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Osteoarthritis 2018

Essentials of Clinical Rheumatology

นพ. สูงชัย อังธารารักษ์


งานโรคข้ อ-ภูมิแพ้ กลุม่ งานอายุรศาตร์ ร.พ. ราชวิถี
กรมการแพทย์
Reference

• Kelley’s textbook of rheumatology 9th 2013


• Up to Date 2017
Definition
• A slowly progressive joint disease with
gradual joint pain, stiffness and limitation
of movement with mild to moderate
synovitis

Hooper MM, Holderbaum D, Moskowitz RW. Clinical and laboratory findings in osteoarthritis.
Arthritis and Allied Conditions A textbook of Rheumatology; 2005. P2227-55.
Epidemiology
• Most common joint disease and most
common cause of disability esp. knee OA
• Involve both sex ( Woman > Man) with age-
relation
• The common joint ; knee , hand, 1st MTP ,
hip?, spine

Felson DT. The epidemiology of osteoarthritis. Results from the Framingham Osteoarthritis Study. Semin
Arthritis Rheum 1990; 20 (Suppl 1): 42-50.
Classification
1. Primary or idiopathic ;
- peripheral joint: knee joint , DIP (Heberden’s
node), PIP (Bouchard’s node), 1st CMC, 1st
MTP (Bunion), hip joint
- axial joint: apophyseal or facet joint,
2. Secondary ;
- trauma , joint disease, metabolic disease,
neuropathic disease , congenital disease
Risk factors
• Age ; strong association( 80-95% of 75 y has OA)
• Obesity ; strong association;
knee (OR 6.17-8.57) > hand joint(OR 3.12) > hip(OR 2.8)
• Gender ; woman > man(2.6:1)
• Genetics ; COL2A1
• Occupation ; repetitive over use
• Sports ; only profession
• Joint diseases(RA , gout , CPPD) , joint injury
• Other ; lack of osteoporosis , muscle weakness ,
acromegaly , proprioceptive defects
Pathology
- Articular cartilage change
- Subchondral bone sclerosis ,
microfracture
- Synovitis ; mild , patchy
- Joint capsule ; thickening ,
stiffness
- Ligaments ; tear
- Muscle ; weak , atrophy
Articular cartilage
Early: swelling, softening

thinning, cleft, fibrillation, superficial erosion

Advance: deep cleft, full thickness erosion


normal
OA

OA
Normal subchondral bone

subchondral bone of OA
Clinical features
• Joint pain /stiffness/loss of function
Early ;
- easy joint pain , more time for recovering
- Joint stiffness, esp. morning or after rest
- May have mild limited ROM
- No systemic inflammation
- PE ; nothing -> mild tenderness
Clinical features
• Joint pain/stiffness/loss of function
- Joint pain ; deep, aching ,
chronic (intermittent -> persistent) , mild to
moderate severity around the joint / joint line
- Use-related pain with improvement on rest
- Joint stiffness ; “ gelling phenomenon”
- Gradual decreased joint function or loss of
ROM
Clinical features
• Joint pain/stiffness/loss of function
Late or advance:
- Persistent pain , some have night pain
- Obvious loss of joint function
- Giving way on walking , locking , instability
- Obvious joint stiffness
- No systemic inflammation
- Morning stiffness < 30 min
Clinical features
• PE
- Tenderness ; mild ; at joint line , within the joint
- Crepitation on motion
- Loss of motion ; from osteophyte , capsular
thickening , synovial hyperplasia
- Bony swelling , may have effusion without
obvious inflammation
- Deformity in late stage ; varus , valgus , snake-like
- Instability , muscle weakness or atrophy
- Early ; negative finding
Investigation
• CBC , ESR , CRP, uric acid , ANA , RF : -ve
finding
• Plain film ; gold std
- Evaluate severity ; minimal to severe finding,
may not correlation with joint pain and
function
- Exclusion other diseases
• MRI /US : for research , doubtful case
Arthocentesis
• Aim ;
- exclusion other diseases ; CPPD ,
gout , hemarthrosis
- relive pressure , decreased pain
- steroid injection
• Synovial fluid ; clear or slightly
turbid , straw color , high viscosity ,
wbc 200-2000 /ml
Knee OA
Varus deformity Valgus deformity
Knee OA
Plain film
• Standing AP vs semiflexion
Kellgren-Lawrence grading scale
Ann Rheum Dis.1957

• 0= no signs of change
• 1= A “doubtful” change in JSN
• 2= minimal change; 1st by osteophytes
• 3= moderate change with multiple
osteophytes and/or def. JSN
• 4= severe change ; severe JSN or loss, bone to
bone contact, and significant osteophytes
- Film both knee standing AP
- Joint space narrowing(unimedial)
- Subchondral bone sclerosis , + cyst
- Marginal osteophyte
2nd knee OA from RA; symmetric joint space narrowing with
minimal osteophyte, minimal subchondral bone sclerosis
DDx knee pain
• OA knee
• Inflammatory arthritis ; RA , CPPD , PsA
• Tendinitis ; torn ligaments, infrapatella
tendinitis , peripatella enthesitis , anserine
bursitis , poppliteal tendinitis , popliteal cyst
• Refer pain from hip disease
55-y-old RA woman with chronic knee pain 2 y,
Rx as OA without improvement
74-y-old woman with chronic knee pain and acute pain on
right knee , right knee effusion and arthrocentesis was done.
58-y-old OA knee woman with progressive joint
space narrowing

2551 2552
65-y-old CPPD woman with episodic knee pain
Patello-femoral joint OA
• Anterior knee pain syndrome
• Usually young adult
• Worse pain on up or down stairs , static flex
knee position
• PE ; aggravating pain when squeeze patella on
femur , + crepitation
Patello-femoral joint wrap-around

Sky view ; OA of patello-femoral joint


Hand OA
• 2nd most common
• Common in woman with peri-menopause(45-
55y) , association with family
• Joint location ; DIP (Heberden’s node),
PIP(Bouchard’s node) , 1st CMC
• S&S ;
- joint pain; dull , non-localized, aching within joint
at rest or activity
- Weakness on finger function
Hand OA
• PE ;
- Bony enlargement on DIP, PIP
- Some with inflammation(acute , episodic ,
chronic)
- Gelatinous cystic on the ant-lat joint side
- Some with deformity
- Limit ROM
• R/O ; PsA , RA , CTS
Gelatinous cyst
Classic OA of DIPs
Chronic DIP joint pain(OA) in late
young adult woman
Hand OA ; mark bony swelling on PIPs
Psoriatic arthritis of left 3rd DIP
Psoriatic arthritis with OA of DIPs and
PIPs
Film both hands AP; OA hands (JSN , subchondral bone sclerosis ,
marginal osteophyte on DIPs and PIPs)
Erosive hand OA
Erosive OA of hand joint ; central erosion , marginal
osteophyte ; seagull’s wing-like
Hand OA
• 1st CMC
- pain and weakness on 1st CMC , esp. on function
- Hx of over-use
- PE; tenderness , squaring knot
- R/O De-Quervain’s tenosynovitis
• OA of MCP joints suggest 2nd OA ( RA , CPPD,
hemochromatosis , hypothyroid)
OA of 1st CMC
Plain film OA of 1st CMC
74-y-old man with chronic hand joint pain , bony swelling on
MCP joints (occupation or hemochromatosis)
Hip OA
• 3rd common in western country
• Uncommon in Thailand and ASIA
• May be 2nd OA from chronic arthritis(SpA),
trauma , AVN
• Manifestation ; groin pain , may have thigh
pain , low back pain , ipsilateral knee joint ,
limitation in walking, bending , up/down stair
Hip OA
• PE ; painful and limitation on internal rotation
, flexion in severe case
• R/O ; lumbar spinal pain , trochanteric bursitis
, meralgia paresthesia(lateral cutaneous nerve
entrapment) , AVN of femoral head , femoral
neck fracture
Hip OA
1st MTP OA
• Common complaint
• Pain on 1st MTP, esp. after
long walking, long standing ,
stand on high heel shoe
• PE ; tenderness, mild
inflammation , bony swelling
, hallux valgus(bunion)
deformity
• DDx ; gout , CPPD , chronic
arthritis(RA , PsA)
1st MTP OA
Acute gout of 1st MTP
X-Ray finding on 1st MTP OA
Punch out lesion from tophi
and OA of 1st MTP
Management
Goals ;
- improved pain and stiffness
- improved joint function
- stop/slow progression
- restoration ?
Management

• Non-pharmacotherapy
• Pharmacotherapy
• Surgery

‘Based on individual patients’


Non pharmacotherapy
1. Education ; natural progression , appropriated work load
, modified activity of daily living
2. Weight loss ; > 5% in 20 weeks
3. Shoes ; fit , comfortable , low heels, boots and shoes
4. Brace , support device , wedge insoles
5. Thermal modality ; cold /hot pack
6. Manual therapy
7. Exercise ; stretching / strengthening / aerobic
- Regular exercises -> less pain, more energy,
improved sleep and improved function
Non pharmacotherapy
6. exercise

Physical Activity for Arthritis.www.CDC.org


Exercise and arthritis by ACR.www.rheuatology.org
AE from hot Rx
Pharmacotherapy
1. Symptomatic treatment;
- acetaminophen ; 1st recommendation
- NSAIDs
- IA steroid(< 4 times/y, good efficacy in joint effusion )
- Topical agent ; NSAIDs , methylsalisylate ,
capsacin , no systemic effect
- Tramadol/codeine
- Antispasmodic
- Tricyclic anti-depressant
Pharmacotherapy
1. Symptomatic treatment
- long acting (SYSADOA);
. IA Hyaluonic acid
. Glucosamine sulfate
. Chondroitin sulfate
. Diacerein
. Platelet rich plasma
. Ginger extracts
. etc
Pharmacotherapy
2. Structure (disease)-modifying agents:
- tetracycline/doxycycline
- glucosamine , chondroitin sulfate
- bisphosphonate
- strontium ranelate

- gene therapy
- osteochondral grafts
- stem cell transplantation
Surgical management
• Indication: failed
conservative treatment
• Consist of
- Osteotomy
- Joint replacement
- Arthroscopic debridement
and/or larvage?
Ann Rheum Dis2018
Balneotherapy
Balneotherapyand
andmassage
massage

Thermotherapy
Conclusion
• OA is a common disease, cause of economic
burden , leading cause of disability ,esp. elderly
• Slowly progressive joint disease
• Common joint ; knee , hand joint(DIP , PIP) , 1st
MTP, hip? , spine
• Manifestation ; chronic joint pain/stiffness and
loss of function , pain relates with activity , less
pain with rest , no systemic symptom
• PE ; normal to total disability , crepitation on
motion with bony enlargement is common and
significantly finding
Conclusion
• Investigation ; only plain film
• Management ;
- non-pharmacology (modified activity ,
appropriated works , exercise , weight loss ,
support or splint , walking aids , thermal modality
, manual-Rx)
- Pharmacology ; acetaminophen , topical agents ,
oral NSAIDs , IA steroid , tramadol ,
antidepressant , no role of systemic steroid
- Controversy ; glucosamine , chondroitin ,
diacerine , hyaluronate , bisphosphonate
THANK YOU