Osteoarthritis 2021 Updated Guidelines

Osteoarthritis is a chronic degenerative disorder of synovial joints in which there is progressive softening and erosion/disintegration of the articular cartilage. In the presentation, I will deal in detail about the condition in every dimension with the most recent evidence.

1. OSTEOARTHRITIS Presented by: Dr. Aryan (Anish Dhakal)

2. Components of Synovial Joint Articular cartilage Subchondral bone Synovial membrane Synovial fluid Joint capsule Synovial Joint

3. Joint Stability

4. It is the most common joint disease It is a chronic degenerative disorder of synovial joints in which there is progressive softening and erosion/disintegration of articular cartilage a frequent, if not inevitable, part of aging Osteoarthritis

5. Prevalence More prevalent in high income countries comparatively 25% with osteoarthritis have multiple joints involvement Prevalence 1%  < 30 years of age 0ver 50%  >60 years of age 80% over 80 years of age have radiographic evidence

6. Risk Factors for Osteoarthritis Age (strongest predictor) Gender (females are more prone) Genetics (no single gene implicated) Joint injury (post traumatic OA) Anatomic factors (joint shape and alignment) Obesity (weight bearing joints) Lifestyle (occupational, higher paced physical activity) Smoking, muscle weakness, physical activity, bone density, etc.

7. Pathophysiology of Osteoarthritis formerly considered to be simply a degenerative "wear and tear" process and therefore often misnamed as degenerative joint disease (an absolute misnomer) P athogenesis of OA is much more complex "- itis" is indicative of an inflammatory process is actually correct D estruction and loss of the articular cartilage is a central component of OA, all joint tissues are affected in some way

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10. Pathophysiology

11. Morphology At early OA, water content of matrix increases and concentration of proteoglycans decreases Proteoglycan content of the cartilage matrix provides turgor and elasticity Vertical and horizontal fibrillation and cracking of the matrix Eventually chondocyte die and full thickness of cartilage are sloughed.

12. Pathology

13. Eburnated articular surface S ubchondral cyst Residual articular cartilage

14. Osteoarthritic Changes

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16. Primary Osteoarthritis more common occurs in joint de novo occurs in old age mainly in weight bearing joints (knee, hip) Secondary Osteoarthritis there is underlying primary disease of joint occurs in any age after adolescence occurs mainly in the hip Classification

17. Localized OA (Monoarticular or Pauciarticular) Classic form of OA Pain & dysfunction of one or more large weight bearing joints Nodal OA, Hip OA, Knee OA Generalized OA (Polyarticular) Most common form of OA Erosive OA (Rapidly Destructive OA) Rapid progression of bone destruction occurs Occurs in elderly women Associated with deposition of calcium pyrophosphate crystals Clinical Variants of Osteoarthritis

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19. Signs and Symptoms P rimary symptoms of osteoarthritis (OA) are joint pain, stiffness, and locomotor restriction On clinical grounds: Persistent usage-related joint pain in one or few joints Age ≥ 45 years Morning stiffness ≤ 15 minutes I maging and laboratory investigations are reserved for patients presenting with atypical symptoms and signs

20. Usually a middle aged women who presents with pain, swelling & stiffness of the finger joints The following joints are affected at almost same time: 1 st carpometacarpal joint Big toe Meta- tarsophalangeal Knee joints Lumbar facet joints Generalized Osteoarthritis

21. Progressive Vs Non-progressive

22. Heberden’s & Bouchard’s nodes (Osteophytes)

23. Clinical Findings

24. 29 Thumb-base OA: prominence and "squaring" of the thumb base: Osteophyte formation and subluxation at the first CMC joint

25. 30 Erosive hand  OA: marked radial deviation and fixed flexion deformity in the left middle PIP joint, radial deviation with restriction in the index PIP joint, and bony swelling

26. 31 Unilateral knee OA: swollen left knee with varus and fixed flexion deformity history of knee trauma. On palpation, there was marked crepitus, restricted flexion, bony swelling, and a small effusion.

27. 32 R ight hip OA with painful restriction with internal rotation in flexion . “Tight-pack " position for the hip (when the capsule is at its tightest) and is the first movement to be affected .

28. 33 Patient with right hip OA, showing fixed flexion and external rotation deformity

29. Investigations Serum Uric acid and RF to rule out specific disorders . Radionuclide scanning with 99M Tc-HDP: increased activity over subchondral regions: increased vascularity and new bone formation

30. X-ray Findings

31. 38 Complete loss of the articular cartilage at all four DIP joints, large osteophytes, and ankylosis of the DIP joint of the middle finger

32. Differential Diagnosis Rheumatoid arthritis (symmetric, atrophic rather than hypertrophic arthritis) Psoriatic arthritis (may be in one finger as dactylitis, and characteristic nail changes are usually present ) Avascular necrosis ( articular cartilage loss precedes bone destruction in OA ) Crystalline arthritis ( urate or CPP crystals in synovial fluid, tophi on imaging in gout) Hemochromatosis (targets the MCP joints and wrists, predominates in men, squared-off bone ends and hook-like osteophytes in the MCP joints) Infectious arthritis : RA, Ankylosing spondylitis, Reiter disease ( inflammatory signs effusion, increased warmth, erythema), culturing the pathogen from the synovial fluid or from the blood Diffuse Idiopathic Skeletal Hyperostosis (bony spurs in pelvic apophyses and vertebral column, usually asymptomatic) Soft tissue abnormalities (bursitis, tendinitis, enthesitis , etc.)

33. Depends on: Joint involved Age of patient Patient’s functional needs Management of Osteoarthritis

34. Pain (5 items ) Stiffness (2 items ) Physical Function (17 items) None (0), Mild (1), Moderate (2), Severe (3), and Extreme (4) 0-20 for Pain, 0-8 for Stiffness, and 0-68 for Physical Function Activities of daily living, functional mobility, gait, general health, quality of life

35. Symptoms characteristically wax and wane , and pain may subside spontaneously for long periods Some forms of OA actually become less painful with the passage of time and the patient may need no more than reassurance and a prescription for pain killers At the other extreme, the recognition (from serial x-rays) that the patient has a rapidly progressive type of OA may warrant an early move to reconstructive surgery before bone loss compromises the outcome of any operation Management of Osteoarthritis

36. Symptomatic treatment T ailored to the patient according to individual needs, goals, and values and should be patient-centered , stall progress Patient preferences for certain types of therapies should also be assessed . Compliance must be assessed. Principles : maintain movement and muscle strength protect the joint from ‘overload’ relieve pain modify daily activities (quality of life) Management of Osteoarthritis

37. Counseling (patient education) Physical Therapy (massage, aerobic and muscle strengthening exercises , local heat application) Load Reduction weight reduction in obese patients wearing shock-absorbing shoes avoiding activities like climbing stairs, standing and running or sitting cross legged and squatting in knee osteoarthritis braces and foot orthoses Non Pharmacological Therapy

38. Pharmacological Therapy Most Recent Evidence Topical NSAIDs Initial treatment one or few joints affected, especially knee and/or hand OA Topical  capsaicin Use may be limited by common local side effects Oral NSAIDs Inadequate symptom relief with topical NSAIDs , patients with symptomatic OA in multiple joints, and/or patients with hip OA ( lowest dose, shortest duration )  Duloxetine Contraindicated oral NSAIDs and for patients with knee OA who have not responded satisfactorily to other interventions Intraarticular glucocorticoid Short duration of its effects (i.e. approximately four weeks ). Not recommended for regular use. Opioids Strong analgesics. P otential side effects (e.g., nausea, dizziness, drowsiness), especially for long-term use and in the older adult population 46

39. Other Therapies (Uncertain Benefits) Nutritional supplements such as glucosamine, chondroitin, vitamin D, diacerein, avocado soybean unsaponifiables (ASU), and fish oil Curcumin (active ingredient of turmeric) and/or  Boswellia serrata might be beneficial,  but the data are limited Insoles and footwear Hyaluronans viscosupplementation weekly injection Platelet-rich plasma (PRP) Transcutaneous electrical nerve stimulation ( TENS) Acupuncture Local heat

40. Progressive joint destruction, with increasing pain, instability and deformity usually requires reconstructive surgery Realignment osteotomy (joint with deformities like high tibial osteotomy for OA knee). Major part of articular cartilage is still preserved. Dramatic pain relief. Vascular decompression of subchondral bone Redistribution of load towards less damaged part of the joint Operative Modalities

41. Debridement synovectomy , excision of osteophytes, removal of loose bodies, chondroplasty, and removal of damaged menisci painful and often requires 6 months of postoperative rehabilitation Arthroscopic treatments of osteoarthritis of the knee include simple lavage, debridement , and abrasion chondroplasty ( less postoperative pain and shorter rehabilitation ) Success rate about 70%, placebo effect is also evident Arthroscopic debridement procedures cannot alter the natural progression of osteoarthritis

42. Arthroscopic view of the removal of cartilaginous loose body

43. 54 Dervin et al.: 126 arthroscopic debridement procedures done for OA knee 44 % of patients had significant pain relief at 2 years after surgery Three variables were significantly associated with improvements in symptoms : medial joint line tenderness positive Steinmann test (forced external and internal rotation of a knee flexed to 90 degrees and pain that is referable to either joint line ) an unstable meniscal tear identified at arthroscopy

44. Operative Modalities Arthrodesis , still a reasonable choice if the stiffness is acceptable and neighboring joints are not compromised (small joints that are prone to OA, e.g. the carpal and tarsal joints and the large toe metatarsophalangeal joint)

45. Operative Modalities Total joint arthroplasty (replacement) is reserved for patients with severe symptomatic OA who have failed to respond to non pharmacologic and pharmacologic management ( intolerable symptoms, marked loss of function and severe restriction of daily activities ) Alternatives to total knee arthroplasty for selected patients with knee OA include unicompartmental knee arthroplasty and knee osteotomy Alternatives to total hip arthroplasty for selected patients with hip OA include hemiarthroplasty, hip osteotomy, and perhaps, for a very specific group, hip resurfacing

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49. Capsular Herniation (Baker’s cyst) Loose bodies (cartilage and bone fragments: intermittent locking) Rotator cuff dysfunction (OA of AC joint: impingement, tendinitis and cuff tears) Spinal stenosis (lumbar apophyseal joints OA) Spondylolisthesis (degenerative spondylolisthesis at L4/L5) Complications of Osteoarthritis

50. Natural History and Prognosis G reat variability among individuals and among different phenotypes Courses of pain and physical functioning have been found to be predominantly stable No single biochemical or imaging markers to predict progressive course Predominantly characterized by minimum/slow rather than marked worsening over time Certain poor prognostic factors have been identified which include higher pain intensity at baseline, presence of depressive symptoms, presence of bilateral knee symptoms

51. References Solomon L, Warwick D, Nayagam S. Apley’s system of orthopedics and fractures, 9 th edition Leticia Alle Deveza et al., Overview of the management of osteoarthritis, https:// www.uptodate.com/contents/overview-of-the-management-of-osteoarthritis Michael Doherty et al., Clinical manifestations and diagnosis of osteoarthritis, https :// www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-osteoarthritis Leticia Alle Deveza et al ., Management of knee osteoarthritis, https:// www.uptodate.com/contents/management-of-knee-osteoarthritis Lyn March, AM et al., Epidemiology and risk factors for osteoarthritis, https:// www.uptodate.com/contents/epidemiology-and-risk-factors-for-osteoarthritis Lisa A Mandl et al., Overview of surgical therapy of knee and hip osteoarthritis, https:// www.uptodate.com/contents/overview-of-surgical-therapy-of-knee-and-hip-osteoarthritis Karine Louati et al., Comorbidities that impact management of osteoarthritis, https:// www.uptodate.com/contents/comorbidities-that-impact-management-of-osteoarthritis Campbells Operative Orthopedics, 14 th edition Maheshwari J, Essential Orthopedics, 6 th Edition Review of Orthopedics, Mark D. Miller, 8 th Edition

52. Thank you