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									Osteoarthritis


        In the name of God

       • Tehran University
       •Amiralam hospital
          •Salehi I. M.D.
         •Rheumatologist

                             I. Salehi
Osteoarthritis




                 I. Salehi
Osteoarthritis


       Introduction :
    • Previous thought : Aging
    • Previous name : DJD
    • Now : Complex interplay of :
        –   Joint integrity
        –   Genetic predisposition
        –   Local inflammation
        –   Mechanical forces
        –   Cellular & Biochemical processes

                                          I. Salehi
Osteoarthritis


        Introduction :
    • The best name : Osteoarthritis
    • Definition : Cartilage Failure
    • Classification:
       –   Primary = Idiopathic
       –   Secondary
       –   Localized
       –   Generalized


                                   I. Salehi
Osteoarthritis

       Epidemiolog :
    • Age of onset :Usually > 40
    • Common joints :
       –   DIP, PIP, CMC1
       –   Spine : C5 , T8 , L3
       –   Knee
       –   Hip
       –   MTP1
    • Uncommon joints :
       – MCPs,Wrist,Elbow,Shoulder,Ankle
                                      I. Salehi
Osteoarthritis

     Clinical Features:
    • History :
       – Mechanical pain
       – Morning stiffness
       – Gelling pain
    • Physical exam.:
       –   Crepitus
       –   Tenderness
       –   Bony enlargement
       –   Decreased ROM
       –   Malalignment
                              I. Salehi
‍ steoarthritis Pathology
O


        Cartilage :
     • Early stage :
         –   Increased type 1 collagen
         –   Increased nonaggrecan proteoglycan
         –   Increased water
         –   Thickening
         –   Increased safranin O staining
     • Late stage :
         –   Decreased proteoglycan
         –   Fissuring
         –   Thining & softening
         –   Decreased safranin O staining
                                              I. Salehi
‍ steoarthritis Pathology
O


       Bone & Synovium :
     • Bone :
         – Osteophyte formation
         – Subchondral bone sclerosis
         – Subchondral bone cyst
     • Synovium :
         – Synovitis

                                    I. Salehi
Osteoarthritis

       P
       ‍ araclinics :
    • Biochemistry : NL
    • Synovial fluid :
        –   Clear
        –   200 <WBC< 2000
        –   PMN< 25%
        –   Viscosity: NL
    • X-Ray findings :
        –   Joint space narrowing
        –   Subchondral sclerosis
        –   Marginal osteophytes
        –   Subchondral bone cysts   I. Salehi
Osteoarthritis Knee


         Epidemiology :
    • World: Third OA ,Iran: First OA
    • F/M ratio: World= 2 /1, Iran= 10 /1
    • Age: usually > 40
    • 60% of Knee problems
    • Black / White ratio= 2 /1
    • > 1 /2 of old people

                                     I. Salehi
Osteoarthritis Knee


         Predisposing factors

       • Aging

       • Sex : F >> M

       • Obesity

       • Trauma

                                I. Salehi
Osteoarthritis Knee


           Stability :
      •   ACL & PCL
      •   Menisci
      •   LCL & MCL
      •   Capsule
      •   Quadriceps muscle
      •   Iliotibial band
      •   Morphology of bones

                                I. Salehi
Osteoarthritis Knee


         Biomechanic :
     •   Q angle
     •   Quadriceps mechanism
     •   Rolling & Sliding
     •   Lever function
         – Walking: 4 -5 x BW
         – Squatting: 10 X BW
     • Obesity
     • Malalignment
                                I. Salehi
Osteoarthritis Knee


        Clinical patterns :

    • Unilateral Knee OA : young M.

    • Bilateral Knee OA : middle Age F.

    • Bil. Knee OA + Nodal OA: m. A. F.

    • Bil. Knee OA within GOA : Old F.


                                      I. Salehi
Osteoarthritis Knee


          History :
     • Mechanical pain
     • Gelling pain
     • Morning stiffness < 30 min
     • Locking
     • Give way
     • PMH of swelling

                                    I. Salehi
Osteoarthritis Knee

           Physical exam. :
       •   May be NL
       •   Tender points
       •   Crepitus
       •   Shrug & Rabot
       •   Swelling:
           – Effusion
           – Bony enlargement
       • Limitation of motion
                                I. Salehi
Osteoarthritis Knee

          Physical exam. :
     •   Movie goer sign
     •   Stiff knee gait
     •   Disuse atrophy
     •   Laxity
     •   Baker cyst : Foucher‟s sign
     •   Malalignment(G. Varus)
     •   Concurrent Bursitis
     •   Referred pain
         – Hip
         – Cruralgia
                                       I. Salehi
Osteoarthritis Knee

               Radiography:
        AP standing, Lat., axial, Interchondilar




                                                   I. Salehi
Osteoarthritis Knee


                Radiography




                              I. Salehi
Osteoarthritis Knee


                Radiography




                              I. Salehi
Osteoarthritis Knee

                Radiography




                              I. Salehi
Osteoarthritis Knee


        Diagnostic criteria
    • All of :
       –   Mechanical knee pain
       –   Morning stiffnes < 30
       –   Crepitus
       –   Age > 40
    • All Of :
       – Mechanical knee pain +
       – Osteophyte in X-Ray

                                   I. Salehi
Chondromalacia Patella


         Introduction :

    • The most common cause of Anterior
      knee pain in age <40
    • Background pathology :
       – Softening of patellar cartilage
       – Disorganized cartilage

    • Overuse & loading => pain


                                           I. Salehi
Chondromalacia Patella


     Clinical features :
      •   Young female
      •   Anterior knee pain
      •   Grab sign
      •   Theatre sign
      •   Noisy knee
      •   Shrug sign
      •   Rabot sign

                               I. Salehi
Osteoarthritis Hand


         Nodal OA :
    •   One of the most common OA
    •   DIP OA : Heberden‟s nodes
    •   PIP OA : Bouchard‟s nodes
    •   H. nodes > B. nodes
    •   F / M ratio = 10 / 1
    •   Hereditary, Familial
    •   Age: most often > 45

                                    I. Salehi
Osteoarthritis Hand

                  Nodal OA :
       • Mechanical hand pain

       • Gelatinous cysts

       • Cobra head configuration

       • Snake like configuration


                                    I. Salehi
Osteoarthritis Hand

                      Nodal OA :




                                   I. Salehi
Osteoarthritis Hand


   Diagnostic criteria of hand OA

    • Hand pain plus at least 3 of :
       – Hard enlargement of> 2 of 10 joints

       – Hard enlargement of > 2 of DIPs

       – < 3 swollen MCPs

       – Deformity of > 1 of 10 joints

    Selected joints:DIP2 ,3 &PIP2 ,3 &CMC1
                                           I. Salehi
Osteoarthritis Hand


               Rhizarthrosis :
    • The second most common OA
    • CMC1 OA
    • Thumb Base OA
    • Menopausal female
    • CMC1 Pain & tenderness
    • Crepitus & LOM

                                  I. Salehi
Osteoarthritis Hand

               Rhizarthrosis :
            • Squaring, Shelf sign
            • Swan-neck deformity &
            • Z deformity of thumb




                                      I. Salehi
Osteoarthritis Erosive


                 Erosive OA :
    • DIP & PIP :
        – most prominently affected
    •   Synovitis:
        – more extensive than other OA
    •   Very destructive
    •   Severe deformities
    •   Bony ankylosis
    •   DD. with RA

                                         I. Salehi
Osteoarthritis Hip


               Introduction :
     • Malum coxae senilis
     • Morbus Coxae senilis
     • Idiopathic OA : 20%
        – Old male
        – Bilateral
     • Secondary OA: 80%
        – Acetabular dysplasia
        – Legg-Cave-Perthes D.
        – Slipped epiphysis
                                 I. Salehi
Osteoarthritis Hip


        Clinical features :
      • Pain
          –   Groin
          –   Outer aspect of hip
          –   Inner aspect of thigh
          –   Buttock
          –   Knee
      • Antalgic gait : Limping
      • Trendelenburg sign

                                      I. Salehi
Osteoarthritis Hip


        Clinical features :
      • Gelling phenomena
      • Limitation of motion: Loss of
          – Internal rotation(I.R.)
          – Extension,…
      • Flexed hip with E.R.
          – Functional shortening
          – Shuffling gait
          – Lumbar lordosis & LBP
      • Difficult sitting
                                        I. Salehi
Osteoarthritis Hip

       Radiologic findings :
     • Osteophytes:
        – Acetabular
        – Capital
        – Femur neck
     • Joint space narrowing
     • Subchondral sclerosis
     • Subchondral bone cysts
     • Deformity


                                I. Salehi
Osteoarthritis Hip


   Radiographic patterns :
    • Superolateral :
       – 60% , M > F

    • Medial pole :
       – 25% , F > M

    • Concentric :
       – 15% , F > M

                             I. Salehi
Osteoarthritis Hip


        Diagnostic criteria :
       • Hip pain plus > 2 of
           – ESR < 20 mm/h

           – Osteophyte in X-Ray

           – Joint space narrowing


                                     I. Salehi
Osteoarthritis Hip

              Classification tree




                                    I. Salehi
Osteoarthritis Spine


              Introduction :
    • Very common
    • Common sites: C5, T8, L3-4
    • Neck :Disk, Apophyseal, Luscka
    • Lumbar :Disk, Apophyseal
    • Disk degeneration: Spondylosis
    • Apophyseal Deg.:true Spinal OA?

                                   I. Salehi
Osteoarthritis Spine

              Cervical OA :
    • Neck Pain
    • Cervicobrachial neuralgia
    • Limitation of motion &Torticollis
    • Spinal canal stenosis
    • Spinal cord compression
    • Vertebro-Basilar A. insufficiency
    • Dysphagia , Hoarseness
                                    I. Salehi
Osteoarthritis Spine

     Back & Low Back OA :
     • Back pain & LBP
     • Radicular pain
     • Limitation of motion
     • Spinal canal stenosis
     • No spinal cord compression
     • Spondylolisthesis
     • Cauda equina synd. : rare
     • DD with DISH & SpA
                                    I. Salehi
Osteoarthritis Feet

                      Feet OA :
       • MTP1 :
          – Hallux limitus & rigidus
              • Tender dorsal bump
              • Crepitus & LOM
              • Blockage in extension
          – Hallux Valgus + Bunion
       • Subtalar OA
       • Talonavicular OA
       • All of them=>troublesome walking
                                        I. Salehi
Osteoarthritis Elbow

           Elbow OA :
     •   Uncommon to rare
     •   Secondary OA
     •   Male : Often
     •   Trauma & Occupation
     •   Resting & nocturnal pain
     •   Flexion contracture
     •   Ulnar entrapment
     •   Secondary osteochondromatosis
                                   I. Salehi
Osteoarthritis Others

                   Other OA :
    • MCP OA: Rare,Secondary,MCP2,3
    • Wrist OA: Rare,Secondary
    • Glenohumeral OA: Rare,Secondary
    • Acromioclavicular OA: Rare,Second.
    • Sternoclavicular OA:
      – Slightly common
      – F / M ratio > 1
      – Hard swelling +Tenderness
                                      I. Salehi
Osteoarthritis Others

                   Other OA :
     • Manubriosternal OA :
        – Rare
        – tender point
        – Chest Pain
     • Temporomandibular (TMJ) OA : Rare
     • Ankle OA : Rare, secondary
     • Tarsometatarsal OA:
        – Lisfranc‟s OA


                                     I. Salehi
Osteoarthritis GOA

        Generalized OA :
       • Kellgren-Moore disease

       • > 3 of the joints :
          – Hand, Feet, Knee, HIP, Spine,
            others

       • DIP & PIP: common
       • ESR rising, RF-
                                      I. Salehi
Osteoarthritis Secondary


          Secondary OA
     •   Trauma
     •   Congenital
     •   Metabolic
     •   Endocrine
     •   „CPPD‟ disease
     •   Neuropathy
     •   Inflammatory
     •   Endemic
                           I. Salehi
Osteoarthritis


            Pathophysiology :
      • Cartilage (Chondrocyte) failure
         induced by a complex interplay of :
          – Genetic
          – Metabolic
          – Biochemical
          – Inflammatory
          – Biomechanical
          – factors
          –
          –              Synthesis < degradation
                                             I. Salehi
Osteoarthritis


            Pathophysiology :
      • Osteoarthritic Chondrocyte
          exhibit increased levels of:
          – Proliferative

          – Synthetic

          – Degradative


          – activity

                                     I. Salehi
‍ steoarthritis Pathophysiology
O

           Initial point :
    • Where?
       – Cartilage
       – Subchondral bone
       – Synovium
    • What?
       –   Overload & overuse
       –   Aging phenomena in chondrocyte
       –   Mutation in gene of collagen II
       –   Mutation in gene of proteoglycan
       –   Mutation in gene of MMPs
       –   Overexpression of mRNA of MMPs
       –   Overexpression of cytokines receptors
       –   Synovitis & oversecretion of IL-1 &TNF-a
       –   Subchondral bone sclerosis
                                                I. Salehi
‍ steoarthritis Pathophysiology
O


           Scenario of OA :
       • In a “Genetic background”
          – Abnormal biomechanic &
          – Abnormal biochemistry &
          – Inflammatory elements
             ==> Chondrocyte failure
             ==> Cartilage failure



                                       I. Salehi
‍ steoarthritis Pathophysiology
O


     Genetic background :
    • Mutation in gene of procollagen II
      :COL2A1
    • Mutation in gene of proteoglycan
    • Mutation in gene of MMPs
    • Overexpression of mRNA of MMPs
    • Overexpression of cytokines
      receptors


                                           I. Salehi
‍ steoarthritis Pathophysiology
O


    Abnormal biomechanic :
    • Cartilage overload =>Chondrocyte :
       – Increased NO
       – Increased MMPs
       – Increased apoptosis
    • Bone overload => Osteoblast :
       – Phenotype changing(very active)
       – Increased TGF-B & IGF-1



                                           I. Salehi
‍ steoarthritis Pathophysiology
O
    Relationship between loading
    & macromolecule production:
        Mechanotransduction




                                  I. Salehi
‍ steoarthritis Pathophysiology
O

    Abnormal biochemistry :
    • Increased MMPs activators &
    • Decreased TIMP         ==>
       – MMP overactivity
       –
    • iNOS(inducible Nitric oxide synthase)
      ==>Nitric oxide overproduction :
       – Synovial vasodilatation
       – Apoptosis of chondrocyte
       – MMP activation
       – Cytokines oversecretion
                                         I. Salehi
Osteoarthritis
                 MMPs




                        I. Salehi
‍ steoarthritis Pathophysiology
O

    Inflammatory process :
    • Cartilage particle (Ag) ==>
    • Synovioblast type A :
       – IL-1
       – TNF-a
       – INF-g      ==>
    • Chondrocyte cytokine receptors(CR)
       –   Increased MMP activator
       –   Increased synthesis of MMP
       –   Overexpression of CR.
       –   Synthesis of : IL-1, TNF-a, INF-g
       –   iNOS activation
       –   Chondrocyte blocking
       –   Chondrocyte apoptosis
                                               I. Salehi
Osteoarthritis




                 I. Salehi
Osteoarthritis




                 I. Salehi
Osteoarthritis




                 I. Salehi
Osteoarthritis


        Causes of pain in OA :
    •   Synovitis
    •   Stretching of capsule
    •   Raised pressure in subch. Bone
    •   Ligament insertion strain
    •   Tendon insertion
    •   Muscle pain
    •   Elevation of periosteum

                                    I. Salehi
Osteoarthritis Treatment

           Flare up of OA :
       • Rest
       • NSAIDs
       • Corticosteroids :
         – Oral
         – IM
         – IA       & if refractory
       • Arthroscopic irrigation
       • Colchicine
                                      I. Salehi
Osteoarthritis Treatment

                     Pain :
     •   Health recommendation
     •   Acetaminophen+ codeine
     •   Capsaicin
     •   Roll on: Democaine
     •   NSAIDs
     •   Duoflex CMO+
     •   Duoflex HPR
     •   Opioids ?

                                  I. Salehi
Osteoarthritis Treatment


           IA Hyaloronan :
       • Synvisc(Hylan G-F 20)

          – This agent has recently
            been approved by the FDA
            for the treatment of knee
            pain due to osteoarthritis


                                         I. Salehi
Osteoarthritis Treatment


            NO inhibition :
       • Vit. A, C, D, E

       • TCA

       • SSRI


                              I. Salehi
Osteoarthritis Treatment

          MMP inhibition :
      • Tetra. Doxy.Minocyclin
         – inhibit Collagenase
         – inhibit Gellatinase
         – inhibit Elastase
      • Arteparon :
         – inhibit Collagenase
      • Rumalon :
         – increase TIMP
      • Cartrofen :
         – inhibit Elastase
                                 I. Salehi
Osteoarthritis Treatment

                 DMOADs :
       • Antimalaric
       • MTX
       • Minocyclin
       • TCA & SSRI
       • Piascledine
       • Glucosamine
       • ….
                            I. Salehi
Osteoarthritis Treatment

     Surgical intervention :
      • Arthroscopic irrigation
      • Arthroscopic ablasion
      • Osteotomy
      • Chondrocyte grafts
      • Subchondral grafts
      • Cell transplantation
         – Chondrocyte
         – Stem cell
      • Total joint replacement
                                  I. Salehi
Osteoarthritis


             Aging :
    • Decreased Matrix Synthesis
    • Increased calcific cartilage
    • Increased cartilage pentosidine
    • Ligament laxity
    • Decreased muscle force
    • Decreased proprioceptive sense

                                     I. Salehi

								
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