OSTEOARTHRITIS

Seti Aji Hadinoto

Background
O Disease of the Cartilage
O Osteoarthritis (OA) is a chronic, degenerative

disorder of multifactorial aetiology, characterised by loss of articular cartilage and periarticular bone remodelling. O OA is the most common form of progressive joint disease

Background

What Areas Does Osteoarthritis Affect?

Females have a higher prevalence of the knees and hands, males have higher prevalence of OA of the hips. For knee OA, the female-to-male incidence ratio is 1.7:1.

Risk factors
Correctable Trauma Profession Obesity Sedentary life syle Non Correctable Joint Dysplasia Family History ( COL2A1 gene mutation) Bone Density

Causes
O Primary OA is idiopathic
O Secondary OA:
O Previous trauma (ie, posttraumatic OA) O Infection

O Crystal deposition
O Acromegaly O Previous rheumatoid arthritis (ie, burnt-out rheumatoid

arthritis) O Heritable metabolic causes (eg, alkaptonuria, hemochromatosis, Wilson disease)

Causes
O Secondary OA:
O Neuropathic disorder leading to a Charcot joint (eg,

syringomyelia,tabes dorsalis, diabetes) O Underlying orthopedic disorders (eg, congenital hip dislocation, slipped femoral capital epiphysis) O Disorders of bone (eg, Paget disease, avascular necrosis)

Normal Histology of Cartilage

Etiopathogenesis
O Stage 1:
O Increased water content due to mecganical

disturbance, and proteolytic breakdown of the cartilage matrix

O Stage 2:
O Chondrocyte response O fibrillation and erosion of the cartilage surface

release of proteoglycan and collagen fragments into the synovial fluid.

O Stage 3:

O Chondrocyte response O a chronic inflammatory response in the

synovium.

Cartilage in OA

Subchondral Change

CLINICAL
O Pain
O Morning stiffness O Stiffness after a period of inactivity and

gradual improvement after a short period of movement

CLINICAL
O inevitable joint deformity and a loss of

function. O bony enlargement O Heberden nodes; Bouchard nodes

Sources of pain in OA
O Joint effusion and stretching of the joint
O O O O O O

capsule Increased vascular pressure in subchondral bone Microfracture Inflammation of periarticular bursae Periarticular muscle spasm Psychological factors Crepitus (a rough or crunchy sensation) may be palpated during motion of an involved joint.

Joint pain cycle

Overload/instability
Cartilage Damage

Inflammation

Inactivity

Pain

X-Ray Study
O

Cardinal sign for OA

1. 2. 3. 4. 5.

Joint space narrowing Osteophytes Subchondral sclerosis Subchondral cysts Bone Remodelling

Kellgren Lawrence Grading Kellgren Lawrence Scale Grading Scale

Grade 1 doubtful narrowing of joint space and possible osteophytic

lipping
Grade 2 Grade 3 definite osteophytes, definite narrowing of joint space moderate multiple osteophytes, definite narrowing of joints space, some sclerosis and possible deformity of bone contour Grade 4 large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour

Osteoarthritis of the knee, Kellgren stage I

Osteoarthritis of the knee, Kellgren stage II

Osteoarthritis of the hip, Kellgren stage III

Osteoarthritis of the hip, Kellgren stage IV

MANAGEMENT
O Goals of managing OA include:
O controlling pain O maintaining and improving the range of

movement and stability of affected joints, O limiting functional impairment. O Protecting joints from overload O Delay the progression of the disease

Management OA Chart
Non Pharmacologic 2. Pharmacologic
1.
a.

b.
c.

Oral Treatment Topical analgesia Intraarticular Injection Debridemant Realignment Osteotomy Arthrodesis Arthroplasty Conventional technique Repair cartilage Cartilage replacement Growing cartilage

3.

Surgery
a.

b.
c. d.

4.

New Methode
a. b. c. d.

Nonpharmacologic therapy
O Patient education O Self-management programs (e.g., Arthritis
O O O O O O

Foundation Self-Management Program) Personalized social support through telephone contact Weight loss (if overweight) Aerobic exercise programs Physical therapy Range-of-motion exercises Muscle-strengthening exercises Assistive Device

Pharmacologic therapy for patients with OA

O Oral O Acetaminophen O COX-2-specific inhibitor O Nonselective NSAID plus misoprostol or a proton pump inhibitor O Nonacetylated salicylate O Injection O Glucocorticoids O Hyaluronan O Topical O Capsaicin O Methylsalicylate

Surgical Therapy
O Indicated in unresponsive conservative treatment O Surgical interventions for OA of the knee

O Arthroscopic lavage O Joint realignment (realignment osteotomy) O Joint fusion (arthrodesis) O Joint replacement (arthroplasty)

Debridemant
O Include :
O Limited synovectomy O Osteophyte excision O Removal of loose bodies O Chondroplasty O Repair meniscus

Osteotomy
O Active patient < 60 y.o O Only one compartment involved

(usually on the medial side) O The principle is to shift weight (unloading) from the damaged cartilage on the medical aspect of the knee to the healthy lateral aspect of the knee. O Can save an individual from having a total knee replacement until they are older.

Osteotomy
O Contraindications:
O knee flexion less than 90, O a flexion extension contracture of more

O
O O

O
O

than 15, varus over 15-20. Instability due to previous trauma or surgery, severe arterial insufficiency, bicompartmental involvement. Bone loss o medial compartment > 2 3 mm

Osteotomy

Arthroplasty
O Total joint replacement is an excellent

treatment in individuals with moderate-tosevere OA. O Significantly improve the patient's quality of life. O Candidates are preferably > 60 years. O The use of cement relieves pain more quickly, but a porous coating may last longer O The prevention of thrombophlebitis and resultant pulmonary embolism is important

Arthroplasty
O UKA
O TKR O THR O BHR O etc

Arthrodesis
O Still a reasonable choice if stiffness is

acceptable O Apply to small joint :

O Carpalia O Tarsalia O MTP 1

O Advantage :
O Quick release of pain O If positioned in anatomic potion, may regain

functional status, although limited

Postoperative details
O After

osteotomy and fusion require partial weightbearing until bony healing occurs. Afterward, exercise is indicated.

O After joint replacement, patients require partial

weightbearing, which progresses weightbearing in 1-3 months.

to

full

O To maintain ROM, directly after surgery, patients

are put in CPM machine

Prognosis
O Prognosis is good for patients who have

undergone joint replacement. O The prosthesis may need revision 10-15 years later, depending upon activity level.

Future Treatment
O Cartilage restoration
O ACI (autologus chondrocyte implantation0

O Cartilage Replacement Technique

O Osteochondral Autograft O Osteochondral Allograft

O Stem Cell O Biological engineering

O etc