Degenerative Joint Disease and Traumatic Arthritis (Last

Updated: 1-Jan-1985) A. J. Lipowitz

and C. D. Newton

Section One: Degenerative Joint Disease

Degenerative oint disease (DJD) is a common disorder o! humans and anima"s# $t is genera""% regarded as a nonin!"ammator% condition o! articu"ar carti"age resu"ting !rom natura" aging& trauma& or disease# 'an% names have (een app"ied to the condition) ho*ever& osteoarthritis and degenerative oint disease are t*o o! the most common and *i"" (e used interchangea("% in this chapter# DJD has (een recogni+ed in anima"s !or a "ong time# ,a"eopatho"ogic e-amination o! dr%-(one preparations has sho*n "esions compara("e to those o! DJD in !ossi" repti"es !rom the 'eso+oic period#(./) A"though caution must (e used in the interpretation o! these !indings& the% point out that articu"ar disease has a!!ected anima"s since anima"s have *a"0ed on earth# DJD has (een c"assi!ied in man% *a%s# 1ne c"assi!ication descri(es DJD as either primar% or secondar%#(1/&28) ,rimar% DJD is that *hich occurs in diarthrodia" oints in *hich there has (een no 0no*n previous trauma or disease# This primar% condition is (est e-emp"i!ied (% the Joint changes seen in o"der anima"s# ,rimar% DJD is genera""% regarded as an aging phenomenon (3&1/&28) in *hich deterioration o! the articu"ar carti"age occurs& "eading to the characteristic oint changes# As the name imp"ies& secondar% DJD is the resu"t o! some insu"t to the a!!ected oint# Usua""% it is a "oca" phenomenon rather than a s%stemic disease& a"though some s%stemic diseases that a!!ect oints ma% u"timate"% "ead DJD# Loca" insu"t *ith resu"ting degenerative changes is (est e-emp"i!ied (% crania" cruciate "igament rupture# T*o ma or categories o! articu"ar disease are descri(ed) nonin!"ammator% and in!"ammator%#(1/&28) DJD is p"aced in the nonin!"ammator% categor% a"though an intermittent in!"ammator% component is recogni+ed# 1ther conditions o! so-ca""ed nonin!"ammator% articu"ar disease inc"ude traumatic arthritis& mechanica" a(norma"ities such as torn menisci& aseptic necrosis& neuroarthropath%& and neop"asia# The in!"ammator% categor% is su(divided into an in!ectious section& *hich inc"udes articu"ar disease caused (% (acteria"& !unga"& vira"& and proto+oa" organisms& and a nonin!ectious section& *hich itse"! is !urther divided into t*o su(categories: immuno"ogic and nonimmuno"ogic# The immune-mediated articu"ar diseases& such as rheumatoid arthritis and s%stemic "upus er%thematosus& and nonimmune in!"ammator% conditions such as cr%sta"-induced arthritis& (i#e#& gout& pseudogout) and chronic hemarthrosis *i"" (e dea"t *ith in other sections o! this te-t# 'ature articu"ar carti"age is a uni4ue tissue in that it does not incorporate its o*n direct

("ood supp"%# The usua" tissue response to insu"t is one o! in!"ammation& *hich re"ies on intrinsic vascu"arit%# 5ithout vascu"arit%& articu"ar carti"age response to insu"t is di!!erent than that o! other tissue# DJD is a se4ue" to carti"age insu"t& (ut (ecause carti"age "ac0s intrinsic vascu"arit% it does not (ecome in!"amed& thus the designation o! DJD as a nonin!"ammator% condition# 6o*ever& DJD is not a condition o! articu"ar carti"age a"one# The s%novia" mem(rane "ining the a!!ected oint cavit% is a"so invo"ved# This tissue& *ith its high degree o! intrinsic vascu"arit%& e-hi(its in!"ammator% change# The intensit% o! these changes varies *ith the e-tent o! the insu"t to the oint and the duration o! the condition# The in!"ammator% changes o! DJD are a"so re!"ected in the ce""u"ar constituents o! the s%novia" !"uid# Tota" ce"" counts need not (e high& (ut certain ce"" t%pes *i"" (e seen& con!irming the in!"ammator% nature o! DJD# Thus& a c"assi!ication s%stem !or canine articu"ar disease *as deve"oped to re!"ect these in!"ammator% changes and is presented in Ta("e 87-1#

TA8L9 87-1 :"assi!ication o! Articu"ar Disease

Pathology

The characteristic structura" changes that t%pi!% DJD are disorgani+ation and "oss o! articu"ar sur!aces and pro"i!eration o! tissues in and ad acent to these sur!aces# The precise se4uence o! histo"ogic change in a!!ected articu"ar tissues is not 0no*n *ith a(so"ute certaint%# ;or instance& in primar% DJD it is not 0no*n *hether s%novia" mem(rane changes precede articu"ar carti"age changes# 'uch o! the sophisticated histo"ogic and (iochemica" research into DJD has concentrated on articu"ar carti"age# DJD has (een o(served in human autops% specimens !rom persons *ho reported"% *ere as%mptomatic during "i!e# This has "ed to the h%pothesis that these "esions ma% (e considera("% di!!erent than those seen in the oints o! s%mptomatic patients# Advancing age is important in the pathogenesis o! DJD (ut is pro(a("% not the primar% cause o! the disease# 5hi"e carti"age (rea0do*n is more !re4uent in o"der humans and anima"s& a"" oints are not a!!ected concomitant"%& and it is evident that "oca" !actors p"a% a ma or pathogenic ro"e# 5ith advancing age a considera("e num(er o! chemica"& (io"ogic& and mechanica" a"terations occur in norma" articu"ar carti"age# $t has (een stated that i! aging itse"! is considered norma"& so then too shou"d these changes#(3) Load (earing is important in the norma" (io"og% o! oints# (2/) As descri(ed in :hapter 8/& the nutrient transport to articu"ar carti"age via the s%novia" !"uid is dependent on oint motion and *eight (earing# $n !act& degenerative changes o! articu"ar carti"age have (een demonstrated in studies in *hich "im(s *ere immo(i"i+ed !or var%ing periods o! time#(9) The a!!ected oints *ere a""o*ed no motion or *eight (earing# At the end o! 5 *ee0s& de!inite changes in articu"ar carti"age& some indistinguisha("e !rom DJD& *ere noted# :onverse"%& heav% use o! *e"" a"igned oints rare"% contri(utes to carti"age (rea0do*n# (15)

The p"acement on oints o! a(norma" ph%sica" stresses that accompanies such conditions as chronic su("u-ation& hip d%sp"asia& s"ipped epiph%ses& and aseptic necrosis< p"a%s a vita" pathogenic ro"e in the deve"opment o! DJD# =tudies have sho*n that oint remode"ing norma""% occurs *ith advancing age& thus changing oint contour and articu"ar sur!ace congruit%# Joints norma""% are not entire"% congruous (ut rather have areas o! >contact> and >noncontact#>(15) 5ith increased "oads on oints& the areas o! contact increase in si+e& and greater oint sur!ace congruit% is achieved# 5ith advancing age& minor a"terations in carti"age a""o* greater congruit% *ith sma""er and sma""er "oads& thus (ringing areas o! norma" noncontact in the intact oint into contact# =uch a"terations in congruit% "ead to erosive and osteoph%tic changes# These "esions o! >"imited progression> have (een o(served in human autops% specimens !rom persons *ho *ere thought to (e as%mptomatic during "i!e# 5hi"e the gross appearance and "ocation o! these "esions di!!er some*hat !rom those seen in patients *ith c"inica""% s%mptomatic oint disease& the (iochemica" characteristics o!< the "esions di!!er "itt"e !rom those o! the c"inica" condition# (15) The c"assic morpho"ogic changes o! osteoarthritic articu"ar carti"age (egin *ith !i(ri""ation&(3&15&3.) a "oca" sur!ace disorgani+ation invo"ving a sp"itting o! the super!icia" "a%ers o! the carti"age# The ear"% sp"itting is tangentia" *ith the carti"age sur!ace& !o""o*ing the a-es o!< the predominant co""agen (und"es# 6ori+onta" !"a0ing o! carti"age occurs a"ong *ith the deve"opment o! sha""o* pits or c"e!ts perpendicu"ar to the carti"age sur!ace# 9ventua""%& the sp"itting e-tends deeper& a"tering the norma" arrangement o! the co""agen (und"es# As the disease progresses& the c"e!ts e-tend entire"% through the carti"age to its unction *ith su(chondra" (one# 5ith disease progression& !i(ri""ation continues and is accompanied (% s%novia" h%perp"asia and ad acent osteoph%te !ormation# :ontinued deterioration o! articu"ar carti"age "eads to e-posure o! su(chondra" (one and a more genera"i+ed s%novia" change# =evere end-stage DJD is characteri+ed (% e-tensive su(chondra" (one e-posure and tremendous de!ormit% in oint sur!ace contour& o!ten "eading to "u-ation# 5hi"e !i(ri""ation is genera""% accepted as the !irst signi!icant change in articu"ar carti"age readi"% identi!ia("e (% "ight microscop%& mo"ecu"ar& chemica"& and other ph%sica" changes precede !i(ri""ation# Thus& !i(ri""ation shou"d (e considered as a common microscopic endpoint o!< (oth norma" and a(norma" occurrences that "ead to carti"age !ai"ure#(3) To understand the processes "eading to carti"age !ai"ure& it is important to "oo0 at the ce""u"ar processes and (iochemica" structure o! norma" carti"age# 6%poce""u"ant% o! norma" articu"ar carti"age as compared *ith other tissues is a stri0ing !eature# The greatest portion o! articu"ar carti"age mass is composed o! a macromo"ecu"ar e-trace""u"ar matri- surrounding the chondroc%tes# 8ecause o! their appearance under "ight microscop%& articu"ar carti"age chondroc%tes *ere once thought to (e rather inert or inactive# $t is no* *e"" recogni+ed that the maintenance and production o! the e-trace""u"ar matri- (% the chondroc%te is an active and continuing process# ?orma" mature articu"ar carti"age is divided histo"ogica""% into !our distinct +ones (ased on the arrangement and orientation o! its ce""u"arit%#(3.) The most super!icia" +one& that c"osest to the articu"ating =ur!ace& is the tangentia" +one# 6ere the !"attened ce""s have

their "ong a-es para""e" to the articu"ar sur!ace# The u"trastructura" appearance o! these ce""s has suggested to some that the% are !i(ro("astic in nature#(3.) $mmediate"% (eneath the tangentia" +one& the ce""s are more rounded and are random"% oriented# This is the transitiona" +one# The chondroc%tes in this area are meta(o"ica""% active& producing co""agen and proteog"%can# 8eneath this region is the radia" +one in *hich ce""s are arranged in short co"umns perpendicu"ar to the articu"ar sur!ace# These ce""s are sma""er than those immediate"% a(ove and appear "ess active# The ca"ci!ied +one& *ith its p%0notic ce""s surrounded (% ca"ci!%ing matri-& resides deep to the radia" +one# :arti"age matri- is a ge"-"i0e su(stance composed o! *ater and the macromo"ecu"ar po"%anionic su(stances& proteog"%can and co""agen#(15&3.) A"though produced separate"%& proteog"%can is "in0ed to co""agen e-trace""u"ar"%# ,roteog"%cans are e"astic mo"ecu"es that e-pand in so"ution and strong"% resist compression into a sma""er vo"ume# ,roteog"%can consists o! a protein core or (ac0(one to *hich are attached side chains o! g"%cosaminog"%cans (@A@s)# Three distinct @A@s have (een identi!ied: chondroitin 3-su"!ate& chondroitin /-su"!ate& and 0eratin su"!ate# 8ecause o! their repe""ing negative charges& the @A@s are attached to the protein core at near"% right ang"es# $n the matri-& the proteog"%can is arranged in high-mo"ecu"ar-*eight aggregates !ormed (% noncova"ent association (et*een proteog"%can su(units& h%a"uronic acid and "in0age protein# 5ith norma" aging the ratio (et*een the various @A@s changes# $n immature carti"age the ratio (et*een chondroitin 3-su"!ate and chondroitin /-su"!ate is near"% 1:1& and there is ver% "itt"e 0eratin su"!ate# As aging progresses the ratio (ecomes 1:3& and (% midd"e age the concentrations o! the 0eratin su"!ate and chondroitin /-su"!ate are near"% e4ua" and account !or a"most 9AB o! the @A@ content o! articu"ar carti"age# ,roteog"%can o! norma" articu"ar carti"age is constant"% degraded and res%nthesi+ed) its ha"!-"i!e has (een estimated at 15A da%s#(3.) The remode"ing s%stem appears to (e en+%me dependent# L%so+%mes such as cathepsin-D and ar%"su"!atase are thought to (e t*o o! the primar% en+%mes responsi("e !or proteog"%can degradation# Li0e proteog"%can& co""agen ma0es up a(out 5AB o! the dr% *eight o! articu"ar carti"age#(3.) :o""agen is composed o! !i(ers and !i(ri"s the structures o! *hich are comp"e- he"ices o! "inear"% arranged amino acids# :o""agen o! s0in di!!ers !rom that o! articu"ating sur!aces as a resu"t o! di!!erent amino acid arrangements#(19&27&.1) $n ear"% studies it *as discovered that co""agen o! s0in and tendon *as composed o! three intert*ined amino acid chains& t*o o! *hich *ere !ound to (e identica"# The t*o identica" chains *ere designated a"pha-1 and the dissimi"ar chain *as designated a"pha2# 1n !urther e-amination o! articu"ar carti"age& the a"pha-1 chains *ere sho*n to (e o! t*o t%pes that di!!ered !rom each other (% a"teration in amino acid se4uence# $t *as !urther discovered that co""agen o! articu"ar carti"age *as composed o! three identica" a"pha chains di!!ering !rom the a"pha-1 o! other tissues (% various amino acid su(stitutions# Thus& t*o t%pes o! a"pha-1 chains *ere recogni+ed: a"pha-1 ($) present in s0in& tendon& (one& and carti"age and a"pha-" ($$) present on"% in articu"ar carti"age# These t*o t%pes o! co""agen *ere designated t%pes $ and $$ respective"%# The ma or distinctions (et*een the t*o t%pes are the di!!erences in amino acid composition and the a(sence o! an a"pha-2 chain in t%pe $$ co""agen# $n addition& there are di!!erences in the pattern o! intramo"ecu"ar and intermo"ecu"ar cross "in0ages# 9ight other t%pes o! co""agen are 0no*n to e-ist# T%pe $$$ is !ound in s0in and the *a""s o! the uterus and

arteries& and t%pes $C and C are !ound in (asement mem(ranes o! various organs#(27) The arrangement o! co""agen !i(ers *ithin canine articu"ar carti"age is simi"ar to that in human articu"ar carti"age& *ith various and distinct +ones noted#(35) The most super!icia" "a%er is the "amina sp"endens& composed o! !ine !i(rous materia"# 8eneath this is the tangentia" "a%er in *hich tight"% pac0ed co""agen !i(ers are para""e" *ith the articu"ar sur!ace# These !i(rous (und"es are at random ang"es to each other& (ut their uni!orm orientation is para""e" *ith the sur!ace# $n the transitiona" +one& the !i(ers assume a more random orientation& a"though in the vicinit% o! the chondroc%tes the !i(ers s*eep in a"most capsu"ar !ashion a(out the "acunae# A distinct "ine o! demarcation is not seen (et*een the transitiona" +one and the deeper radia" +one# 6o*ever& co""agen !i(er orientation (ecomes "ess random and more perpendicu"ar to the articu"ar sur!ace in the radia" +one# @enera""% spea0ing& the num(er o! co""agen !i(ri"s per unit area decreases *ith increasing distance !rom the articu"ar sur!ace# $n addition& the diameter o! the co""agen !i(ri"s increases *ith increasing distance !rom the sur!ace#(35) 9-cessive or a(norma" use and direct in ur% such as !ractures or "igamentous disruptions have a"*a%s (een the o(vious e-p"anation !or DJD deve"opment# Det it has (een sho*n in humans that *hat ma% (e considered greater than norma" use does not necessari"% "ead to degenerative changes# $n a stud% comparing !ormer runners *ith a contro" popu"ation o! nonrunners& the runners had "ess DJD o! the primar% t%pe#(15) 9vidence has not %et (een produced that sho*s that e-cessive use *ithout in ur% "eads to DJD#(3) 5hi"e the etio"og% o! DJD ma% (e mu"ti!actoria" and the rate o! morpho"ogic changes varia("e& the end resu"t is a decrease in oint motion and !unction& an increase in de!ormit%& oint insta(i"it%& and pain# DJD is common"% seen in var%ing degrees associated *ith hip d%sp"asia& crania" cruciate "igament rupture& ununited anconea" process& ununited (!ragmented) coronoid process& osteochondritis dissecans& "igamentous in uries& and as a se4ue"a to articu"ar !ractures# Tissues respond to insu"t in a characteristic manner& *ith the magnitude o! responsive change compara("e to the e-tent o! insu"t# The degree o! articu"ar carti"age response to in ur% "i0e*ise *i"" var% *ith the degree o! damage# $t shou"d (e recogni+ed that the !o""o*ing description o! the morpho"ogic and (iochemica" changes o! articu"ar carti"age in response to insu"t and the su(se4uent deve"opment o! DJD is presented more as an overa"" revie* o! these changes and not as a de!initive se4uence o! events that occurs in ever% instance o! DJD# GROSS CHANGES DJD changes are !irst recogni+ed as a !oca" area o! du""ness on the articu"ar carti"age sur!ace#(28) This is accompanied (% a co"or change !rom the more norma" g"istening *hite to a mott"ed gra% or %e""o*# ;i(ri""ation& as descri(ed a(ove& is occurring in these regions# 8ecause o! a"teration in the matri- composition& these areas a"so (ecome so!ter than norma"# :hondroc%tes ad acent and super!icia" to the so!tened areas (ecome more numerous& *hi"e those *ithin the =o!tened areas decrease in num(er# $n e-perimenta""% induced DJD& chondroc%te densit% increases in areas ad acent to the sp"its or c"e!ts and the num(er o! "acunae *ith t*o or more nuc"ei a"so increases#(17) As the !i(ri""ation

continues& c"ones o! t*o or more ce""s are particu"ar"% a(undant around severe"% !i(ri""ated sites# This response o! increased num(ers o! carti"age ce""s at the initia" site o! in ur% has (een vie*ed (% some as an attempt at intrinsic carti"age repair (;ig# 87-1)# (28) As the c"e!ts and sp"its in the co""agen deepen& a(rasion o! the !i(ri""ated carti"age continues& eventua""% e-posing the under"%ing su(chondra" (one# 5ith continued disruption o! the osteochondra" unction& hemorrhage and (one necrosis occur# 1steochondra" repair ta0es the !orm o! granu"ation tissue and !i(rocarti"age# 5ith continuing "oss o! the carti"age sur!ace and increased (one e-posure& the (one (ecomes sc"erotic# $n severe cases o! DJD the e-posed (one ma% actua""% (ecome *e"" *orn& smooth& and po"ished# =uch (one is descri(ed as e(urnated# (28&./) ;$@# 87-1 ;i(ri""ation o! articu"ar carti"age# :"e!ts and sp"its (egin on the carti"age sur!ace para""e" *ith the articu"ar p"ane# The% then e-tend deeper into the carti"age su(stance (ecoming perpendicu"ar to the oint sur!ace# (6 E 9 - /A) Areas o! (one rare!action& or >c%sts&> ma% appear (eneath the e(urnated sur!aces# These spaces !ormed (% the "oss o! tra(ecu"ae are a !i(rom%oid degeneration o! the marro*# 1n occasion& !ragments o! dead (one& carti"age& and amorphous materia" ma% a"so (e !ound *ithin these areas# 8ecause these "esions on"% rare"% contain poc0ets o! mucoid !"uid and do not have a !i(rous (order or capsu"e& the% are not considered true c%sts# (./) Another (on% change that o!ten accompanies DJD is that o! e-oph%tic gro*th at the margins o! the articu"ar sur!ace# 'argina" osteoph%tes occur at the unction or inter!ace (et*een the articu"ar carti"age and s%novia" mem(rane# The% ma% appear as protu(erances into the oint space or deve"op *ithin capsu"ar or "igamentous attachments at the oint margins# The direction o! osteoph%te !ormation is governed (% the "ine o! mechanica" !orce imparted to the area o! gro*th# 1steoph%te !ormation (egins as a deposition o! minera" outside the e-isting (on% corte-#(/) ;urther deposition o! ne* (one& resorption& and remode"ing u"timate"% produce a mature osteoph%te# :apped (% a h%a"ine or !i(rocarti"age sur!ace& mature osteoph%tes communicate !ree"% *ith the marro* spaces o! the (one !rom *hich the% arose (;igs# 87-2 and 87-.)# $n e-periments in *hich the anterior cruciate "igament o! dogs *as severed to produce DJD& (eginning osteoph%te deve"opment *as detected (% microangiographic techni4ues 7 da%s a!ter "igament transection 'acroscopica""% and radiographica""%& osteoph%tes cou"d (e seen at 2 *ee0s and 5 *ee0s respective"% !o""o*ing "igament transection# 5hi"e in itse"! the presence o! osteoph%tes (i#e#& *ithout carti"aginous de!ects) is pro(a("% not evidence !or a diagnosis o! DJD& it is indicative o! a(norma" activit% *ithin a oint# A third signi!icant (on% change o! DJD is the deve"opment o! sc"erosis in the

su(chondra" area# The (one in this area (ecomes more dense *ith increasing "oss o! the articu"ar carti"age a(ove# This sc"erosis has (een descri(ed as (eing the resu"t o! increased "oads p"aced on the (one (ecause o! the articu"ar carti"age "oss#(3&28) ;$@# 87-2 1steoph%tes on "atera" aspect o! "atera" !emora" cond%"e# 1steoph%tes deve"op at the inter!ace o! articu"ar carti"age and s%novia" mem(rane Cascu"arit% o! the s%novia" mem(rane can (e seen (arro*)#

;$@# 87-. 1steoph%tes on the pro-ima" aspect o! the !emora" troch"ea#

BIOCHEMICA CHANGES ;or the most part& (iochemica" a"terations in articu"ar carti"age undergoing changes associated *ith DJD precede the characteristic macroscopic changes#(3&18) 5hi"e there are some con!"icting reports regarding the changes in *ater content& production and t%pe o! co""agen present& and the ratio o! proteog"%can constituents& the genera" consensus is that *ater content increases a"ong *ith an initia" increase in chondroc%tic s%nthesi+ing activities# 5ith progression o! DJD and continued "oss o! articu"ar carti"age su(stance and there!ore "oss o! the chondroc%tes themse"ves& it is o(vious that chondroc%te activities decrease# The *ater content o! norma" articu"ar carti"age is (et*een 72B and 78B#(15) $n DJD not on"% is the *ater content increased (ut the *ater is more tight"% (ound and there!ore "ess !ree"% e-changea("e *ith the oint space# (15&3.) $t is suspected that o*ing to proteog"%can dep"etion& "arger amounts o! *ater (ecome more avid"% (ound to co""agen# The "oss o! *ater-trans!er capa(i"ities ma% have a de"eterious e!!ect on chondroc%te nutrition& articu"ar carti"age e"asticit%& and oint "u(rication#(3.) 5hi"e the tota" co""agen content o! osteoarthritis articu"ar carti"age is simi"ar to that o! norma" carti"age& the composition and orientation o! the co""agen !i(ri"s are changed# (3.) in the upper region o! degenerative carti"age the tota" num(er o! co""agen !i(ri"s remains near"% the same as norma" carti"age) ho*ever& there is a decrease in the num(er o! "arge-diameter !i(ri"s#(35) As might (e e-pected& !i(ri" orientation is severe"% a"tered# Father than remaining in tight"% pac0ed (und"es para""e" *ith the articu"ar =ur!ace& the !i(ri"s are in a "ooser arrangement *ith a random orientation# These !indings o! a higher proportion o! sma""-diameter co""agen !i(ri"s and random orientation o! the !i(ri"s are a"so characteristic o! the deeper "a%ers o! the a!!ected carti"age# $n addition& the t%pe o! co""agen !i(ri" !ound in osteoarthritis articu"ar carti"age is di!!erent than that !ound in norma" carti"age# =evera" reports have sho*n that osteoarthritis chondroc%tes produce not on"% t%pe $$ co""agen (ut su(stantia" amounts o!

t%pe $ co""agen& that *hich is usua""% !ound in s0in and (one#("5&.9&3.) 5hi"e evidence to the contrar% has a"so (een reported&> it is genera""% (e"ieved that the changes in the t%pe o! co""agen !i(rin and the a"terations in their si+e and orientation serve to a!ter the mechanica" properties o! arthritic carti"age#(3.) $t is genera""% accepted that the tota" proteog"%can content o! osteoarthritis articu"ar carti"age is decreased and that the decrease is direct"% proportiona" to the disease severit%# (15) 6o*ever& *hi"e tota" @A@ content o! a!!ected carti"age is diminished& not a"" @A@ components are a!!ected e4ua""%# 5hen compared *ith norma" carti"age& there is a re"ative decrease in 0eratin su"!ate and an increase in chondroitin 3-su"!ate such as is !ound in norma" %oung or immature carti"age# Thus& chondroc%tic s%nthesi+ing activit% continues in a!!ected carti"age (ut the products produced are di!!erent#(13&18) 5hat triggers this a"teration in production is not 0no*n& (ut it has (een suggested that it ma% (e an attempt to hea" the carti"aginous de!ects#(15) $t must (e noted that these changes are !ound on"% in areas o! carti"aginous "esions such as !i(ri""ation# $n intact areas o! carti"age !rom the same oint sur!ace& @A@ content is norma"# (.9) $n addition& @A@ content is increased in areas o! osteoph%tic activit%# $n "ater stages o! DJD& there is a continued decrease in @A@ s%nthesis and a re"ative decrease in chondroitin su"!ate compared *ith 0eratin su"!ate#(3A) These decreases corre"ate *e"" *ith the histo"ogic severit% o! the disease# CE S O! AR"IC# AR CAR"I AGE

There is amp"e evidence to sho* that in the ear"% stages o! DJD there is an increase in the num(er o! chondroc%tes ad acent to the sp"its in the carti"age# The rate at *hich ne* ce""s are produced has (een !ound to (e proportiona" to the severit% o! the disease (ased on a histochemica" grading s%stem !or ear"% and moderate "esions#(15) These ce""s& particu"ar"% near the articu"ar sur!ace& have a microscopic appearance suggestive o! !i(ro("asts# U"trastructura""%& the% have an increase in rough endop"asmic reticu"um& mitochondria& and @o"gi apparatus& *hich are the organe""es associated *ith increased matri- production#(3.) $n addition& some o! these ce""s are !ound to have a decrease in stored g"%cogen& a"so suggestive o! increased ce""u"ar activit%#(35) $n advanced severe "esions& ne* ce"" production is decreased and the ce""s present appear to (e undergoing degenerative changes#(3.) Thus it seems as i! the increased s%nthesi+ing activit% o! @A@ and production o! ne* ce""s cannot 0eep pace *ith the !orces and activities responsi("e !or carti"age destruction# This has (een descri(ed as a !ai"ure> or (rea0do*n in the reparative mechanism that accompanies increasing disease activit%#("5) L%sosoma" activit% and en+%matic degradation are a"so !actors in the osteoarthritis process and ma% in !act e-p"ain ho* there can (e a "oss o! matri- components in the !ace o! increased matri- s%nthesis# 5hi"e the initiating !actors !or en+%me re"ease are not 0no*n& there is no dou(t that the% are present in increased amounts in osteoarthritis carti"age# Acid phosphatase& ar%"su"!atase A and 8# and cathepsin 8 and D have (een !ound in greater amounts than norma" in carti"age !rom a!!ected oints#(.&5&.3) These en+%mes a!!ect the matri- in various *a%s& (ut in genera" the% cause a degradation o! proteog"%can# As mentioned a(ove& some o! these en+%mes are necessar% !or the norma"

turnover o! proteog"%can# 5hat causes their increased production or decreased remova" is not 0no*n# 6o*ever& it is 0no*n that their activit% contri(utes to the (rea0do*n o! the proteog"%can structure and su(se4uent "oss o! matri- su(stance# ,rotease inhi(itors are 0no*n to (e present in articu"ar :arti"age& and it has (een h%pothesi+ed that an impaired a(i"it% o! the chondroc%tes to s%nthesi+e these su(stances "eads to the "oss o! matri- components# (.9) $n this theor%& the degradative en+%mes norma""% present in articu"ar :arti"age are he"d in chec0 (% other en+%mes produced (% the chondroc%tes# 8ut in DJD& !or some un0no*n reason& the protease production is decreased and there!ore the chec0 he"d on the degradative en+%mes is "ost# 5hi"e this h%pothesis has not (een proven to date& it remains an interesting concept& especia""% in "ight o! *hat is 0no*n o! other regu"ator% (io"ogic mechanisms# CHANGES IN S$NO%IA MEMBRANE The connective tissue that surrounds diarthrodia" oints is designated the oint capsu"e# $ts outer part& composed o! dense connective tissue rein!orced (% tendons and aponeuroses& is termed the !i(rous capsu"e# The inner part is termed the s%novia" mem(rane# The s%novia" mem(rane has severa" components# $ts inner "a%er& *hich is immediate"% ad acent to the oint sur!ace& is a g"istening tissue composed o! s%novioc%tes t*o to three ce""s thic0# 8eneath this is the su(s%novioc%tic tissue& a "oose connective tissue that vanes in depth& vascu"arit%& and amount o! interspersed adipose tissue# 5ithin the su(s%novioc%tic "a%er are co""agen and e"astic !i(ers& as *e"" as !i(roc%tes& occasiona" histioc%tes& macrophages& and mast ce""s# Just as the ear"iest changes o! articu"ar carti"age in primar% DJD have not (een identi!ied& "i0e*ise the ear"iest changes o! s%novia" mem(rane are not *e"" descri(ed# This is due to the inaccessi(i"it% o! the tissues# The insidiousness o! primar% DJD ma0es it a"" (ut impossi("e to produce e-perimenta""% or to gain 0no*"edge !rom (iops% specimens ("ithe spontaneous disease# $n!ormation a(out s%novia" mem(rane changes in DJD comes !rom tissues ta0en a!ter the spontaneous disease has (een present !or some time or !rom e-perimenta" mode"s o! DJD& *hich more accurate"% re!"ect the changes o! secondar% DJD#(3/) Tissue ta0en !rom human patients *ith primar% DJD seen 1 to 1/ %ears !o""o*ing the onset o! s%mptoms sho*s three over"apping stages o! s%novia" mem(rane in!"ammation# (.7) $n the initia" stages& s"ight to moderate s%novioc%te h%pertroph% is noted# There is a"so an increase in the num(er o! s%novioc%tes& thus thic0ening the inner s%novia" mem(rane "a%er# 5ithin the su(s%novioc%tic +one& !i(ro("astic pro"i!eration is noted& a"ong *ith a moderate"% h%peremic change due to ("ood vesse"s# The vesse"s are thin"% surrounded (% in!i"trates o! "%mphoc%tes and p"asmoc%tes# ;oca" aggregations o! simi"ar ce""s are seen occasiona""%# 9dema& a"though present& is on"% moderate# $n the progressive stages o! the disease& s%novioc%te h%perp"asia is more prominent& *ith the "a%er no* (eing three to !ive ce"" "a%ers thic0# $ncreases in !i(ro("astic activit% are noted in the su(s%novioc%tic "a%er& in *hich the !i(ro("asts are more numerous# $n addition& an increase in co""agen !i(ers is seen as *e"" as a signi!icant increase in the su(s%novioc%tic vascu"arit% (;ig# 87-3)#

;$@# 87-3 =%novia" mem(rane !rom the sti!"e o! a dog in *hom the crania" cruciate "igament *as e-perimenta""% transected 8 *ee0s previous"%# The s%novioc%tic "a%er is 5 to 7 ce""s thic0# =uper!icia" ce""s are perpendicu"ar rather than para""e" *ith the oint space (J)# 8eginning !i(rosis o! the norma" adipose su(s%novia" tissues is apparent (arro*)# ( 6 E 9 - /A) The advanced stage is characteri+ed (% a maintenance o! the s%novioc%tic h%pertroph% and h%perp"asia and a mar0ed h%perce""u"arit% o! !i(ro("asts in the super!icia" and deeper regions o! the su(s%novioc%tic "a%er# $n severa" p"aces (road co""agen !i(ers are noted# A"so& in severa" "a%ers the su(s%novioc%tic tissues *ith their comp"ement o! co""agen& !i(ro("asts& and vesse"s are thro*n into !o"ds or vi""i e-tending a(ove the ad acent !"at s%novioc%tic sur!ace and protruding into the oint space# 5hi"e some vi""i are norma""% present in the s%novia" mem(rane& especia""% in those areas o! the oint capsu"e that undergo a great dea" o! stretching during oint motion& these vi""i are a(norma" (ecause o! the a"tered architecture o! the s%novioc%tic and su(s%novioc%tic "a%ers# $n!"ammation o! the s%novia" mem(rane& characteri+ed (% s%novia" ce"" h%pertroph% and h%perp"asia& p"asma ce"" and "%mphoc%te in!i"tration& and increased vascu"ari+ation o! the su(s%novium& are prominent !eatures o! e-perimenta""% produced DJD in the dog# =u(s%novia" !i(rosis is a"so a common !inding#(3/) The increased !i(rosis o! the s%novia" tissue and the progressive !ormation o! vi""i cou"d easi"% contri(ute to the oint sti!!ness and pain!u" s%mptoms o!ten associated *ith advanced DJD#

Clinical Presentation

,rimar% DJD is an insidious progressive condition that most common"% a!!ects o"der anima"s& *hereas secondar% DJD ma% (e more acute in onset and occurs in the %oung or o"d patient# 1nce the patho"ogic trans!ormation o! the tissues (egins& the genera" signs and s%mptoms are simi"ar# Dogs *ith DJD are usua""% presented *ith a comp"aint o! "ameness or gait change#(1A) $n some cases the o*ner *i"" state that the anima" has di!!icu"t% in per!orming certain acts that hereto!ore *ere per!ormed readi"%# 'ost common"%& the anima" is no "onger a("e to ump *ith as much vigor as he had previous"% or no* has di!!icu"t% in c"im(ing a !"ight o! stairs that previous"% *ere easi"% negotia("e# The astute c"inician 0no*s there are man% a!!"ictions and conditions that produce "ameness andGor gait a(norma"ities in the dog& and one must 0eep an open mind *hen per!orming a ph%sica" e-amination on such patients# 9ver% o"der @erman shepherd presented *ith hind"im( "ameness and *ea0ness does not have DJD secondar% to hip d%sp"asia& nor does ever% %oung giant (reed dog presented *ith !ore"eg "ameness have osteochondritis dissecans o! the shou"der#

=ince the ma orit% o! cases o! DJD that occur in the dog are the resu"t o! another condition& the primar% condition must (e diagnosed and treated in order to curtai" the degenerative processes that are occurring in the a!!ected oint# $n addition& there are man% conditions that produce "ameness or gait changes in the dog that do not a!!ect the oints#(.2) 1ne must (e a("e to di!!erentiate these pro("ems !rom those that are articu"ar diseases# A care!u""% ta0en histor% and thorough ph%sica" e-amination& inc"uding a neuro"ogic assessment o! the patient& are necessar% in eva"uating "ameness# The anima"<s (reed and age are com(ined *ith the in!ormation g"eaned !rom the histor% and ph%sica" e-amination and are centra" in reducing the "ist o! di!!erentia" diagnoses# A"so& anima"s ma% (e presented *ith concomitant conditions& and it must (e 0ept in mind that (oth pro("ems ma% (e contri(uting to the patient<s "ameness# =uch a situation ma% occur in o"d @erman shepherds *ho have degenerative m%e"opath% o! the spina" cord and DJD secondar% to hip d%sp"asia# A partia" "ist o! conditions that ma% mani!est as "ameness andGor gait a(norma"ities and there!ore ma% (e mista0en initia""% !or articu"ar disease is presented in Ta("e 87-2#

TA8L9 87-2 ?onarticu"ar :onditions That 'a% :ause Lameness or @ait A(norma"ities

,h%sica" e-amination o! the anima" shou"d inc"ude a"" (od% s%stems and especia""% a neuro"ogic e-amination) it shou"d not (e con!ined so"e"% to the apparent"% a!!ected "im(# 9-amination o! the a!!ected "im( shou"d inc"ude pa"pation o! the muscu"ature and oints and a comparison *ith the opposite norma" "im(#(.2) =evere pain on oint pa"pation and manipu"ation is unusua" in the dog *ith DJD# 6o*ever& pain ma% (e e"icited in such conditions as osteochondritis dissecans o! the shou"der# The a!!ected oint shou"d (e manipu"ated gent"% through its !u"" range o! motion and the vi(rator% sensations o! crepitus shou"d (e noted i! present# :repitation is usua""% indicative o! articu"ar carti"age *ear or osteoph%te !ormation# $n addition& "igamentous and tendinous structures o! the oint shou"d (e assessed !or integrit% and "a-it%# Joint range o! motion shou"d (e measured *ith a goniometer& compared *ith the same oint on the opposite norma" "im(& and the resu"ts noted in the patient record# 9-tensive oint e!!usion is not a prominent !eature o! DJD a"though s"ight increases in oint !"uid vo"ume are not unusua"# $n chronic cases the e!!usion is usua""% "ess severe and ma% not (e readi"% detecta("e (% pa"pation# 6o*ever& as mentioned in :hapter 8/& signi!icant changes are present in the ce""u"ar constituents o! the s%novia" !"uid !rom osteoarthritis oints& and s%novia" !"uid ana"%sis shou"d (e an integra" part o! the diagnostic eva"uation o! the patient# Joint en"argement is most !re4uent in the more chronic cases and varies *ith the degree o! periarticu"ar so!t tissue !i(rosis& oint capsu"e thic0ening& and osteoph%te !ormation# A"though DJD is an in!"ammator% disease o! articu"ar tissues& a pa"pa("e increase in temperature o! the tissues over"%ing the a!!ected oint ma% not (e readi"% detecta("e even in the acute condition# Thermographic studies& ho*ever& ma% sho* increases in tissue temperatures# =uch techni4ues have (een used in humans and in horses#(32) it

shou"d (e noted that most in!"ammator% conditions are associated *ith increases in tissue temperatures and that thermograph% cannot (e used to an% signi!icant degree in di!!erentiating degenerative oint disease !rom other in!"ammator% conditions o! oints# $n addition to the usua" comp"ete e-amination o! a"" (od% s%stems& it must (e determined *hether the anima" has a "oca" or s%stemic condition& a"though a "oca"i+ed condition ma% a!!ect mu"tip"e sites# (1/) :are!u" 4uestioning o! the o*ner shou"d accompan% the actua" e-amination o! the patient# $t must (e determined *hen the "ameness *as !irst noticed and under *hat circumstances# 5as there a >traumatic> incident or an unusua" e-perience such as overuseH The pattern o! invo"vement& i! an%& shou"d (e determined# $n *hat order& i! an%& did the oint invo"vement occurH $s the "ameness more noticea("e a!ter rest or a!ter e-erciseH Does the patient >*arm> in or out o! the "amenessH $s the invo"vement se"!-"imited& migrator%& or progressiveH(1/) 'igrator% means that the process su(sides in one oint on"% to mani!est itse"! in another# ,rogressive means that the !irst oint remains invo"ved (ut additiona" oints (ecome a!!ected as *e""# ,revious treatment shou"d (e determined# 5hat *as given& !or ho* "ong& and *hat e!!ect did the therap% have on the conditionH $n addition& an% side-e!!ects produced (% the medication must (e noted#

Ra&iogra'hic E(a)ination

A"" anima"s suspected o! having articu"ar disease o! an% t%pe must have the appropriate oints radiographed# The usua" tenets o! good radiographic techni4ue and protoco" must (e !o""o*ed# These inc"ude accurate patient positioning& at "east t*o standard vie*s o! the a!!ected & oint or oints& sedation or genera" anesthesia o! the patient to ease patient positioning and prevent motion on the !i"m& the use o! proper !i"m and screens !or the area o! the (od% to (e radiographed& and proper e-posure o! the !i"m# $t has (een stated that there are t*o t%pes o! signs o! articu"ar disease: the c"inica" and the radiographic#(25) Anima"s *ith c"inica""% o(vious articu"ar disease ma% have !e* radiographic a(norma"ities& *hi"e those *ith e-tensive radiographic changes ma% sho* !e* c"inica" a(norma"ities# There!ore& radiograph% is (ut one diagnostic too") ust (ecause a oint appears !ree o! radiographic change does not mean it is !ree o! articu"ar disease# Fadiographic !indings must (e interpreted and integrated *ith the other diagnostic in!ormation& especia""% *ith the !indings o! ph%sica" e-amination and s%novia" !"uid ana"%sis# :haracteristic radiographic !eatures o! DJD inc"ude sc"erosis o! su(chondra" (one& su(chondra" (one c%sts& osteoph%te !ormation& su("u-ation& narro*ing o! the oint space& and intra-articu"ar or periarticu"ar ca"ci!ication (;ig# 87-5 and 87-/)#(21) =c"erosis o! su(chondra" (one is seen in more chronic cases o! DJD and suggests that (one (eneath the carti"age is (eing su( ected to increased stress that norma""% is (orne (% the articu"ar carti"age# =c"erotic su(chondra" (one appears radiographica""% as a homogeneous& radiodense area (eneath the articu"ar sur!ace o! the a!!ected oint#

As mentioned a(ove& the so-ca""ed su(chondra" (one c%sts o! DJD are not tru"% c%sts (ut !"uid- or mucoid !i""ed spaces in the su(chondra" (one pro(a("% created (% micro!ractures o! su(chondra" tra(ecu"ae# 8ecause the% "ac0 a de!inite capsu"e& these areas are not true c%sts# Their presence in dogs and cats *ith DJD is unusua"& a"though the% are !re4uent"% !ound in the horse and other "arge anima"s#(21) 5hen present& the% appear as rounded& "ucent areas surrounded (% a thin "a%er o! sc"erotic su(chondra" (one#

;$@# 87-5 Latera" radiographic vie* o! the e"(o* o! a dog *ith DJD# 1steoph%tes are seen on the crania" (1) and cauda" (2) aspects o! the oint# =c"erosis o! the radia" head (.) and pro-ima" u"na (3) is a"so present#

;$@# 87-/ Latera" (A) and crania"-cauda" (8) radiographic vie*s o! the sti!"e o! a dog *ith DJD# 1steoph%tes are present on the pro-ima" aspect o! the !emora" troch"ea (1)& pro-ima" and dista" aspects o! the pate""a (2)& !emora" cond%"es (.)& and pro-ima" ti(ia (3)# =c"erosis o! the pro-ima" ti(ia (5) is a"so present# 1steoph%tes are common"% seen radiographica""% in more chronic cases o! DJD& especia""% in the sti!"e& hip& shou"der& and e"(o* oints# The% appear as periarticu"ar spurs or outgro*ths o! (one arising !rom the margins o! the articu"ar sur!ace# :orre"ations have not (een made (et*een the presence o! osteoph%tes and the presence o! articu"ar carti"age (rea0do*n or disease# $n other *ords& does the radiographic !inding o! osteoph%te !ormation automatica""% mean the presence o! DJDH 5hi"e it is true that osteoph%tes are common in oints a!!ected *ith DJD& & oints that have osteoph%tes ma% not have the other !eatures o! DJD#(23) To date& this controvers% has not (een reso"ved# $t is sa!e to sa% that osteoph%tes a"one pro(a("% are not pathognomonic o! DJD (ut their presence does indicate some a(norma" activit% *ithin or ad acent to the a!!ected oint# =u("u-ation has (een descri(ed as a radiographic !eature o! DJD o! the sti!"e o! the dog# (2A) A"though pro(a("% due more to concomitant "igamentous andGor menisca" in ur% than to an%thing e"se& the su("u-ation is demonstra("e in man% cases *hen the radiographs are ta0en *ith the patient in a *eight-(earing position# A(norma" oint "a-it% due to the "oss o! supporting structures p"a%s a signi!icant ro"e in the perpetuation o! DJD# The a(norma" stresses to *hich the oint tissues are su( ected (ecause o! supporting structure "oss continua""% !eed the !ire o! in!"ammation& resu"ting in oint tissue destruction# 5hether the "a-it% preceded the degenerative changes and there!ore resu"ted in secondar% DJD or *hether the "a-it% occurred as a resu"t o! the "igamentous destruction in the ongoing process o! primar% DJD is& at "east !or this discussion& immateria"# 5hat is important is that su("u-ation can (e seen radiographica""% in DJD# $n the hip it is o!ten seen in the DJD o! hip d%sp"asia# Joint "a-it% ma% a"so (e demonstrated radiographica""% (% o(taining >stress> vie*s o! the a!!ected oint# =tress vie*s are o(tained (% app"%ing a(norma" media" or "atera"

pressure to a oint that is (eing radiographed# Li0e*ise& the oint ma% (e radiographed in h%per!"e-ion or h%pere-tension# :hanges in radiographic appearance o! the oint space in DJD or other articu"ar diseases must (e udged and interpreted *ith care# ?arro*ing or co""apse o! the oint space is said to (e a !air"% consistent !eature o! chronic DJD#(21) This is due to the "oss o! signi!icant amounts o! articu"ar carti"age& a""o*ing su(chondra" (one& *hich is more radiodense than articu"ar carti"age& to come in c"oser contact& there!ore giving the appearance o! a narro* oint space# This in !act is the case& (ut the radiographic appearance o! the oint space *i"" a"so (e a!!ected (% patient positioning& assumption o! a *eight-(earing or non-*eight-(earing position *hen the radiograph *as ta0en& oint e!!usion& and integrit% o! the "igamentous structures o! the a!!ected oint# As noted a(ove& dogs *ith hip d%sp"asia and DJD o! the co-o!emora" oint have oint e!!usion that a!!ects the inter!ace (et*een the !emora" head and the aceta(u"um#("2&1.) $n these anima"s the oint space *i"" appear 4uite di!!erent i! radiographs are ta0en (e!ore and a!ter arthrocentesis# True assessment o! changes in the *idth o! the oint space are (est made *ith the patient in a *eight-(earing position# :a"ci!ication o! the supporting so!t tissues o! a oint& *hether intra-articu"ar or periarticu"ar& is rare"% seen in the dog# This !inding has (een associated *ith DJD o! "ong duration# 6o*ever& so!t tissue ca"ci!ication a"one& *ithout other radiographic signs& is pro(a("% a poor indication o! the presence o! DJD#(21) =%novia" chondromatosis is a condition in *hich chondri!ication and minera"i+ation o! the s%novia" mem(rane occur# A"though rare in the dog& the patient presents *ith "ameness and minera"i+ed densities *ithin the oint# The etio"og% o! the condition is un0no*n in humans and in dogs& and the oint in!"ammation that ensues is secondar% to the origina" pro("em# $ntra-articu"ar minera"i+ation can a"so (e seen *ith osteochondritis dissecans# Loose (odies !orm !rom the dis"odged carti"aginous !"ap# The carti"age is nurtured (% the s%novia" !"uid and remains via("e# $n some cases the !ree !"ap (ecomes em(edded in the s%novia" mem(rane# 1nce again& this unusua" !inding is not characteristic o! DJD) it is ust an odd !inding in the occasiona" case o! osteochondritis dissecans#

Clinical a*oratory !in&ings

There are no speci!ic "a(orator% !indings characteristic o! DJD# Fesu"ts o! a hemogram& urina"%sis& and ("ood chemistr% determinations are usua""% *ithin norma" "imits# Fesu"ts o! rheumatoid !actor tests and "upus er%thematosus (L9) c"ot tests are negative& as is the search !or antinuc"ear anti(odies# 9-amination o! the s%novia" !"uid *i"" usua""% con!irm the presence o! a "o*-grade intra-articu"ar in!"ammator% processes in the acute condition or in secondar% DJD associated *ith common conditions such as osteochondritis dissecans& hip d%sp"asia& or ruptured crania" cruciate "igament& s%novia" !"uid vo"ume is o!ten increased# =%novia" !"uid co"or ranges !rom pa"e %e""o* to stra* co"or and is usua""% c"ear# 6a+iness or !"occu"ence ma% (e seen in some cases o! secondar% DJD& especia""% those in *hich there is an articu"ar carti"age de!ect# Ciscosit% is usua""% norma" and the mucin c"ot test rated !"air to good#

Tota" *hite ce"" count rare"% e-ceeds 5AAA ce""sG mm.) the predominant ce""s are "%mphoc%tes and monoc%te-macrophages# ,hagoc%tic vacuo"es ma% (e seen on c"ose e-amination o! the macrophages# ?eutrophi"s are rare"% encountered#

"reat)ent

1steoarthritis is not a condition that can (e cured in the sense o! returning the patient to comp"ete norma"c%# $n most cases& some residua" a(norma"it% *i"" remain in the a!!ected oint or oints& and this a(norma"it% is o!ten o! such a nature as to continua""% produce di!!icu"ties !or the patient# The goa"s in the treatment o! DJD are to a""eviate the anima"<s discom!ort& to prevent the occurrence o! !urther degenerative changes& and to restore the a!!ected oint or oints to as near norma" and pain-!ree !unction as possi("e# :ompared *ith the treatment o! other conditions such as a (acteria" in!ection& treatment o! DJD is rather s%mptomatic and nonspeci!ic# Fest and ph%sica" therap% are emp"o%ed to initia""% decrease in!"ammation o! the a!!ected oint and then to strengthen the supporting structures o! the oint# 'edica" therap% inc"udes a *ide variet% o! compounds and medicaments& each *ith essentia""% the same purpose-to reduce in!"ammation and act as an ana"gesic# =urgica" treatment in concert *ith medica" and ph%sica" therap% ma% prove (ene!icia" in some cases# GENERA CONSIDERA"IONS 9-cessive use o! the oint ma% aggravate the s%mptoms o! DJD and acce"erate degenerative changes# Fest p"a%s a signi!icant ro"e in the management o! DJD in humans and shou"d a"so in the dog# Too o!ten this important aspect o! therap% is over"oo0ed# $t ma% (e argued that dogs rest most o! the time& in that e-cept !or the true *or0ing or racing anima" most dogs have "itt"e true ph%sica" activit%# $ndeed& this ma% (e so# This does not& ho*ever& prevent o*ners !rom e-pecting their more sedentar% pets to per!orm certain acts or games that invo"ve running or umping# 5hi"e e-ercise ma% (e a va"ua("e portion o! the treatment regime& it must (e contro""ed and speci!ica""% tai"ored to each situation and anima"# Just as rheumato"ogists *ou"d counse" their patients on the t%pe and e-tent o! e-ercise& so too shou"d the veterinarian counse" the c"ient *ho has a dog *ith DJD# $n the acute stages o! DJD& *hen oint e!!usion is present and the in!"ammator% process is at its pea0& e-ercise shou"d not (e a""o*ed# 1ur patients are at some*hat o! a disadvantage in that even the act o! moving !rom one spot to another ma% invo"ve use o! an a!!ected oint& *hereas a person ma% use a crutch or cane to aid in reducing the stress# 1nce the oint e!!usion has su(sided and the ana"gesic anti-in!"ammator% medications have (een given& contro""ed e-ercise is advisa("e# =tress!u" activit% shou"d (e 0ept to a minimum and the anima"<s to"erance to activit% udged care!u""%# 5a"0ing on a "eash severa" times a da% !or short distances is advisa("e initia""%# As the patient responds to this and there are no unto*ard e!!ects such as re"uctance to ta0e the *a"0& sti!!ness or soreness severa" hours !o""o*ing the activit%& or changes in gait patterns& the *a"0ing

shou"d increase in "ength# 'ore strenuous activities can (e introduced as the anima" gains strength# 5hi"e the re"ationship (et*een o(esit% per se and DJD in humans remains controversia"& reduction to idea" *eight appears prudent& since degenerative changes are initiated or aggravated (% e-cessive or a(norma""% directed pressures on articu"ar carti"age#(22) 5eight reduction (% dietar% contro" shou"d (e considered !or the over*eight dog as *e""# This is o!ten di!!icu"t to accomp"ish o*ing to the re"uctance o! o*ners to !eed their anima"s "ess and o*ing to the "imited activit% o! the patient# :a"oric re4uirements shou"d (e ca"cu"ated !or the anima" (ased on idea" (od% *eight and amount o! activit%) a dietar% p"an can then (e esta("ished !or the o*ner to !o""o*# DR#G "HERAP$ There are no drugs or com(inations o! drugs that *i"" consistent"% prevent or reverse the patho"ogic changes o! DJD# Drugs are administered to DJD patients primari"% as ana"gesics and anti-in!"ammatories !or s%mptomatic re"ie! o! c"inica" signs# As'irin Acet%"sa"ic%"ic acid (aspirin) is an ana"gesic and anti-in!"ammator% as *e"" as an antip%retic and is the (asic drug !or the treatment o! DJD# $t is the (asic drug in a c"ass 0no*n as nonsteroida" anti-in!"ammator% agents# Used proper"% it can (e 4uite e!!ective and !ree o! side-e!!ects# Aspirin has an impact on a *ide variet% o! meta(o"ic processes and en+%me s%stems# 'i"d to moderate periphera" pain is re"ieved (% its a(i"it% to ("oc0 the e!!ects on pain endings o! in!"ammator% mediators such as (rad%0inin#(2) $n contrast to the opiates& aspirin acts periphera""% rather than centra""% as an ana"gesic# Aspirin<s actions as an anti-in!"ammator% agent are due primari"% to its a(i"ities to inhi(it prostag"andin (ios%nthesis# (15) As *ith an% drug& su!!icient dosages must (e ta0en to o(tain ade4uate e!!ects# A dosage o! 25 mgG0g three times per da% is given initia""% and the therapeutic resu"ts o(served# (2&.5&37) $! the desired e!!ects have not (een o(tained in 3 to 5 da%s& the dosage ma% (e increased s"ight"%# Dosages reaching 5A mgG0g ma% produce emesis#(35) Comiting can occur at "o*er doses as *e"" and ma% (e prevented (% administering the drug *ith !ood# ,atients *ith gastric into"erance to p"ain aspirin ma% !ind it *e"" to"erated *hen ta0en *ith ora" antacids such as magnesium-a"uminum h%dro-ide# 5hen ta0en at therapeutic "eve"s& aspirin is virtua""% !ree o! serious side-e!!ects# @ross overdoses ma% produce h%perthermia& severe acid-(ase and e"ectro"%te distur(ances& rena" damage& hemorrhage& convu"sions& and coma#(2) Treatment !or such acute and severe pro("ems inc"udes gastric "avage to remove an% una(sor(ed drug& urine a"0a"ini+ation *ith sodium (icar(onate to enhance rena" e-cretion o! sa"ic%"ate& and peritonea" dia"%sis to remove sa"ic%"ate !rom p"asma#(2) Less "i!e-threatening to-ic mani!estations inc"ude s0in eruptions& edema& gastrointestina" ("eeding and u"ceration& h%poprothrom(inemia& vomiting& and dea!ness# $n the dog& the most common o! these are vomiting and me"ena# 5ithho"ding the medication *i"" a""eviate these pro("ems#(2)

Phenyl*+ta,one ,hen%"(uta+one has (een used *ith a good dea" o! success in the s%mptomatic treatment o! chronic DJD# $t has (een 4uite va"ua("e in some cases o! DJD that *ere unresponsive to aspirin# 8ecause o! the (one marro* depression it ma% cause& phen%"(uta+one has not (een used as *ide"% in humans as it has in anima"s# 5hen proper"% administered and monitored& it can (e a most va"ua("e drug !or the s%mptomatic treatment o! DJD in the dog# ,hen%"(uta+one is a nonsteroida" anti-in!"ammator% drug *ith a mechanism o! action simi"ar to that o! aspirin#(.5) $t is given in dosages ranging !rom A#5 mg to 1#A mgG0g o! (od% *eight three times per da%# 8one marro* depression ma% (e the most serious o! its side-e!!ects# ,eptic u"cers& ma"aise& pruritus& rashes& rena" d%s!unction& and other pro("ems have a"so (een reported in humans# Other Nonsteroi&al Anti-in.la))atory Agents 5ithin recent %ears a variet% o! agents have (een introduced !or treatment o! articu"ar disease# There is a categor% o! nonsteroida" anti-in!"ammator% agents that are common"% re!erred to as aspirin-"i0e# These drugs a"so are anti-in!"ammator%& ana"gesic& and antip%retic& and their mode o! action is the inhi(ition o! prostag"andin s%nthesis or re"ease# The drugs o! this t%pe present"% approved in the United =tates !or use in humans inc"ude !enopro!en& i(upro!en& indomethacin& ne!anamic acid& napro-en& o-%phen%"(uta+one& su"indac& and to"metin#(2.) 'ec"o!enamic acid has (een approved !or use in the horse# The e!!icac% o! man% o! these drugs in the dog has %et to (e esta("ished# 1n a c"inica" (asis& mec"o!enamic acid has (een as e!!ective as aspirin in some cases o! DJD in the dog#I $(upro!en given ora""% in a tota" dose o! 15 mgG0g (od% *eight divided into three doses dai"% and indomethacin in an ora" dose o! 1#AA mg to 1#25 mgG0g divided into t*o or three doses dai"% have (een suggested !or the treatment o! DJD in the dog#(28) 5ith chronic use (oth drugs ma% cause gastrointestina" pro("ems# To date& there is "itt"e convincing data that sho* that an% o! the ne*er compounds are superior to aspirin in e!!ectiveness *hen the o( ective o! therap% is an immediate antiin!"ammator% e!!ect#(33) The compounds do& ho*ever& have !e*er side-e!!ects& and !or that reason a"one have !ound great acceptance (% the ph%sician and the genera" pu("ic# 5e""-designed and *e""-e-ecuted studies *i"" (e needed (e!ore their e!!ectiveness in the dog and the cat can (e determined# $t is important to note that as o! this *riting man% o! these ne*er drugs have not (een approved (% the appropriate authorities !or use in the dog# There!ore& one cannot "ega""% administer or prescri(e them# I 5a""ace LJ: Unpu("ished data Corticosteroi&s :orticosteroids are potent anti-in!"ammator% drugs that ma% (e o! (ene!it in some cases

o! DJD# Their mechanism o! action is re"ated to retardation o! "eu0oc%te migration& decreased permea(i"it% o! microvascu"ature& inhi(ition o! prostag"andin re"ease& and sta(i"i+ation o! $%sosoma" mem(ranes# (7&.5) :orticosteroids shou"d not (e considered as the agent o! choice in the treatment o! DJD# The% are reserved !or those cases that are unresponsive or s"o*"% responsive to the previous"% mentioned agents# :orticosteroids are most common"% administered ora""% or parentera""% in "o* doses and given !or short periods o! time# ,redniso"one ma% (e given parentera""% at a dose o! " mg to 2 mgG0g !o""o*ed (% an ora" maintenance dose o! A#5 to 1#A mgG0g once dai"%# The "o*est possi("e maintenance dose shou"d (e esta("ished& such as a"ternate da% or ever% third da% administration o! A#5 mg to 1#A mgG0g# :orticosteroids have (een used in com(ination *ith nonsteroida" anti-in!"ammator% drugs# Aspirin and corticosteroids are administered concomitant"% in the doses mentioned a(ove# 9ach su(se4uent da%& sma""er doses are given so that (% the !i!th or si-th da% corticosteroids are no "onger administered and the aspirin is (eing given in "o* maintenance doses# 5hi"e some patients respond to this regime& the% ma% (e prone to gastrointestina" hemorrhage# $ntra-articu"ar insti""ation o! corticosteroids has (een used in humans and in anima"s !or the treatment o! DJD# 9!!ects o! the drug "ast !or var%ing periods o! time and are o!ten repeated on an >as needed> (asis# $t has (een suggested that the (ene!icia" e!!ects o! such treatment are due to a(sorption and s%stemic distri(ution o! the drug#(22) The practice o! intra-articu"ar corticosteroid in ection is not *ithout comp"ications# ,ostin ection !"are& a s%novitis induced (% corticosteroid cr%sta"s& ma% occur# $n addition& the in ected oint ma% (e more suscepti("e to in!ection# 9-perimenta" *or0 in anima"s and c"inica" o(servations in humans sho* that intra-articu"ar corticosteroids have a de"eterious e!!ect on carti"age that is a"read% damaged (% disease#(22) To date& su!!icient studies in the dog and cat have not (een recorded that con!irm or den% that these anima"s are as suscepti("e or as prone to the comp"ications o! intra-articu"ar corticosteroids as are humans# $ntra-articu"ar corticosteroids in the dog and cat shou"d (e used *ith great discretion unti" such in!ormation is avai"a("e# Other Dr+gs $ntra-articu"ar in ection o! h%a"uronic acid is present"% under investigation as a treatment !or DJD in humans and in anima"s# A hea"ing e!!ect on traumatic "ameness in the horse has (een reported# (..) 6o*ever& c"inica" tria"s in human osteoarthritic 0nee oints have so !ar sho*n either no (ene!icia" e!!ect or var%ing degrees o! improvement o! s%mptoms#(22) Unti" !urther reports are avai"a("e& this drug shou"d pro(a("% not (e considered a part o! the treatment regime !or DJD# 1rgotein is another drug that ma% have potentia" in the treatment o! DJD) to date it has not (een studied in su!!icient depth or "ength to (e recommended# 1rgotein is a supero-ide dismutase that e-erts its e!!ects (% mem(rane sta(i"i+ation& promotion o! "eu0oc%te chemota-is& and& most important"%& (% inhi(ition o! certain en+%me !unctions that promote in!"ammation#(.5) $n ection into osteoarthritic hips and 0nees o! humans produced sustained improvement& and such treatment has (een used in the horse *ith some success#(22&.5) AC#P#NC"#RE

Acupuncture has (een sho*n to (e e!!ective in the reduction o! certain t%pes o! pain# 6o*ever& reports o! its e!!icac% in humans *ith DJD are con!"icting#(22) 5hi"e it ma% (e o! some (ene!it in anima"s *ith DJD& contro""ed studies are "ac0ing# Unti" such reports are avai"a("e# acupuncture *i"" remain a controversia" and curious phenomenon# S#RGER$ The main purposes o! surger% in the treatment o! DJD are to increase oint !unction and reduce or e"iminate oint pain# The t*o ma% not (e compati("e# ;or instance& arthrodesis is done most common"% to reduce oint pain and return a "im( to use& (ut o(vious"% the a!!ected oint *i"" no "onger (e !unctiona"# The ma orit% o! sma"" anima"s *ho are operated upon !or oint disease have secondar% osteoarthritis# 1steochondritis dissecans o! the shou"der and ruptured crania" cruciate "igament o! the sti!"e are good e-amp"es# 9ach condition& especia""% i! it is o! severa" *ee0s duration& is a"most a"*a%s associated *ith changes o! secondar% DJD# 8% appropriate surgica" treatment o! each& the primar% condition is e"iminated& thus ending the cause o! the secondar% DJD# 1rthopaedic procedures re"ated to oint disease ma% (e categori+ed as articu"ar& u-taarticu"ar (immediate"% ad acent to the oint)& and para-articu"ar (near a oint)#(8) Artic+lar =%novectom%& the surgica" remova" o! s%novia" mem(rane& is usua""% per!ormed in cases o! immune-mediated arthritis such as rheumatoid arthritis# Femova" o! the active pro"i!erative s%novium o!ten causes remission o! s%mptoms and return to !unction !or "ong periods o! time# $t is not a procedure recommended !or DJD# ;usion o! a oint& or arthrodesis& as noted a(ove& is used to sta(i"i+e a severe"% pain!u" andGor de!ormed oint in hopes o! increasing use o! the entire "im(# $n the dog& the carpus& hoc0& and sti!"e are the oints !used most !re4uent"%# 1n rare occasions& the e"(o* and shou"der ma% a"so (e arthrodesed#(31) Arthrop"ast% is re(ui"ding a oint and inc"udes the insertion o! a tota" prosthesis& as is done !or the severe DJD o! hip d%sp"asia& or a troch"eop"ast% o! the dista" !emur !or pate""ar "u-ation# Fesection arthrop"ast% is re(ui"ding (% removing the ad acent ends o! (one ma0ing up the oint and a""o*ing a pseudoarthrosis to deve"op# This is the rationa"e !or !emora" head and nec0 e-cision in cases o! severe hip d%sp"asia# 1ther e-amp"es o! resection arthrop"ast% in the treatment o! conditions resu"ting in secondar% DJD inc"ude remova" o! ununited (!ragmented) coronoid and ununited anconea" processes !rom the e"(o* oint# J+(ta-artic+lar =urger% ma% (e per!ormed on structures ne-t to rather than direct"% inside a oint# :apsu"orrhaph% procedures !or pate""ar "u-ation or e-tracapsu"ar sta(i"i+ation techni4ues o! the sti!"e !or anterior cruciate "igament rupture are e-amp"es# Para-artic+lar 1steotom% is a surgica""% induced !racture that a""o*s a then rea"igned (one to hea" so

that di!!erent !orces are imparted to the ad acent oints# 1steotomies are done to correct dista" radia" and u"nar gro*th de!ormities& *hich i! uncorrected ma% "ead to DJD o! the carpus and e"(o* oints# ,e"vic osteotomies are no* per!ormed in se"ected cases o! hip d%sp"asia to prevent !urther degenerative changes !rom occurring in the co-o!emora" oint# Tendon surger% ma% (e o! (ene!it in certain cases o! DJD# Transsection o! the pectineus musc"e is used in se"ect cases o! hip d%sp"asia to reduce pain in the a!!ected oint# $t must (e remem(ered that the surgica" procedures mentioned here are not meant to (e speci!ic treatments o! DJD# Father the% are part o! a treatment p"an designed to decrease pain and increase oint and "im( !unction# The treatment o! primar% and secondar% DAD is essentia""% the same e-cept that the initiating cause o! secondar% DJD must (e treated as *e""# :ontro""ed e-ercise and ph%siotherap% are important to the anima"<s *e""-(eing& and the o*ner shou"d (e given speci!ic instructions in this regard# Diet must a"so (e discussed *ith the o*ner& particu"ar"% !or the o(ese anima"# Drug therap% usua""% (egins *ith aspirin# ;avora("e response to the drug o!ten ta0es 2 to . da%s to occur# $! "ess than !avora("e resu"ts are seen at this time and the patient has not sho*n into"erance to the drug& the dosage shou"d (e increased !rom 25 mgG0g three times dai"% to .5 mg to 3A mgG0g three times dai"%# Another 2 to . da%s o! therap% ma% (e re4uired (e!ore resu"ts are seen# 1*ners o!ten e-pect immediate resu"ts a!ter the% administer medication to their pets# The% must (e counse"ed regarding the di!!icu"ties in the treatment o! osteoarthritis and (e made a*are o! its incura(i"it%# ;ran0 discussion (et*een the o*ner and the veterinarian *i"" u"timate"% resu"t in (etter treatment !or the patient# 1nce a !avora("e response is o(tained *ith the e-ercise program and the aspirin administration& the tota" dai"% dose o! drug shou"d s"o*"% (e reduced# As improvement continues& the drug ma% then (e given on an >as needed> (asis# Those anima"s *ho do not respond *e"" to aspirin ma% (e given phen%"(uta+one or corticosteroids# 1ur (est success *ith phen%"(uta+one has (een in dogs *ith severe co-o!emora" DJD that *as unresponsive to aspirin# As noted a(ove corticosteroids are used a!ter aspirin and phen%"(uta+one have proven unsatis!actor% or in cases o! acute in!"ammation# :oncomitant use o! aspirin and corticosteroids in decreasing dosages ma% (e o! (ene!it# 1nce the ne*er nonsteroida" anti-in!"ammator% drugs have (een approved !or use in the dog& the% ma% prove to (e even (etter than aspirin in the treatment o! DJD# The goa" in treating DJD is to ena("e an anima" to (e as active and pain-!ree as possi("e *hi"e at the same time ta0ing the "o*est possi("e dosages o! medication#

Re.erences
DEGENERA"I%E JOIN" DISEASE

1# 8o""et AJ: An essa% on the (io"og% o! osteoarthritis# Arthritis Fheum 12: 152& 19/9 2# Davis L9: :"inica" pharmaco"og% o! sa"ic%"ates# J Am Cet 'ed Assoc 17/:/5& 198A .# 9hr"ich '@& 'an0in 6J& Tread*e"" 8C: Acid h%dro"ase activit% in osteoarthritis and norma" human carti"age# J 8one Joint =urg 55A: 1A/8& 197. 3# @ardner DL: @enera" patho"og% o! the periphera" oints# $n =o0o"o!! L (ed): The Joints and =%novia" ;"uid& vo" 2# ?e* Dor0& Academic ,ress& 198A 5# @hosh ,: L%sosoma" en+%mes in oint disease# Aust ?J J 'ed 8: 12& 1978 /# @i"(ertson 9'': Deve"opment o! periarticu"ar osteoph%tes in e-perimenta""% induced osteoarthritis in the dog# Ann Fheum Dis .3:12& 1975 7# Kantor T@: Anti-in!"ammator% and ana"gesic drugs# $n Kat+ 5A (ed): Fheumatic Diseases# ,hi"ade"phia& J8 Lippincott& 1977 8# Kau!!man '=: Arthritis surger%# $n Kat+ 5A (ed): Fheumatic Diseases# ,hi"ade"phia& J8 Lippincott& 1977 9# Langens0io"d A& 'iche"sson J# Cideman T: 1steoarthritis o! the 0nee in the ra((it produced (% immo(i"i+ation# Acta 1rthop =cand 5A: 1& 1979 1A# Leach D& =umner-=mith @# Dagg AJ: Diagnosis o! "ameness in dogs: A pre"iminar% stud%# :an Cet J 18:58& 1977 11# Lippie""o L& 6a"" D& 'an0in 6&J: :o""agen s%nthesis in norma" and osteoarthritic human carti"age# #$ :"in $nvest 59:59.& 1977 12# Lust @# 8ei"man 5T& 8endano CT: A re"ationship (et*een degree o! "a-it% and s%novia" !"uid vo"ume in co-o!emora" oints o! dogs predisposed !or hip d%sp"asia# Am J Cet Fes 31: 55& 198A 1.# Lust @# 8ei"man 5T& Due"and DJ et a": $ntra-articu"ar vo"ume and hip oint insta(i"it% in dogs *ith hip d%sp"asia# J 8one oint =urg /2A:57/& 198A 13# Lust @# ,rons0% 5# =herman D': 8iochemica" and u"trastructura" o(servation in norma" and degenerative canine articu"ar carti"age# Am J Cet Fes ..:2329& 1972 15# 'c:art% DJ: Di!!erentia" diagnosis o! arthritis: Ana"%sis o! signs and s%mptoms# $n 'c:art% DJ (ed): Arthritis and A""ied :onditions# ,hi"ade"phia& Lea E ;e(iger& 1979 1/# 'cDevitt :& @i"(ertson 9& 'uir 6: An e-perimenta" mode" o! osteoarthritis: 9ar"% morpho"ogica" and (iochemica" changes# #$ 8one Joint =urg 598:23& 1977 17# 'cDevitt LA& 'uir 6: 8iochemica" changes in the carti"age o! the 0nee in e-perimenta" and natura" osteoarthritis in the dog# #$ 8one Joint =urg 588:93& 197/

18# 'an0in 6J: The reaction o! articu"ar carti"age to in ur% and osteoarthritis# ? 9ng" J 'ed 291:1285& 1973 19# 'inor FF: :o""agen meta(o"ism# Am J ,atho" 98: 227& 198A 2A# 'organ J,: Fadio"ogica" patho"og% and diagnosis o! degenerative oint disease in the sti!"e oint o! the dog# J =ma"" Anim ,ract 1A:531& 19/9 21# 'organ J,: Fadio"og% in Ceterinar% 1rthopedics& pp 185-18/# ,hi"ade"phia& Lea E ;e(iger& 1972 22# 'os0o*it+ F5: Treatment o!< osteoarthritis# $n 'c:art% DJ (ed): Arthritis and A""ied :onditions& 9th ed# ,hi"ade"phia& Lea E ;e(iger& 1979 2.# ?ic0ander F# 'c'ahon ;@& Fido"!o A=: ?onsteroida" anti-in!"ammator% agents# Ann Fev ,harmaco" To-ico" 19:3/9& 1979 23# 1"sson =9: Degenerative oint disease (osteoarthrosis): A revie* *ith specia" re!erence to the dog# J =ma"" Anim ,ract 12: ...& 1971 25# 1*ens J'& Ac0erman ?: Foentgeno"og% o! arthritis# Cet :"in ?orth Am 8:35.& 1978 2/# ,a"mos0i 'J& :o"%er FA& 8randt KD: Joint motion in the a(sence o! norma" "oading does not maintain norma" articu"ar carti"age# Arthritis Fheum 2.:.25& 198A 27# ,eacoc0 99 Jr& Can 5in0"e 5 Jr: 5ound Fepair& 2nd ed& pp 82-83# ,hi"ade"phia& 58 =aunders& 197/ 28# ,ederson ?:& ,oo" F: :anine oint disease# Cet :"in ?orth Am 8:3/5& 1978 29# ,ederson ?:& 5eisner K& :ast"es JJ et a": ?onin!ectious canine arthritis: The in!"ammator% nonerosive arthritides# J Am Cet 'ed Assoc 1/9:.A3& 197/ .A# ,erman C: =%novia" !"uid# $n Kane0o J (ed): :"inica" 8iochemistr% o! Domestic Anima"s& .rd ed# ?e* Dor0& Academic ,ress& 198A .1# ,roc0op DJ& Kiviri00a K$& Tuderman L et a": The (ios%nthesis o! co""agen and its disorders# ? 9ng J 'ed .A1: 1.& 77& 1979 .2# Fo% 59;: 9-amination o! the canine "ocomotor s%stem# Cet :"in ?orth Am 1:5.& 1971 ..# F%de"" ?5& 8ut"er J# 8a"a+s 9A: 6%a"uronic acid in s%novia" !"uid: C$# 9!!ect o! intra-articu"ar in ection o! h%a"uronic acid on the c"inica" s%mptoms o! arthritis in trac0 horses# Acta Cet =cand $ 1:1.9& 197A .3# =ch*art+ 9F: 'eta(o"ic response during ear"% stages o! surgica""% induced osteoarthritis in mature (eag"es# J Fheumato" 7:788& 198A

.5# =hort :F& 8ead"e F9: ,harmaco"og% o! antiarthritic drugs# Cet :"in ?orth Am 8:3A1& 1978 ./# =o0o"o!! L: The 8io"og% o! Degenerative Joint Disease# :hicago& Universit% o! :hicago ,ress& 19/9 .7# =oren A: 6istodiagnosis and :"inica" :orre"ation# Fheumatoid and 1ther =%novitis# ,hi"ade"phia& #$8 Lippincott 1978 .8# =tephens F5& @hosh ,# Ta%"or TK;: The pathogenesis o! osteoarthritis# 'ed 6%potheses 5:8A9# 1979 .9# =*eet '89& Thomas J'A& $mme"man AF et a": 8iochemica" changes in progressive osteoarthritis# Ann Fheum Dis ./:.87& 1977 3A# Thompson F: Jr& 1egema TF: 'eta(o"ic activit% o! articu"ar carti"age in osteoarthritis# J 8one Joint =urg /1A:3A7& 1979 31# Turner T# Lipo*it+ AJ: Arthrodesis# $n 8o ra( 'J (ed): :urrent Techni4ues in =ma"" Anima" =urger% $$# ,hi"ade"phia& Lea E ;e(iger& 198. 32# Caden ';& ,urohit F:& 'c:o% 'D et a": Thermograph%: A techni4ue !or su(c"inica" diagnosis o! osteoarthritis# Am &J Cet Fes 31: 1175& 198A 3.# 5eiss :: ?orma" and osteoarthritis articu"ar carti"age# 1rthop :"in ?orth Am 1A:175& 1979 33# 5i"0ens F;: The use o! nonsteroida" anti-in!"ammator% agents# J Am 'ed Assoc 23A:1/.2& 1978 35# 5i"t(erger 6# Lust @: U"trastructure o! canine articu"ar carti"age: :omparison o! norma" and degenerative (osteoarthritis) hip oints# Am J Cet Fes ./:727& 1975 3/# 5ong ,L& Lipo*it+ A&J& =tevens J8: =%novia" mem(rane changes a!ter e-perimenta" transection o! the anterior cruciate "igament in dogs# Am J Cet Fes (in press) 37# Dear"% FA& 8rant FJ: Aspirin dosages !or the dog# J Am Cet 'ed Assoc 1/7:/.& 1975 http:GG***#at"antae4uine#comGpagesGc"ientL"i(LdegeneratJointD#htm"

Enfermedad comn degenerativa (DJD)

La enfermedad comn degenerativa (DJD), designada a menudo osteoartritis , es una causa mu! comn de" "ameness en ca#a""os de" funcionamiento. La ma!or$a de "as estrategias e%uinas de" entrenamiento imp"ican "a prevenci&n !'o e" mantenimiento de una cierta forma de enfermedad comn. La carencia de" funcionamiento como resu"tado de "a enfermedad comn precede a menudo "ameness a#ierto !'o cam#ios radiogr(ficos. Cuntos diversos tipos de empalmes hay? )a! 3 tipos de empa"mes %ue se c"asifi%uen segn su gama de" movimiento. Los Synarthroses son empa"mes inmue#"es. Los

Amphiarthroses se mueven "evemente. Los Diart*roses son empa"mes movi#"es. La ma!or parte de "os empa"mes en e" miem#ro e%uino son diart*rodia" en natura"eza ! son genera"mente "os %ue nos asociamos a "ameness e%uino. Los empa"mes de Diart*rodia" por "o tanto ser(n descritos con e" fin de esta discusi&n. Qu estructuras componen un empalme? +" empa"me s!novia" o diart*rodia" consiste en, superficies de articu"aci&n de" *ueso (""amado *ueso su#c*ondra") capa de" cart$"ago (%ue cu#re e" *ueso su#c*ondra") una c(psu"a comn fi#rosa s!novium (mem#rana ! "$%uido s!novia" %ue consisten en) "igamentos de soporte asociados

La com#inaci&n de una superficie "isa ! de un "$%uido s!novia" grueso de" cart$"ago proporciona un am#iente de "a #a-o.fricci&n a trav/s de e" cua" "as superficies de articu"aci&n puedan moverse "i#remente e independientemente de uno a.

Qu hace el l!"uido synovial tan grueso y desli#adi#o? Dentro de mem#rana ! de "$%uido s!novia" est( una mo"/cu"a grande ""amada *!a"uronan. Hyaluronan es e" componente primario de" "$%uido s!novia" %ue te da sus caracter$sticas gruesas ! des"izadizas. 0uesto %ue "a fricci&n de reducci&n a" m$nimo es cr$tica a "a funci&n comn norma", "a presencia de *!a"uronan norma" dentro de un empa"me es mu! importante. La carencia de *!a"uronan dentro de" "$%uido s!novia" aumenta "a fricci&n asociada a "a mem#rana s!novia" ! a "as superficies articu"ares, por "o tanto predisponiendo e" cart$"ago a" desgaste ! a "a erosi&n e1cesivos. Qu causa la inflamaci$n comn (artritis)? La inf"amaci&n comn es una consecuencia de lesin !'o de "a inestabilidad comunes. La inesta#i"idad puede ocurrir como resu"tado de" compromiso de "as estructuras de soporte de" empa"me (ta"es como "os "igamentos co"atera"es), de "a p/rdida de cart$"ago articu"ar (como puede ocurrir en osteoc*ondrosis), de" overuse, !'o de "a edad creciente. Qu causa dolor comn? La ma!or$a de "os conc"usiones de nervio miente dentro de "a cpsula fibrosa ! de "os ligamentos de soporte del empa"me. )a! sensi#i"idad mu! pe%ue2a en e" cart$"ago ! e" s!novium. Las tres causas primarias de" do"or comn, por "o tanto, est(n,

1# +fusi&n comn (es decir "$%uido creciente dentro de" empa"me) dando por resu"tado "a
distenci&n %ue estira de "a c(psu"a comn,

2# 3i#rosis'e" marcar con una cicatriz de "a c(psu"a comn (designada a menudo .#
capsu"itis ), ! 4nf"amaci&n dentro de "os "igamentos de soporte asociados de" comn (""amado desmitis )

+"iminando e1ceso de "$%uido s!novia", "a inf"amaci&n dentro de "a c(psu"a fi#rosa, ! "a inf"amaci&n dentro de "os "igamentos de soporte producir(n genera"mente un empa"me c&modo. C$mo la enfermedad comn degenerativa (DJD) ocurre? +" cic"o degenerativo se inicia como resu"tado de inesta#i"idad !'o de "esi&n comunes. La inf"amaci&n de "a mem#rana s!novia" (una condici&n ""amada synovitis) ocurre secundario para articu"ar inesta#i"idad'trauma. Las c/"u"as inf"amatorias dentro de "a mem#rana ! de" "$%uido s!novia" *acen dos cosas,

1# 5u presencia aumenta "a presi&n *idrost(tica dentro de" empa"me ! 2# Lanzan a "as enzimas cata#&"icas ("!soz!mes) ! a otros mediadores %u$micos en e"
empa"me. La presi&n *idrost(tica creciente da "ugar a "a af"uencia de" "$%uido en e" empa"me (efusi&n s!novia"), "a distenci&n (estirando ) de "a c(psu"a comn, ! e" do"or. Las enzimas "anzaron por "as c/"u"as inf"amatorias degradan *!a"uronan ("a mo"/cu"a %ue est( imp"icada en "a "u#ricaci&n norma" de" empa"me) as$ como "a capa de" cart$"ago. +" compromiso ! "a erosi&n eventua" de" cart$"ago acodan resu"tados en p/rdida de congruenc! articu"ar, %ue a"ternadamente aumenta inesta#i"idad comn. 4nteresante, "a presencia de" do"or tam#i/n acenta "a actividad'e" "anzamiento de "os mediadores de" producto %u$mico da2oso en e" empa"me. 4nesta#i"idad comn creciente, "a persistencia de mediadores %u$micos dentro de" empa"me, ! resu"tado de" do"or en una reacci&n inf"amatoria creciente. 6 e" cic"o comienza7

C$mo tratamos DJD? 0ara %ue "a estrategia de" tratamiento sea acertada, /" de#a centrarse en e" siguiente, 8a1imizaci&n de esta#i"idad comn 9rauma de reducci&n a" m$nimo a" empa"me 5!novitis de reducci&n a" m$nimo (inf"amaci&n comn) +fusi&n s!novia" de reducci&n a" m$nimo ("$%uido comn e1cesivo) 3i#rosis de reducci&n a" m$nimo de "a c(psu"a comn (%ue ocurre como resu"tado de "a inf"amaci&n cr&nica) Norma"izando e" am#iente comn (es decir ma1imizando "a cantidad de *!a"uronan norma" dentro de" s!novium) Do"or de reducci&n a" m$nimo

Actua"mente, no tenemos ninguna manera eficaz de esta#i"izar "a ma!or$a de "os empa"mes diart*rodia" sin e" compromiso de su funci&n ! gama de" movimiento. Disminuir e" desaf$o (es decir e" grado de "a e1tensi&n'de "a f"e1i&n) a "os empa"mes se puede a"canzar a menudo con ca"zar correctivo, no o#stante persistir( un cierto grado de inesta#i"idad genera"mente. La cirug$a puede ser eficaz en me-orar esta#i"idad comn ! disminuir trauma en "os casos %ue imp"ican "esiones ortop/dicas de desarro""o (ta"es como osteoc*ondrosis, :CD, %uistes su#c*ondra") ! a"gunos tipos de fracturas. 0ara "a ma!or parte, sin em#argo, de#emos confiar en "as terapias dise2adas para reducir "a inf"amaci&n ! para do"er ! para norma"izar "os am#ientes s!novia" como me-or es posi#"e. +stas medicaciones se refieren como art*rot*erap! , e inc"u!en formas systemic ! locales. Cul es arthrotherapy %&%'E()C? Cua"%uier medicaci&n administrada fuera de" empa"me (por via ora", intravenoso, o intramuscu"ar por e-emp"o) con e" fin de me-orar "a funci&n !'o "a comodidad comunes se considera una forma de art*rot*erap! s!stemic. Las medicaciones antiinf"amatorias (ta"es como p*en!"#utazone), a"gunos mitigadores de" do"or (ta"es como capsaicin), ! "os sup"ementos de" empa"me (ta"es como Ade%uan;, Legend;, ! Cose%uin;) se inc"u!en en esta categor$a. Los sup"ementos de" empa"me *an considerado uso amp"io estos "timos a2os, ! son "o m(s a menudo posi#"e "a primera "$nea de" c"iente de" tratamiento para DJD en sus ca#a""os. La meta fundamenta" de" sup"emento comn es estimu"ar actividad norma" ! "a funci&n de "a mem#rana s!novia" de ta" modo %ue rea"za "a integridad de" am#iente comn. Las formas ora"es, intravenosas, e intramuscu"ares e1isten. La ma!or$a de "os estudios demuestran %ue "as medicaciones ora"es (e.g. Cose%uin;, 858, f"e1i&n 3ree;, Corta.f"e1;, etc.) son a#so"utamente eficaces cuando est(n a#sor#idas en e" sistema. +ste tipo de tra#a-os art*rot*erap! especia"mente #ien en "a gente ! "os perros, %ue pueden a#sor#er "as mo"/cu"as re"ativamente grandes (como e" su"fato de" g"ucosamine ! de" c*ondroitin) a trav/s de su pared intestina" f(ci"mente. Los ca#a""os, por otra parte, no son genera"mente peritos en a#sor#er "as mo"/cu"as grandes en su sistema de "a zona intestina". 0or "o tanto, una porci&n de "a medicaci&n ora" (! de "a inversi&n de" c"iente) no puede ser uti"izada tota"mente. 8uc*as compa2$as est(n tra#a-ando continuamente para encontrar maneras de me-orar e" a#sor#a#i"it! de sup"ementos ora"es en e" ca#a""o. Las medicaciones %ue puentean "a zona intestina" de ca#a""os (! por "o tanto no conf$an en "a a#sorci&n intestina") se prefieren genera"mente actua"mente. <stos son in!ecta#"es e inc"u!en formas profi"(cticas ! terap/uticas. La c"$nica e%uina de At"anta recomienda art*rot*erap! profi"(ctico para e" siguiente, En caballos sin evidencia actual de la enfermedad comn. El propsito de la medicacin est a retrasa el inicio de !

+n ca#a""os con enfermedad comn suave. +" prop&sito de "a medicaci&n es a"iviar s$ntomas #astante para %ue e" ca#a""o se rea"ice #ien en su capacidad prevista +n ca#a""os con moderados a "a enfermedad comn severa %ue se *an tratado previamente con "a terapia "oca" (es decir in!ecci&n). +" prop&sito de "a medicaci&n es pro"ongar e" efecto de "a in!ecci&n ! retrasa "a repetici&n de muestras c"$nicas. Las medicaciones profi"(cticas inc"u!en Ade%uan;, Acet!"g"ucosamine, C*ondroprotec;, ! e" ="ucosamine (entre otros). La ma!or$a de "os protoco"os de tratamiento imp"ican una in!ecci&n (>cc o >??mg) en e" mscu"o una vez semana"mente por @ semanas consecutivas ! entonces una vez o dos veces mensua"mente despu/s de eso (indefinidamente). +" coste var$a donde%uiera a partir e" ABC a A>? por dosis. La c"$nica e%uina de At"anta recomienda art*rot*erap! terap/utico para e" siguiente, 3"#$% horas antes de una ra&a' de una cl(nica' o de una demostracin. El propsito de la medicacin es ma)imi&ar el funcionamiento del caballo para un acontecimiento seleccionado. Las medicaciones terap/uticas inc"u!en Legend;, 8A0.>, ! (entre otros). +stas medicaciones se administran genera"mente intravenoso (en "a vena) en "as dosis %ue var$an. +" coste de una so"a dosis puede e1tenderse a partir de" AD> a AE>. 5i e" tratamiento s!stemic (terap/utico) regu"ar se re%uiere para producir !'o mantener va"idez o no da "ugar a una respuesta satisfactoria, despu/s art*rot*erap! "oca" puede ser considerada. Cul es arthrotherapy *+C,*? Art*rot*erap! "oca" imp"ica t$picamente "a in!ecci&n de medicaciones directamente en e" empa"me. 9$picamente, una com#inaci&n de *!a"uronan sint/tico ! e" esteroide se infunden. +" esteroide es e1tremadamente eficaz en "a e"iminaci&n de "a inf"amaci&n ("a presencia de c/"u"as inf"amatorias) dentro de" empa"me. Cuando "as c/"u"as inf"amatorias se van, "a presi&n *idrost(tica dentro de" empa"me disminu!e, e1ceso de" "$%uido dentro de" empa"me se va, "a c(psu"a comn se descomprime, ! se e"imina e" ma"estar. Los esteroides de 4ntraarticu"ar, por "o tanto, son e1tremadamente eficaces en me-orar comodidad comn. 0or otra parte, "os esteroides tam#i/n promueven "a degradaci&n de *!a"uronan, "a mo"/cu"a %ue *ace grueso f"ido ! des"izadizo s!novia". Degradaci&n de resu"tados *!a"uronan en consistencia f"ida s!novia" po#re, p/rdida de protecci&n de "a capa de" cart$"ago, ! degeneraci&n comn ace"erada. 0or "o tanto, "os esteroides tam#i/n tienen un efecto de"et/reo a" am#iente comn. )!a"uronan sint/tico se infunde t$picamente concurrentemente en e" empa"me para com#atir "os efectos degradantes de" esteroide. Aun%ue *!a"uronan sint/tico no proporciona muc*o "a "u#ricaci&n por s$ mismo, su presencia en e" empa"me estimu"a "a mem#rana s!novia" para producir un *!a"uronan (end&geno) m(s norma", de ta" modo indirectamente me-orando integridad comn. +s mu! importante determinarse cu(" es "os menos de dos ma"es, ) cara B) %ue permite %ue "a presencia de c/"u"as inf"amatorias ! de sus efectos degradantes persista dentro de" empa"me, o C "as consecuencias de" esteroide de infusi&n en e" empa"me. +n a"gunos casos, e" esteroide de infusi&n en e" empa"me es "a opci&n m(s sana. 9omar "a decisi&n derec*a ""ega a ser particu"armente cr$tico en vista de "os empa"mes (diart*rodia") de" a"to.movimiento, donde una pe%ue2a degeneraci&n comn puede ir una manera "arga.