TITLE:

Osteoarthritis (Wear & Tear or Degenerative Joint Disease)

DEFINITION A progressive disorder of the joints due to failure in repair of joint damage involving

progressive softening and disintegration of articular cartilage
inflamed synovium produce excess synovial fluid causing joint swelling
development of bony spurs osteophytes
cyst formation at margins of joints
capsular fibrosis capsule and ligaments thickens and contract
bone angulation deformity varus deformity

PATHOGENESIS Disparity between stress applied to articular cartilage and ability of cartilage to withstand
stress
-weakening of articular cartilage: genetic defect in Type II collagen or enzymatic activity in
inflammatory disorder
-increased mechanical stress in some part of articular surface
: excessive impact loading/ decrease in articular contact area in unstable joint
: subchondral bone defect

Important mediators in degradation
Cytokines: TNF-a, IL-1, Il-6, collagenases, metalloprotineases, aggrecanases

Important mediators in protection
IL-4 and TIMP , TGF-b, & IGF-1 protective

PATHOLOGY softening of articular cartilage : frayed and fibrillated, leading to underlying
bone exposed

shedding of fibrillated fragments from articular cartilage, release of

enzymes from damaged cells -> low grade synovitis

synovitis -> vascular congestion -> increased interosseus pressure -> pain

remodelling process occurs to restore a measure of congruity to the

increasingly maloppposed/deformed joint surface

peripheral cartilage proliferates and ossifies -> capsular fibrosis (joint stiffness)
bony outgrowth -> osteophytes


EPIDEMIOLOGY Prevalence: commonest form of arthritis
Female > Male
Elderly > 50 yrs old

RISK FACTORS
Non Modifiable Modifiable
Age Trauma
: Old cartilage repairs less well : fractures involving articular
: Reduced muscle strength and surface
bulk : injuries causing joint instability
: Reduced joint proprioception Occupation
Female : repetitive stress, knee bending
Family history activities
: mothers with generalised OA) Overweight/obese
Joint dysplasia
: congenital acetabular dysplasia
: Perthes disease

: slipped upper femoral epiphysis

CLASSIFICATION Primary OA Secondary OA
Generalised OA, a condition Metabolic
associated with Heberdens nodes : acromegaly
and polyarticular disease : haemachromatosis
Commonly seen in hand (female, : chondrocalcinosis
FDR)
Anatomic
: slipped femoral epiphysis
: Perthes disease
: congenital dislocation of the hip
: leg length discrepancy
: hypermobility syndrome
: avascular necrosis

Trauma
: major joint trauma
: fracture through a joint

Chronic occupational: repetitive
injury or stress

Inflammatory
: Septic Arthritis, Psoriatic arthritis

: Rheumatoid Arthritis
CLINICAL
FEATURES Symptoms Signs
- Joint pain - insidious in onset, Gait antalgic gait/swinging
may be intermittent and relapsing,
increased by joint use and impact, Deformity - may be present in any of the
relieved by rest, nIght pain may peripheral joints with OA. Most notable in
occur in severe OA. IP joints of the hand, knees (varus) or the
hips (shortened limb)
- Stiffness - sensation of tightening
of the involved joint, occurs after
inactivity, such as in the morning Heberden's nodes (DIP)
or when arising after sitting for a
prolonged period. Usually lasts
only a few minutes

- Swelling - with or without
associated warmth and loss of
function.
Bouchard's nodes (PIP)
- Gait disturbance a/w increased
muscle spasm and a reduced
quality of life. An affected knee or
hip can produce a prominent limp.

- Impaired function of a weight-
bearing joint cause added stress on
the contralateral weight-bearing Square hand
joints (patient with impaired right - The first carpometacarpal joint is also a
knee function and pain have common area affected in osteoarthritis.
difficulty with the left hip and vice Enlargement of this joint results in a
versa) squared appearance to the palm areasw

- Loss of muscle bulk due to
inactivity secondary to pain

- Limb deformity varus deformity

- Clicking or grinding sensation with
joint motion resulting in
discomfort or pain

- Instability leading to use of cane or
crutch.

 Varus angulation at knee ("bow-legged")

Fixed flexion deformity in knee OA

Muscle wasting - quadriceps

Tenderness

Joint effusion due to synovitis patellar
tap test, bulge test

Crepitus - Grinding, gritty sensation felt on
palpation during flexion and extension

Limited range of motion - as a result of
synovitis/effusion, periarticular soft tissue
contractures, muscle spasm, osteophytes


GRADING SYSTEM



Ddx Crystalline arthropathies (gout & pseudogout)
Inflammatory arthritis (e.g RA)
Seronegative spondyloarthropathies
Septic arthritis
Postinfectious arthropathy

INVESTIGATIONS Diagnosis is primarily clinical
Often history and exam is enough
Typical patterns of symptoms & joints involved
Blood tests is done TRO other types of arthritis
X-rays often show typical features: early findings may be subtle

X-ray findings in OA
L : loss of joint space
O : osteophyte formation
S : subchondral sclerosis
S : subchondral cyst

(OA of knees- Medial & lateral degeneration of the cartilage)









(OA of hips)




MANAGEMENT

Goals of treatment:
Relieve pain
Maintain or restore function with rehabilitation and exercise
Delay progression if possible

 Management OA

Early (Non Operative)

Intermediate
: relieve pain Late
: arthroscopic
: incease movement : joint replacement
debridement
: reduce load


NON OPERATIVE

1)Lifestyle Modification

a. Weight Reduction
- pain reduction and improvement of function
- each unit of weight loss will result in 4-fold reduction in the load exerted on the knee
per step during daily activities

b. Exercise
- reducing pain in hip and knee OA
- frequency, intensity and duration and rate of progression of exercise can vary.

2)Physiotherapy
- improve muscle strength, balance, coordination and joint mobility
- individualised exercise program : muscle strengthening, low impact aerobic exercise
- should be started as soon as possible: short term benefit for knee OA

3)Occupational Therapy
- aims to improve health, prevent disability and help to achieve optimum functional
level and independence in performing ADL
- referred for splinting and assistive device provision






4)Orthoses
- orthoses are defined as any medical device added to a person's body to support,
align, position, immobilise, prevent or correct deformity, assist weak muscles or
improve function
- in knee OA, orthoses decrease pain and improve physical function
- walking shoes with neutral, contoured orthoses reduce pain and stiffness, and
improve function in knee OA at one year
(NO knee brace in OA)

PHARMACOLOGICAL TREATMENT

i. Simple analgesics - paracetamol
ii. Weak opioid analgesics - tramadol
iii. Analgesics with anti-inflammatory properties NSAIDS and COX 2 Inhibitors
iv. Nutraceutical - glucosamine, chondroitin
v. Intra articular corticosteroid injection: short term pain relief in acute excerbation


SURGICAL TREATMENT

If symptoms of the affected joints significantly affect the QOL and interfere with ADL.
- pain (sleep interruption and while resting)
- limitations to ADL (walking and self-care)
- psychosocial health (psychological well-being)
- economic impact and recent deterioration

The types of surgery that can be offered are:-
- Arthroscopic Surgery
- High Tibial Osteotomy
- Total Joint Replacement
- Partial Joint Replacement

1) Arthroscopic Surgery
- arthroscopic lavage with or without debridement in knee OA
- debridement involve removal of osteophytes, cartilage tags, and loose bodies
- indication : young OA patients a/w mechanical symptoms such as locking, catching or
giving way of the joint caused by presence of loose bodies or flaps of meniscus or
cartilage.
- studies showed no additional benefit in terms of pain relief and improvement in joint
function compared to optimised physical and medical therapy




 2) High Tibial Osteotomy (HTO)
- in patients with isolated medial compartment arthritis ( < 50yo, have at least 120
degrees of knee flexion)
- tibial bone is osteotomised at its upper end and repositioned
- aim : realign the mechanical axis of the limb away from the diseased area
: allows even redistribution of weight on a more normal compartment
-relieves pain and may delay the progression of OA
-joint replacement is better option

3) Total Joint Replacement
- indicated in patients with severe OA who have failed to respond to all other therapies.
- result in a dramatic reduction in pain and a significant
improvement in ADL
- > 90% success rate
-prosthesis last +15 years


COMPLICATIONS Chondrolysis - Rapid, complete breakdown of cartilage resulting in loose tissue material
in the joint

Bone death (osteonecrosis)

Stress fractures (hairline crack in the bone that develops gradually in response to
repeated injury or stress).

Heamarthroses -Bleeding inside the joint.

Septic arthritis - Infection in the joint.

Gout/Pseudogout

Joint instability - Deterioration or rupture of the tendons and ligaments around the
joint, leading to loss of stability.

Pinched nerve (in osteoarthritis of the spine).