Osteoarthritis

Dr. Angelo Smith M.D

WHPL
 Osteoarthritis (OA)
• OA is the most common form
of arthritis and the most
common joint disease
• Most of the people who have
OA are older than age 45, and
women are more commonly
affected than men.
• OA most often occurs at the
ends of the fingers, thumbs,
neck, lower back, knees, and
hips.
•The repair mechanisms of tissue absorption and
synthesis get out of balance and result in
osteophyte formation (bone spurs) and bone cysts
OA
OA is a disease of
joints that affects all
of the weight-bearing
components of the
joint:

•Articular
cartilage
•Menisci
•Bone
 OA – Articular Cartilage
Articular cartilage is the main tissue affected
OA results in:
•Increased tissue swelling
•Change in color
•Cartilage fibrillation
•Cartilage erosion down to subchondral bone
OA – Articular Cartilage

A) Normal articular
cartilage from 21-year
old adult (3000X)
B) Osteoarthritic
cartilage (3000X)
 Commonly Affects

– Hips
– Knees
– Feet
– Spine
– Hands (Interphalangeal joints)
 Uncommonly Affected Joints
• Shoulder
• Wrist
• Elbow
• Metacarpophalangeal joint
• TMJ
• SI
• Ankle
OA

Nodal osteoarthritis
Note bony
enlargement of distal
and proximal
interphalangeal
joints (Heberden's
nodes and
Bouchard's nodes,
respectively).
 Risk factors –
Conditions that contribute to
osteoarthritis
 OA – Risk Factors
Age
• Age is the strongest risk factor for OA. Although OA can start in young
adulthood, if you are over 45 years old, you are at higher risk.

Female gender
• In general, arthritis occurs more frequently in women than in men. Before
age 45, OA occurs more frequently in men; after age 45, OA is more
common in women. OA of the hand is particularly common among
women.

Joint alignment
• People with joints that move or fit together incorrectly, such as bow legs, a
dislocated hip, or double-jointedness, are more likely to develop OA in
those joints.
Hereditary gene defect
• A defect in one of the genes responsible for the cartilage component
collagen can cause deterioration of cartilage.

Joint injury or overuse caused by physical labor or sports

• Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip
increases your risk for developing OA in these joints. Joints that are
used repeatedly in certain jobs may be more likely to develop OA
because of injury or overuse.

Obesity
• Being overweight during midlife or the later years is among the
strongest risk factors for OA of the knee.
Pathogenesis of Osteoarthritis
An Interplay of Factors
Risk factors you cannot change
• Family history
of disease
• Increasing Age
• Being female
 Risk factors you can change
• Overuse of the
joint
• Major injury
• Overweight
• Muscle weakness
 Diagnosing osteoarthritis
Medical history
Physical exam
X-ray
Other tests
 OA – Symptoms
• OA usually occurs slowly - It
may be many years before the
damage to the joint becomes
noticeable
• Only a third of people
whose X-rays show OA
report pain or other
symptoms:

– Steady or intermittent pain in a joint

– Stiffness that tends to follow periods of inactivity, such as sleep
or sitting
– Swelling or tenderness in one or more joints [not necessarily
occurring on both sides of the body at the same time]
– Crunching feeling or sound of bone rubbing on bone (called
crepitus) when the joint is used
 Two Major Types of OA
• Primary or Idiopathic
– Most common type
– Diagnosed when there is no known cause for
the symptoms
• Secondary
– Diagnosed when there is an identifiable cause
• Trauma or Underlying joint disorder
• Each of these major types has subtypes
 OA vs. Aging

Unlike aging, OA is progressive and a significantly

more active process
 OA – Overall Changes

Osteoarthritis with lateral osteophyte, loss of articular cartilage and

some subchondral bony sclerosis- X-ray shows loss of joint space
 Laboratory findings in OA
• THERE ARE NO DIAGNOSTIC LAB
TESTS FOR OSTEOARTHRITIS
• OA is not a systemic disease, therefore:
– ESR, Chem 7, CBC, and UA all WNL
• Synovial fluid
• Mild leukocytosis (<2000 WBC/microliter)
• Can be used to exclude gout, CPPD, or septic
arthritis if diagnosis is in doubt
 Synovial fluid analysis
• Severe, acute joint pain is an
uncommon manifestation of OA

• Clear fluidWBC <2000/mm3

• Normal viscosity
 Differential Diagnosis
• Rheumatoid Arthritis
• Gout
• CPPD (Calcium pyrophosphate crystal
deposition disease)
• Septic Joint
• Polymyalgia Rheumatica
 OA – Radiographic Diagnosis

Asymmetrical joint space narrowing from loss of

articular cartilage
The medial (inside) part of the knee is most commonly affected by osteoarthritis.
OA – Radiographic Diagnosis
•Asymmetrical
joint space
narrowing

•Periarticular
sclerosis

•Osteophytes

•Sub-chrondral
bone cysts
 OA – Arthroscopic Diagnosis
Arthroscopy allows earlier
diagnosis by demonstrating the
more subtle cartilage changes
that are not visible on x-ray

Normal Articular Cartilage

Ostearthritic degenerated cartilage

with exposed subchondral bone
 OA – Disease Management
•OA is a condition which progresses slowly over a
period of many years and cannot be cured
•Treatment is directed at decreasing the symptoms of
the condition, and slowing the progress of the
condition

•Functional treatment goals:

•Limit pain
•Increase range of motion
•Increase muscle strength
 Management/Treatment of OA
• Goals
– Educate patient about disease and management
– Improve function
– Control pain
– Alter disease process and its consequences
 Management/Treatment of OA
• No known cure for OA
• HOWEVER
– Impaired muscle function
– Reduced fitness
• Affect pain and dysfunction
• Are amenable to therapeutic exercise
 Management/Treatment of OA
• Topical
• Pharmacologic
– Capsaicin
– Acetaminophen
– Methylsalicylate
– NSAIDS
– NSAIDS
• Cox-2 specific
inhibitors • Intra-articular
• With PPI or misoprostol – Corticosteroids
– Nonacetylated – Hyaluronic acid
salicylate
– Tramadol
– Opioids
 Treatment/Management of OA
• Pharmacologic
– Herbal therapy
• Avocado soybean unsaponifiables (ASU’s) with
promising results in 2 studies on:
– Functional index, pain, NSAID use, and global evaluation
• Reumalex (willow bark preparation) inconclusive
• Tipi tea inconclusive
 Management/Treatment of OA
• Possible structure/disease modifying stuff
– Glucosamine
– Diacerein
– Cytokine inhibitors
– Cartilage repair
– Bisphosphonates
– Degradative enzyme inhibitors
• Tetracyclines, metalloproteinase inhibitors
 Treatment/Management of OA
• Pharmacologic
– Glucosamine 20 studies with >2500 patients
• If only high quality studies evaluated:
– No benefit over placebo on pain
• If all studies included:
– Pain may improve by as much as 13 points
• 2 RCT’s using Rotta preparation:
– Demonstrated slowing of radiological progression of OA
over a 3 year period
 Treatment/Management of OA
• Pharmacologic
– Diacerein
• Pain improved 5 points compared to placebo
• Over 3 years,
– Slowed progress of OA in the hip compared to placebo
– Did not slow progress of OA in the knee
• Diarrhea is most common side effect
– 42 out of 100 had diarrhea in the first 2 weeks
– 18 discontinued because of side effects (13 in placebo)
 Glucosamine/Chondroitin--My
Take
• I recommend in ALL patients with knee and
hip OA
– GS 1500 mg/ CS 800 mg
• 3 month trial, evaluate efficacy; continue if
helping
• Consider indefinite use even if no pain
relief for joint space preservation
 Management/Treatment of OA
• Non-pharmacologic • Non-pharmacologic
– Patient education – Assistive devices
– Self-management – Patellar taping
programs – Appropriate footwear
– Weight loss – Lateral-wedged insoles
– PT/OT – Bracing
– ROM exercises – Joint protection and
– Muscle strengthening energy conservation
 Summary
• Non-pharmacologic therapy is important in the
prevention and treatment of OA
• The best studied and most effective non-
pharmacologic therapy is EXERCISE
• Exercise helps control weight, increase strength,
improve and maintain function and decrease pain
• Traditional belief - patients concerned that joint use
will “wear out” a damaged joint that is already “worn
out” - NOT true for moderate intensity exercises
 OA – Arthroscopic Treatment
•In addition to being the most accurate way of determining how
advanced the osteoarthritis is:
•Arthroscopy also allows the surgeon to debride the knee joint
•Debridement essentially consists of cleaning out the joint of all debris
and loose fragments. During the debridment any loose fragments of
cartilage are removed and the knee is washed with a saline solution.
•The areas of the knee joint which are badly worn may be roughened with
a burr to promote the growth of new cartilage - a fibrocartilage material
that is similar scar tissue.
•Debridement of the knee using the arthroscope is not 100% successful. If
successful, it usually affords temporary relief of symptoms for somewhere
between 6 months - 2 years.

•Arthroscopy also allows access for surgical treatment of articular

cartilage: graft-transplantation, micro-fracture techniques, sub-
chondral drilling
 OA – Non-operative Treatments

•Pain medications
•Physical therapy
•Walking aids
•Shock absorption
•Re-alignment through
orthotics
•Limit strain to affected
areas
 Proximal Tibial Osteotomy

•Osteoarthritis usually
affects the inside half
(medial compartment) of
the knee more often than
the outside (lateral
compartment).

•This can lead to the lower

extremity becoming
slightly bowlegged, or in
medical terms, a genu
varum deformity
 Proximal Tibial Osteotomy
•The result is that the weight bearing line of the lower
extremity moves more medially (towards the medial
compartment of the knee).

•The end result is that there is more pressure on the medial

joint surfaces, which leads to more pain and faster
degeneration.

•In some cases, re-aligning the angles in the lower extremity

can result in shifting the weight-bearing line to the lateral
compartment of the knee. This, presumably, places the
majority of the weight-bearing force into a healthier
compartment. The result is to reduce the pain and delay the
progression of the degeneration of the medial compartment.
 Proximal Tibial Osteotomy
•In the procedure to realign the
angles, a wedge of bone is
removed from the lateral side
of the upper tibia.

•A staple or plate and screws

are used to hold the bone in
place until it heals.

•This converts the extremity

from being bow-legged to
knock-kneed.
•The Proximal Tibial Osteotomy buys some time before ultimately
needing to perform a total knee replacement. The operation
probably lasts for 5-7 years if successful.
 Total Knee Replacement
The ultimate solution for osteoarthritis of the knee is to
replace the joint surfaces with an artificial knee joint:
•Usually only considered in people over the age of 60
•Artificial knee joints last about 12 years in an elderly population

•Not recommended in younger patients because:

•The younger the patient, the more likely the artificial joint will fail
•Replacing the knee the second and third time is much harder and much
less likely to succeed.
•Younger patients are more active and place more stress on the artificial
joint, that can lead to loosening and failure earlier
•Younger patients are also more likely to outlive their artificial joint, and
will almost surely require a revision at some point down the road.
•Younger patients sometimes require the surgery (simply because
no other acceptable solution is available to treat their condition)
 Total Knee Replacement
•The ends of the femur, tibia, and patella are shaped to accept
the artificial surfaces.
•The end result is that all moving surfaces of the knee are
metal against plastic
Total Knee Replacement