Transcript degenerative osteoarthritis

DEGENERATIVE
OSTEOARTHRITIS
Assoc. Prof. Ece AYDOĞ
Physical Medicine and
Rehabilitation
Learning objectives:
1. be able to describe the pathogenesis of
osteoarthritis
2. be able to enumerate the reasons of primer
and secondary osteoarthritis
3. be able to enumerate risk factors for
osteoarthritis
4. be able to enumerate clinical and
radiographic features of osteoarthritis (espc.
knee, hip, hand)
5. be able to enumerate approaches to
diagnosis and treatment of osteoarthritis
Joint Structures
Structural classification is based on the materials that
hold the joint together and whether or not a cavity is
present in the joint. There are three structural classes.
• Fibrous joints are held together by fibrous
connective tissue. No joint cavity is present.
Fibrous joints may be immovable or slightly
movable.
• Cartilaginous joints are held together by
cartilage (hyaline or fibrocartilage). No joint
cavity is present. Cartilaginous joints may be
immovable or slightly movable.
• Synovial joints are characterized by a synovial
cavity (joint cavity) containing synovial fluid.
Synovial joints are freely movable and
characterize most joints of the body.
Functional Classification
-is based on the degree to which the joint
permits movement. There are three types:
• A synarthrosis joint permits no movement.
Structurally, it may be a fibrous or
cartilaginous joint.
• An amphiarthrosis joint permits only slight
movement. Structurally, it may be fibrous or
cartilaginous joint.
• A diarthrosis joint is a freely movable joint.
Structurally, it is always a synovial joint.
OSTEOARTHRITIS
OA
"Osteoarthritis" is derived from the
Greek word "osteo", meaning "of the
bone", "arthro”, meaning "joint", and
"itis", meaning inflammation, although
many sufferers have little or no
inflammation.
Synonyms
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Degenerative joint disease
Arthrosis
Osteoarthrosis
Hypertrophic arthritis
Degenerative arthritis
• Osteoarthritis is a type of
arthritis that is caused by
the breakdown and
eventual loss of the
cartilage of one or more
joints. Cartilage is a
protein substance that
serves as a "cushion"
between the bones of the
joints.
Constituents of hyaline cartilage
• Chondrocytes
• Matrix (extracellular material)
– Collagen fibres
– Proteoglycan molecules
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• Cartilage is an avascular
connective tissue which is
composed of two elements:
cellular component (5%) the chondrocytes
extracellular component
(95%) - the matrix
• Water comprises
approximately 70% of the
matrix, the remainder
consists primarily of
collagen (especially collagen
II) which is meshed with
proteoglycan aggregates.
Proteoglycan Aggregate
• Large hygroscopic
molecules
• Long central chain of
hyaluronic acid
• Numerous side chains
alongs its length, each
with
– Central cores of protein
– Chondroitin sulphate and
keratan sulphate side
chains
• Pg’s attract water and put
collagen under tension
Normal Articular Cartilage
The swelling pressure of
the fully hydrated but
compressed aggrecans is
counterbalanced by the
tight collagen network.
Due to this unique
composite structure,
healthy articular cartilage
can resist major pressure
and shear forces
Softening and swelling of
cartilage
• Rupture of collagen fibres,
the protein makeup of
cartilage degenerates
• More water is absorbed by
proteoglycans
• Cartilage is considerably
weakened
Fibrillation and cracks
– Fine flakes of superficial cartilage
become loosened and flake off (and
cause mild secondary synovitis which
can lead to ‘cold’ effusions)
– Cracks appear in cartilage: eventually
run through full thickness of cartilage
Erosion of cartilage and
eburnation
– Progressive loss of cartilage
– Ultimate loss of full thickness
of cartilage
– Exposed bone becomes very
hard with a polished
appearance:
‘eburnation’ of bone
(looks like ivory)
Synovitis
Synovial effusions:
small and “cold”
Subchondral cysts:
Fluid is forced through
clefts in cartilage into
the underlying bone,
can seen on X-ray
Osteoblastic stimulation (repair attempt)
– Underneath the damaged cartilage: subchondral
sclerosis on X-ray
– Around edge of joint forming lip of bone: fibroosseus
osteophytes
Summary
• Softening and swelling
• Fibrillation
• Full thickness cracks
• Eburnation
• Subchondral cysts
• Subchondral sclerosis
• Osteophyte formation
Epidemyology
• Most common disease of joints over age 65
• Radiologically correlates poorly with
symptoms
• Rapid increase in radiologic evidence of
OA after age 40
• Before age 45, osteoarthritis occurs more
frequently in males. After age 55 years, it
occurs more frequently in females.
• Osteoarthritis commonly affects the
hands, feet, spine, and large weightbearing joints, such as the hips and
knees.
• Most cases of osteoarthritis have no
known cause : PRIMARY osteoarthritis.
• When the cause is known, the
condition is referred to as SECONDARY
osteoarthritis.
• Primary OA is mostly
related but no caused
by aging.
Secondary OA
Genetic
Endocrine
Metabolic
Anatomic
Traumatic
Inflammatory
Neuropathic
Secondary OA
Genetic: A genetic defect
may promote breakdown
of the protective architecture
of cartilage.
Ehlers-Danlos syndrome
Secondary OA
Endocrine:
• DM,
• Acromegaly,
• Hypotroidism,
• Hypertroidism,
• Obesity.
Metabolic:
• Paget disease
• Wilson disease
Secondary OA
Congenital or developmental: Abnormal
anatomy such as unequal leg length may be
a cause of osteoarthritis.
Posttraumatic: Macrotrauma or
microtrauma. -Microtrauma may occur over
time (chronically). An example of this would
be repetitive movements or the overuse
noted in several occupations.
Secondary OA
Inflammatory joint diseases: This category
would include infected joints, chronic gouty
arthritis, and rheumatoid disease.
Neuropathic: Diseases such as diabetes can
cause nerve problems. The loss of sensation
may affect how the body knows the position
and condition of the joints or limbs. In other
words, the body can't tell when it is injured.
Secondary OA
Others: Nutritional problems
Hemophilia
Sickle cell anemia
Individual risk factors for
development of OA
• Obesity: knee > Hip
• Family history (genetic): polyarticular esp
hands
• Trauma
• Hypermobility
• Dysplasia: Hip and knee
• Occupation and sport: excessive and
repeated loading of a joint
Clinical features
Pain and tenderness
• Originates in joint /periarticular soft tissue
• Diffuse/ sharp and stabbing local pain
• Initially, symptomatic patients incur pain during
activity, which can be relieved by rest and may
respond to simple analgesics.
• Joints may become unstable as the OA progresses;
therefore, the pain may become more prominent
(even during rest) and may not respond to
medications.
Morning joint stiffness usually lasts for less than
30 minutes.
PAİN
• Sources of pain in osteoarthritis include the
following:
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Joint effusion and stretching of the joint capsule
Increased vascular pressure in subchondral bone
Torn menisci
Inflammation of periarticular bursae
Periarticular muscle spasm
Psychological factors
Crepitus (a rough or crunchy sensation) may be
palpated during motion of an involved joint.
Types of pain
• Mechanical:
– Increases with use of the joint
• Inflammatory:
• Rest pain later on in 50%
• Night pain in 30% later on
Movement abnormalities
• “Gelling”: stiffness after periods of
inactivity ;Passes over within minutes
of using joint again
• Coarse crepitus: palpate/hear
• Reduced ROM: capsular thickening and
bony changes in joint.
Deformities
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Mild synovitis
Osteophytes
Joint laxity
Asymmetrical joint destruction leading
to angulation
Hand OA
DIP, PIP, CMC
Heberden’s nodes, large
firm swellings some of
which are tender and red
due to associated
inflammation of the
periarticular tissues
as well as the joint.
KNEE OA
OA of the knees can affect
any combination of the
three main compartments
of each knee. It is usually
asymmetrical, and the
compartments most
frequently involved are
the medial tibiofemoral
and patellofemoral
compartments.
KNEE OA
• Mild varus angulation
of the knee joints due
to asymmetrical OA
of the medial
tibiofemoral
compartments.
Imaging
Special Investigations
• Blood tests: Normal
• Radiological features:
– Cartilage loss : Joint space narrowing
– Subchondral sclerosis
– Cysts
– Osteophytes : Outgrowth of bone
Radiological Grading of Knee OA
Kellgren and Lawrence
Special Investigations
MRI: This study is a complex, noninvasive
imaging technique that is unlike x-rays. Xrays provide information mainly on bones.
However, MRI is capable of visualizing all
structures within the joint. MRI technology is
sophisticated and requires an expert to
interpret the study.
CT scan: This study may be used to image a
joint. CT scanning mainly provides
information on the bony structures of the
joint but in greater detail than plain x-rays
Aspiration
Treatment Principles
• Education
• Physiotherapy
– Exercise program
– Pain relief modalities
• Aids and appliances
• Medical Treatment
• Surgical Treatment
•Prevent overloading of joint; Obesity!!
•Appropriate use of treatment modalities
•Importance of exercise program
Creating an exercise program for
lower-limb osteoarthritis
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The program should be individualised
after considering:
1. Severity of pain
2. Joint stability
3. Patient’s resources (time, money,
facilities, equipment)
4. Patient’s interests
Exercises
• Flexibility exercises — daily stretching and range-ofmovement exercises.
• Strengthening exercises — (a) Isometric exercises
(static muscle contraction that does not move a joint
or alter muscle length) up to twice daily during acute
inflammatory periods; and (b) Isotonic exercises
(resistance training exercises, often with weights),
maximum two days per week.
• Endurance/fitness exercises — such as walking,
swimming, dancing, aquarobics, cycling, 3–4 times
per week.
• The intensity, duration, and frequency of exercise
should be specified and graded to allow for
progression.
TENS, Deep and superficial heat,
ice,
Aids and appliances
Braces / splints
• Special
shoes/insoles
• Mobility aids
• Aids: dressing,
reaching, tap
openers, kitchen
aids
• Taping of patella in
patello femoral OA
Tapping
Medical Treatment
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Simple analgesics: paracetamol
Topical treatment; NSAI, capsaicin creams
Glucoseamine; oral, topical
NSAID’s
Tramadol or opioidis
Intra-articular corticosteroids
Intra-articular viscosupplementation
Non steroidal anti inflammatory
drugs
• Risk of upper gastrointestinal tract complications
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Age > 65 years
Comorbid medical conditions
Use of oral glucocorticoids
History of peptic ulcer disease
History of upper-gastrointestinal haemorrhage
• Risk of renal complications
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Age > 65 years
Raised serum creatinine level
Hypertension
Congestive heart failure
Use of angiotensin-converting enzyme inhibitors
Use of diuretics
• A 2005 review of injections of
hyaluronic acid, known as
vicosupplementation, did not find that
it led to clinical improvement in OA. A
subsequent 2009 study found similar
results. Injection of glucocorticoids
(such as hydrocortisone) leads to short
term pain relief that may last between a
few weeks and a few months.
EULAR Recommendations 2003
1-The optimal management of knee OA
requires a combination of non
pharmacological and pharmacological
treatment modalities (1B)
EULAR Recommendations 2003
2-The treatment of knee OA should be tailored
according to:
• Knee risk factors (obesity, adverse mechanical
factors, physical activity)
• General risk factors (age, comorbidity,
polypharmacy)
• Level of pain intensity and disability
• Sign of inflammation—for example, effusion
• Location and degree of structural damage.
EULAR Recommendations 2003
4-Non-pharmacological treatment of knee OA
should include, education, exercise, appliances
(sticks, insoles, knee bracing) and weight
reduction
5-Topical applications (NSAID, capsaicin) have
clinical efficacy and are safe
6-NSAIDs should be considered in patients
unresponsive to paracetamol. In patients with an
increased gastrointestinal risk, non-selective
NSAIDs and effective gastroprotective agents, or
selective COX 2 inhibitors should be used
EULAR Recommendations 2003
7- Opioid analgesics, with or without paracetamol,
are useful alternatives in patients in whom
NSAIDs, including COX 2 selective
inhibitors, are contraindicated, ineffective,
and/or poorly tolerated
8-SYSADOA (glucosamine sulphate, chondroitin
sulphate, ASU, diacerein, hyaluronic acid) have
symptomatic effects and may modify structure
EULAR Recommendations 2003
7-Opioid
analgesics, with or without paracetamol,
are useful alternatives in patients in whom
NSAIDs, including COX 2 selective
inhibitors, are contraindicated, ineffective,
and/or poorly tolerated
8 -SYSADOA (glucosamine sulphate, chondroitin
sulphate, ASU, diacerein, hyaluronic acid) have
symptomatic effects and may modify structure
EULAR Recommendations 2003
9-Intra-articular injection of long acting
corticosteroid is indicated for flare of knee
pain, especially if accompanied by effusion
10-Joint replacement has to be considered
in patients with radiographic evidence of
knee OA who have refractory pain and
disability
Joint replacement surgery
• Indications: pain affecting work, sleep,
walking and leisure activities
• Complications
– sepsis
– loosening
– lifespan of materials (mechanical
failure)