OSTEOARTHRITIS

REBECCA OJABO
600 LEVEL MEDICAL STUDENT
AFE BABALOLA UNIVERSITY
OUTLINE
• INTRODUCTION ● CLINICAL FEATURES

• DEFINITION ● OSTEOARTHRITIS OF COMMON

JOINTS
• RELEVANT ANATOMY
● INVESTIGATIONS
• CLASSIFICATION

• EPIDEMIOLOGY ● TREATMENT

• RISK FACTORS ● PROGNOSIS

• PATHOGENESIS ● CONCLUSION
INTRODUCTION
● Osteoarthritis is the most common type of joint disease.

● Affects more than 30 million individuals in the US.

● Leading cause of chronic disability in older adults.

● It can be thought of as a degenerative disorder with inflammatory components

arising from the biochemical breakdown of articular (hyaline) cartilage in the
synovial joint.

● Current studies show it affects the whole joint organ and not just the articular
cartilage
● Predominantly affects weight-bearing joints including the knees, hips, cervical
& lumbosacral spine and feet.

● Other commonly affected joints include;

○ DIP

○ PIP

○ CMC

● It represents a heterogeneous group of conditions with common radiological

and histopathological changes.

● Once diagnosed, it is progressive.

DEFINITION
● Osteoarthritis is defined as a chronic disorder of synovial joints in which there
is a progressive softening and disintegration of articular cartilage and bone at
the joint margins (osteophytes), cyst formation and subchondral sclerosis,
mild synovitis and capsule fibrosis.
RELEVANT ANATOMY
CLASSIFICATION
● Primary Osteoarthritis

● Secondary Osteoarthritis
Primary Osteoarthritis
● Idiopathic

● Mainly affects the distal interphalangeal, first carpometacarpal, hips, knees,

and apophyseal joints of the spine.

● Women are more affected than men

● There may be a hereditary component.

● But the aetiology is unknown.

Secondary Osteoarthritis
● Affects previously damaged joints and is more common in weight-bearing joints.

● Both sexes are equally affected.

● Local causes are:

○ Fractures

○ Acquired or congenital deformities

○ Joint injury (chondral lesions)

○ Diabetic neuropathy (Charcot joints)

○ Avascular necrosis.
EPIDEMIOLOGY
● The most common articular disease worldwide.

● 80 - 90% of adults older than 65 years are affected by the disease.

● Incidence is higher in women.

● More prevalent in Native Americans.

● More common in whites than in blacks.

RISK FACTORS
● Aging ● Crystal deposition

● Obesity ● Acromegaly

● Trauma ● Previous inflammatory arthritis

● Genetics ● Metabolic causes

● Reduced sex hormone level ● Haemoglobinopathies

● Muscle weakness ● Neuropathic disorders

● Repetitive use ● Previous Surgery

● Infection ● Diabetes mellitus

PATHOGENESIS
● Matrix metalloproteinases and proinflammatory cytokines (interleukin-1 [IL–1])
appear to be important mediators of cartilage destruction in patients with
primary OA.

● IL-1 increases the synthesis of matrix metalloproteinases and, hence, plays

an important role in OA.

● During the initial stages of OA, fibrillation and cracking of the superficial layers
of the articular cartilage occurs.

● As the degeneration continues, deep layers become involved finally resulting

in erosions that produce bare subchondral bone.
● Denatured type II collagen is found in abundance in OA articular cartilage; it is
characterized by a decrease in the water content and in the ratio of
chondroitin-sulfate to keratan-sulfate constituents.
PATHOGENESIS
AETIOPATHOGENESIS

STAGE FEATURES

STAGE 1 Proteolytic breakdown of the cartilage matrix.

Fibrillation and erosion of the cartilage surface develop, with

STAGE 2 subsequent release of proteoglycan and collagen fragments into the
synovial fluid.

Breakdown products of cartilage induce a chronic inflammatory

STAGE 3 response in the synovium, which in turn contributes to further cartilage
breakdown.
CLINICAL PRESENTATION
● Asymptomatic ● Mal-alignment with bony enlargement

● Asymmetric ● Crepitus

● Stiffness ● Bland effusion

● Gelling ● Muscle atrophy

● Antalgic gait ● Locked joint

● Pain ● Herbeden nodes

● Reduced range of movement

OSTEOARTHRITIS OF
COMMON JOINTS
GLENOHUMERAL JOINT
Diagnosis is made from the history, PE and radiographic findings.
OSTEOARTHRITIS OF THE GLENOHUMERAL JOINT

● Either primary or, more commonly, secondary.

● Secondary arthritis is commonly post-traumatic.

● Or could be as a result of end-stage rotator cuff disease.

ELBOW
Elbow Joint Anatomy
OSTEOARTHRITIS OF THE ELBOW
● Primary osteoarthritis of the elbow is increasing in frequency.

● Most cases of arthritis are secondary to previous trauma, osteo-chondritis

dissecans or congenital problems.

● Common in patient’s 40- to 60-year-old (male)

● Heavy manual occupation.

● Pain is the primary problem (along with locking).

● In addition, ulnar nerve symptoms may present.

WRIST
Wrist Anatomy
OSTEOARTHRITIS OF THE WRIST
● Although not as common as OA of weight bearing joints. It is not uncommonly
encountered by orthopedic surgeons on a day - to - day basis.

● The radiocarpal joint can develop primary or secondary osteoarthritis.

● Following an intra-articular trauma and infection.

● Non-operative management begins with conservative measures.

● Operative management, following failed conservative treatment.

● Results in both severe pain and restriction of movement.

Wrist Radiograph in OA Patient
HAND
Joints of the Hand
OSTEOARTHRITIS OF THE HAND
● Commonly affected are the distal interphalangeal (Heberden’s nodes),
proximal interphalangeal (Bouchard’s) and the thumb carpometacarpal joints.

● Symptoms rarely correlate with radiographic appearances.

● Inflammatory changes are typically present, less pronounced or usually go

unnoticed.

● Herbeden nodes are more characteristics in women.

OSTEOARTHRITIS OF THE HAND
Diagnostic Criteria

● Hand aching and stiffness plus at least three of the following

1. Hard tissue enlargement of 2 or more of 10 selected joints; 2 nd and 3rd DIP, 2nd and 3rd PIP &
the first CMC joint of both hands.

2. Hard enlargement of two or more DIP

3. Fewer than three swollen MCP joint

4. Deformity of at least 1 of the 10 selected joints.

HIP JOINT
Anatomy of the Hip Joint
OSTEOARTHRITIS OF THE HIP
● The most consistent symptom is pain in the groin followed by limitation of movement.

● Groin pain occurs secondary to irritation of the obturator nerve, which crosses the hip
joint.

● The pain may also radiate down to the knee joint and in some cases, the only
presenting feature may be a painful knee.

● Most patient’s finding difficult putting on a sock or getting in or out of a car.

● Clinical examination may reveal gluteal muscle wasting and an effusion with crepitus
anteriorly.

● There may also be a limp with a positive Trendelenburg’s sign.

Clinical Criteria
● The presence of hip pain plus at least 2 of the following 3.

1. ESR < 20mm/hour

2. Radiographic osteophytes

3. Joint space narrowing on radiography

Radiographic Features OA of Hip - AP View
● Severe superior migration of the femoral
head.

● Subchondral sclerosis.

● Prominent osteophytes.

● Large Egger cyst in the superior

acetabulum.

● Mild flattening of the superior aspect of the

femoral head
KNEE JOINT
Knee Joint Anatomy
OSTEOARTHRITIS OF THE KNEE
● The knee is one of the most common joints to be affected by osteoarthritis
and the incidence is higher in women than in men.

● Secondary osteoarthritis in the knee may occur because of a previous

fracture, a neuropathic joint, osteonecrosis or a previous menisectomy.

● Primary osteoarthritis of the knee, as in the hip, is idiopathic.

Clinical Criteria
● The presence of knee pain plus at least 3 of the following 6

1. > 50 years of age

2. Morning stiffness of less than 30 minutes

3. Crepitus on active motion of the knee

4. Bony tenderness

5. No palpable warmth
OSTEOARTHRITIS OF THE SPINE
● Most common at spinal levels C5, T8 & L3.

● Two syndromes of clinical importance occur due to OA of the spine.

○ Cervical spondylosis

○ Lumbar spondylosis
INVESTIGATIONS
● OA is a clinical and radiological diagnosis. ● Uric Acid Levels

● Plain Radiograph AP/L View ● Arthroscopy

● Radionuclide Bone Scan ● Ultrasonography

● Computed Tomography Scan ● Potential Markers

● Magnetic Resonance Imaging ○ Cartilage Oligomeric Protein (COMP)

● Synovial Fluid Analysis ○ Pyridinoline & Bone Sialoprotein

○ Metalloproteinases
● Inflammatory Markers
○ Hylauronan
● Immunologic Tests (ANA & RF)
X-RAY SHOWING OA OF HIP
RADIOLOGICAL FEATURES
● Mnemonic LOSS

○ L- Loss of joint space

○ O- Osteophytes

○ S- Subchondral cyst

○ S- Subchondral sclerosis
JOINT ARTHROSCOPY
MANAGEMENT
● Aim

○ Reduce pain

○ Prevent deformity

○ Improve function

○ Improve quality of life

MANAGEMENT
● Non-surgical

● Non-pharmacological

● Pharmacological

● Surgical
NON-PHARMACOLOGIC MANAGEMENT
● Patient education ● Physiotherapy

● Encourage joint rest.

● Walking aid

● Excercise
● Supportive bracing
● Diet control

● Acupuncture

● Thermotherapy
● Transcutaneous Electrical Nerve
Stimulation

● Muscle training
Hip Bracing
Bracing
PHARMACOLOGICAL MANAGEMENT
● Analgesic agents

● Intra-articular injections
PHARMACOLOGICAL MANAGEMENT FOR HAND & WRIST OA

(ACR) conditionally recommends using one or more of the following:

● Topical capsaicin

● Topical nonsteroidal anti-inflammatory drugs (NSAIDs)

● Oral NSAIDs

● Tramadol
PHARMACOTHERAPY FOR KNEE OA
The ACR conditionally recommends using one of the following:

● Acetaminophen

● Oral NSAIDs

● Topical NSAIDs

● Tramadol

● Intra-articular corticosteroid injections

PHARMACOTHERAPY FOR HIP OA
The ACR conditionally recommends using 1 or more of the following for initial
management:

● Acetaminophen

● Oral NSAIDs

● Tramadol

● Intra-articular corticosteroid injections

SURGICAL MANAGEMENT
● Arthroscopic debridement

● Osteotomy

● Excision arthroplasties

● Arthrodesis

● Total joint replacement

Joint Replacement
Right ankle arthrodesis and left ankle arthroplasty performed sequentially in a patient
with bilateral ankle osteoarthritis.
DIFFERENTIAL DIAGNOSES
● Rheumatoid arthritis ● Neuropathic arthropathy

● Spondyloarthropathy ● Lyme disease

● Crystalline arthropathies ● Psoriatic arthritis

● Septic arthritis

● Fibromyalgia

● Tendonitis

● Avascular necrosis
PROGNOSIS
● Depends on the joints involved and on the severity of the condition.

● No proven disease modifying drugs are currently known.

● Some associated risk factors are associated with severe progression of the
disease.

● Patients with OA who have undergone joint replacement have a good

prognosis.
CONCLUSION
● OA is one of the most common joint diseases in the world.

● It can occur in any synovial joint, the commonest sites being the knees, hips
and small joints of the hand.

● Current treatments available are only temporary.

● As a general rule, nonoperative measures should be tried before surgery is

considered.

● Management is multidisciplinary.
REFERENCES
● N.S. William, C.J.K Bulstrode, P.R. O’Connell. 2013. Bailey & Love’s Short
Practice of Surgery. 26th Edition.

● G. McLatchie, N. Borley, J. Chikwe. 2013. Oxford Handbook of Clinical

Surgery. 4th Edition.

● Ian B. Wilkinson, T. Raine, et al. 2017. Oxford Handbook of Clinical Medicine.

10th Edition.

● Osteoarthritis. Medscape. Available

at http://www.emedicine.medscape.com/html. Accessed 11th June, 2020.
THANKS FOR LISTENING