OSTEOARTHRITIS

BY Dr. Eyad Skaik MD. PhD.

* Osteoarthritis is a non-inflammatory disorder of movable joints characterized by deterioration of articular cartilage and formation of new bone at the joint surface and margins. It is also known as degenerative joint disease.

Pathological findings in OA:

-early degeneration or disruption of the articular cartilage, softening, flaking or fibrillation, occurs most commonly on the weight-bearing surfaces of the joint. - proceed to complete loss of articular cartilage and eburnation of the bone, which becomes highly polished and has a sclerotic surface. - cyst areas may occur in the subarticular bone, usually on the weight bearing surface due to microfractures that degenerate. - new bone formation is usually found at the base of the articular cartilage and surrounding the cyst, creating an area of sclerosis.

Although OA affects primarily the articular cartilage of synovial joints, pathophysiologic changes also occur in the synovial fluid, as well as in the underlying (subchondral) bone and overlying joint capsule. The affected cartilage initially develops small tears, known as fibrillations, at the articular surface, followed by larger tears; the cartilage eventually fragments off into joints. The cartilage-forming cells (ie, chondrocytes) replicate in an attempt to keep up with the cartilage loss; however, they eventually are unable to do so, and the underlying bone becomes exposed because of gross areas of bone denuded of cartilage.

In the early degenerative process, increased expression and content of various metalloproteinases occurs. These proteinases are very much involved in the excessive matrix degradation that characterizes cartilage degeneration in OA . Bone along the periphery of the joint replicates to form osteophytes, while the subchondral bone along the mid portion of the joint becomes sclerotic, and areas within it may eventually undergo cystic degeneration because of focal resorption. Synovial fluid is formed through an ultrafiltration process of serum by cells that form the synovial membrane (synoviocytes). Synovial cells also manufacture the major protein component of synovial fluid, hyaluronic acid (also known as hyaluronate). Synovial fluid provides nutrients to the avascular articular cartilage and provides viscosity for shock absorption with slow movements and elasticity for shock absorption with rapid movements.

The osteoarthritic joint is characterized by decreased concentration of hyaluronic acid because of reduced production by synoviocytes and increased water content because of inflammation, particularly during later stages of the disease. Pain is usually of insidious onset, is generally described as aching or throbbing, and may result from changes that have occurred over the last 15-20 years. Most often, the pain is worse with activity involving the affected joint and is initially relieved with rest; eventually pain occurs even at rest.

* Since cartilage itself is not innervated, the pain is presumed to be from a combination of mechanisms, including (1) osteophytic periosteal elevation, (2) vascular congestion of subchondral bone leading to increased intraosseous pressure, (3) synovitis with activation of synovial membrane nociceptors, (4) fatigue of muscles that cross the joint, and (5) overall joint contracture. In addition to the underlying pathophysiologic changes described above, overall, the joint may undergo mechanical deformation with resultant malalignment and instability. Alternatively, the joint can ankylose.

Factors are important in the etiology of degenerative joint disease?

-obesity -genetics and heredity -occupation (IP joint degeneration in fingers of cotton mill workers) - multiple endocrine disorders (DM, acromegaly). - multiple metabolic disorders(Pagets disease, gout, calcium pyrophosphate deposition disease).

Epidemiology
by age of 40 years, 90% of all persons have some degenerative changes in the weight-bearing joints, even though clinical symptoms are generally absent . - x-ray manifestations of the disease commonly occur in the third decade. - when minimal disease is excluded, the prevelance of OA is 20%. - under 45 years the prevelance was greater among men, where as prevalence was greater in women after age 55 years.

Osteophytes is one of the main characteristics of osteoarthritis, are outgrowths of ossified cartilage , usually marginal . because of the vascularization of the subchondral bone, proliferation of adjacent cartilage and enchondral ossification occur. Outgrowths extend from the free articular space along the path of least resistance.

Pathological abnormalities of osteoarthritis:

- cartilage erosion - increased cellularity of subchondral bone- bone eburnation. - Synovial fluid intrusion into bone- subchondral cysts. - Synovial membrane stimulation- osteophytes. - Compression of weakened bone bone collapsed. - Fragmentation of osteochondral surface loose bodies. - Destruction and disruption of capsular ligamentsdeformity and malalignment.

History: Patients with osteoarthritis (OA) generally complain of insidious throbbing arthralgias with activity. Initially, resting relieves the pain. Eventually, the pain occurs even at rest. Morning stiffness, which usually lasts less than 30 minutes, may also be experienced in the joint. Intermittent joint swelling and give-way weakness in the knees.

Signs and symptoms: Primary osteoarthritis is a common disorder of the elderly, and patients are often asymptomatic. Patients with symptoms usually do not notice them until after they are aged 50 years. Deep, achy, joint pain exacerbated by extensive use is the primary symptom. Also, reduced range of motion and crepitus are frequently present. Joint malalignment may be visible. Heberden nodes, which represent palpable osteophytes in the distal interphalangeal joints, are characteristic in women but not men. Inflammatory changes are typically absent or at least not pronounced.

Early in the disease process, physical examination findings include the following: - Joints may appear normal. - Gait may be antalgic if weight-bearing joints are involved. - Later in the disease process, physical examination findings include the following:

- Visible osteophytes may be noted. - Joints may be warm to palpation. - Palpable osteophytes frequently are noted. - Joint effusion frequently is evidenced in superficial joints. - Range-of-motion limitations, because of bony restrictions and/or soft tissue contractures, are characteristic. - Crepitus with range of motion is not uncommon.

Differential diagnosis of osteoarthritis

Crystal deposition disease Gout Pseudogout Inflammatory arthritis Seronegative spondyloarthropathies Rheumatoid arthritis Infected joint Lyme disease Underlying mechanical pain

Major complication of OA:

- loss of joint space, angulation of the affected extremity. - Subluxation of the joint as seen on carpometacarpal joint of the thumb. - Ankylosis or complete bony fusion of a joint . - Intra articular loose body or joint mice related to subchondral fractures.

Heberdens node: the are detectable bony enlargements about the distal interphalangeal joints of the hands. Bouchards node: they are bony enlargements in the proximal interphalangeal joints. Mucinous cyst: arise from the joint capsule in the distal or proximal interphalangeal joints . They generally contain degenerative myxomatus fibrous tissue from the degenerative arthritis.. A bunion: is a combination of degenerative joint disease at the first metatarsal phalangeal joint and angulation or valgus at the same joint.

Lab Studies: No laboratory studies can assist in diagnosis of osteoarthritis (OA) per se. Previous work has not led to a clinically useful diagnostic test. Researchers have looked at monoclonal antibodies, synovial fluid markers, and urinary pyridinium cross-links (ie, breakdown products of cartilage). Erythrocyte sedimentation rate (ESR) is not usually elevated, but it may be slightly elevated in cases of erosive inflammatory arthritis.

Clinical and radiological findings of osteoarthritis :

- Plain radiographs are often negative early in the disease. The Kellgren & Lawrence Grading System, which is the most universally accepted method of classifying radiographic osteoarthritis, uses the following 4 radiographic features: - Joint space narrowing - Osteophytes - Subchondral sclerosis - Subchondral cysts

Kellgren-Lawrence Radiographic Grading Scale of Osteoarthritis of the Tibiofemoral Joint Grade of OsteoarthritisDescription 0 - No radiographic findings of osteoarthritis 1- Minute osteophytes of doubtful clinical significance2Definite osteophytes with unimpaired joint space 3- Definite osteophytes with moderate joint space narrowing 4 - Definite osteophytes with severe joint space narrowing and subchondral sclerosis

Erosive osteoarthritis:
Involves primarly the distal and proximal interphalangeal joints, it is maybe hereditary. Severe inflammatory episodes lead to joint deformities and sometimes to ankylosis. Cysts maybe painful land tender. Post menopausal women are most frequently affected. Radiology reveals severe bony erosions and subchondral bony sclerosis. Severe joint destruction is noted.

DISH
Diffuse idiopathic skeletal hyperostosis, a type of osteoarthritis with a significant amount of osteophyte formation. The spine shows calcification on the anterior longitudinal ligament and the peripheral disc margins. The disc height is preserved. The compliant is spinal stiffness, with little pain

Treatment of OA: - NSAID - Intraarticular injections with CS, Na hyaluronate. - Surgical correction of the deformities. - Mosaic arthroplasty - Arthroscopic debridement - Joint replacement surgery.

THANX