Osteoarthritis

dr M Arman Nasution SpPD

 Osteoarthritis

 Osteoarthritis is a non-inflammatory,
degenerative condition of joints
Characterized by degeneration of articular
cartilage and formation of new bone i.e.
osteophytes.
 Common in weight-bearing joints such as
hip and knee.
 Also seen in spine and hands.
 Both male and females are affected.
 But more common in older women i.e.
above 50 yrs,particularly in
postmenopausal age.
 Risk factors
 Obesity esp OA knee

 Abnormal mechanical loading

eg.meniscectomy, instability

 Inherited type II collagen defects in

premature polyarticular OA

 Inheritance in nodal OA

 Occupation eg farmers

 Infection:Non-gonococcal septic arthritis

Hereditary
Ageing process in joint cartilage

Defective lubricating mechanism

Incompletely treated congenital

dislocation of hip
 Classification of OA

OA

Primary OA Secondary OA
 Primary OA
 More common than secondary OA
 Cause –Unknown
 Common-in elders where there is no
previous pathology.
 Its mainly due to wear and tear changes
occuring in old ages mainly in weight
bearing joints.
 Secondary OA
 Due to a predisposing cause such as:
1.Injury to the joint
2.Previous infection
3.RA
4.CDH
5.Deformity
6.Obesity
7.hyperthyriodism
 Types of OA
 Nodal Generalised OA
 • Crystal Associated OA
 • OA of Premature Onset
Nodal Generalised OA
• Heberden’s nodes
• Bouchard’s nodes
• CMC of thumb
• Hallux
valgus/rigidus
• Knees & hips
• Apophyseal joints
Crystal Associated OA
Calcium pyrophosphate
dihydrate occurs
mainly in elderly
women, and principally
affects the knee
OA of Premature Onset
• Previous meniscectomy
• Haemochromatosis
 Pathology

 OA is a degenerative condition primarily

affecting the articular cartilage.
1.articular cartilage
2.Bone
3.Synovial membrane
4.capsule
5.Ligament
6.muscle
 Articular Cartilage
 Cartilage is the 1st structure to be affected.
 Erosion occurs,often central & frequently in wt.
bearing areas.
 Fibrillation,which causes softening,splitting and
fragmentation of the cartilage,occur in both wt.
bearing & non-wt. bearing areas.
 Collagen fibres split and there is disorganisation
of the proteoglycon collagen relationship such as
H2O is attracted into cartilage, which causes
futher softening and flaking.these flakes of
cartilage break off and may be impacted b/w the
jt.surfaces causing locking and inflammation.
Right: Early OA with
area of cartilage loss in
the center.

Left: More advanced

changes with extensive
cartilage loss and
exposed underlying
bone
Arthroscopic appearances
in OA of the knee joint:
fibrillated surface of the
cartilage on the medial
femoral condyle
 Bone(Eburnation)
 Bone surface become hard & polished as
there is loss of protection from the
cartilage.
 Cystic cavities form in the subchondral
bone because eburnated bone is brittle
and microfractures occur.
 Venous congestion in the subchondral
bone.
Gross superior view of a
femoral head from a
patient with radiographic
stage I OA. This shows an
area of complete cartilage
loss, with polishing or
eburnation of the
underlying bone.
 Osteophytes form at the margin of the
articular surface,which may get projected
into the jt. Or into capsule &
ligament,bone of the wt.-bearing jt.
 There is alteration in the shape of the
femoral head which becomes flat and
mushroom shaped.
 Tibial condyles become flatened.
Osteophyte at margin of articular surface
 Synovial Membrane
 Synovial membrane undergo hypertrophy and
become oedematous (which can lead to ‘cold’
effusions).
 Reduction of synovial fluid secretion results in
loss of nutrition and lubricating action of
articular cartilage.
Capsule
It undergoes fibrous degeneration and there are
low-grade chronic inflammatory changes
 Ligament
 Undergoes fibrous degernation
 There is low grade chronic inflammatory
changes and acc.to the aspect joint
become contracted or elongated.
Muscles
Undergoes atrophy,as pt. is not able to use
the jt. Because of pain which further limits
movts. and function.
 Clinical features of OA
 Pain
 Stiffness

 Muscle spasm

 Restricted movement

 Deformity

 Muscle weakness or wasting

 Joint enlargement and instability

 Crepitus

• Joint Effusion
Clinical

features 1
Pain and tenderness
Usually slow onset of discomfort, with gradual and
intermittent increase
Pain is more on wt. bearing due to stress on the
synovial membrane & later on due to bone
surface,which r rich in nerve endings coming in
contact.
-initially relieved by rest but later on disturb sleep.
-Diffuse/ sharp and stabbing local pain
Clinical features
Pain and tenderness (cont)

Types of pain

 Mechanical: increases with use of the joint

 Inflammatory phases

 Rest pain later on in 50%

 Night pain in 30% later on

Clinical features
Movement abnormalities

2
‘Gelling’: stiffness after periods of inactivity, passes
over within minutes (approx 15min.) of using joint
again
Coarse crepitus: palpate/hear (due to flaked cartilage
& eburnated bone ends)

Reduced ROM: capsular thickening and bony

changes in joint,ms. Spasm or soft tissue contracture.
Clinical features 3
Deformities
Soft tissue swelling:
 mild synovitis
 small effusions

Osteophytes
Joint laxity
Asymmetrical joint destruction leading to angulation
Osteoarthritis of the DIP
joints. This patient has the
typical clinical findings of
advanced OA of the DIP
joints, including large firm
swellings (Heberden’s
nodes), some of which are
tender and red due to
associated inflammation of
the periarticular tissues as
well as the joint.
Knee joint effusion
A patient with typical
OA of the knees. In the
normal standing
posture there is a mild
varus angulation of the
knee joints due to
symmetrical OA of the
medial tibiofemoral
compartments.
 Pseudolaxity due to
cartilage loss. The
joint is not loaded in
the first photograph
Unstable distal
interphalangeal joints
in OA. The examiner
is able to push the
joint from side to side
due to gross
instability, a common
finding in late
interphalangeal joint
OA.
Radiographic
Stage 1
Classification
Bony spur only

Stage 2 Narrowing of jt.

Space,less than half of
the normal jt. space
Stage 3 Narrowing of jt.
Space,more than half
of the normal jt. space
Stage 4 Obliteration of jt. space

Stage 5 Subluxation or
sec.lateral arthrosis
Distribution of OA of the
hip joint. OA can
maximally affect the
superior pole, inferior pole,
posterior part or other
segments of the hip joint.
Superior pole involvement,
with a tendency for the
head of the femur to sublux
superolaterally, is the
commonest pattern.
Involvement of the whole
joint (concentric OA) is
relatively uncommon.
Special Investigations
Blood tests: Normal

Radiological features:
Cartilage loss
Subchondral sclerosis
Cysts
Osteophytes
Treatment Principles
Education
Physiotherapy
Exercise program
Pain relief modalities
Aids and appliances
Medical Treatment
Surgical Treatment
Education
Nonsystemic nature of disease
Prevent overloading of joint. Obesity!!
Appropriate use of treatment modalities
Importance of exercise program
Aids, apliances, braces
Medial treatments
Surgical treatments
Exercise
Will not ‘wear the joint out’

Important for cartilage nutrition

Some evidence that lack of exercise leads to

progression of OA
Exercise
Encourage full range low impact movements eg
swimming, cycling
Avoid
Prolonged loading
Activities that cause pain
Contact sports
High impact sports eg running
Quadriceps exercises for
knee OA. Quadriceps
exercises are of proven
value for pain relief and
improving function, and
everyone with knee OA
should be taught the
correct techniques and
encouraged to make
these exercises a lifetime
habit. There is a weight
on the ankle.
Use of transcutaneous
nerve stimulation
(TENS) as an adjunct to
other therapy for pain
relief at the knee joint.
The use of acupuncture,
TENS and other local
techniques to aid pain
relief in difficult cases of
OA is often worthwhile.
Aids and appliances
Braces / splints
Special shoes/insoles
Mobility aids
Aids: dressing, reaching, tap openers, kitchen aids
Taping of patella in patello femoral OA
Use of a cane, stick or other walking aid. This patient,
who has hip OA, has found that she can reduce the pain
in her damaged left hip by leaning on the stick in the
right hand as she walks. The reduction in loading can be
huge, and the effect on symptoms and confidence with
walking very beneficial.
The use of shoes and
insoles to reduce impact
loading on lower limb
joints. Modern sports shoes
(‘trainers’) often have
appropriate insoles.
Alternatively, special heel
or shoe insoles of
sorbithane or viscoelastic
materials can be used. They
may help relieve pain as
well as reducing the peak
impact load on the joints
during walking.
Medical Treatment
Simple analgesics: paracetamol, low dose ibuprofen
NSAID’s/Coxibs PRN regular
Intra-articular corticosteroids
Topical treatment eg NSAID creams, capsaicin
‘Chondroprotective agents’
A patient with OA of the
carpometacarpal joint of
the left thumb
undergoing
arthrocentesis for
injection of a depot
corticosteroid
preparation. The
operator is distracting
the patient’s thumb to
open up the joint space.
Joint replacement surgery
Indications: pain affecting work, sleep, walking and
leisure activities

Complications
sepsis
loosening
lifespan of materials (mechanical failure)
 Osteoporosis: Challenges to
meet

DRAFT Aclasta Brand Book

 Bone and its component
 Bone Homeostasis
 Bone remodeling
 Definition and classification of
osteoporosis
 Prevalence
 Risk Factors and presentation
 Diagnosis
 Consequences
 Management principle
 Treatment goal
Osteoporosis: Challenges to meet| BICC | 27 th July, 2010
 Organic Component:
 protein collagen &
specialized cells called
osteoclasts, osteoblasts, and
osteocytes

 Inorganic component:
 Mainly as calcium
phosphate, in the form of
Hydroxyapatite
Osteoporosis: Challenges to meet| BICC | 27 th July, 2010
 Bone Homeostasis:
 the situation when the body
requires and achieves an equal
amount of bone resorption
Homeostasis
and bone formation

 the amount of bone eroded

by osteoclasts is equal to the
amount of bone produced by
osteoblasts, thereby
producing a stable net mass of
bone in the body
Osteoporosis: Challenges to meet| BICC | 27 th July, 2010
 The combined processes of breaking down bone and
building new bone are called Bone Remodeling.

 It is the body’s way of maintaining bone homeostasis.

 5 Stages:
 Initiation,
 Resorption,
 Reversal,
 Bone formation and
 Completion of remodeling.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

Osteoclast precursor cells are attracted to a bone site and
penetrate the bone lining cells. These osteoclast precursor
cells then form activated osteoclasts that align themselves
in direct contact with mineralized bone matrix.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

The osteoclasts erode a cavity by removing mineral and
organic components from the bone. The osteoclasts
eventually die. This completes the resorption phase.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

Cells of unknown origin prepare the bone surface for new
bone formation by smoothing the surface of the cavity and
depositing a thin layer of a cement-like substance.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

Cells of unknown origin prepare the bone surface for new
bone formation by smoothing the surface of the cavity and
depositing a thin layer of a cement-like substance.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

The lining cells rest on the bone surface until the next
cycle of bone remodeling begins.

Some osteoblasts become osteocytes.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010
Challenges of Osteoporosis

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

National Osteoporosis Foundation:
 a disease characterized by low bone
mass an micro-architectural
deterioration of bone tissue,
leading to bone fragility and an
increased susceptibility to
fractures.”

World Health Organization (1994) :

 bone mineral density T-score
greater than –2.5 standard
deviations from the mean peak
adult bone mass (ie. a woman in her
30’s).”
Osteoporosis: Challenges to meet| BICC | 27 th July, 2010
Osteoporosis: Challenges to meet| BICC | 27 th July, 2010
Losing bone with years
“Osteoporosis, the silent thief of your bone”

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

Worldwide, over age of 50
 1 in 3 women / 1 in 8 men have osteoporosis.

 80 % of those suffering from osteoporosis are women.

 Affects 75 million persons in the US, Europe and Japan.

 Over 50% of women aged 50 years or older and 20% of

men will suffer an osteoporosis-related fracture within
their remaining lifetime

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Being female
 Older age
 Family history of osteoporosis or broken bones
 Being small and thin
 History of broken bones
 Low sex hormones
• Low estrogen levels in women, including menopause
• Missing periods (amenorrhea)
• Low levels of testosterone and estrogen in men

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Diet
• Low calcium intake
• Low vitamin D intake
• Excessive intake of protein,
sodium and caffeine
 Inactive lifestyle
 Smoking , Alcohol abuse
 Certain medications
• steroid , anticonvulsants etc
 Certain diseases
• anorexia nervosa, rheumatoid
arthritis, gastrointestinal
diseases and others

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 People may not know that they
have osteoporosis until they break
a bone.
 Vertebral (spinal) fractures may
initially be felt or seen in the form
of
 Persistent, unexplained back
pain
 Loss of height
 Spinal deformities such as
kyphosis or stooped posture.
Osteoporosis: Challenges to meet| BICC | 27
th
July, 2010
 Bone mineral density (BMD) tests can measure bone
density in various sites of the body.

 BMD test is done to diagnose and predict fracture

risk and to monitor therapy.

 For patients on pharmacotherapy, it is typically

performed 2 years after initiating therapy and every 2
years thereafter; however, more frequent testing may be
warranted in certain clinical situations.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Dual-energy X-ray Absorptiometry (DXA) Scan

• “Gold-standard” for BMD measurement.

• Measures “central” or “axial” skeletal sites: spine and
hip.
• May measure other sites: total body and forearm.
• Validated in many clinical trials.
• Available in Bangladesh.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Dual-energy X-ray Absorptiometry (DXA) Scan
Classification T-score
Normal -1 or greater
Osteopenia Between -1 and -2.5
Osteoporosis -2.5 or less
-2.5 or less
Severe Osteoporosis
and fragility fracture

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 FRACTURE ,
The most serious complication of
Osteoporosis that leads to

 Increased morbidity
 Increased mortality
 Decreased quality of life

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Wrist fracture
men 1 in 40 (2.5%)
women 1 in 6 (16%)

Spinal fracture
men 1 in 20 (5%)
women 1 in 6 (16%)

Hip fracture
men 1 in 17 (6%)
women 1 in 6 (17.5%)

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Decreased fracture risk

Life style modification Therapeutic Intervention

• Minimizing risk factors Slowing/stopping
bone loss

• Minimizing factors that Maintaining or increasing

Contribute to fall bone density and strength

Maintaining or improving
bone microarchitecture

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Supplements
 such as which maintain bone mass Calcium,
Vitamin D

 Anti-resorptive agents
 which inhibit bone resorption Bisphosphonates

 Anabolic agents,
 which stimulate bone formation and, in turn,
increase bone mass.

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

 Prevent further bone loss
 Increase or at least stabilize bone density
 Prevent further fractures
 Relieve deformity (e.g., kyphoplasty)
 Relieve pain
 Increase level of physical functioning
 Increase quality of life

Osteoporosis: Challenges to meet| BICC | 27 th July, 2010

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