Osteoarthritis

Osteoarthritis

1. Osteoarthritis Dr Siti Salihah House Officer Hospital Selayang

2. D efinition Osteoarthritis (OA) is a type of joint disease that results from breakdown of joint cartilage and underlying bone. Which may lead to Joint pain Joint swelling Decrease range of motion Weakness and numbness of arms and legs.

3. Statistics In the Global Burden of Disease 2010 study , it was estimated that 251 million people suffered from knee OA worldwide. Musculoskeletal disease which include OA was the second greatest cause of disability as measured by years lived with disablity .

4. Demographics Occurs in ♀ > ♂ Incidence rates increase with age Racial disparities exist in the treatment of osteoarthritis African American males are the least likely to receive total joint replacement when compared to whites and Hispanics

5. Anatomy A joint is where the ends of two or more bones meet. The knee joint, for example, is formed between the bones of the lower leg (the tibia and the fibula) and the thighbone (the femur). The hip joint is where the top of the thighbone (femoral head) meets a concave portion of the pelvis (the acetabulum ). Articular cartilage is the smooth, white tissue that covers the ends of bones where they come together to form joints. Healthy cartilage in our joints makes it easier to move. It allows the bones to glide over each other with very little friction. Articular cartilage can be damaged by injury or normal wear and tear.

6. Synovial fluid is a viscous, non-Newtonian fluid found in the cavities of synovial joints. The fluid contains hyaluronan secreted by fibroblast-like cells in the synovial membrane, lubricin (proteoglycan 4; PRG4) secreted by the surface chondrocytess of the articular cartilagee and interstitial fluid filtered from the blood plasma. [ T he principal role of synovial fluid is to reduce friction between the articular cartilage of synovial joints during movement.

7. Causes Primary Secondary

8. Primary OA: It occurs in old age, mainly in the weight bearing joints (knee and hip). Can also occur over the trapezio - metacarpal joint of the thumb and distal interphalangeal joints of the fingers.

9. Secondary OA: In this type there is an underlying primary disease of the joint which leads to degeneration of the joint, often occurs many years later. It may occur at any age after adolescence, and occurs commonly at the hip. It is less common than primary OA.

10. Risk Factors Modifiable Non-modifiable

11. Modifiable Obesity Trauma Occupation, hard labor Muscle weakness Metabolic syndrome – central ( abdominal) obesity, dyslipidemia ( high triglycerides and low-dens lipoproteins), high blood pressure , and elevated fasting glucose levels.

12. Non-modifiable Gendre – Females at increased risk Age Genetics Race – some Asian populations at lower risk.

13. Pathophysiology In a healthy joint, the ends of bones are encased in smooth cartilage. Together, they are protected by a joint capsule lined with a synovial membrane that produces synovial fluid. The capsule and fluid protect the cartilage, muscles, and connective tissues.

14. Healthy joint

15. With osteoarthritis , there is decrease in proteoglycan ( lubricin ) content within cartilage. The breakdown of collagen fibers results in a net increase in water content resulting in increase of synovial fluid .

16. Without the protective effects of the proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and thus exacerbate the degeneration . Inflammation of the synovium and the surrounding joint capsule can also occur . New bone outgrowths, called "spurs" or osteophytes , can form on the margins of the joints . The subchondral bone volume increases resulting in reduced joint space.

17. Differential diagnosis Osteoporosis Rheumatoid arthritis Septic arthritis ACL/ PCL avulsion Osgood – Schlatter disease Fracture Prepatellar bursitis

18. Formulating diagnosis History taking Age, sex Pain ( onsent , duration, character ) Hx of fall / trauma Taking any medication prior to this. Hx of numbness/ lock knee/ weakness Social hx ( work, lifestyle) Risk factors ( underlying diseases)

19. Physical Examination ( Look, feel , move) Look: Bone deformity, length discrepancy, muscle wasting, swelling, valgus / varus , instability, gait Feel: Warmth of skin, swelling, tenderness upon palpation, fluid shift. Move: Check the range of motion, crepitus, stifness

20. Clinical features Mostly occurs in elderly Mostly in major joints of the lower limb ( hip or knee) Frequently bilaterally. Pain is the earliest symptoms It become intermittent initially and become constant over months and years. Worsening during physical activites Swelling of the joint is a late sign, due to inflammation.

21. Physical examination Tenderness at the joint line Crepitus on moving the joint Irregular and enlarged looking joint due to formation of peripheral osteophytes Deformity – Varus and valgus of the knee Effusion – rare Terminal limitation of the joint movement Subluxation detected on ligament testing Wasting of quadriceps femoris muscle .

22. Radiographic changes Kellgren and Lawrence classification

23. Investigation Diagnosis of OA is mainly clinical. Blood investigations and synovial fluid analysis are seldom required except to exclude other diagnosis such as septic, inflammatory and crystal arthropathy . There are no specific laboratory investigations for diagnosis of OA. Inflammatory markers such as (ESR , CRP) are likely to be normal or only mildly elevated. Synovial fluid analysis is also essentially normal in OA.

24. Treatment 3 goals of osteoarthritis treatment: to control pain To delay the progression of the disease to restore/ improve joint function

25. Treatment approaches 1. Drugs 2. Chondroprotective agents 3. Viscusupplements 4. Supportive therapy 5. Surgical treatment

26. Medications/ pain relievers Oral Treatment Oral treatment consists of:- i. Simple analgesics - paracetamol ii. Weak opioid analgesics - tramadol iii. NSAID – Sodium diclofenac , Arcoxia iV . Cyclo-oxygenase-2 Inhibitors – Celexocib Topical analgesics: i. Deep heat rub ii. Ketoprofen patch

27. Chondroprotective agents Glucosamine Chondroitin sulphate

28. Intra-articular corticosteroid injections Provides temporary pain relief. Generic names: Betamethasone, methylprednisolone, triminolone . Steroids are similar to natural substances produced by the body hormones that help reduce inflammation. If inflammations is not a symptom of your osteoarthritis, steroids are less likely to be helpful. Steroids may be used to reduce inflammation in tendons and ligaments in osteoarthritic joints .

29. Non-drug pain relief and alternative therapies. Transcutaneous electrical nerve stimulation (TENS): TENS is a technique that uses a small electronic device to direct mild electric pulses to nerve endings that lie beneath the skin in the painful area. TENS may relieve some arthritis pain. It seems to work by blocking pain messages to the brain and by modifying pain perception.

30. Supportive therapy Weight reduction Avoidance of stress and strain to the affected joint in a day-to-day activities. Local heat – provides relief of pain and stiffness Exercises for building up the muscles controlling the joint help in providing joint stability

31. Walking aids

32. Surgical treatment Hand Joint fusion Joint replacement Knee : Osteotomy – High tibial osteotomy Total knee replacement Arthroscopic debridement Hip : Osteotomy – Intertrochanteric osteotomy Hip resurfacing Total hip replacement.

33. Osteotomy Tibial osteotomy was first performed in Europe in the late 1950s and brought to the United States in the 1960s. This procedure is sometimes called a "high tibial osteotomy."  It literally means "cutting of the bone." In a knee osteotomy, either the tibia (shinbone) or femur (thighbone) is cut and then reshaped to relieve pressure on the knee joint.

34. Advantages and Disadvantages Knee osteotomy has three goals: To transfer weight from the arthritic part of the knee to a healthier area To correct poor knee alignment To prolong the life span of the knee joint It may delay the need for a joint replacement for several years The recovery is typically more difficult than a partial knee replacement because of pain and not being able to put weight on the leg.

35. A: A normal knee joint B: Osteophyte formation that has formed at one side of the knee causing malalignment A B

36. Procedure Most osteotomies for knee arthritis are done on the tibia (shinbone) to correct a bowlegged alignment that is putting too much stress on the inside of the knee . During this procedure, a wedge of bone is removed from the outside of the tibia, under the healthy side of the knee. When the surgeon closes the wedge, it straightens the leg

37. Total knee replacement Prepare the bone.  The damaged cartilage surfaces at the ends of the femur and tibia are removed along with a small amount of underlying bone . Position the metal implants .  The removed cartilage and bone is replaced with metal components that recreate the surface of the joint. These metal parts may be cemented or "press-fit" into the bone . Insert a spacer.  A medical-grade plastic spacer is inserted between the metal components to create a smooth gliding surface. A knee replacement (also called knee arthroplasty ) might be more accurately termed a knee " resurfacing“ because only the surface of the bones are actually replaced

38. Types of implant There are more than 150 knee replacement models Mimic the ‘hinge’ concept Components ( tibial , femur and patella) Material : Titanium alloy, Cobalt-chromium , Tantalum Cemented or cementless . Designs: 1) Posterior stabilized design 2) Cruciate retaining design 3) Unicompartment implants

39. Rehabilitation Day of surgery Deep breathing exercises Active ankle ROM Postop day 1 Lower-limb isometrics including quadriceps, hamstrings, and gluteral sets Wearing a knee immobilizer until the development of active knee enstension and demonstration of good leg control during ambulation Weight-bearing after TKA may be partial or full, depending on the surgeon’s discretion

40. Postop day 2 Standing at the bedside with knee immobilizer and partial weight-bearing on the operated limb Active assisted ROM                       Postop day 4 Progressive isotonic and isometric knee and hip muscle strengthening Concentrate on terminal knee extension through active knee extension exercises

41. Refferences Netter’s Concise orthopaedic anatomy. Apleys ’ system of orthopaedics and fractures. www.orthoinfo.org www.orthobullets.com www. uptodate.com

42. Thank you