Transcript water knee

osteoarthritis
Dr.A.Noori
Rheumatologist
www,arrh.ir
Introduction
• Osteoarthritis is a common disorder
of synovial joints.
• Strongly age-related, being less
common before 40 years,but rising in
frequency with age, such that most
people older than 70 years have
radiological evidence of osteoarthritis
in some joints.
Epidemiology
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Most common joint disease in human
Most frequent rheumatic compliant
Common cause of disability in elderly
Over 20 million affected in U.S.
About 12% :age>60 y
6%:age>30 y
• Nodal OA involving DIP and PIP joints is
more common in women and their first
degree female relatives
• OA of knee is more common in African
American women
Joint = Bone + Cartilage +
Synovial Fluid
Cartilage = Cushion
Risk factors
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Age
Gender( female)
Race
Genetic factors
Obesity
sport
Repetitive stress &
joint overload
• Prior inflammatory
joint disease
• Congenital
/developmental defect
• Major joint trauma
• Metabolic /endocrine
disorder
• muscle weakness
Age
•
OA – Risk Factors
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. 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.
OA – Risk Factors
Hereditary gene defect
•
A 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.
Risk factors you cannot change
• Family history
of disease
Risk factors you cannot change
• Family history
of disease
• Increasing age
Risk factors you cannot change
• Family history
of disease
• Increasing age
• Being female
Risk factors you can change
• Overuse of the
joint
Risk factors you can change
• Overuse of the
joint
• Major injury
Strong Risk Factor for OA
Obesity
• 50% decrease in
OA with with 11#
wt loss
• Larger effect in
women
Strong Risk Factor for OA
Joint Trauma
Risk factors you can change
• Overuse of the
joint
• Major injury
• Overweight
• Muscle weakness
Risk Factors
Mechanical abnormalities
Normal cartilage
Degenerative Cartilage
Joint
• EPIPHYSEAL BONE
• CARTILAGE
• SYNOVIAL MEMBRANE
• CAPSULE
• LIGAMENTS
• MUSCLE & TENDONS
• BURSAE
Cartilage
• Function :
–Reduce friction in the joints
• Lubrecin
• Water cushion
–Absorb the shock associated
with locomotion
Cartilage
• Consist of :
– Water :70%
– Type II collagen
– Proteoglycan :
• Aggrecan Sub Unit
– Core Protein
– Glycosaminoglycans, Link Protein
• Hyaluronic Acid
– Chondrocyte
Normal cartilage
Cartilage
• Layer:
–
–
–
–
–
–
Superficial
Intermediate
Deep
Tidemark
Calcified cartilage
Subchondral
Collagen
* Compressible XI
* Elasticity
* Self- lubrication
IX
II
Cartilage
Cartilage
Biomechanic of Joint
Normal Cartilage
Articular Cartilage
Cartilage Layers
Cartilage metabolism
• Cartilage is metabolically active
– Synthesis matrix
– Destruct matrix
Serine
proteases
Plasmine
TPA factor
Elastase
Collagenases
Proteinases Metloproteinases
(MMP)
Systeine
proteases
Gelatinases
Stromelysines
Catepsines
Cartilage remodeling
Synthetic
activities
Degradative
activities
=
s
degradative activity
t
a
s
Matrix
Matrix
synthesis
degradation
CHONDROCYTE
h
synthesis activity
o
m
o
I
s
=
s
collagen
proteoglica
n
degradative activity
t
a
s
Matrix
Matrix
synthesis
degradation
CHONDROCYTE
h
synthesis activity
o
m
o
proteinase
s
synoviocyte
I
s
=
s
degradative activity
t
a
s
Matrix
Matrix
synthesis
collagen
proteoglica
n
degradation
CHONDROCYTE
h
synthesis activity
o
m
o
proteinase
s
activatio
n
IL-1 , TNF
inflammation
synoviocyte
I
s
h
synthesis activity
o
m
o
=
s
degradative activity
t
a
s
Matrix
Matrix
synthesis
NO synthase
up regulation
IL-1 ,
TNF
CHONDROCYTE
collagen
proteoglica
n
degradation
proteinase
s
activation
IL-1 , TNF
NO
inflammation
synoviocyte
I
s
h
synthesis activity
o
m
o
=
s
degradative activity
t
a
s
Matrix
Matrix
synthesis
NO synthase
Up
regulation
IL-1 ,
TNF
CHONDROCYTE
apoptosis
collagen
proteoglica
n
degradation
proteinase
s
activatio
n
IL-1 , TNF
NO
inflammation
synoviocyte
I
s
h
synthesis activity
o
m
o
=
s
Matrix
synthesis
Inferior quality of matrix
Collagen I
Collagen III differentiatio
n
I
Matrix
degradation
CHONDROCYTE
collagen
proteoglica
n
degradative activity
t
a
s
proteinase
s
TGF
IGF
bone
s
OA
OA is a disease of joints
that affects all of the
weight-bearing
components of the joint:
•Articular
cartilage
•Menisci
•Bone
Macroscopic Change
• Erosion, detachment
of fragments of
cartilage
• subchondral microcyst
& sclerosis
Articular Cartilage
Core Protein-Aggrecan
Hyaluronic Acid
Link
Glycoprotein
Glycosaminoglycan
Chondroitin Sulfate Chain
Normal
joint
Cracking in cartilage
Gaps in Cartilage
Cyst in subchondral bone
Bone change
• Overactivity of Osteoblast
Growth factor
TGFβ,
ILGF¹
• Cartilage destruction
• Bone hypertrophy (subchondral
Sclerosis )
• Osteophyte formation
Subchondral sclerosis
Clinical findings
Causes of pain
osteophyte fracture
micofracture
CLINICAL FEATURES
Periosteal
Capsule
• Pain
Subchondral • Mechanic
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• Inflammatory
• Night pain
Stiffness 5-30 mi
Joint swelling
Synovitis
Deformity
Crepitus
Signs Of Osteoarthritis
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Bony enlargement
Tenderness at joint margins
Limitation of motion
Periarticular muscle weakness
Joint instability
Locking of joint during motion
Crepitus
Joint effusion
Classification Of OA
• Idiopathic
Localized
Generalized
• Secondary
Classification Of OA
: heberden, Bouchard,erosive
• Idiopathic* Hand
Rhizarthrosis
Localized
* Knee: Medial,Lateral,Patellofemoral
* Hip: Eccentric, Concentric, Diffuse
* Spine: Apophysial , intervertebral,
Spondylosis
* Others
Generalized Osteoarthritis
Hand
Osteoarthritis
Artherosis of hand’s
joints
• F/m : 4/1
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20-65 ( >45 ) years
Hereditary:50%
Associated with Knee disease & obesity
DIP ( Heberden’s node )
PIP ( Buchardd’s node )
CMC1 ( Rhizarthrosis )
Normal hand
OA: Heberden’s and Bouchard’s nodes
Heberden
node
OA: first carpometacarpal joint (radiograph)
DIP Arthrosis
( Rizarthrosis of thumb)
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CMC1
Female
With Heberden’s node
Pain in Abd. & Apposition
Thenderness in base thumb
Squaring of the thumb base
• Shelf sign
• Criptation
• Limitation in Abd.
OA: Heberden’s nodes, inflammation
Snake deformity
KNEE
OSTEOARTHRITIS
Epidemiology
• The most common arthrosis after
interphalangeal joint arthrosis
• The most common case of disability
in old person
• More common in women
Normal knee (AP)
Compartements of Knee
Clinical findings
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Symptoms
Pain
Joint stiffness
Limitation of motion
Alteration in joint shape
Crepitus
Feeling of instability
Normal knee (lateral)
OA: knees, medial and lateral
cartilage degeneration
OA: knee, advanced disease
Risk Factors
Mechanical abnormalities
Clinical findings
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Crepitus
Restriction of motion
Tenderness
Rabot’s sign and shrug’s sign
Bone hypertrophy
Effusion
Angular deformity
Limp
Muscle atrophy
Instability
Signs
Knee Varus deformity
Hip Osteoarthritis
Osteoarthritis of Hip
Protrusio acetabuli
First MTP
OA
First MTP
OA
Hallus Valgus ( first MTP OA)
Spine OA
Classification Of OA
• Idiopathic
Localized
Generalized
Spinal OA
Cervical osteoarthritis
Laboratory findings
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Normal ESR
Negative CRP
Negative autoantibodies
Normal other tests
Other imagings
• Radionucleid scan
• CT
• MRI
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3.
Treatment
Reduction of knee loading
Weight reduction
Rest
Recommendation to avoidance of activities
that case excessive loading of the knee
4. Modification of workplace and life style
5. Cane
Evidence for Benefit from
Exercise
in Treating Knee and Hip OA
• Regular aerobic walking
for (Ia)
• Home-based quad
strength exercises (Ia)
• Water-based aerobic
exercise (Ia)
EXercise
Exercise
Lateral Wedge Insoles
(LOE 1a for knee)
• Medial tibio-femoral
OA
Brace
Treatment
• Pain reduction
1.
2.
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4.
Acetaminophen
NSAID’s
Capsaicin
Opioids
Guidelines
• Non-pharmacologic measures
─ Used with or without pharmacotherapy
• Pharmacologic measures
– Systemic pharmacotherapy
• Acetaminophen
• NSAIDs
• -Topical NSAID and Analgesic
– IA injection- steroids or hyaluronic acid
– Topical capsaicin
– surgery
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Nonpharmacology -therapy
• Exercise- regular aerobic,
muscle strengthening and
ROM exercises
• Obesity reduction• Yoga
• Low –energy lasers
• Ultrasound
• Therapeutic
massage/Acupuncture
• Patient education
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• Reduction of joint load
Exercise
• Range of motion
• Muscle
strengthening
• Aerobics
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Reducing joint load
• Cane
• Walker
• Wedged lateral
insoles
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Vitamins
• OA: less liklely to worsen in people
who have high dietary intake of Vit C
and Vit D.
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Pharmacologic therapy
• Systemic drugs
• Topical applications
• Intra-articular injections
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Topical Treatments:
Useful as Adjuncts
• Topical NSAIDs
– for pain, stiffness, function
– As effective as oral; safer
• Side effects = placebo
– Onset slightly slower than oral
– Duration??
• Capsaicin
– for knee pain
– 40% have stinging, burning, erythema
Non-steroidal antiinflammatory drugs
• NSAIDs both analgesic and antiinflammatory
• Non-selective NSAIDs inhibit both
COX-1 and COX-2 enzymes
• Use of NSAIDs is associated with
many adverse effects
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Diacerein
• Inhibit IL-1 and reduce cartilage
breckdown and major adverse event is
diarrhea(is dose dependent)
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Opioids
• For moderately severe to
severe pain, opioids can
be used
– acetaminophen+ codein
– Tramadol
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Acetaminophen (ACET)
• Analgesic by elevating pain
threshold
• No gastric irritation
• Consistently recommended by
all major guidelines as the first
drug of choice for OA pain
• Inexpensive
• Up to 4 grams daily if no liver
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problems, for mild to
Piascledine
• Avocado/soybean:is commonly used for
hip and knee OA in europe the evidence
of its efficacy is small.
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Colchicine
• Recommended for inflammatory OA that
doesnot improve with
nonpharmmacologic therapies and
NSAID.
• Recommend colchicine for flar of OA
that is resistant to other treatment.
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Hydroxychloroqine
• Recommended for sever inflammatory
OA and who have bone damage related
to OA .
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Glucosamine/Chondroitin-• recommend in 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
Intra-articular injections
• Intra-articular
injection used for OA
pain due to
inflammation or
effusions
• Corticosteroids or
hyaluronan
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Intra-articular glucocorticoid
• Supress inflammation and relieve arthritis
symptoms.
• Recommended for OA who still have pain
despite use of NSAID or who donot get
adequate pain relif with them.
• 3-4 injection per year
Intra-articular Hyaluronate
• Recommended for OA who cannot use of
NSAID or who donot get adequate pain relif
with them.
• Pain relif may last for several months.
Surgery
• Arthroscopy
synovectomy/
• Realignment
• Fusion
• Joint replacement
• Cartilage grafting
Arthroscopy with
Lavage and Debridement
• NO BENEFIT for
unselected OA
(mechanical or
inflammatory causes),
Other Knee Surgeries
• Osteo-Articular
Transplant (OAT)
procedures
• Autologous
Chondrocyte
Implantation (ACI)
• Cadaver allografts
Knee Joint
Replacement
• LOE III
• Universally
recommended to
improved pain,
function, QOL
– Unicompartmental
– Total joint replacement
NO inhibitors
• Fluxetin, Tricyclic antidepressant
♠
• Vitamin : ♠
♠
♠
Vit
Vit
Vit
Vit
A
D
C
E
Arthroplasty
Gelling pain
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