OA is a chronic joint d/o progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage, bone at joint

t margin and capsular fibrosis the most common form of arthritis Asymmetrical distributed, often localized It can affect any joint of the body, but most common knees, hips

Obesity: knee > Hip Family history (genetic): polyarticular esp hands and hips Trauma Hypermobility Occupation and sport: excessive and repeated loading of a joint

PRIMARY OA

SECONDARY OA
1.

Idiopathic Degenerative / aging process

2.

3.

4.

Metabolic disorders Ochronosis (alcaptonuria) Wilson disease Haemochromatosis Anatomic abnormalities Congenital hip dislocation Charcot join Trauma Occupational/sport Fracture Joint surgery Inflammatory arthritis rheumatoid arthritis Septic arthritis

OA NORMAL ARTICULAR CARTILAGE

The swelling pressure of the proteoglycans is counterbalanced by the tight collagen network.

More water is absorbed by proteoglycans

Softening and swelling of cartilage Rupture of collagen fibres

can resist major pressure and shear forces

The cartilage becomes softer, the pressure and shear resistance is diminished, which leads to further damage to the collagen network.

Decreased local synthesis of collagen type II Increased breakdown of pre-existing collagen Weakening of collagen network Number of functional chondrocytes reduced Tensile strength reduced Chondrocytes in the deeper layers will proliferate Repair the damage by producing new collagen
Maintain Joint integrity

chondrocytes loss and changes in the extracellular matrix SHIFTED FROM REPARATIVE -> PREDOMINANTLY DEGENERATIVE

Weakening of the articular cartilage Increased mechanical stress in articular cartilage Damage to collagen network & loss of proteoglycan from the matrix Deformation & structural disintegration Softening of articular cartilage Articular surface become worn away & expose underlying bone In area of greatest stress, cyst form and around which the trabeculae become thickened or sclerotic Cartilage in unstressed area proliferate & ossifies producing osteophyte

Shedding of fragments from fibrillated articular cartilage & release of enzyme from damaged cell Low grade synovitis Capsular fibrosis Joint stiffness Capsule is sensitive to stretching & bone is sensitive to pressure changes Pain in the joint

articular cartilage and synovium have no nerve supply

5 cardinal signs: Progressive loss of cartilage thickness Subarticular cyst formation & sclerosis Remodelling of bone end & osteophyte formation Synovial irritation Capsular fibrosis

Joint pain

Onset: gradually Increases over months/years Aggrevated by exertion Relieved by rest (with time, relief is less)
Common, occurs after a periods of inactivity With time it become constant and progressive Intermittent suggesting an effusion Continuos capsular thickening or osteophytes

Stiffness

Swelling

Deformities

Varus deformity Heberdens nodes (DIP) Bouchards nodes (PIP)

Difficulty in climbing stairs Restriction in walking distance

Loss of function

 On

Examination

Examine all joint : may show others are affected in varying degree Swelling and deformity Long standing cases: muscle wasting Local tenderness, synovial thickening and osteophyte may be felt Movement always restricted but often painless within the permitted range, accompanied by crepitus

Heberdens node
Bouchards node

~Varus deformity ~Knee Effusion

 Plain

radiograph View of the affected joint 4 Classical findings:

Joint space narrowing (from loss of cartilage) Subchondral bone sclerosis (increased bone density) Subchondral cysts Osteophytes at margin of joint(bone spurs)

 Radionuclide scanning
Shows increased activity during the bone phase in the subchondral region of affected joints Due to increase vascularity and new bone formation.

Black arrows point to osteophytes. White arrow points to narrowed medial compartment

Black arrows point to subchondral sclerosis. White arrow points to osteophytes. Black arrowheads point to joint narrowing. Medial compartment narrrowing.

Arowheads point to narrowed medial compartments and osteophytes. Arrows point to the varus deformity of both tibia.

Loss of joint space

Enlarged AP radiograph of the right hip joint showing OA changes

Subchondral sclerosis

osteophyte

White arrowheads point to osteophytes. White arrows point to narrowed joint space. Black arrows point to sclerosis.

Joint space narrowing of radiocarpal, carpometacrapal joint of thumb and metacarpophalangeal joints

Cartilage loss with narrowing of interphalangeal joints B: Bouchard nodes (osteophytes proximal interphalangeal joints) H: Heberden nodes (osteophytes distal interphalangeal joints)

Depending on the stage Early ( Mild) decrease joint space Intermediate (moderate) - Osteophytes Late ( severe) deformity, malalignment

CONSERVATIVE
1) Patient education
2) Relieve pain - NSAIDs - Rest - Modification of activities 2) Reduce load - Walking sticks - Wear soft-soled shoes - Weight reduction - Avoid prolonged, stressful activities 3) Improve mobility - Physiotherapy

OPERATIVE
-Indications : unrelieved pain, progressive disability
1) Osteotomy 2) Arthroplasty

3) Arthrodesis = surgical fixation of a joint by fusion of the jt surfaces ( artificial ankylosis)

Early

Patient Education Activity modification Relieve pain

Analgesic, NSAIDs (powerful PGi reduce vascular congestion in subchondral bone)/ Opiods Rest Increase movement - Range of Motion Exercise / Physiotherapy , Prevent joint stiffness , Strengthen muscles

Reduce load

Help to take pressure off patients joint Weight loss Use walking stick wearing soft soled shoes Relative rest Avoid prolonged stressful activity (jogging & climbing stairs)

INTERMEDIATE TREATMENT

If conservative treatment failed

Arthroscopic

debridement

Removal of interfering osteophytes, cartilage tags and loose bodies

~Arthroscopic shaving of fibrillated and irregular cartilage ~Removal of foreign bodies

 Realignment

osteotomy

For hip and knee OA Must be done while joint still stable and mobile, and x-ray show major part of articular surface is preserved

 LATE
Progressive joint destruction + increasing pain + instability + deformity = reconstructive surgery Arthroplasty ( joint replacement)

Knee joint replacement

Proximal interphalangeal joint replacement.

Arthrodesis ~artificial ankylosis or syndesis, is the artificial induction of joint ossification between two bones via surgery