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Hooper MM, Holderbaum D, Moskowitz RW. Clinical and laboratory findings in osteoarthritis.
Arthritis and Allied Conditions A textbook of Rheumatology; 2005. P2227-55.
Epidemiology
• Most common joint disease and most
common cause of disability esp. knee OA
• Involve both sex ( Woman > Man) with age-
relation
• The common joint ; knee , hand, 1st MTP ,
hip?, spine
Felson DT. The epidemiology of osteoarthritis. Results from the Framingham Osteoarthritis Study. Semin
Arthritis Rheum 1990; 20 (Suppl 1): 42-50.
Classification
1. Primary or idiopathic ;
- peripheral joint: knee joint , DIP (Heberden’s
node), PIP (Bouchard’s node), 1st CMC, 1st
MTP (Bunion), hip joint
- axial joint: apophyseal or facet joint,
2. Secondary ;
- trauma , joint disease, metabolic disease,
neuropathic disease , congenital disease
Risk factors
• Age ; strong association( 80-95% of 75 y has OA)
• Obesity ; strong association;
knee (OR 6.17-8.57) > hand joint(OR 3.12) > hip(OR 2.8)
• Gender ; woman > man(2.6:1)
• Genetics ; COL2A1
• Occupation ; repetitive over use
• Sports ; only profession
• Joint diseases(RA , gout , CPPD) , joint injury
• Other ; lack of osteoporosis , muscle weakness ,
acromegaly , proprioceptive defects
Pathology
- Articular cartilage change
- Subchondral bone sclerosis ,
microfracture
- Synovitis ; mild , patchy
- Joint capsule ; thickening ,
stiffness
- Ligaments ; tear
- Muscle ; weak , atrophy
Articular cartilage
Early: swelling, softening
OA
Normal subchondral bone
subchondral bone of OA
Clinical features
• Joint pain /stiffness/loss of function
Early ;
- easy joint pain , more time for recovering
- Joint stiffness, esp. morning or after rest
- May have mild limited ROM
- No systemic inflammation
- PE ; nothing -> mild tenderness
Clinical features
• Joint pain/stiffness/loss of function
- Joint pain ; deep, aching ,
chronic (intermittent -> persistent) , mild to
moderate severity around the joint / joint line
- Use-related pain with improvement on rest
- Joint stiffness ; “ gelling phenomenon”
- Gradual decreased joint function or loss of
ROM
Clinical features
• Joint pain/stiffness/loss of function
Late or advance:
- Persistent pain , some have night pain
- Obvious loss of joint function
- Giving way on walking , locking , instability
- Obvious joint stiffness
- No systemic inflammation
- Morning stiffness < 30 min
Clinical features
• PE
- Tenderness ; mild ; at joint line , within the joint
- Crepitation on motion
- Loss of motion ; from osteophyte , capsular
thickening , synovial hyperplasia
- Bony swelling , may have effusion without
obvious inflammation
- Deformity in late stage ; varus , valgus , snake-like
- Instability , muscle weakness or atrophy
- Early ; negative finding
Investigation
• CBC , ESR , CRP, uric acid , ANA , RF : -ve
finding
• Plain film ; gold std
- Evaluate severity ; minimal to severe finding,
may not correlation with joint pain and
function
- Exclusion other diseases
• MRI /US : for research , doubtful case
Arthocentesis
• Aim ;
- exclusion other diseases ; CPPD ,
gout , hemarthrosis
- relive pressure , decreased pain
- steroid injection
• Synovial fluid ; clear or slightly
turbid , straw color , high viscosity ,
wbc 200-2000 /ml
Knee OA
Varus deformity Valgus deformity
Knee OA
Plain film
• Standing AP vs semiflexion
Kellgren-Lawrence grading scale
Ann Rheum Dis.1957
• 0= no signs of change
• 1= A “doubtful” change in JSN
• 2= minimal change; 1st by osteophytes
• 3= moderate change with multiple
osteophytes and/or def. JSN
• 4= severe change ; severe JSN or loss, bone to
bone contact, and significant osteophytes
- Film both knee standing AP
- Joint space narrowing(unimedial)
- Subchondral bone sclerosis , + cyst
- Marginal osteophyte
2nd knee OA from RA; symmetric joint space narrowing with
minimal osteophyte, minimal subchondral bone sclerosis
DDx knee pain
• OA knee
• Inflammatory arthritis ; RA , CPPD , PsA
• Tendinitis ; torn ligaments, infrapatella
tendinitis , peripatella enthesitis , anserine
bursitis , poppliteal tendinitis , popliteal cyst
• Refer pain from hip disease
55-y-old RA woman with chronic knee pain 2 y,
Rx as OA without improvement
74-y-old woman with chronic knee pain and acute pain on
right knee , right knee effusion and arthrocentesis was done.
58-y-old OA knee woman with progressive joint
space narrowing
2551 2552
65-y-old CPPD woman with episodic knee pain
Patello-femoral joint OA
• Anterior knee pain syndrome
• Usually young adult
• Worse pain on up or down stairs , static flex
knee position
• PE ; aggravating pain when squeeze patella on
femur , + crepitation
Patello-femoral joint wrap-around
• Non-pharmacotherapy
• Pharmacotherapy
• Surgery
- gene therapy
- osteochondral grafts
- stem cell transplantation
Surgical management
• Indication: failed
conservative treatment
• Consist of
- Osteotomy
- Joint replacement
- Arthroscopic debridement
and/or larvage?
Ann Rheum Dis2018
Balneotherapy
Balneotherapyand
andmassage
massage
Thermotherapy
Conclusion
• OA is a common disease, cause of economic
burden , leading cause of disability ,esp. elderly
• Slowly progressive joint disease
• Common joint ; knee , hand joint(DIP , PIP) , 1st
MTP, hip? , spine
• Manifestation ; chronic joint pain/stiffness and
loss of function , pain relates with activity , less
pain with rest , no systemic symptom
• PE ; normal to total disability , crepitation on
motion with bony enlargement is common and
significantly finding
Conclusion
• Investigation ; only plain film
• Management ;
- non-pharmacology (modified activity ,
appropriated works , exercise , weight loss ,
support or splint , walking aids , thermal modality
, manual-Rx)
- Pharmacology ; acetaminophen , topical agents ,
oral NSAIDs , IA steroid , tramadol ,
antidepressant , no role of systemic steroid
- Controversy ; glucosamine , chondroitin ,
diacerine , hyaluronate , bisphosphonate
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