osteoarthritis - wickupwickup.weebly.com/uploads/1/0/3/6/10368008/osteoarthritis.pdf · •the...
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Osteoarthritis
Dr Elsa van Duuren
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Osteoarthritis (OA)
• Most common joint disease in the world
• Prevalence increases with age
– Majority of people over the age of 65 have radiographic features of OA
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Consequence of OA
• Disability:
– Second to heart disease as the leading cause of disability in working men over 50 years old
– OA of the knees is the leading cause of disability among the elderly in developed countries
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Pathogenesis and pathology of OA
• Disease of synovial joints
• Progressive loss of cartilage
• Reaction by joint structures
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Susceptibility to OA
Susceptibility:
• Obesity
• Heredity
• Hormonal
• Bone density
• Hypermobility
• Neuromuscular dysfunction
• Metabolic disorders
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The OA process
Insults
Repair
Trauma
Metabolic abnormality
Instability
Aging
Environmental/
Constitutional
factors
Osteoarthritis Osteophyte
remodelling
Synovial
response Capsular
response
Chondrocyte
metabolism
Outcome
Compensation-
No/mild symptoms
or disability
Decompensation-
Symptoms /
Disability
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Changes in the OA joint
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Early cartilage change
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Bone changes
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Synovitis
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Cartilage debris in the synovial fluid
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Synovitis
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Medial compartment OA knee
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Lateral compartment OA knee
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Hip OA
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Hand OA
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DIP cyst
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Cyst on DIP
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OA MTP 1
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Evaluation of OA
• Diagnosis on clinical picture
– Joint pain with activity
– Transient stiffness in the morning or after rest
– Reduced range of motion
– Joint crepitus or periarticular tenderness, or both
– Bony swelling
• X rays
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Examination of the OA patient
• Body weight
• Range of motion in the joint
• Location of tenderness
• Muscle strength
• Ligament stability
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Blood tests in OA
• No diagnostic blood tests
• Experimental tests to look at disease activity
• FBC, creatinine, LFTs before starting NSAIDS,
– Especially for elderly people
– Other chronic illnesses
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MRI in OA
• Magnetic resonance imaging may be used to diagnose other causes of knee pain
– Eg osteochondritis dissecans and avascular necrosis
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The meniscus in knee OA
• High incidence of pts with knee osteoarthritis have meniscal tears
– Not necessarily a cause of increased symptoms
– Menisectomy not indicated unless symptoms of locking or extension blockade
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Management of OA
• Guidelines well established:
– OARSI
– American academy of orthopaedic surgeons
– EULAR
– NICE
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Aim of treatment:
– Alter the disease process and its consequences
– Educate patients about the disease and its management
– Relief of symptoms
– Optimise function
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Non-pharmacologic management
• Important part of treatment, but neglected
• Emerging biomechanical approaches
– Long term load reduction will palliate pain
– Delays progression of structural joint degeneration
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Reduce load on joints
• Protect compromised joints from excessive loading
– Weight loss
– Modify inappropriate daily/occupational activities
– Use walking stick/ bracing
– Shock absorbing shoes and insoles
– Correct leg length discrepancy
– Patellar taping
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Exercise in OA
• Maintain joint motion and stability
– Regular movement- little and often
• Muscle strengthening exercises
– Decreases pain ( quads for knee OA)
– Improve function
– Reduce fall risk
• Physical training rather than passive therapy
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Analgesic Therapy
• Paracetamol
• Tramadol
• Opioid anagesics
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NSAIDs
• NSAIDs and COXIBs • No difference between drugs
• If no response to one, may respond to another
• Lower doses may be effective
• Gastroprotection for long term use
• Side effects: GI, renal, worsening CHF, BP, edema
• Antiplatelet effects may be hazardous
• Coxib risk: political and medico-legal, not medical
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Polysulfated glycosaminoglycans
• Glucosamine sulphate/ chondroitin: • Symptomatic benefit in some studies
• no known side effects
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Topical Agents
• Local cold or heat: Hot packs, hydrotherapy
• Topical analgesic agents: no evidence
• Capsaicin-containing topicals
• Liniments = methyl salicylates
• Topical NSAIDs
• Evidence of benefit for superficial joints:
• Hand OA
• Knees
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Intra-articular steroids
• Intra-articular steroids indication:
– Acute exacerbations of pain and signs of local inflammation with joint effusion
• Short term benefit for pain and function
* Altman, et al. J Rheumatol. 1998;25:2203.
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Hyaluronate injections
• Symptomatic relief in some patients
• Improved function
• Expensive
• Require series of injections
• No evidence of long- term benefit
• Limited to knees
• Not recommended
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Surgical Therapy for OA
• Arthroscopy
• American Academy of Orthopaedic Surgeons:
• Recommend against performing arthroscopy with debridement or lavage in patients with primary OA of knees
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Osteotomy:
• Only recommended in specific cases
– Symptomatic unicompartment OA with malalignment
• May delay need for TKR for 5 - 10 years
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Total joint replacement:
• Proper selection of patients
• Good to excellent results can be expected in 95%
• Survival rate of the implant is expected to be 95% at 15 year
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OA Summary • Osteoarthritis is a disease of the whole joint,
not just cartilage • The diagnosis of osteoarthritis is based on
clinical presentation and supported by radiography
• Effective drugs and non-pharmacological treatments are available for the management of osteoarthritis; non-drug treatments should be tried first
• Surgical intervention should be considered when medical treatment has failed