oa for undergraduates
TRANSCRIPT
OSTEOARTHRITIS
Prof. Abdel-Azim Alhefny
Prof. of Internal Medicine, Rheumatology & Immunology
Ain Shams University
Synovium
Secretes the
synovial fluid
Capsule
Ligaments hold the
bones together
Synovial fluid
Lubricates the
joint capsule
Bone
Cartilage
Protects the
end of the bone
Anatomy of a normal synovial joint
Muscle
Tendon
Dieppe P. 1998
Osteoarthritis
OA is a slowly progressive
degenerative disease
leading to gradual loss of
articular cartilage.
It is characterized by focal
degeneration and new bone
formation.
OA is not a disease of a single tissue (articular cartilage );
but a disease of an organ (the synovial joints) in which all
the tissues are affected
including:-
Subchondral bone.
Ligaments.
Capsules.
Synovial membrane.
Peri-articular muscles.
As there is heart failure , kidney
failure also we have joint Failure.
Osteoarthritis
Classification Of OA
A- Primary : (Localized, Generalized & erosive) Most common form of OA Commonly occurs in weight-bearing joints Is rare before age of 40 , prevalence increases with age Genetic predisposition, particularly for
hand arthritis
1-Localised: Hands: Heberdens and Bushard`s nodes Feet: Hallux valgus Hip : Spine Apophyseal joints
2-Generalised (3 areas or more).3- Erosive: hand DIP/PIP (OA) associated with synovitis and
radiographic central erosions of the articular surface.
B-Secondary: Preceded by a predisposing disorder such as joint trauma
Occurs in any joint at any age
1. Traumatic : Acute – Chronic - occupational (Sports).
2. Cogenital or Developmental
3. Mechanical Factors
4. Metabolic
5. Endocrinal
6. Calcium Deposition Disease
7. Neuropathic
8. Endemic
9. Miscellanous
Classification Of OA
Risk factors for primary OA
OA
Obesity
Occupation
Old age
Family history
Genetics
Joint
dysplasia
Bone injury
Ƒ Gender
Joint injury
Bad Prognostic Factors for OA
1. Older age.
2. Female sex.
3. Heberden`s nodes.
4. Low dietary intake of
vitamin C.
5. Low dietary intake of vitamin D.
Knee osteoarthritis
Most common form of arthritis .
10 % of people over 55 have disabling knee
symptoms (1/4 of them are severely disabled).
30 % of subjects over 65yrs have radiographic
evidence of OA (1/3 is symptomatic).
Risk of disability same for knee OA as for cardiac
disease.
WHO –considers OA the 4th cause of disability in
women, & the 8th cause in men.
OA RA
Type of Arth. Degenerative Inflammatory
Site Mostly weight
bearing joints,
affects DIP,
1st CMC
Small joints of the
hands and feet,
bil. Symmetrical,
DIP are spared,
Stiffness Morning stiffness
< 15 M.
Morning stiffness
>30 m.
Extra-
articular
manifestations
not present Present (cardiac, lung,
kidney, skin, S.c.
nodule, eye, vasculitis )
Laboratory
Tests
-ve, unremarkable +ve ( ESR, RF, Anti CCP,
CRP, occasionally ANA)
Pattern of joint involvement in OA
Commonly occurs in weight-bearing joints
Common Signs & Symptoms in OA
Symptoms
Joint pain (usage)
Joint stiffness < 15min
Crepitus
Alteration in joint shape
Deformity, swelling
Functional impairment
Limited mov., instability
Common Signs & Symptoms in OA
Signs
Crepitus
Restricted movement
Tenderness
Bony & soft tissue swelling
Limp
Deformity: Hand Heberden's or
Bouchard's nodes, Knee: varus or valgus
Muscle atrophy / weakness
Cool effusion
Instability
Heberden’s nodules
in a patient with OA
Heberden’s and Bouchard’s Nodes
Sciops-Medical Division
Heberden’s nodes :Hard or bony swellings which develop in the DIP.
Bouchard's nodes: bony growths in the proximal interphalangeal (PIP) joints
Hallux valgus and cock-up toe
deformities, characteristic of
osteoarthritis in the foot.
Deformities
Knee deformity in OA
Sciencephoto.com
Deformities
Deformity
INVESTIGATIONS
Routine Lab. work usually normal.
ESR usually normal.
RF, CCP, ANA, dsDNA are negative.
Joint fluid is straw-colored with good viscosity, fluid WBCs < 2000/ml; (of value in ruling out crystal induced arthritis or infective arthritis).
Radiogtaphs may show:- Joint space narrowing
Marginal osteophyte.
subchondral bone sclerosis
subchondral cysts
Osteophytes
Muskuloskeletal Ultrasonography:
MRI: early cartilage changes.
Arthroscopy: showed surface erosion and fissuring
Cool effusion
Joint Effusion
Synovial fluid
should aspirated & sent for
1.Cell count.
2.Gram stain.
3.Culture & Sensitivity.
Plain radiograph showing advanced OA
Non-weight
bearing
Weight-bearing
Radiographic features
1st CMC
(thumb base)
Subchondral sclerosis
Osteoarthritis: Narrowing Sclerosis Osteophyte
formation
Kissing Osteophytes: Lumbar Spine
Differential Diagnosis
Crystal-induced arthritides
Osteonecrosis
Charcot joint
Rheumatoid arthritis
Psoriatic arthritis
TREATMENT
Goals of The Treatment
Relief pain, swelling and inflammation.
Inhibit joint damage, to.
• Prevent or retard Disease Progression
• Improve function and Minimize Disability
Improve quality of life.
Osteoarthritis and Cartilage (2008) 16, 624e630
Modalities Of OA Management
1-Nonpharmacological:
Educational strategies
Physical treatment
2-Pharmacological
Drugs
Nutritional approaches.
3-Surgical intervention
Components of Multimodal OA Treatment
Opioid Analgesics
Intra Articular Injections (corticosteroids & hyaluronic
acid)
Pharmacologic Therapy Acetaminophen
NSAIDS / COX2
Topical agents / Nutritional supplements
DMOADs
Non Pharmacological Education/ Exercise / Weight control / Physical therapy /
Occupational therapy / Assistive devices
Surgery
Pharmacological Therapy
Drug Interventions Has been
Classified Into
Symptoms modifying
drugs
Structures modifying
drugs
Pharmacological Therapy
List of
Drugs
Analgesics
NSAIDs
Myorelaxants
Vit. C, D and E.
Oligoeliment Supplementation (Sel, Cu)
Symptom modifying drugs
Paracetamol
COX-2 specific
inhibitors
Nonselective NSAIDs
(plus misoprostol or a
pump inhibitor)
Nonacetylated
salicylates
1-Analgesics and NSAIDs 2-Pure Analgesics
Tramadol
Opioid
3-IA injection
• Glucocorticoids
• Hylauronan
4-Topical
• Capsaicin
• Methylsalicylate
Structures Modifying Drugs
Glucosamine & chondroitin Supplements. Used as
complementary and alternative therapies to relieve the chronic pain of OA.
These supplements are not medications and are not regulated by the U.S. Food and drug (FDA).
IL-1ß inhibitor (diacerine):Inhibition of the
production and activity of IL-1
With repoted side effects
Drugs
Glucocorticoids
• Psychosis
• Acute Addisonian crisis due to
withdrawal
Nonsteroidal anti-inflammatory
drugs
• Acute gastritis
• Perforated / bleeding peptic ulcer
• Acute enteritis
• Analgesic nephropathy
• Acute interstitial nephritis
• Hypersensitivity reactions
• Thrombocytopenia
• Pancytopenia
• Steven Johnson syndrome
• Erythema multiforme
• Toxic epidermal necrolysis
• Acute interstitial nephritis
Disease- modifying
antirheumatic drugs
• Hypersensitivity reactions
• Thrombocytopenia
• Aplastic anaemia
• Exfoliative dermatitis
• Steven Johnson syndrome
Surgical Treatment
Surgery may be considered in patients with
intractable pain, loss of function who are not
responding to other measures.
Surgical Intervention
Patellar taping
Osteotomy
Arthrodesis
Arthroplasty
Tidal knee Irrigation
Arthroscopic lavage with or
without debridement
Total knee replacement.
American College of Rheumatology
2000 Guidelines for OA of the Knee
Nonpharmacologic Modalities
Acetaminophen
Viscosupplements
COX-2–specific inhibitor
NSAID and GI-protective agent
Glucocorticoid injection
At increased risk
for an upper GI adverse event
Not at risk
for an upper GI adverse event
Viscosupplements
COX-2–specific inhibitor
Low-dose NSAID
Glucocorticoid injection
Surgery