Osteoarthritis Show

8/3/2019 Osteoarthritis Show

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OsteoarthritisOsteoarthritis

Hoveda Mufti M.D.Hoveda Mufti M.D.

9/6/069/6/06


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DefinitionDefinition

Also known asAlso known asdegenerative jointdegenerative jointdisease or wear anddisease or wear andtear arthritis.tear arthritis.

Progressive loss ofProgressive loss ofcartilage withcartilage withremodeling ofremodeling ofsubchondral bone andsubchondral bone andprogressive deformityprogressive deformityof the joint (s).of the joint (s).

Cartilage destructionCartilage destructionmay be a result of amay be a result of a

variety of etiologiesvariety of etiologies


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Prevalence and epidemiologyPrevalence and epidemiology

Over 20 million affected in U.S.Over 20 million affected in U.S.About 60About 60--90% of people over age 6590% of people over age 65 Under 45 yrs it is equally common in menUnder 45 yrs it is equally common in men

and womenand women Over 55 yrs its more common in womenOver 55 yrs its more common in women Nodal OA involving DIP and PIP joints isNodal OA involving DIP and PIP joints is

more common in women and their firstmore common in women and their firstdegree female relativesdegree female relatives


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Premature OA associated with gene mutationsPremature OA associated with gene mutationsthat encode collagen types 2, 9, 10that encode collagen types 2, 9, 10

OA of knee is more common in African AmericanOA of knee is more common in African Americanwomenwomen

Commonest cause of longCommonest cause of long--term disabilityterm disability Large economic impact as a result of medicalLarge economic impact as a result of medicalcostscosts

OA cost the U.S. economy nearly $125 billionOA cost the U.S. economy nearly $125 billionper year in direct expenses and lost wages andper year in direct expenses and lost wages andproduction.production.


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It is not an inevitable part of aging, someIt is not an inevitable part of aging, somepeople are more susceptible than otherspeople are more susceptible than others

A combination of different factors areA combination of different factors are

involved.involved. Both mechanical and biologic destructiveBoth mechanical and biologic destructive

processes play a role in OA.processes play a role in OA.


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Risk factorsRisk factors

Metabolic (hemachromatosis)Metabolic (hemachromatosis) Inflammatory (RA, infection)Inflammatory (RA, infection) ageage

gendergender genetic factorsgenetic factors traumatrauma

weightweight


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ClassificationClassification PrimaryPrimary IdopathicIdopathic Localized orLocalized or

generalizedgeneralized

Local: knee, hip,Local: knee, hip,spine, handsspine, hands Generalized:Generalized: largelarge

joints and spinejoints and spine

Small peripheral jointsSmall peripheral jointsand spineand spine Mixed and spineMixed and spine

SecondarySecondary PostPost--traumataictraumataic Congenital orCongenital or

developmentaldevelopmental

Localized orLocalized orgeneralizedgeneralized

Calcium depositionCalcium depositiondiseasedisease

Other:Other: InflammatoryInflammatory Avascular necrosisAvascular necrosis


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Inflammatory OAInflammatory OA

OA is generally a nonOA is generally a non--inflammtory arthritis.inflammtory arthritis. Increasing evidence for inflammatory type:Increasing evidence for inflammatory type:

caused by cytokines, metalloproteinase release.caused by cytokines, metalloproteinase release.

This erosive inflammatory type may have flaresThis erosive inflammatory type may have flaresbut later acts like typical OA.but later acts like typical OA.

Primarily in womenPrimarily in women May be suspected from evidence of activeMay be suspected from evidence of active

synovitis, chondrocalcinosis on xsynovitis, chondrocalcinosis on x--rays, morningrays, morningstiffness greater than 30 mins, history ofstiffness greater than 30 mins, history ofswelling and night pain.swelling and night pain.


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Overview of the processOverview of the process

Articular cartilageArticular cartilagegets disruptedgets disrupted

Damage progressesDamage progressesdeeper todeeper tosubchondral bonesubchondral bone


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Fragments ofFragments ofcartilage released intocartilage released intojointjoint

Matrix degeneratesMatrix degenerates

Eventually there isEventually there iscomplete loss ofcomplete loss ofcartilagecartilage

Bone is exposedBone is exposed


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left: Normal xleft: Normal x--rayray Right: worn away cartilage reflected byRight: worn away cartilage reflected by

decreased joint spacedecreased joint space


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The processThe process at a cellular levelat a cellular level Cartilage matrix has increased water content andCartilage matrix has increased water content and

decreased proteoglycandecreased proteoglycan This is different from the changes that occur with agingThis is different from the changes that occur with aging

cartilage dries up.cartilage dries up. Increased activity of proteinases compared to inhibitorsIncreased activity of proteinases compared to inhibitors

of proteinases.of proteinases.

Breakdown products of cartilage cause inflammatoryBreakdown products of cartilage cause inflammatoryreaction of synoviumreaction of synovium Cytokines cause matrix degeneration. Where do theyCytokines cause matrix degeneration. Where do they

come from?come from? chondrocyteschondrocytes

Cycle of destruction startsCycle of destruction starts Compensatory bone overgrowth occursCompensatory bone overgrowth occurs -- subchondralsubchondralbone increases in densitybone increases in density


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Left: View of normal elbow cartilage through anLeft: View of normal elbow cartilage through an

arthroscopearthroscope -- white, glistening, smoothwhite, glistening, smoothRight: severe elbow osteoarthritisRight: severe elbow osteoarthritis -- cartilage is lostcartilage is lost

and the bone underneath is exposedand the bone underneath is exposed


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The process contdThe process contd

Bony proliferations at joint margins form,Bony proliferations at joint margins form,what are they called?what are they called? osteophytesosteophytes

Thought to be new bone formation inThought to be new bone formation inresponse to degenerating cartilageresponse to degenerating cartilage

They cause joint motion restrictionThey cause joint motion restriction


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What to look for in an xWhat to look for in an x--rayray

Radiographic changes visible relatively lateRadiographic changes visible relatively latein the diseasein the disease

Subchondral sclerosisSubchondral sclerosis

Joint space narrowing esp where there isJoint space narrowing esp where there isstressstress

Subchondral cystsSubchondral cysts

OsteophytesOsteophytes Bone mineralization should be normalBone mineralization should be normal


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Joint space narrowingJoint space narrowingwhere there is morewhere there is more

stressstress Subchondral bone hasSubchondral bone has

thickenedthickened

bony overgrowthbony overgrowth


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significant joint space narrowing as well as proliferativesignificant joint space narrowing as well as proliferativebone formation around the femoral neck (arrows)bone formation around the femoral neck (arrows)


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Left: normal hipLeft: normal hipRight: There is some joint space medially but the superior portion isRight: There is some joint space medially but the superior portion is

completely destroyed. Supralateral aspects affected most becausecompletely destroyed. Supralateral aspects affected most becausethe weight is transfered through the roof of the acetabulum.the weight is transfered through the roof of the acetabulum.

Note the sclerosis and oseophyte formation (arrow).Note the sclerosis and oseophyte formation (arrow).


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painful bone on bone contact at the CMC joint and the large bonepainful bone on bone contact at the CMC joint and the large bonespursspurs ---- osteophytes.osteophytes.


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XX--ray shows lateral osteophytes, varus deformity, narrow joint space inray shows lateral osteophytes, varus deformity, narrow joint space ina 70 yr old female with OAa 70 yr old female with OA


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Are crystals found in osteoarthritic joints?Are crystals found in osteoarthritic joints?YesYes Calcium pyrophosphate dihydrate andCalcium pyrophosphate dihydrate and

apatite.apatite.

Are of unknown significance andAre of unknown significance andasymptomaticasymptomatic


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Clinical features and diagnosisClinical features and diagnosis PainPainSourcesSources

Joint effusion and stretching of the joint capsuleJoint effusion and stretching of the joint capsule Torn menisciTorn menisci Inflammation of periarticular bursaeInflammation of periarticular bursae

Periarticular muscle spasmPeriarticular muscle spasm Psychological factorsPsychological factors

Deep, aching localized to the jointDeep, aching localized to the joint

Slow in onsetSlow in onset Worsened with activity in initial stagesWorsened with activity in initial stages Occurs at rest with advanced diseaseOccurs at rest with advanced disease


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May be referred eg hip pain referred toMay be referred eg hip pain referred tothe thigh, groin, knee.the thigh, groin, knee.

Pain may be aggravated with weatherPain may be aggravated with weatherchangeschanges


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ExamExam

Joint line tendernessJoint line tenderness Bony enlargement ofBony enlargement of

jointjoint +/+/-- effusioneffusion CrepitusCrepitus

Decreased range ofDecreased range ofmotionmotion


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Joint examJoint exam

Joint line pain canJoint line pain canindicate tear of theindicate tear of thelining of the capsulelining of the capsuleor the meniscus.or the meniscus.

Where is the patella?Where is the patella?


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Joint examJoint exam

In the evaluation of jointIn the evaluation of jointline pain, perform aline pain, perform a varusvarusoror valgus stress testvalgus stress test..

Apply stress across theApply stress across thejoint, place fingersjoint, place fingersdirectly over the joint linedirectly over the joint lineto assess for pain, a clunkto assess for pain, a clunk

may indicate amay indicate a meniscalmeniscalteartear, or crepitus may, or crepitus mayindicate cartilageindicate cartilagedamage.damage.


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Have the patient to lie supine on the examHave the patient to lie supine on the examtable with leg muscles relaxedtable with leg muscles relaxed Press the patella downward and quicklyPress the patella downward and quickly

release it.release it.

the patella visibly rebounds.the patella visibly rebounds. What does this mean?What does this mean?

a large knee effusiona large knee effusion Ballotable patellaBallotable patella


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Have the patient lie supineHave the patient lie supine

with leg muscles relaxedwith leg muscles relaxed Compress the suprapatellarCompress the suprapatellarpouch with your thumb, palm,pouch with your thumb, palm,and index finger.and index finger.

"Milk" downward and laterally"Milk" downward and laterallyso that any excess fluidso that any excess fluid

collects on the medial side.collects on the medial side. Tap gently over the collectedTap gently over the collected

fluid and observe the effect onfluid and observe the effect onthe lateral sidethe lateral side

A fullness on the lateral sideA fullness on the lateral sideindicates the presence smallindicates the presence small

knee effusionknee effusion


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Involved jointsInvolved joints

DIP, PIPDIP, PIP 11ststcarpometacarpalcarpometacarpal cervical/lumbar facet jointscervical/lumbar facet joints

11stst

metatarsophalangealmetatarsophalangeal HipsHips KneesKnees

UncommonUncommon Wrist, elbows, shoulders,Wrist, elbows, shoulders,anklesankles


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11ststmetatarsometatarso--phalangeal most commonlyphalangeal most commonlyaffected in OA of the foot.affected in OA of the foot.


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Typical findingsTypical findings

Heberdens nodesHeberdens nodes

Bouchards nodesBouchards nodes


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Rt: varus deformity of the kneeRt: varus deformity of the knee


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TreatmentTreatment

NonNon--pharmacokineticpharmacokinetic No proven medicationNo proven medication--based disease modifyingbased disease modifying

intervention exists.intervention exists. Analgesics (acetominophen)Analgesics (acetominophen) NSAIDSNSAIDS

Help pain symptoms but controversial for longHelp pain symptoms but controversial for longterm use in nonterm use in non--inflammatory OA because ofinflammatory OA because ofrisks vs benefitsrisks vs benefits

NarcoticsNarcotics

IntraIntra--articular steroidsarticular steroids Chondroprotective agentsChondroprotective agents AntiAnti--depressantsdepressants


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NonNon--pharmacokinetic rxpharmacokinetic rx

Reasonable evidence forReasonable evidence for

efficacyefficacy ExerciseExercise prevent disuseprevent disuse

atrophy of musclesatrophy of muscles

Physical therapy:Physical therapy:

Hydrotherapy/heat/cold,Hydrotherapy/heat/cold,paraffin bathsparaffin baths

Weight lossWeight loss EducationEducation

Wedges shoeWedges shoeinsoles/bracesinsoles/braces Refer to physiatrist forRefer to physiatrist for

management plan.management plan.


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AnalgesicsAnalgesics

Acetominophen at doses of upto 4g perAcetominophen at doses of upto 4g perdayday 2004 meta analysis of 10 trials showed2004 meta analysis of 10 trials showed

that acetominophen superior to placebothat acetominophen superior to placebobut less efficacious in relieving pain thanbut less efficacious in relieving pain thanNSAIDSNSAIDS

Do you worry about hepatotoxicity?Do you worry about hepatotoxicity?

Only seen in pts who are taking excessiveOnly seen in pts who are taking excessiveamounts of alcohol, underlying disease.amounts of alcohol, underlying disease.


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Opioid analgesicsOpioid analgesics

Generally should be avoided for long termGenerally should be avoided for long termuseuse

For short term rx they may be effective. AFor short term rx they may be effective. Astudy showed oxycodone to be synergisticstudy showed oxycodone to be synergistic

with NSAIDS.with NSAIDS. In older pts use caution because of sideIn older pts use caution because of sideeffects such as confusion, constipation,effects such as confusion, constipation,sedation.sedation.

Can use tramadol with acetominophen, inCan use tramadol with acetominophen, inaddition to NSAID/COXaddition to NSAID/COX--2 inhibitor2 inhibitor


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A controlled study showed codeine andA controlled study showed codeine andacetominophen combination to beacetominophen combination to beequivalent to to tramadol andequivalent to to tramadol andacetominophenacetominophen

Consider opiates if pt is not a candidateConsider opiates if pt is not a candidatefor surgery, or is at high risk for sidefor surgery, or is at high risk for side

effects from NSAIDSeffects from NSAIDS


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NSAIDSNSAIDS

Useful in nonUseful in non--inflammatory OA when paininflammatory OA when painis moderate to severeis moderate to severe

Topical preparations availableTopical preparations available

PGE2 may contribute to local inflammationPGE2 may contribute to local inflammation

and so there is a role for NSAIDS inand so there is a role for NSAIDS ininflammatory OAinflammatory OA


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There is variability amongst patients inThere is variability amongst patients in

terms of side effects and efficacy ofterms of side effects and efficacy ofNSAIDSNSAIDS

NonNon--acetylated salicylates have less renalacetylated salicylates have less renaltoxicity:toxicity:

Sulindac, salsalateSulindac, salsalate

Indomethacin has been associated withIndomethacin has been associated withaccelerated joint destruction, so avoid itaccelerated joint destruction, so avoid itfor long term use in pts with hip OAfor long term use in pts with hip OA


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Selective COXSelective COX--2 inhibitors2 inhibitors

They have 200They have 200--300 times selectivity for300 times selectivity forCOXCOX--2 over COX2 over COX--1.1.

Less gastroduodenal toxicityLess gastroduodenal toxicity But if used with ASA pts may be atBut if used with ASA pts may be at

increased risk for GI bleeding.increased risk for GI bleeding.

Use GI prophylaxisUse GI prophylaxisAvoid in pts with atherosclerotic CADAvoid in pts with atherosclerotic CAD -- useuse

traditional NSAIDS with atraditional NSAIDS with aPPI/sucralfate/misoprostolPPI/sucralfate/misoprostol


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Side effectsSide effects

R

ash/hypersensitivityR

ash/hypersensitivity GI bleedingGI bleeding CNS dysfunction in elderlyCNS dysfunction in elderly

Impairment of renal/hepatic/plateletImpairment of renal/hepatic/plateletfunction. How can NSAIDS lead to renalfunction. How can NSAIDS lead to renaldysfunction?dysfunction?

By interfering with vasodilator renal PGBy interfering with vasodilator renal PGand causing renal ischemia.and causing renal ischemia.


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IntraIntra--articular corticosteroidsarticular corticosteroids May be used if NSAIDS are contraindicated,May be used if NSAIDS are contraindicated,

persistent pain despite use of other medications.persistent pain despite use of other medications. (not > 4 injections per year per joint)(not > 4 injections per year per joint) 2004 meta2004 meta--analysis of controlled trials (w/analysis of controlled trials (w/

placebo) showed short term improvement inplacebo) showed short term improvement in

knee pain, but efficacy in other joints isknee pain, but efficacy in other joints isuncertain.uncertain. saline vs steroid injection?saline vs steroid injection? A study comparing the two in knee OA showedA study comparing the two in knee OA showed

no effect on joint space narrowing or significantno effect on joint space narrowing or significantdifference in pain at the end of the study, butdifference in pain at the end of the study, butover a 2 yr period saline injections has less painover a 2 yr period saline injections has less painrelief.relief.


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IntraIntra--articular hyaluronansarticular hyaluronans

Evidence shows they have a smallEvidence shows they have a smalladvantage in terms of pain control,advantage in terms of pain control,compared to intracompared to intra--articular placebos orarticular placebos orNSAIDS.NSAIDS.

No evidence for improvement in functionNo evidence for improvement in function Two studies comparing intraTwo studies comparing intra--articulararticular

steroids to hyaluronans have come tosteroids to hyaluronans have come to

opposite conclusionsopposite conclusions--more trials aremore trials areneeded.needed.


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Surgical: arthroscopySurgical: arthroscopy

arthroscopy is not recommended forarthroscopy is not recommended fornonspecific "cleaning of the knee.nonspecific "cleaning of the knee.

Used to fix specific structural damage onUsed to fix specific structural damage on

imaging (repairing meniscal tears,imaging (repairing meniscal tears,removing fragments of torn menisci thatremoving fragments of torn menisci thatare producing symptoms).are producing symptoms).


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Joint replacementJoint replacement

If all other rxIf all other rxineffective, and painineffective, and painis severeis severe

Loss of joint functionLoss of joint function

Joints last 8Joints last 8--15 years15 yearswithout complicationswithout complications


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The endThe end

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