OSTEOARTHRITIS

Orthopaedic & Traumatology Department

Soetomo General Hospital
Surabaya
2015
 BASIC SCIENCE AND PATHOLOGY
Synovial joint
Hyaline cartilage:
- Avascular
- nutrients diffuse through
the matrix from synovial
fluid, synovium, or from
the underlying bone.
 Joint cartilage
Transmit load
It increases the area of the articular surfaces
Distributes compressive forces widely to the
subarticular bone
Covered by a film of synovial fluid which is
more slippery than any man-made material
Very little frictional resistance to movement
and surface gliding.
 Joint cartilage:
- consists of extracellular matrix (ECM) (95%)
and chondrocytes (5%)
- Extracellular Matrix:
* Collagen (Type 2): 50%
*Proteoglycan
- Hyaluronic acid
- Glycosaminoglycan
- Water: 60-80%
- Chondrocyte:
* the only cells found in articular cartilage
* responsible for the production, organization,
and maintenance of the ECM.
 Mechanisms of Cartilage Repair

Repair of articular cartilage is limited by lack of vascularity

Cartilage also lacks undifferentiated cells that can migrate,
proliferate, and participate in the repair response.
Repair of superficial lacerations
1. Superficial lacerations generally do not heal.
2. Chondrocytes proliferate near the site of injury and
synthesize new matrix, but they do not migrate toward
the lesion and do not repair the defects.
3. The poor healing response: the lack of hemorrhage and
the lack of an inflammatory response necessary for proper
healing
 Repair of deep lacerations
1. Cartilage defects that penetrate into underlying
subchondral bone may heal with fibrocartilage.
2. Fibrocartilage is produced by undifferentiated
marrow mesenchymal stem cells that later
differentiate into cells capable of producing
fibrocartilage.
3. The repair tissue does not resemble the normal
structure, composition, or mechanical properties of an
articular surface and is not as durable as hyaline
cartilage.
 DEFINITION
Osteoarthritis OA is a degenerative disease of
diarthrodial (synovial) joints, characterized by
Breakdown of articular cartilage
and proliferative changes of surrounding
bones
Osteoarthritis is a dynamic phenomenon; it
shows features of both destruction and repair.
 EPIDEMIOLOGY
Osteoarthritis(OA) is the most common joint
disease
Affects the weight-bearing joints & joints that
receive the greatest stress, such as the knees,
toes, & lower spine
OA of the knee joint is found in 70% of the
population over 65 years of age
 Arthritis
Rheumatoid Arthritis Osteoarthritis
Autoimmune Asymmetrical
Symmetrical Joint pain, stiffness
Joint pain, swelling, Pain is worse with
stiffness, fatigue use
Better once joint is Bony enlargement
used Weight bearing
Non weight bearing joints
joint Joint space
narrowing
 RISK FACTORS FOR PRIMARY OA
Age > 65
Sex: women > men
Obesity
Genetics: defect in collagen type II gene
Repetitive trauma
Increased mechanical stress
 SECONDARY OSTEOARTHRITIS
Trauma
Previous joint disorders;
Congenital hip dislocation
Infection: Septic arthritis, TB
Inflammatory: RA
Metabolic: Gout
Hematologic: Hemophilia
Endocrine: DM
 DIAGNOSIS
Joint pain: starts insidiously and increases
slowly over months or years
Aggravated by exertion and relieved by rest,
although with time relief is less and less
complete. Late stage pain in bed at night
Stiffness following inactivity, progressive
Limitation of ROM later stages
Restricition of ADL
Physical examination
LOOK: - Deformity (varus/valgus)
- Scars
- Muscle atrophy
- Swelling
FEEL: - Skin temperature
- Crepitus
- Local tenderness
MOVEMENT: limitation of ROM
Radiological finding
STANDING POSITION !!
The cardinal signs :
Asymmetrical narrowing of the joint space
Sclerosis of the subchondral bone
Subchondral cysts
Osteophytes at the margins of the joint
Late features: joint displacement, bone
destruction.
Radiological grading
 TREATMENT
EARLY STAGES
Principles :
1. Maintain movement & muscle strength
2. Protect the joint from overload
3. Relieve pain: NSAID
4. Modify daily activity
Physiotherapy:
- Directed at maintaining joint mobility &
improving muscle strength
- Aerobic exercise but avoid increase
impact loading
- Massage & application of warmth reduce
pain but short-lived has to be repeated
Load reduction
- Protecting joint from excessive load may slow
down the rate of cartilage loss
- Relieving pain
- Weight reduction: diet
- Wearing shock absorbing shoes, avoiding
activities like climbing stairs
Intermediate treatment
Joint debridement remove osteophytes,
cartilage tags & loose bodies arthroscopic
Localized cartilage defects grafted w/
autologous chondrocytes
Realignment osteotomy:
- must be done while joint still stable & mobile
- x-ray show major part of articular surface is
preserved
 Glucosamine Chondroitin??
An analysis of clinical trials on glucosamine
and chondroitin sulfate for treating
osteoarthritis has shown that these
compounds may have some efficacy against
the symptoms of this form of arthritis
(AAOS 2007)
 RECOMMENDATION 6
We cannot recommend using glucosamine and chondroitin for
patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Strong
At this time, both glucosamine and chondroitin sulfate have been
extensively studied. Despite the availability of the literature, there is
essentially no evidence that minimum clinically important outcomes
have been achieved compared to placebo, whether evaluated alone
or in combination. The strength of the recommendation is based on
lack of efficacy, not on potential harm.

(AAOS summary of OA recommendation)

 Pain relief :
- vascular decompression of subchondral bone
- redistribution of loading forces toward less
damaged parts of joint fibrocartilagemay
grow to cover exposed bone
Late treatment
Progressive joint destruction, w/ pain,
instability & deformity requires
reconstructive surgery
Arthrodesis
Arthroplasty
Total joint replacement
REHABILITATION AND EDUCATION