OsteoarthritisOsteoarthritis

Pradeep Fernando MS, FRCSPradeep Fernando MS, FRCS

DescriptionDescription ClassificationClassification AetiologyAetiology Clinical featuresClinical features Radiological featuresRadiological features Treatment Treatment

OsteoarthritisOsteoarthritis degenerative disorder degenerative disorder

of synovial joints of synovial joints characterized by focal characterized by focal loss of articular loss of articular cartilage with cartilage with reactive changes in reactive changes in subchondral and subchondral and marginal bone, marginal bone, synovium and para-synovium and para-articular structures.articular structures.

OsteoarthritisOsteoarthritis degenerative joint diseasedegenerative joint disease hypertrophic arthritishypertrophic arthritis osteoarthrosis.osteoarthrosis.

The most common chronic joint The most common chronic joint condition in the elderlycondition in the elderly

ClassificationClassification PrimaryPrimary – no discernible underlying – no discernible underlying

causecause

SecondarySecondary – preceded by a – preceded by a predisposing disorderpredisposing disorder

ClassificationClassification LocalizedLocalized

GeneralizedGeneralized if three or more extra-spinal if three or more extra-spinal joints are affectedjoints are affected Nodal (Kellgren Moore type)Nodal (Kellgren Moore type)

more in females, familial tendency, Heberden’s (at more in females, familial tendency, Heberden’s (at DIP) and Bouchard’s (at PIP) nodesDIP) and Bouchard’s (at PIP) nodes

Non-nodalNon-nodal slightly more in males, some familial tendencyslightly more in males, some familial tendency

Heberden’s and Bouchard’s Heberden’s and Bouchard’s nodesnodes

Primary, generalized, nodal OA

Inflammatory diseasesInflammatory diseases Rheumatoid arthritis, infectionRheumatoid arthritis, infection

Physical factorsPhysical factors Trauma, obesity, neuropathic Trauma, obesity, neuropathic joint conditions, hyperlaxity joint conditions, hyperlaxity syndromes, AVN, CDH, syndromes, AVN, CDH, Acetabular dysplasia, Perthes’, Acetabular dysplasia, Perthes’, SUFE, deformitySUFE, deformity

Endocrine diseasesEndocrine diseases Diabetes mellitusDiabetes mellitus, acromegaly , acromegaly Hemochromatosis, Hemochromatosis, hyperparathyroidism, Wilson's hyperparathyroidism, Wilson's disease, ochronosis, disease, ochronosis,

Metabolic diseasesMetabolic diseases crystalline (urate, calcium crystalline (urate, calcium pyrophosphate, hydroxyapatite) pyrophosphate, hydroxyapatite) arthropathy, Paget's disease, arthropathy, Paget's disease, amyloidosis amyloidosis

Nutritional factorsNutritional factors Kashin-Bek diseaseKashin-Bek disease

Aetiology

Obesity and OAObesity and OA 3-6 times the excess wt. is transmitted 3-6 times the excess wt. is transmitted

across the kneeacross the knee 4x risk in women 4x risk in women Wt. loss - Wt. loss - ↓risk and ↓pain↓risk and ↓pain

Also Also ↑ in hand OA↑ in hand OA

Clinical featuresClinical features

Pain on exertion Pain on exertion → night pain→ night pain Limitation of movementLimitation of movement Swelling – thickening, effusion, Swelling – thickening, effusion,

osteophytesosteophytes InstabilityInstability CrepitusCrepitus DeformityDeformity

OA- the problemsOA- the problems

painpain deformitydeformity instabilityinstability

Varus knee in OA

Valgus knee in OA on RA

OA -deformityOA -deformity

OA -deformity

RadiologyRadiology

The main radiographic features of OA, The main radiographic features of OA, including three which represent destruction including three which represent destruction and one which represents attempted repair, and one which represents attempted repair, are:are:

·         Joint space narrowing (destruction) ·         Joint space narrowing (destruction) ·         Subchondral sclerosis (destruction)·         Subchondral sclerosis (destruction) ·         Subchondral cyst formation ·         Subchondral cyst formation

(destruction)(destruction) ·         Osteophytosis (attempted repair)·         Osteophytosis (attempted repair) Weight bearing or stress radiographic views Weight bearing or stress radiographic views

better delineate joint space narrowing, better delineate joint space narrowing, sclerosis, cysts, and osteophytes.sclerosis, cysts, and osteophytes.

OA - RadiographyOA - Radiography

Joint space Joint space reduction reduction

sub-chondral sub-chondral sclerosis (Gr sclerosis (Gr IV)IV)

OsteophytesOsteophytes

OA - RadiographyOA - Radiography

varus valgus

OA - RadiographyOA - Radiography

OA - RadiographyOA - Radiography

RA with protrusioRA with protrusio

ManagementManagement Non-medical – Reduce weight, Toilet Non-medical – Reduce weight, Toilet

modification, use of an aidmodification, use of an aid

Drugs – simple analgesics, NSAIDS, Drugs – simple analgesics, NSAIDS, COX-2 inhibitorsCOX-2 inhibitors

Glucosamine, chondroitinGlucosamine, chondroitin

Management SurgicalManagement Surgical Osteotomy – change wt bearing areaOsteotomy – change wt bearing area

Arthroscopic washoutArthroscopic washout

ArthrodesisArthrodesis

Arthroplasty – limited life span. costArthroplasty – limited life span. cost

EpidemiologyEpidemiologyThe Walrus and the CarpenterThe Walrus and the CarpenterWere walking close at hand;Were walking close at hand;They wept like anything to They wept like anything to

seeseeSuch quantities of sand:Such quantities of sand:"If this were only cleared "If this were only cleared

away,"away,"They said, "it would be They said, "it would be

grand!"grand!"

By 2020 around 20% will be >60 yrs By 2020 around 20% will be >60 yrs (20% of 20,000,000 = 4,000,000) (20% of 20,000,000 = 4,000,000)

Prevalence rates for OA in this group Prevalence rates for OA in this group are in the region of 30% (are in the region of 30% (Framingham, Framingham, NHANES etc) NHANES etc)

In the US 652,000 primary joint In the US 652,000 primary joint replacements were done in 2003 for a replacements were done in 2003 for a population of 295,000,000population of 295,000,000

For a population of 20,000,000 this For a population of 20,000,000 this would be 42,000 (approx)would be 42,000 (approx)

Currently we do around 300 p.a Currently we do around 300 p.a We would have to do 140 times what We would have to do 140 times what

we are doing nowwe are doing now

The answer does not lie in The answer does not lie in joint replacementjoint replacement

"If seven maids with seven mopsSwept it for half a year.Do you suppose," the Walrus said,"That they could get it clear?""I doubt it," said the Carpenter,And shed a bitter tear.