Osteoarthritis

OsteoarthritisOsteoarthritis

Prof. DrProf. Dr..

Heba Abd El Wahab SeliemHeba Abd El Wahab Seliem

DefinitionDefinition OsteoarthritisOsteoarthritis) ) OAOA, also known as, also known as

degenerativedegenerative arthritis or or degenerative joint degenerative joint diseasedisease), is a group of diseases and mechanical ), is a group of diseases and mechanical abnormalities involving degradation ofabnormalities involving degradation of jointsjoints includingincluding articular cartilage and the and the subchondral bone next to it next to it. .

OA is the most prevalent form of arthritisOA is the most prevalent form of arthritis . . It It affect the joints of the hand, spine and weight affect the joints of the hand, spine and weight bearing joints (hips and knees of lower bearing joints (hips and knees of lower extremityextremity..

*OA is the most common form of arthritis and the most common joint disease

*Over 10 million Americans suffer from OA of the knee alone

*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.

osteoarthritisosteoarthritis

AETIOLOGY

*Osteoarthritis may result from wear and tear on the joint

•The normal cartilage lining is gradually worn away and the underlying bone is exposed.

OsteoarthritisOsteoarthritis(OA or Degenerative Arthritis)(OA or Degenerative Arthritis)

Osteoarthritis is a type of Osteoarthritis is a type of arthritis that is that is caused by breakdown of cartilage, with caused by breakdown of cartilage, with eventual loss of the cartilage of the joints. eventual loss of the cartilage of the joints. Cartilage is a protein substance that serves as a Cartilage is a protein substance that serves as a "cushion" between the bones of the joints. "cushion" between the bones of the joints. When the cartilage deteriorates (degenerates), When the cartilage deteriorates (degenerates), the bone next to it becomes inflamed and can the bone next to it becomes inflamed and can be stimulated to produce new bone in the form be stimulated to produce new bone in the form of a local bony protrusion, called a "spur."of a local bony protrusion, called a "spur."

OA can be classified as primary or secondary according to its cause or major predisposing factors. Primary OA is the most common type and has no identifiable etiology or predisposing cause. Secondary OA although it has an identifiable underlying cause, is pathologically indistinguishable from primary OA.

Risk factorsRisk factors::

Age

Age is the strongest risk factor for OA. Although OA can start in

young adulthood, if you are over 45 years old, you are at higher

risk .

Female gender

In general, arthritis occurs more frequently in women than in men.

Before age 45, OA occurs more frequently in men; after age 45,

OA is more common in women. OA of the hand is particularly

common among women .

Joint alignment

People with joints that move or fit together incorrectly, such as bow

legs, a dislocated hip, or double-jointedness, are more likely to

develop OA in those joints .

Hereditary gene defectA defect in one of the genes responsible for the cartilage component collagen can cause deterioration of cartilage .

Joint injury or overuse caused by physical labor or sports

Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip

increases your risk for developing OA in these joints. Joints that

are used repeatedly in certain jobs may be more likely to

develop OA because of injury or overuse .

Obesity

Being overweight during midlife or the later years is among the

strongest risk factors for OA of the knee .

ClassificationClassification Osteoarthritis can be Osteoarthritis can be

classified into either classified into either primary or secondary primary or secondary depending on if there is depending on if there is or is not an identifiable or is not an identifiable underlying cause.underlying cause.

Primary OA Primary OA 1-Localized OA1-Localized OA HeberdenHeberden’’ nodes in the DIP nodes in the DIP

without other joint involvemet without other joint involvemet represent the most common represent the most common form of primary OA.form of primary OA.

Genetic factors are important in Genetic factors are important in the development of heberdenthe development of heberden’’s s nodes.nodes.

These nodes are ten times more These nodes are ten times more common in women than men.common in women than men.

Primary OAPrimary OA 2-Generalized OA2-Generalized OA It is defined by involvement of 3 or more joints.It is defined by involvement of 3 or more joints. OA commonly affects the OA commonly affects the hands, , feet, , spine, and the , and the

large large weight bearing joints, such as the joints, such as the hips and and knees, although in theory, any joint in the body can , although in theory, any joint in the body can be affected. As OA progresses, the affected joints be affected. As OA progresses, the affected joints appear larger, are stiff and painful, and usually feel appear larger, are stiff and painful, and usually feel worseworse, the more they are used throughout the day, , the more they are used throughout the day, thus distinguishing it from thus distinguishing it from rheumatoid arthritis..

Primary OAPrimary OA In smaller joints, such as at the fingers, hard bony In smaller joints, such as at the fingers, hard bony

enlargements, called enlargements, called Heberden's nodes (on the distal (on the distal interphalangeal joints) and/or interphalangeal joints) and/or Bouchard's nodes (on (on the proximal interphalangeal joints), may form, and the proximal interphalangeal joints), may form, and though they are not necessarily painful, they do limit though they are not necessarily painful, they do limit the movement of the fingers significantly. OA at the the movement of the fingers significantly. OA at the toes leads to the formation of toes leads to the formation of bunions, rendering , rendering them red or swollen. Some people notice these them red or swollen. Some people notice these physical changes before they experience any pain. physical changes before they experience any pain.

Secondary OASecondary OA This type of OA is caused by other factors but the This type of OA is caused by other factors but the

resulting pathology is the same as for primary OA:resulting pathology is the same as for primary OA: Congenital disorders of joints of joints Diabetes. . Inflammatory diseases (such as Inflammatory diseases (such as Perthes' disease), (), (

Lyme disease), and all chronic forms of arthritis (e.g. ), and all chronic forms of arthritis (e.g. costochondritis, , gout, and rheumatoid arthritis). In , and rheumatoid arthritis). In gout, gout, uric acid crystals cause the cartilage to crystals cause the cartilage to degenerate at a faster pace. degenerate at a faster pace.

Injury to joints, as a result of an to joints, as a result of an accident. .

Secondary OASecondary OA Septic arthritis ( a infection of a joint ) ( a infection of a joint ) Ligamentous deterioration or instability may deterioration or instability may

be a factor. be a factor. Marfan syndrome Obesity Alkaptonuria Hemochromatosis and and Wilson's disease

Pathological changesPathological changes

II.. Early changes: Early changes:The articular cartilage surface becomes The articular cartilage surface becomes

irregular, superficial clefts within the irregular, superficial clefts within the tissue become apparent.tissue become apparent.

Distribution of prototeoglycan is alteredDistribution of prototeoglycan is altered . .

II. late changes:II. late changes: - - Clefts deepen .Clefts deepen . - Surface irregularities increase. - Surface irregularities increase. - Articular cartilage ulcerates, exposing - Articular cartilage ulcerates, exposing

the underlying bone.the underlying bone. - Marginal osteophytes form.- Marginal osteophytes form. - Water content - Water content ↓↓ 60-70% in superfacial 60-70% in superfacial

zone of articular cartilagezone of articular cartilage.. - Type І collagen concentration increase - Type І collagen concentration increase

within extracellular matrix within extracellular matrix

DIAGNOSIS OF OADIAGNOSIS OF OA

ACR radiologic and clinical ACR radiologic and clinical criteria for OA:criteria for OA:

Knee OA:Knee OA:I.I. knee pain (mechanical) plus one of the knee pain (mechanical) plus one of the

followingfollowing: : ► 1.Age>50y.1.Age>50y.► 2.MS <30m.2.MS <30m.► 3.Crepitus3.CrepitusII. Radiological osteophytes.II. Radiological osteophytes.

Asymmetrical joint space narrowing Periarticular sclerosis Osteophytes Sub-chrondral bone cysts

OA – SymptomsOA – Symptoms

**OA usually occurs slowly - It may be many OA usually occurs slowly - It may be many years before the damage to the joint years before the damage to the joint becomes noticeablebecomes noticeable

**Only a third of people whose x-rays show Only a third of people whose x-rays show OA report pain or other symptomsOA report pain or other symptoms::

*Steady or intermittent pain in a jointStiffness 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

What are symptoms of What are symptoms of osteoarthritisosteoarthritis??

Osteoarthritis of the cervical spine or lumbar Osteoarthritis of the cervical spine or lumbar spine cause pain in the neck or low back. Bony spine cause pain in the neck or low back. Bony spurs, called osteophytes, that form along the spurs, called osteophytes, that form along the arthritic spine can irritate spinal nerves, arthritic spine can irritate spinal nerves, causing severe pain, numbness, and tingling of causing severe pain, numbness, and tingling of the affected parts of the body.the affected parts of the body.

General Clinical ManifestationsGeneral Clinical Manifestations A- HistoryA- History SymptomsSymptoms Symptomatic patients are usually over 40.Symptomatic patients are usually over 40. Pain is gradual onset in one or few joints.Pain is gradual onset in one or few joints. Pain first occur after normal joint use & is Pain first occur after normal joint use & is

relived by rest.relived by rest. As the disease progresses pain during rest As the disease progresses pain during rest

develops & night pain is common.develops & night pain is common.

General Clinical ManifestationsGeneral Clinical Manifestations Morning stiffness & stiffness after inactivity Morning stiffness & stiffness after inactivity

are common. are common. Systemic symptoms are absent.Systemic symptoms are absent. 2-The most common joints involved are:2-The most common joints involved are: DIP jointsDIP joints First CMC jointFirst CMC joint First MTP jointFirst MTP joint Knee jointsKnee joints

General Clinical ManifestationsGeneral Clinical Manifestations Hip jointsHip joints Lumber spinesLumber spines Cervical spinesCervical spines 3-The rare joints involved are:3-The rare joints involved are: MCP jointsMCP joints Wirst jointsWirst joints Elbow jointsElbow joints Shoulder &Ankle jointsShoulder &Ankle joints

General Clinical ManifestationsGeneral Clinical Manifestations B- Physical ExaminationB- Physical Examination Localized joint tenderness.Localized joint tenderness. If synovitis is present→ swelling, warmth & If synovitis is present→ swelling, warmth &

erythema are present.erythema are present. Pain with weight bearing without pain on Pain with weight bearing without pain on

passive range of motion.passive range of motion.

General Clinical ManifestationsGeneral Clinical Manifestations Joint enlargement may Joint enlargement may

result fromresult from Presense of effusion ORPresense of effusion OR Synovial hyperplasia ORSynovial hyperplasia OR OsteophytesOsteophytes As the disease progress As the disease progress

there may be:there may be: Crepitus, Gross deformity, Crepitus, Gross deformity,

or subluxationor subluxation

How is osteoarthritis diagnosed?How is osteoarthritis diagnosed?

There is no blood test for the diagnosis of There is no blood test for the diagnosis of osteoarthritis. Blood tests are performed to osteoarthritis. Blood tests are performed to exclude diseases that can cause secondary exclude diseases that can cause secondary osteoarthritis, as well as to exclude other osteoarthritis, as well as to exclude other arthritis conditions that can mimic arthritis conditions that can mimic osteoarthritis osteoarthritis

How is osteoarthritis diagnosed?How is osteoarthritis diagnosed?

X-rays of the affected joints can suggest X-rays of the affected joints can suggest osteoarthritis. The common osteoarthritis. The common X-ray findings of findings of osteoarthritis include loss of joint cartilage, osteoarthritis include loss of joint cartilage, narrowing of the joint space between adjacent narrowing of the joint space between adjacent bones, and bone spur formation. Simple X-ray bones, and bone spur formation. Simple X-ray testing can be very helpful to exclude other testing can be very helpful to exclude other causes of pain in a particular joint as well as causes of pain in a particular joint as well as assist in decision making as to when surgical assist in decision making as to when surgical intervention should be considered.intervention should be considered.

How is osteoarthritis diagnosed?How is osteoarthritis diagnosed?

Arthrocentesis is often performed in the is often performed in the doctor's office. During arthrocentesis, a sterile doctor's office. During arthrocentesis, a sterile needle is used to remove joint fluid for needle is used to remove joint fluid for analysis. Joint fluid analysis is useful in analysis. Joint fluid analysis is useful in excluding gout, infection, and other causes of excluding gout, infection, and other causes of arthritis. Removal of joint fluid and injection arthritis. Removal of joint fluid and injection of corticosteroids into the joints during of corticosteroids into the joints during arthrocentesis can help relieve pain, swelling, arthrocentesis can help relieve pain, swelling, and inflammation.and inflammation.

How is osteoarthritis diagnosedHow is osteoarthritis diagnosed??

Finally, a careful analysis of the location, Finally, a careful analysis of the location, duration, and character of the joint symptoms duration, and character of the joint symptoms and the appearance of the joints helps the and the appearance of the joints helps the doctor in diagnosing osteoarthritis. Bony doctor in diagnosing osteoarthritis. Bony enlargement of the joints from spur formations enlargement of the joints from spur formations is characteristic of osteoarthritis. Therefore, is characteristic of osteoarthritis. Therefore, the presence of Heberden's nodes, Bouchard's the presence of Heberden's nodes, Bouchard's nodes, and bunions of the feet can indicate to nodes, and bunions of the feet can indicate to the doctor a diagnosis of osteoarthritis.the doctor a diagnosis of osteoarthritis.

OA – Disease Management

OA is a condition which progresses slowly over a period of many years and cannot be curedTreatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition

Functional treatment goals:Limit painIncrease range of motion

•Increase muscle strength

General TreatmentGeneral Treatment *Reassurance of the patients.*Reassurance of the patients. *Correction of predisposing factors before *Correction of predisposing factors before

anatomical factors occur:anatomical factors occur: -weight reduction.-weight reduction. -Valgus & varus knee deformity.-Valgus & varus knee deformity. -Eversion & inversion ankle deformity. -Eversion & inversion ankle deformity.

General TreatmentGeneral Treatment *Joint rest *Joint rest -Excessive use of an involved joint may -Excessive use of an involved joint may

increase symptoms & accelerate degenerative increase symptoms & accelerate degenerative changes.changes.

Weight bearing may be unloaded by use of a Weight bearing may be unloaded by use of a cane (held in the hand opposite to the involved cane (held in the hand opposite to the involved extremity) or walker.extremity) or walker.

TreatmentTreatment Lifestyle modificationLifestyle modification No matter the severity or location of OA, No matter the severity or location of OA,

conservative measures such as conservative measures such as weight control, , appropriate appropriate rest, , exercise, and the use of , and the use of mechanical support devices can be beneficial. mechanical support devices can be beneficial. In OA of the knees, In OA of the knees, knee braces can be can be helpful. A cane, or a helpful. A cane, or a walker can reduce can reduce pressure on involved leg joints which can be pressure on involved leg joints which can be helpful for walking and support. helpful for walking and support.

Physical measuresPhysical measures Relieve pain & stiffness.Relieve pain & stiffness. Recover & maintain joint mobility.Recover & maintain joint mobility. Strengthen supporting muscles.Strengthen supporting muscles. A) Heat therapy: (Infra-red, short wave, hot A) Heat therapy: (Infra-red, short wave, hot

packs, ultra-sound & paraffin wax).packs, ultra-sound & paraffin wax). B) Therapeutic exercises.B) Therapeutic exercises.

Medical:Medical:► NSAIDsNSAIDs► Intra articular steroids, hyaloronic acid Intra articular steroids, hyaloronic acid

derivativesderivatives► Nutriceuticals: nutritional supplements, as Nutriceuticals: nutritional supplements, as

glucosamine and chondroitin sulphate. They glucosamine and chondroitin sulphate. They stimulate of synthesis of cartilage .stimulate of synthesis of cartilage .

MedicationMedication Paracetamol (analgesics)Paracetamol (analgesics) Paracetamol (acetaminophen), is commonly used to Paracetamol (acetaminophen), is commonly used to

treat the pain from OA treat the pain from OA

Non-steroidal anti-inflammatory drugs Non-steroidal anti-inflammatory drugs In more severe cases, In more severe cases,

non-steroidal anti-inflammatory drugs (NSAID) (NSAID) reduce both the pain and inflammation; they all act by reduce both the pain and inflammation; they all act by inhibiting the formation of inhibiting the formation of prostaglandins, which play , which play a central role in inflammation and pain a central role in inflammation and pain

Non-steroidal anti-inflammatory Non-steroidal anti-inflammatory drugs drugs

Most prominent drugs in the class include Most prominent drugs in the class include diclofenac, , ibuprofen, ibuprofen, naproxen and and ketoprofen. High oral drug . High oral drug doses are often required.doses are often required.

Even more importantly all systemic NSAIDs are Even more importantly all systemic NSAIDs are rather taxing on the rather taxing on the gastrointestinal tract, and may , and may cause cause stomach upset, upset, cramping, , diarrhea, and , and peptic ulcer. Such systemic adverse side effects are . Such systemic adverse side effects are normally not observed when using NSAIDs topically, normally not observed when using NSAIDs topically, that is, on the skin around the target area. that is, on the skin around the target area.

Non-steroidal anti-inflammatory Non-steroidal anti-inflammatory drugsdrugs

Another type of NSAID, Another type of NSAID, COX-2 selective inhibitors (such as (such as celecoxib, , rofecoxib and and valdecoxib) have often been used ) have often been used but are no more effective than the other but are no more effective than the other NSAIDs. The latter two NSAIDs (rofecoxib and NSAIDs. The latter two NSAIDs (rofecoxib and valdecoxib) carry an elevated risk for valdecoxib) carry an elevated risk for cardiovascular disease, and have been , and have been withdrawn from the market. Studies suggest that withdrawn from the market. Studies suggest that naproxen has the lowest cardiovascular risk. has the lowest cardiovascular risk.

Corticosteroids Corticosteroids Oral Oral steroids are not recommended in the are not recommended in the

treatment of OA because of their modest treatment of OA because of their modest benefit and high rate of adverse effects. benefit and high rate of adverse effects. However intra - articular corticosteroid However intra - articular corticosteroid temporarily improve symptoms as discussed temporarily improve symptoms as discussed below.below.

Topical Topical There are several NSAIDs available for topical use There are several NSAIDs available for topical use

(e.g. diclofenac, ibuprofen, and ketoprofen) with (e.g. diclofenac, ibuprofen, and ketoprofen) with little, if any, systemic side-effects and at least some little, if any, systemic side-effects and at least some therapeutic effect. The more modern NSAID therapeutic effect. The more modern NSAID formulations for direct use, containing the drugs in an formulations for direct use, containing the drugs in an organic solution or the Transfersome carrier based organic solution or the Transfersome carrier based gel, reportedly, are as effective as oral NSAIDs.gel, reportedly, are as effective as oral NSAIDs.

Creams and lotions, containing capsaicin, are Creams and lotions, containing capsaicin, are effective in treating pain associated with OA if they effective in treating pain associated with OA if they are applied with sufficient frequency.are applied with sufficient frequency.

Injectable Injectable A 2005 review of injections of hyaluronic A 2005 review of injections of hyaluronic

acid, known as viscosupplementation, did not acid, known as viscosupplementation, did not find that it led to clinical improvement in find that it led to clinical improvement in OA.A subsequent 2009 study found similar OA.A subsequent 2009 study found similar results. Injection of glucocorticoids (such as results. Injection of glucocorticoids (such as hydrocortisone) leads to short term pain relief hydrocortisone) leads to short term pain relief that may last between a few weeks and a few that may last between a few weeks and a few months months

Surgery Surgery If the above management is ineffective, joint If the above management is ineffective, joint

replacement surgery may be required. replacement surgery may be required. Individuals with very painful OA joints may Individuals with very painful OA joints may require surgery such as fragment removal, require surgery such as fragment removal, repositioning bones, or fusing bone to increase repositioning bones, or fusing bone to increase stability and reduce pain. Arthroscopic stability and reduce pain. Arthroscopic surgical intervention for osteoarthritis of the surgical intervention for osteoarthritis of the knee has been found to be no better than knee has been found to be no better than placebo at relieving symptoms placebo at relieving symptoms