Josep Vidal AlaballHCE

OSTEOARTHRITISOSTEOARTHRITIS

• Commonest condition to affect synovial joints

• Single most important cause of locomotor disability

• Previously considered a degenerative disease, inevitable consequence of ageing and trauma

• Now viewed as a metabolically dynamic, essentially reparative process.

• Is a condition of synovial joints with focal cartilage loss and accompanying reparative bones response.

• In most cases this slow but metabolically active process keeps pace with various triggering insults and is non-progressive.

• But sometimes it fails to compensate, resulting in joint failure.

• Various extrinsic and intrinsic insults cause different patterns of arthritis, and multiple constitutional and environmental factors modify response and outcome.

• Osteoarthritis targets specific joints, possibly those that have undergone recent evolutionary change in function (relating to bipedal locomotion and precision grip) without yet adapting adequately.

ASSESSMENTASSESSMENT

• For many plain radiographplain radiograph remains the best means of assessment:– Evidence of cartilage loss (joint space

narrowing)– Bone response (osteophytes and sclerosis)

• There is often considerable discordance between structural change and clinical outcome

RISK FACTORSRISK FACTORS

1. AGE– NOT and inevitable consequence of ageing, BUT

strongly related to age– Uncommon in people under 45– Prevalence increases up to age 65, when al least

50% of people have RX evidence of OA in at least one joint group

– May represent cumulative insult to the joint, possibly aggravated by decline in neuromuscular function

2. SEX– Pronounced FEMALE preponderance in– hands and knee

3. ETHNIC GROUP– Uncommon in Black and Asian populations– This seems to reflect genetic rather than

cultural differences

4. INDIVIDUAL RISK FACTORS– Generalised factors

• Obesity

• Genetic factors

• Female

– Localised factors E.g.:• Meniscectomy

• Instability

• Dysplasia

TYPES OF OATYPES OF OA

1. NODAL GENERALISED OA

• Characterised by multiple Heberden´s nodes (distal interphalangeal joint) and Bouchard´s nodes (interphalangeal joint)

• Symptoms usually starting around menopause

• Aetiology unknown

2. CRISTAL ASSOCIATED OA

• Calcium crystals, notably calcium pyrophospate dyhidrate and apatite, may deposit in cartilage.

• Predominantly in elderly women, affecting the knee

3. OA OF PREMATURE ONSET• Development of single joint OA after severe

trauma is not uncommon• Premature onset in multiple joints may be a

presenting feature of other conditions:– Haemochromatosis

– Ochronosis

– Acromegaly

– Thiemann’s disease

– Hereditary type II collagen defects

– Endemic OA

CLINICAL FEATURESCLINICAL FEATURES

• PAIN– Typically sharp pain on using the joint or dull

ache which may occur at rest or during the night– Greatly influenced by personality, anxiety,

depression and daily activity

• GELLING OF JOINTS– Stiffness after immobility, morning stiffness

lasting no more than 30 min.

• FUNCTIONAL IMPAIRMENT

• CREPITUS

• BONY ENLARGEMENT

• DEFORMITY

• INSTABILITY

• SYNOVITIS

• MUSCLE WEAKNESS OR WASTING

THERAPEUTIC OPTIONSTHERAPEUTIC OPTIONS• Non-pharmacological treatment

– Education (patient and spouse or family)

– Social support (telephone contact)

– Physiotherapy (aerobic exercises, muscle strengthening, and patellar strapping)

– Occupational therapy (aids and appliances, joint protection)

– Weight loss

– Acupuncture

– Transcutaneous electrical nerve stimulation (TENS)

• Pharmacological treatment– Simple analgesia

– Non-steroidal anti-inflammatory drugs

– COX-2 inhibitors (cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drugs)

– Topical (NSAID drugs, capsaicin)

– Chondroprotective agents

• Intra-articular treatment– Corticosteroids

– Hyaluronans

– Tidal irrigation

PATIENT EDUCATIONPATIENT EDUCATION

• Trials contrasting education vs. effects of NSAIDs confirmed a significant beneficial effect on education in joint pain but not on disability.

• Any member of the care team can provide education in several forms: literature, audiocassette, computer…

• Emphasise weight reduction and exercise

OCCUPATIONAL THERAPYOCCUPATIONAL THERAPY

• In OA of the knee controlled studies have shown that regular telephone contact from healthcare produces significant improvement in pain and function

SOCIAL SUPPORTSOCIAL SUPPORT

• Walking aids, orthoses, splints

PHYSICAL THERAPYPHYSICAL THERAPY

• Muscle strengthening programmes– Specific for certain joints– Shown to improve pain and disability in OA of

the knee

• TENS (transcutaneous electrical nerve stimulation)

– Modest pain relief compared with placebo

• Acupuncture

Changes in lifestyle for patients with OA

• General measures – Maintain optimal weight

– Encourage activity and regular general exercise

– Maintain positive approach

• Specific measures – Strengthening of local muscles

– Use of appropriate footwear and walking aids

– Pay attention to specific problems caused by disability (such as shopping, housework, and job)

ANALGESICS, NSAIDs, COX-2 iANALGESICS, NSAIDs, COX-2 i

• PARACETAMOL– It is safe and effective– Slight benefit from addition of

dextropropoxyphene

• NSAIDs– More effective than placebo in reducing pain

and improving function– Few studies have lasted longer than 2 years– No evidence they affect progression of OA

– Evidence that MISOPROSTOL and PPI reduce risk of upper GI injury

– Cost utility of prophylactic use is controversial– Recommended to initiate NSAIDs only after

consideration of side effects– Prescription should be reviewed every 6 months

• COX-2 INHIBITORS– Published data remains scarce– Trials have shown similar efficacy to NSAIDs

with GI toxicity comparable with placebo– Cost effective strategy for their use far from clear

Relative contraindications to starting treatment with NSAIDs * Gastrointestinal toxicity. Caution in:

- Those aged >65 years- Patients with a history of peptic ulcer disease- Concomitant treatment with corticosteroids and anticoagulants- Smokers- Patients with cardiovascular disease- Heavy alcohol drinkers

* Renal toxicity. Caution in:- Those aged >65 years- Patients with hypertension- Patients with congestive cardiac failure- Concomitant medication with ACE inhibitors and diuretics

TOPICAL TREATMENTTOPICAL TREATMENT

• NSAIDs and CAPSAICIN– Strong evidence that they are effective and safe– Fewer side effects probably should be used

more often– However substantial doubt as their superiority

over simple rubefacients

INTRA-ARTICULAR THERAPYINTRA-ARTICULAR THERAPY

• CORTICOSTEROIDS– Use controversial in uncomplicated OA– Superior short term efficacy to intra-articular

placebo– Benefits last 2 to 4 weeks– Indicated in patients with acute crystal associated

synovitis and those unfit for or awaiting surgery– Potential for multiple injections to accelerate

cartilage damage

• HYALURONIC ACID– In people with OA there is a reduced

concentration of this acid– Trials suggest superior pain relief to placebo and

equivalent to corticosteroids injections with greater duration of action

• TIDAL IRRIGATION– Irrigation of knee joint with saline– Trials suggest some role in treatment of knee OA

CHONDROPROTECTIVE AGENTSCHONDROPROTECTIVE AGENTS

• Clinical trials provide some justification for the use of CHONDROITIN and GLUCOSAMINE preparations but only for their analgesic or anti-inflammatory effects

SURGERYSURGERY

• JOINT REPLACEMENTS

• ARTHROSCOPIC LAVAGE

• OSTEOTOMY

• ARTHRODESIS

THE ENDTHE END