OsteoarthritisOsteoarthritisIntroductionIntroductionBackgroundBackgroundOsteoarthritis (OA) is the most common Osteoarthritis (OA) is the most common articular disease worldwidearticular disease worldwide..

It also called degenerative joint disease, represents failure of the diarthrodial (movable, synovial-lined) joint.

Idiopathic (primary) OA:

•The most common form of the disease, no predisposing factor is apparent .

Secondary OA:

pathologically indistinguishable from idiopathic OA but is attributable to anunderlying cause

PathophysiologyPathophysiology

• It involves the entire joint organ, including the subchondral It involves the entire joint organ, including the subchondral bone and synovium.bone and synovium.

• Inflammation occurs as cytokines and metalloproteinases Inflammation occurs as cytokines and metalloproteinases are released into the joint. are released into the joint.

• Osteoarthritis predominantly involves the weight-bearing Osteoarthritis predominantly involves the weight-bearing joints, including the knees, hips, cervical and lumbosacral joints, including the knees, hips, cervical and lumbosacral spine, and feet. Other commonly affected joints include the spine, and feet. Other commonly affected joints include the distal interphalangeal (DIP) and proximal interphalangeal distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of the hands.(PIP) joints of the hands.

• Cartilage is grossly affected.Cartilage is grossly affected.• Focal ulcerations eventually lead to cartilage loss and Focal ulcerations eventually lead to cartilage loss and

eburnation. Subchondral bone formation also occurs, with eburnation. Subchondral bone formation also occurs, with development of bony osteophytes.development of bony osteophytes.

The etiopathogenesisThe etiopathogenesis•

Stage 1: Stage 1: Proteolytic breakdown of the cartilage matrix. Chondrocyte Proteolytic breakdown of the cartilage matrix. Chondrocyte

metabolism is affectedmetabolism is affected, , leading to an increased production of leading to an increased production of enzymes, which includes metalloproteinases (eg, collagenase, enzymes, which includes metalloproteinases (eg, collagenase, stromelysin) that destroy the cartilage matrixstromelysin) that destroy the cartilage matrix . .

Stage 2Stage 2 : :fibrillation and erosion of the cartilage surface, with a subsequent release fibrillation and erosion of the cartilage surface, with a subsequent release

of proteoglycan and collagen fragments into the synovial fluidof proteoglycan and collagen fragments into the synovial fluid . .

Stage 3Stage 3 : :The breakdown products of cartilage induce a chronic inflammatory The breakdown products of cartilage induce a chronic inflammatory response in the synovium. Synovial macrophage production of response in the synovium. Synovial macrophage production of cytokines, interleukin 1 (IL-1), tumor necrosis factor-alpha, and cytokines, interleukin 1 (IL-1), tumor necrosis factor-alpha, and

metalloproteinases, occursmetalloproteinases, occurs . .Tissue destructionTissue destruction . .

these events alter the joint architecture, and compensatory bone these events alter the joint architecture, and compensatory bone overgrowth occursovergrowth occurs

FrequencyFrequency

InternationalInternational

Osteoarthritis is the most common Osteoarthritis is the most common articular disease. Estimates vary articular disease. Estimates vary

among different populationsamong different populations . .

Mortality/MorbidityMortality/Morbidity

The disease progression of The disease progression of osteoarthritis is characteristically osteoarthritis is characteristically slow, occurring over several slow, occurring over several

years or decadesyears or decades . .

PainPain . .

potential weight gainpotential weight gain

RaceRace

The prevalence of osteoarthritis differs The prevalence of osteoarthritis differs among different ethnic among different ethnic groups.Whether these differences groups.Whether these differences are genetic or due to differences in are genetic or due to differences in joint usage related to life-style or joint usage related to life-style or

occupation is unknownoccupation is unknown . .

Heredity

No mutation has been identified in the common primary (i.e., idiopathic) form of OA. Most of the mutations identified are associated with relatively rare syndromes afeature of which can be classified as secondary OA

SexSex

The likelihood increases with ageThe likelihood increases with age..

The disease is equally common among The disease is equally common among men and women aged 45-55 yearsmen and women aged 45-55 years . .

After age 55 years, the disease After age 55 years, the disease becomes more common in womenbecomes more common in women . .

DIP and PIP joint involvement that DIP and PIP joint involvement that results in Heberden and Bouchard results in Heberden and Bouchard nodes is more common in womennodes is more common in women

AgeAge

occurs in 30% of affected individuals occurs in 30% of affected individuals aged 45-65 years and in more than aged 45-65 years and in more than 80% by their eighth decade of life, 80% by their eighth decade of life, although most are asymptomatic.although most are asymptomatic.

ClinicalClinical

HistoryHistoryPainPain

Initially, symptomatic patients incur pain during Initially, symptomatic patients incur pain during activity, which can be relieved by rest and may activity, which can be relieved by rest and may respond to simple analgesicsrespond to simple analgesics . .

Morning joint stiffness usually lasts for less than Morning joint stiffness usually lasts for less than 30 minutes30 minutes . .Stiffness during rest (gelling) may developStiffness during rest (gelling) may develop . .

Joints may become unstable as the osteoarthritis Joints may become unstable as the osteoarthritis progresses; therefore, the pain may become progresses; therefore, the pain may become more prominent (even during rest) and may more prominent (even during rest) and may not respond to medicationsnot respond to medications..

PhysicalPhysical

Signs limited to the affected jointsSigns limited to the affected joints . .Malalignment with a bony enlargementMalalignment with a bony enlargement . .

Most cases of osteoarthritis do not involve Most cases of osteoarthritis do not involve erythema or warmth over the affected erythema or warmth over the affected joint(s);an effusion may be presentjoint(s);an effusion may be present . .

Limitation of joint motion or muscle atrophy Limitation of joint motion or muscle atrophy around a more severely affected jointaround a more severely affected joint..

Sources of painSources of pain : : 1.1. Joint effusion and stretching of the joint capsule Joint effusion and stretching of the joint capsule

2.2. Increased vascular pressure in subchondral Increased vascular pressure in subchondral bone bone

3.3. Torn menisci Torn menisci

4.4. Inflammation of periarticular bursae Inflammation of periarticular bursae

5.5. Periarticular muscle spasm Periarticular muscle spasm

6.6. Psychological factors Psychological factors

7.7. Crepitus (a rough or crunchy sensation) may be Crepitus (a rough or crunchy sensation) may be palpated during motion of an involved joint.palpated during motion of an involved joint.

CausesCauses

• Risk factors : Risk factors : – Increasing age Increasing age – Obesity – Female sex Female sex – Trauma – Infection Infection – Repetitive occupational trauma Repetitive occupational trauma – Genetic factors Genetic factors – History of inflammatory arthritis History of inflammatory arthritis – Neuromuscular disorder Neuromuscular disorder – Metabolic disorderMetabolic disorder

Differential DiagnosesDifferential Diagnoses

• other arthritides (eg, other arthritides (eg, rheumatoid arthritis). ).

• spondyloarthropathy .spondyloarthropathy .

•Reactive arthritis . .

WorkupWorkup

• Laboratory StudiesLaboratory Studies• No specific laboratory abnormalities No specific laboratory abnormalities

are associated with osteoarthritis (OA). are associated with osteoarthritis (OA). – Levels of acute-phase reactants and Levels of acute-phase reactants and

erythrocyte sedimentation rate are within erythrocyte sedimentation rate are within the reference range. the reference range.

– Synovial fluid analysis usually indicates a Synovial fluid analysis usually indicates a WBC count below 2000/WBC count below 2000/µµL with a L with a mononuclear predominance.mononuclear predominance.

Imaging StudiesImaging Studies

• Radiography . Radiography . – The presence of osteophytes (ie, spurs The presence of osteophytes (ie, spurs

at the joint margins) is the most at the joint margins) is the most characteristic findings. characteristic findings.

– Other findings in osteoarthritis include Other findings in osteoarthritis include asymmetric joint-space narrowing, asymmetric joint-space narrowing, subchondral sclerosis, and subchondral subchondral sclerosis, and subchondral cyst formation. cyst formation.

ProceduresProcedures

• Arthrocentesis of the affected joint Arthrocentesis of the affected joint can help exclude inflammatory can help exclude inflammatory arthritis, infection, and/or crystal arthritis, infection, and/or crystal arthropathy.arthropathy.

TreatmentTreatment

• Medical CareMedical Care• Nonpharmacologic interventions are the Nonpharmacologic interventions are the

cornerstones of osteoarthritis (OA) therapy and cornerstones of osteoarthritis (OA) therapy and include:include:

• patient educationpatient education• temperature modalitiestemperature modalities• weight lossweight loss• exerciseexercise• physical therapyphysical therapy• occupational therapy occupational therapy • joint unloading in certain joints (eg, knee, hip).joint unloading in certain joints (eg, knee, hip).

Physical therapyPhysical therapy

– Aerobic and muscle-strengthening Aerobic and muscle-strengthening exercises. exercises.

– Hydrotherapy. Hydrotherapy. – Heat and capsaicin creamHeat and capsaicin cream– Ice. Ice.

Pharmacologic therapyPharmacologic therapy

The goals :The goals :– pain alleviation pain alleviation – improvement of functional status. improvement of functional status.

no practical medication-based disease or no practical medication-based disease or structure-modifying intervention has structure-modifying intervention has been proven. been proven.

TreatmentTreatment: :

– Acetaminophen for mild or moderate pain without Acetaminophen for mild or moderate pain without apparent inflammation. apparent inflammation.

– Nonsteroidal anti-inflammatory drug (NSAIDs). Nonsteroidal anti-inflammatory drug (NSAIDs). – Tramadol. Tramadol. – Muscle relaxants . Muscle relaxants . – Contemplate intra-articular injections of glucocorticoidsContemplate intra-articular injections of glucocorticoids– Systemic glucocorticoids have no roleSystemic glucocorticoids have no role– Intra-articular injections of hyaluronic acid (HA) are Intra-articular injections of hyaluronic acid (HA) are

approved as symptomatic therapy of osteoarthritis in the approved as symptomatic therapy of osteoarthritis in the knee knee

– Judicious use of narcotics (eg, acetaminophen with Judicious use of narcotics (eg, acetaminophen with codeine) is reserved for patients with severe osteoarthritis.codeine) is reserved for patients with severe osteoarthritis.

Surgical CareSurgical Care

• Joint lavage: Joint lavage: • Arthroscopy: for repairing meniscal tears, removing Arthroscopy: for repairing meniscal tears, removing

fragments of torn menisci that are producing symptoms). fragments of torn menisci that are producing symptoms). • Osteotomy Osteotomy

– malaligned hip or knee joint. malaligned hip or knee joint. – younger patients . younger patients . – Osteotomy can lessen the pain, although it can lead to more Osteotomy can lessen the pain, although it can lead to more

challenging surgery later if the patient requires arthroplasty.challenging surgery later if the patient requires arthroplasty.• Arthroplasty Arthroplasty

– if all other modalities are ineffective and osteotomy is not if all other modalities are ineffective and osteotomy is not viable or if a patient cannot perform his or her daily activities viable or if a patient cannot perform his or her daily activities despite maximal therapy. despite maximal therapy.

Follow-upFollow-up

• Overweight patients who have early Overweight patients who have early signs of osteoarthritis (OA) or who signs of osteoarthritis (OA) or who are at high risk should be are at high risk should be encouraged to lose weight. encouraged to lose weight.

• Recommend quadriceps-Recommend quadriceps-strengthening exercises in patients strengthening exercises in patients with osteoarthritis of the knees.with osteoarthritis of the knees.

PrognosisPrognosis

• The prognosis of osteoarthritis The prognosis of osteoarthritis depends on joints involved and depends on joints involved and severity severity

Patient EducationPatient Education

• Educate the patient on the natural Educate the patient on the natural history of and management options history of and management options for osteoarthritis.for osteoarthritis.

• Explain the differences between Explain the differences between osteoarthritis and other more rapidly osteoarthritis and other more rapidly progressive arthritides such as progressive arthritides such as rheumatoid arthritis. rheumatoid arthritis.

Osteoarthritis: What Is Osteoarthritis: What Is ItIt??

Also called "wear and tear" arthritisAlso called "wear and tear" arthritis

Osteoarthritis: Osteoarthritis: SymptomsSymptoms

•slowly. pain or soreness ,stiff or slowly. pain or soreness ,stiff or creaky. In the hands: bony creaky. In the hands: bony

enlargements in the fingers, which enlargements in the fingers, which may or may not cause painmay or may not cause pain

Osteoarthritis: Where Does Osteoarthritis: Where Does It HurtIt Hurt ??

Osteoarthritis: What Osteoarthritis: What Causes ItCauses It??

Risk Factors You Can't Risk Factors You Can't ControlControl

Risk Factors You Can Risk Factors You Can ControlControl

• sports ,jobs , Obesity .sports ,jobs , Obesity .

Impact on Daily LifeImpact on Daily Life

..

Diagnosing Diagnosing OsteoarthritisOsteoarthritis

• symptoms and signssymptoms and signs

• X-rays &blood testsX-rays &blood tests

Long-Term ComplicationsLong-Term Complications

• Deformities. Deformities.

• Bow-legged appearance Bow-legged appearance

• Irritate nervesIrritate nerves

Treatment: Physical Treatment: Physical TherapyTherapy

• No treatment No treatment

• Ways to improve joint Ways to improve joint function(physical , hot or cold function(physical , hot or cold therapies )therapies )

Supportive DevicesSupportive Devices

• Finger splints or knee braces, canes, Finger splints or knee braces, canes, crutches, or walkers . crutches, or walkers .

• Back brace or neckBack brace or neck

collarcollar..

Medication for OAMedication for OA

• over-the-counter pain and over-the-counter pain and anTinflammatory medication, Pain-anTinflammatory medication, Pain-relieving creams . injection of relieving creams . injection of steroids or hyaluronans .steroids or hyaluronans .

SupplementsSupplements• no benefits of glucosamine and no benefits of glucosamine and

chondroitinchondroitin..

Osteoarthritis and Osteoarthritis and WeightWeight

• Losing weight not only cuts down on Losing weight not only cuts down on pain, but may also reduce long-term pain, but may also reduce long-term joint damagejoint damage..

Osteoarthritis and Osteoarthritis and ExerciseExercise

• low-impact activities such as low-impact activities such as swimming, walking, or bicycling can swimming, walking, or bicycling can improve mobility and increase improve mobility and increase strength. strength.

Is Surgery for YouIs Surgery for You??

• If : interferes , and the symptoms If : interferes , and the symptoms don't improve = joint replacement don't improve = joint replacement surgery is an option. surgery is an option.

Preventing Preventing OsteoarthritisOsteoarthritis

•keep your weight in checkkeep your weight in check . .

Preventing injuries.Preventing injuries.