Arthritis

OSTEOATHRITIS
 Osteoarthritis
◆ Osteoarthritis is an idiopathic disease
◆ Characterized by degeneration of
articular cartilage
◆ Leads to fibrillation, fissures, gross
ulceration and finally disappearance
of the full thickness of articular
cartilage
 Risk Factors
◆ Age
◆ Female versus male sex
◆ Obesity
◆ Lack of osteoporosis
◆ Occupation
◆ Sports activities
◆ Previous injury
◆ Muscle weakness
◆ Proprioceptive deficits
◆ Genetic elements
◆ Acromegaly
◆ Calcium crystal deposition disease
 Pathologic lesions
◆ Primary lesion appears to occur in
cartilage
◆ Leads to inflammation in synovium
◆ Changes in subchondral bone,
ligaments, capsule, synovial
membrane and periarticular muscles
 Osteoarthritis
Etiology & Pathophysiology
 Idiopathic Osteoarthritis
◆ Localized or generalized forms
◆ Localized OA most commonly affects
the hands, feet, knee, hip, and spine
◆ Other joints less commonly involved
– shoulder, temporomandibular, sacroiliac,
ankle, and wrist joints
◆ Generalized OA
– three or more joint sites
 Patterns of Presentation
◆ Monoarticular in young adult
◆ Pauciarticular, large-joint in middle
age
◆ Polyarticular generalized
◆ Rapidly progressive
◆ Secondary to trauma, congenital
abnormality, or systemic disease
 Secondary Osteoarthritis
◆ Trauma
◆ Congenital or developmental disorders
◆ Calcium pyrophosphate dihydrate
deposition disease (CPPD)
◆ Other bone and joint disorder
– osteonecrosis, rheumatoid arthritis, gouty
arthritis, septic arthritis, and Paget disease of
bone
◆ Other diseases
– diabetes mellitus, acromegaly, hypothyroidism,
neuropathic (Charcot) arthropathy, and
frostbite
 Clinical Features
◆ Age of Onset > 40 years
◆ Commonly Affected Joints
– Cervical and lumbar spine
– First carpometacarpal
joint
– Proximal interphalangeal
joint
– Distal interphalangeal
joint
– Hip
– Knee
– Subtalar joint
– First metarsophalangeal
joint
 Uncommonly Affected Joints
◆ Shoulder
◆ Wrist
◆ Elbow
◆ Metacarpophalangeal joint
◆ TMJ
◆ SI
◆ Ankle
 Clinical Diagnosis
◆ Symptoms
– Pain
– Stiffness
– Gelling

◆ Physical examination
– Crepitus
– Bony enlargement
– Decreased range of motion
– Malalignment
– Tenderness to palpation

◆ The more features, the more likely the diagnosis

 Synovial fluid analysis
◆ Severe, acute joint pain is an
uncommon manifestation of OA

◆ Clear fluidWBC <2000/mm3

◆ Normal viscosity
 Osteoarthritis
Diagnostic Studies
Bone Scan
CT
MRI
General x-ray

Radiologic changes do not correlate

with the degree of disease
 Radiographic Features
◆ Joint space narrowing
◆ Subchondral sclerosis
◆ Marginal osteophytes
◆ Subchondral cyst
 Joint Space Narrowing
◆ OA typically asymmetrical

Paget’s disease
 Subchondral Sclerosis
◆ Increased bone density or thickening
in the subchondral layer
 Osteophytes
◆ Bone spurs
 Subchondral Cysts
◆ Fluid-filled sacs in subchondral bone
 OA of the Knee: Classic Criteria
1. Greater than 50 years of age
2. Morning stiffness for less than 30 minutes
3. Crepitus on active motion of the knee
4. Bony tenderness
5. Bony enlargement
6. No palpable warmth

◆ 3 of 6 criteria give sensitivity of 95% and

specificity of 69%
 OA of the Knee: Addition of X-rays
◆ ACR Criteria of:
1. knee pain
2. radiographic evidence of osteophytes
3. one of three additional findings:
◆ age greater than 50 years of age
◆ morning stiffness of less than 30 minutes
◆ crepitus

– Sensitivity and specificity for OA of 91

and 86%
 Hand Osteoarthritis
◆ Diagnosis by hand pain
◆ Plus at least three of the following four features:
1. Hard tissue enlargement of 2 or more of 10
selected joints.
◆ The 10 selected joints are the second and
third distal interphalangeal (DIP) joints, the
second and third proximal interphalangeal
(PIP) joints, and the first carpometacarpal
(CMC) of both hands
2. Hard enlargement of two or more DIP joints
3. Fewer than three swollen
metacarpophalangeal (MCP) joints
4. Deformity of at least 1 of the 10 selected
joints

◆ Sensitivity and Specificity for hand OA of 94 and

87%
 Hip Osteoarthritis Diagnosis
◆ Use history, physical, laboratory, and
radiographic features (ACR)
◆ Hip Pain, plus at least two of the
following three features:
1. ESR of less than 20 mm/h
2. Radiographic osteophytes
3. Joint space narrowing on radiography
◆ Sensitivity of 89 percent and a
specificity of 91 percent
 Osteoarthritis
Treatment Goals

No cure

Focus:

Managing pain
Preventing disability
Maintaining and improving joint
function
 Osteoarthritis
Treatment Goals
Rest and Joint Protection
Balance of rest and activity
Assistive devices
Heat and Cold Applications
Hot packs, whirlpools, ultrasound, paraffin wax
baths, pool therapy
Nutritional Therapy & Exercise
Weight reduction – Goal: decrease load on the
joints & increase joint mobilization
 Osteoarthritis - Tx Goals
Drug Therapy
Tylenol – up to 1000 mg q6h
Aspirin
Nonsteroidal anti-inflammatory drugs
Motrin (OTC) 200 mg qid++
Traditional NSAID – decrease platelet aggregation –
prolong bleeding time
Newer generation – Cox inhibitors (cyclooxygenase)
e.g., Celebrex
Intraarticular injections—knees; shoulder
Intraforamenal-intervertebral Injections – vertebral
Corticosteroids – decrease local inflammation & effusion
Hyaluronic Acid – increased production of synovial fluid –
Hyalgan, Synvisc
 Osteoarthritis
Treatment Goals
Surgical Treatment

Joint Replacement

Hip, Knee, Shoulder

Spinal Surgery –

Diskectomy /spinal fusion

 Arthroscopic Interventions
◆ Controversial
◆ Arthroscopic debridement with
lavage
◆ Sham-surgery versus arthroscopic
lavage/debridement study
◆ Remove loose pieces of bone and
cartilage
◆ Resurface (smooth out) bones
 Prosthetic Joints
◆ Commonly of the hip or knee or
shoulder
◆ Several types: metal, plastic,
ceramic
◆ Last 10-15 years or more
◆ About 10% need to be redone
◆ Usually a treatment of “last resort”
 Joint Replacement
◆ Surgical candidate?
◆ Often greater improvement in pain
rather than function
◆ Recovery can be strenuous and
lengthy
◆ Infection rate 1%
◆ Low mortality 0.6% to 0.7%
◆ Complications include
thrombo-embolic events 5%
RHEUMATOID ATHRITIS
Rheumatoid Arthritis
 Osteoarthritis
Rheumatoid Arthritis
 Rheumatoid Arthritis
Anatomic 4 Stages
Stage 1 – Early
No destructive changes on x-ray; possible osteoporosis
Stage II – Moderate
X-ray osteoporosis; no joint deformities; possible
presence f extraarticuloar soft tissue lesions
Stage III – Severe
X-ray evidence of cartilage and bone destruction in
addition to osteoporosis; joint deformity—subluxation,
ulnar deviation, hyperextension, bony ankylosis; muscle
atrophy, soft tissue lesions
Stage IV – Terminal
Fibrous or bony ankylosis; criteria of Stage III
 Rheumatoid Arthritis
Clinical Manifestations
Insidious – fatigue, anorexia, weight loss,
generalized stiffness
Joints
Stiffness becomes localized—pain, edema,
limited motion, inflammation, joints warm to
touch, fingers—spindle shaped
“Morning Stiffness” – 60+ mins to several hours
depending on disease progression
 Rheumatoid Arthritis
Clinical Manifestations
Extraarticular Manifestations
Sjorgren Syndrome – decreased lacrimal
secretion—burning, gritty, itchy eyes with
decreased tearing and photosensitivity
Valvular lesions/pericarditis
Interstitial fibrosis / pleuritis
Lymphadenopathy
Raynaud’s Phenomenon
Peripheral neuropathy & edema
Myositis
 Rheumatoid Arthritis
Clinical Manifestations
 Rheumatoid Arthritis
Diagnostic Studies
Lab Studies
Rheumatoid Factor – 80% of patients
ESR
C-Reactive Protein
WBC up to 25,000/ul

Synovial biopsy – inflammation

Bone Scan
 Rheumatoid Arthritis
Treatment Goals
Drug Therapy
NSAIDs
Disease-modifying antirheumatic drugs
(DMARDS) - Anti-inflammatory action
Mild Disease – Plaquenil (antimalarial drug)
Moderate – Severe Disease -- Methotrexate
Severe Disease - Gold Therapy (weekly injections x
5 months)
Corticosteroid Therapy
Nutrition – balanced diet
 Rheumatoid Arthritis

Rest alternating with activity as

tolerated -- Energy conservation
Joint protection
Time-saving joint protective devices
Heat / Cold Therapy – relieve stiffness,
pain, and muscle spasm
Exercise –individualized –Aquatic Therapy
Psychological Therapy – individual &
family support system