibrosis
Pathogenesis
the normal homeostasis in the joint is disturbed
OA is a disease of wear-&-tear based on: Occur in old age Weight bearing joints Increase frequency in the joints predisposed to
abnormal mechanical stress obese & previous joint deformity
Genetic factors Risk increased with:
Reduced Bone density High levels of oestrogen
Characterized by significant changes of: Composition Mechanical properties of cartilage
Early the degenerating cartilage Increased in water Decreased concentration of proteoglycans Weakening of collagen network (reduce type II
collagen) IL-1, TNF and NO are increased in the joint Increased apoptosis of chondrocytes
These resulted in: Reduce tensile strength Reduce resilience DEGENERATION
Morphology Early stage:
Increased in chondrocytes
Subsequently cracking of the matrix
Gross Granular surface Small fractures &
dislodge , producing ‘joint mice’
Osteophytes formation
Clinical features
Pain Stiffness Swelling Deformities Joint instability Loss of function
History
Age – 50++, obese? Occupation – what type? Any history of trauma that involve joint? Rule out secondary causes – cong, RA Any joint pain? – become worst by activity, relieve by rest(usually patient complaint cannot walk long distance, stand
for long) Joint stiffness – early morning, long rest Noticed swelling? Ask daily activity affected or not??- Climbing stairs- How do they pray?- House works – cooking, laundry
Physical examination
1. General examination Elderly, obese lady2. Inspection• Antalgic gait• Varus deformity• Muscle wasting over the quadriceps• Joint is swollen• No redness or discoloured 3. Palpation Min/no joint effusion (patella tap) Check for tenderness Synovial membrane not thickened Protuberant (osteophyte) at the edge of articular cartilage
4. Movement Limited (reduced ROM) Crepitus on movement5. Special test Valgus and varus stress test
Clinical course
Insidious onset Deep, achy pain that
worsen with use Morning stiffness Crepitus Limited ROM Impingement on
spinal foramina by osteophytes radicular pain, muscle spasm & atrophy
Typically, only one or a few joints
Joint involved: Hips Knees Lower lumbar & cervical Proximal & distal IP
joints First carpometacarpal First metatarsal
Heberden nodes: In women, not in
men Prominent
osteophytes at the distal IP joints
No satisfactory means of preventing primary OA
Permanent disability
Investigation
X – ray features: Narrowing or loss of joint space (1st sign of OA)
reflects loss of articular cartilage; main pathology Osteophyte formation-around the periphery of
the joint Subchondral sclerosis-looks very white on the
radiograph Subchondral cyst
Treatment of osteoarthritis can be divided into 2: Conservative management Operative management
indicated for patients with persistent symptoms
TREATMENTTry to treat patient conservatively, if failed-surgical
1. CONSERVATIV
E
Relieve pain– Analgesic and
NSAIDS- Intra articular corticosteroid- Rest period
and modification of
activity
To increase movement to
prevent ms wasting and
deformity/contracture-
physiotherapy/exercise
programme,non -weight bearing
exercise to strengthen ms
strength (cycling.swimming)
To reduce load on the joint
-Weight loss if patient is obese- Use of walking
stick to distribute the load- avoid
unnecessary stress,eg
jogging,climbing stairs
2.OPERATIVE MANAGEMENT
Arthroscopic debridement and
cleaning of the joint cavity and infusion
of synthetic synovial fluid
Realignment osteotomy- for
unicompartmental OA, to redistribute
the loading forcetowards less damaged parts of
the jt
Arthrodesis-If stiffness is
acceptable and neighbouring joints are not likely to be
prejudiced- Usually done in
young patient
Arthroplasty-Joint replacement- Usually done in
old patient