OSTEOARTHRITIS

Definition & Epidemiology

It is a joint failure
A disease all structures of
the joint have undergone
pathologic change, often in
concert.
The pathologic sine qua non of
disease:
1. hyaline articular cartilage
loss, present in a focal and,
initially, nonuniform manner.
2. accompanied by increasing
thickness and sclerosis of the
subchondral bony plate,
3. by outgrowth of osteophytes
at the joint margin,
4. by stretching of the articular
capsule,
5. by mild synovitis in many
affected joints, and
6. by weakness of muscles
bridging the joint.
7. In knees, meniscal
degeneration is part of the
disease

Risk Factors
Joint Vulnerability &
Joint Loading

Pathogenesis
Joint Protective Mechanisms and
Their Failure

(Systemic Fxs)
Old age: >60y/o
Female gender
Race/ethnicity
Nutritional

Joint protectors include:

Joint capsule
Ligaments
Muscle
Sensory afferents
Underlying bone

(Local Envt Fxs)

Previous injury
Bridging muscle weakness
Increasing bone density
Malalignment
Proprioceptive
deficiencies
Use (loading) factors
acting on joints
Obesity
Injurious physical activities

Cartilage and Its Role in Joint

Failure
Two major macromolecules in
cartilage
1.Type 2 collagenprovides
cartilage its tensile strength.
2.Aggrecana proteoglycan
macromolecule linked with hyaluronic
acid, which consists of highly
negatively charged
glycosaminoglycans.

Pathology
initially shows surface fibrillation
1.
and irregularity.
focal erosions develop
2.
extend down to the subjacent bone
cartilage erosion down to bone
3.
expands to involve a larger proportion 4.
of the joint surface.
Chondrocytes undergo mitosis and
clustering.
5.
net effect of this activity is to
promote proteoglycan depletion in the
Matrix surrounding the chondrocytes
Collagen matrix becomes
6.
damaged.
Negative charges of proteoglycans
get exposed.
cartilage swells from ionic
attraction to water molecules
cartilage becomes vulnerable to
further injury.

Clinical Symptoms
History
Pattern of spread:
Additive; however, only one joint may be
involved
Onset: Usually insidious
Progression& Duration:
Slowly progressive, with temporary
exacerbations after periods of overuse
Associated Symptoms:
1. Small effusions in the joints may be
present, especially in the knees; also
bony enlargement
2. Possibly tender, seldom warm, and
rarely red
3. Intermittent stiffness: Frequent but
brief (usually 510 min), in the
morning and after inactivity
4. Limitation of motion often develops
Generalized symptoms are usually
absent
Physical Examination
Common locations:
Knees, hips, hands (DIP,PIP), cervical and
lumbar spine, wrists (first carpometacarpal
joint), joints previously injured or diseased
Findings in osteoarthritis:
Bony bumps on the finger joint closest to
the fingernail (Heberden's nodes )
bony bumps on the middle joint of the
finger (Bouchard's nodes )
bony bumps at the base of the thumb.
Tenderness and/or swelling in weightbearing joints such as the hips and
knees.
Pain, limited movement, and/or a creaking
noise or feeling (crepitus) that occurs
when the joints are moved. Pain on both
active and passive movement
Joints that have been affected by injury or
infection may also show signs of bone or
tissue damage.

Diagnosis
Classification criteria by American College
Rheumatology
OA of Hip
Hip pain plus femoral or acetabular
osteophytes on radiographs or
Hip pain plus joint space narrowing on
radiographs and an ESR of less than 20 mm
per hour
OA of Hands
Hand pain, aching or stiffness +
Hard tissue enlargement of two or more of 10
selected joints* +
Fewer than three swollen
metacarpophalangeal joints +
Hard tissue enlargement of two or more distal
interphalangeal joints or
Deformity of two or more of 10 selected joints*
* - 10 selected joints are the second and third
distal interphalangeal joints, the second and
third proximal interphalangeal joints and the
first carpometacarpal joints (of both hands).
OA of Knee
Knee pain and osteophytes on radiographs or
Knee pain plus patient age of 40 years or older,
morning stiffness lasting 30 minutes or less
and crepitus on motion

1.
2.
3.
4.

Synovial fluid analysis

Noninflammatory syno-vial fluid is:
clear,
viscous, and
amber-colored,
WBC count of <2000/L and a predominance
of mononuclear cells.

Radiography
Structural abnormalities:
1. cartilage loss (seen as joint space loss on
x-rays)
2. osteophytes (a bony outgrowth)

Treatment
Supportive/Palliative
NONPHARMACOLOGIC

SURGICAL
1.Arthroscopic debridement and lavage Randomized trials evaluating this operation
have showed that its efficacy is no greater
Mainstay of treatment:
than that of sham surgery or no treatment
for relief of pain or disability
1.
altering loading across the painful joint
2.Arthroscopic meniscectomy - indicated for
acute meniscal tears in which symptoms
2.
improving the function of joint protectors
such as locking and acute pain are clearly
related temporally to a knee injury that
produced the tear.
3.For patients with knee OA isolated to the
A. Alter loading across the painful joint
medial compartment, operations to realign
the knee to lessen medial loading can
1. Avoid activities that precipitate pain
relieve pain. These include:
a. high tibial osteotomy - the tibia is
broken just below the tibial plateau and
2. Lose weight
realigned so as to load the lateral,
nondiseased compartment, or
3. Splinting minimize pain by limiting motion of
b.
a unicompartmental replacement with
joints; for pts with first CMC , DIP or PIP joint
realignment.
involvement
4.total knee or hip arthroplasty for patients
with knee or hip OA in which medical
4. Use cane in the hand opposite to the affected
treatment modalities have failed and
area for partial wt-bearing
remains in pain, with limitations of physical
function that compromise the quality of life
5. Use crutches or walkers

B. Improve Function of Joint protectors

1. Exercise
a.

aerobic and/or

b.

resistance training - focuses on

strengthening muscles across the joint

2. Correction of malalignment
a. fitted brace, which takes an often varus
osteoarthritic knee and straightens it by
putting valgus stress across the knee
b. use of orthotics in footwear
c. Use a brace to realign patellar

Cartilage Regeneration
1. Chondrocyte transplantation - has not
been found to be efficacious in OA,
perhaps because OA includes pathology of
joint mechanics, which is not corrected by
chondrocyte transplants.
2.Abrasion arthroplasty (chondroplasty) has
not been well studied for efficacy in OA, but
it produces fibrocartilage in place of
damaged hyaline cartilage.
- Both of these surgical attempts to
regenerate and reconstitute articular
cartilage may be more likely to be
efficacious early in disease when joint
malalignment and many of the other
noncartilage abnormalities that
characterize OA have not yet
developed

malalignment
d. use of tape to pull the patella back into the
trochlear sulcus or reduce its tilt
e. neoprene sleeves pulled to cover the knee
lessen pain and are easy to use and
popular among patients
3. acupuncture - produces modest pain relief
compared to placebo needles and may be
an adjunctive treatment

PHARMACOLOGIC
- serves an important adjunctive role in OA
treatment
1. Acetaminophen- is the initial analgesic of
choice for patients with OA in knee, hip, or
hands.
-

Doses up to 1 g 4 times daily

2. NSAIDs - administered topically or taken orally

on an "as needed" basis
Naproxen dose: 375-500mg BID
Salsalate 1500mg BID
Ibuprofen- 600-800mg 3-4 times a day
3.

COX-2 Inhibitors

Celecoxib low dose, 200mg a day

4.

Glucocorticoid used for acute flares of

pain; given via intraarticular injection

5.

Hyaluronic acid given via intraarticular

injection