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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
Heberdens nodes
Bouchards 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

Movement abnormalities
Clinical
features
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 (Heberdens
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
Bony spur only
Classification
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
NSAIDs/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 patients 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 |
27th 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 |
27th July, 2010

Bone Homeostasis:
the situation when the body
requires and achieves an
equal amount of bone
resorption and bone
formation

Homeostasis

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 |
27th July, 2010

The combined processes of breaking down bone


and building new bone are called Bone
Remodeling.

It is the bodys way of maintaining bone


homeostasis.

5 Stages:
Initiation,
Resorption,
Reversal,
Bone formation and
Completion of remodeling.
Osteoporosis: Challenges to meet| BICC |
27th 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 |


27th 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 |


27th 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 |


27th 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 |


27th 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 |


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Osteoporosis: Challenges to meet| BICC |


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Challenges of Osteoporosis
Osteoporosis: Challenges to meet| BICC |
27th 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 30s).
Osteoporosis: Challenges to meet| BICC |
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Osteoporosis: Challenges to meet| BICC |


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Losing bone with years

Osteoporosis, the silent thief of your bone


Osteoporosis: Challenges to meet| BICC |
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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 |


27th 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 |


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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 |

27th 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
Osteoporosis: Challenges to meet| BICC |
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posture.
th

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 |


27th 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 |


27th 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

Severe Osteoporosis

-2.5 or less
and fragility fracture

Osteoporosis: Challenges to meet| BICC |


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FRACTURE ,
The most serious complication of
Osteoporosis that leads to
Increased morbidity
Increased mortality
Decreased quality of life

Osteoporosis: Challenges to meet| BICC |


27th 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 |


27th July, 2010

Decreased fracture risk


Life style modification

Therapeutic
Intervention

Minimizing risk
factors

Slowing/stopping
bone loss

Minimizing factors
that
Contribute to fall

Maintaining or
increasing bone
density and strength
Maintaining or
improving bone
microarchitecture

Osteoporosis: Challenges to meet| BICC |


27th 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 |


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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 |


27th July, 2010

Ass Wr Wb