Osteoarthritis and Osteoarthritis and Related ConditionsRelated Conditions

Brian J. Keroack, MDBrian J. Keroack, MD

Clinical Features of Clinical Features of OsteoarthritisOsteoarthritis

Onset as young as mid 30’s (usually>40)Onset as young as mid 30’s (usually>40) Early OA (1-2 years):Early OA (1-2 years):

InflammatoryInflammatory symptoms prominent: Morning symptoms prominent: Morning stiffness (<1hr). “If I just keep going I’m OK.”stiffness (<1hr). “If I just keep going I’m OK.”

Red, prominent PIP, DIP jointsRed, prominent PIP, DIP joints Normal RadiographsNormal Radiographs

Later:Later: AM stiffness <30 min. AM stiffness <30 min. ‘‘Mechanical’ symptoms: Worse with use. “I Mechanical’ symptoms: Worse with use. “I

really pay for what I do.” “I just don’t have really pay for what I do.” “I just don’t have the strength I use to.” (e.g. jars, doors)the strength I use to.” (e.g. jars, doors)

Joint abnormalities preclude normal useJoint abnormalities preclude normal use

Clinical Features of Late OA: Clinical Features of Late OA: continuedcontinued

Little Evidence of InflammationLittle Evidence of Inflammation Deformities more prominent (angulation, bony Deformities more prominent (angulation, bony

proliferation)proliferation) Radiographs abnormalRadiographs abnormal Some patients actually get LESS symptomatic Some patients actually get LESS symptomatic

in non-weight bearing joints. You will see in non-weight bearing joints. You will see many patients with hand deformities that are many patients with hand deformities that are asymptomaticasymptomatic

““My hands really don’t bother me like the use My hands really don’t bother me like the use to.” “Once they deformed, they stopped to.” “Once they deformed, they stopped hurting.”hurting.”

Weight bearing joint symptoms usually Weight bearing joint symptoms usually progress.progress.

Risk Factors for OsteoarthritisRisk Factors for Osteoarthritis

WeightWeight TraumaTrauma Genetics?—Amino acid substitutions Genetics?—Amino acid substitutions

in Type II Collagen.in Type II Collagen. Secondary Osteoarthritis (later)Secondary Osteoarthritis (later)

Consequences of Consequences of OA: Spinal StenosisOA: Spinal Stenosis

Erosive OsteoarthritisErosive Osteoarthritis More aggressiveMore aggressive DestructiveDestructive Persistent Persistent

symptomssymptoms Inflammatory Inflammatory

findings on examfindings on exam

Secondary OsteoarthritisSecondary Osteoarthritis

TraumaTrauma Congenital deformityCongenital deformity EndocrinopathiesEndocrinopathies Neuropathic ArthropathyNeuropathic Arthropathy Avascular NecrosisAvascular Necrosis Padget’s DiseasePadget’s Disease Diffuse Idiopathic Skeletal Hyperostosis Diffuse Idiopathic Skeletal Hyperostosis

(DISH)(DISH) Hemophilia Hemophilia Crystals (CPPD, Hydroxyapetite)Crystals (CPPD, Hydroxyapetite)

Illnesses Associated with Illnesses Associated with Neuropathic Arthropathy (Charcot Neuropathic Arthropathy (Charcot

Joint)Joint) DiabetesDiabetes AlcoholismAlcoholism Tabes DorsalisTabes Dorsalis Syrinx (meningomyelocele—cord Syrinx (meningomyelocele—cord

compression)compression)

TherapyTherapy Joint ConservationJoint Conservation ExerciseExercise Weight Loss (Wt Bearing Joints)Weight Loss (Wt Bearing Joints) NSAIDS (Cough medicine analogy: not disease NSAIDS (Cough medicine analogy: not disease

modifying)modifying) Not benign: Ulcers 4%, greater with risk Not benign: Ulcers 4%, greater with risk

factors (age>60, coumadin, past ulcer, factors (age>60, coumadin, past ulcer, prednisone use). Hypertension, prednisone use). Hypertension, ACE+Diuretic+NSAID=trouble (e.g. CHF, ACE+Diuretic+NSAID=trouble (e.g. CHF, Renal failure)Renal failure)

COX-2: Safer for those at risk for ulcer (>65, COX-2: Safer for those at risk for ulcer (>65, coumadin, prednisone, previous ulcer) similar coumadin, prednisone, previous ulcer) similar renal effects. Cardiovascular effects? 2.5 X renal effects. Cardiovascular effects? 2.5 X increase in MI or CVA. Mechanisms—1. increase in MI or CVA. Mechanisms—1. Increase Thromboxane A2 (platelets Increase Thromboxane A2 (platelets stickier).---2. Vascular remodeling (18 stickier).---2. Vascular remodeling (18 months)--Hypertensionmonths)--Hypertension

Therapy: ContinuedTherapy: Continued ??DMARDS—not yet??DMARDS—not yet The problem: Sclerosis of subchondral bone in mid The problem: Sclerosis of subchondral bone in mid

thirties, apoptosis of chondrocytes in late thirtiesthirties, apoptosis of chondrocytes in late thirties If DMARDS are to succeed they will have to be If DMARDS are to succeed they will have to be

studied a decade before symptoms startstudied a decade before symptoms start Remind me not to volunteer for a medicine that Remind me not to volunteer for a medicine that mightmight work that I will have for take for 10 years work that I will have for take for 10 years without knowing the long term effectswithout knowing the long term effects

Joint Replacement/FusionJoint Replacement/Fusion Medical vs Surgical Disease?Medical vs Surgical Disease?

Bone on Bone (X-rays never told me about Bone on Bone (X-rays never told me about symptoms)symptoms)

Night PainNight Pain ““As soon as I step on the knee it hurts and it is As soon as I step on the knee it hurts and it is

all down hill from there.”all down hill from there.”