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1 Author(s): Seetha Monrad, M.D., 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Noncommercial Share Alike 3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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3 Osteoarthritis Seetha Monrad M.D. Fall 2009
4 Case 1 Help Your Bilateral Knee Osteoarthritis by soni2006, Hubpages.com 77 year old man Bilateral knee pain Began insidiously ten years ago Pain worsens as the day goes on and with activity Denies any other systemic symptoms.
5 Case 2 59 year old woman Notes that her knuckles are changing shape over the past several years Difficulty opening jars, typing for prolonged periods of time on the computer because of pain American College of Rheumatology
6 Osteoarthritis Disease characterized by Loss of articular cartilage Increased bone formation Mild synovitis Results in joint pain and dysfunction Source Undetermined
7 Impact of Osteoarthritis Disables 10% of persons >60 2 nd only to ischemic heart disease as cause of work disability in men > 50 Economic impact >$60 billion (U.S.) Sun, Rheum Dis Clin N Am, 2007
8 American College of Rheumatology
9 Normal Cartilage Extracellular matrix Collagens (mainly II) Hyaluronan Proteoglycans (mainly aggrecan) Chondrocytes Synthesize matrix Generate degradative enzymes Avascular A. Kierszenbaum. Histology and Cell Biology. Mosby, Inc For further review, see M1MS lecture on cartilage
10 Cartilage in Osteoarthritis Altered chondrocyte phenotype Perpetuated by surrounding synoviocytes, osteoblasts Imbalance between matrix synthesis/ degradation Alteration in matrix composition Source Undetermined
11 Rheumatology Image Bank
12 Inflammation in OA? Classically, OA has been considered a noninflammatory, degenerative disorder There is increasing evidence that inflammation may be playing some role Histologically: evidence of inflammation, elevated inflammatory cytokines Radiographically: evidence of synovial thickening Clinically: Local response to injectable steroids Clinical subset: inflammatory osteoarthritis Source of inflammation unclear Crystals?
13 Risk factors for OA Age (75% of persons >70)
14 Age-Related Prevalence of OA: Changes on X-Ray Men Women Prevalence of OA (%) 80 DIP Knee 20 0 Hip Prevalence of OA (%) 80 DIP 60 Knee Hip Age (years) Age (years) Source Undetermined
15 Risk factors for OA Age (75% of persons >70) Genetics (~50%) Biomechanical factors Trauma Obesity Female sex Neuromuscular dysfunction Metabolic disorders
16 Clinical features of OA Symptoms Pain worse with use Pain as day progresses Minimal morning stiffness (<30 minutes) and after inactivity (gelling) When severe, can have rest and nocturnal pain Signs Pain with movement Bony enlargement Restricted movement Crepitation Joint instability Joint deformity
17 Source Undetermined
18 OA: Laboratory Tests No specific tests No associated laboratory abnormalities; eg, sedimentation rate Investigational: Cartilage degradation products in serum and joint fluid
19 OA: Joint fluid analysis J. Klippel. Primer on the Rheumatic Diseases. 13 th Ed. Springer Science+Media Business, LLC Source Undetermined
20 OA: Xrays Joint space narrowing Marginal osteophytes Subchondral cysts Bony sclerosis Malalignment Rheumatology Image Bank
21 Xrays in OA Diagnosis is made clinically; xrays are supplementary/confirmatory Early OA can be painful but without xray changes Radiographic OA can be present but without pain, or not the source of patient s pain
22 American College of Rheumatology (Both Images) Hand OA
23 First CMC OA American College of Rheumatology American College of Rheumatology
24 American College of Rheumatology (Both Images) Knee OA
25 Rheumatology Image Bank Knee OA
26 American College of Rheumatology Normal hips
27 American College of Rheumatology OA of hips
28 What if the patient has OA in the Then you must consider secondary causes of OA Ask about previous trauma and/or overuse Consider neuromuscular disease, especially diabetic or other neuropathies (lower extremity bias) Consider metabolic disorders, especially CPPD (calcium pyrophosphate deposition disease) (upper extremity bias) wrong joint? Source Undetermined
29 Secondary OA: Diabetic MTPs 2 to 5 involved in addition to the 1st bilaterally Destructive changes on x-ray far in excess of those seen in primary OA Midfoot involvement also common Neuropathy American College of Rheumatology
30 Differential Diagnosis Non-joint pain Hip pain: ex. trochanteric bursitis, iliopsoas tendinitis Knee pain: ex. pes anserine bursitis, patellar tendinitis Inflammatory arthritis
31 Goldman: Cecil Medicine, 23rd ed., 2007
32 Treatment Goals Patient education about disease and management Pain control Improving function and decrease disability Altering the disease process and its consequences* Treatment modalities Nonpharmacologic Pharmacologic Surgical
33 Nonpharmacologic Patient education Heat/cold application Weight loss Physical therapy: progressive exercise to Increase function Increase endurance and strength Reduce fall risk Orthotics Neoprene sleeves Braces (unicompartmental knee OA) Shoe inserts
34 Regents of the University of Michigan Aqua Fit by GWSA
35 Pharmacologic: Analgesia Acetaminophen: first line Maximum dose 4 g/day Hepatic toxicity Caution with multiple acetaminophen containing compounds NSAIDs: if acetaminophen ineffective/signs of inflammation Possibly more effective than acetaminophen but more toxicity (GI, renal, cardiovascular) Lowest effective dose COX-2 inhibitors Topical NSAIDs (1% diclofenac gel)
36 Pharmacologic therapy Tramadol Affects opioid and serotonin pathways Nonulcerogenic May be added to NSAIDs, acetaminophen Side effects: nausea, vomiting, lowered seizure threshold, rash, constipation, drowsiness, dizziness Opioids Topical agents Capsaicin NSAIDs
37 OA: Intra-articular Therapy Intra-articular steroids Good pain relief Most often used in knees, up to q 3 mo With frequent injections, risk infection, worsening diabetes, or CHF Hyaluronate injections Symptomatic relief Improved function Expensive Require series of injections Predominantly used in knees
38 Other pharmacologic agents Nutraceutical: Glucosamine sulfate/ chondroitin sulfate Analgesia Possibly reduced joint space narrowing?
39 Surgical Arthroscopic irrigation: No benefit (Bradley JD et al, Arthritis Rheum 2002; Mosely JB et al, NEJM, 2002) Osteotomy: May delay need for TKR for 2 to 3 years Total joint replacement: When pain severe and function significantly limited
40 OA: Management Summary First: Be sure the pain is joint related (not a tendonitis or bursitis adjacent to joint) Initial treatment Muscle strengthening exercises and reconditioning walking program Weight loss Acetaminophen first Local heat/cold and topical agents
41 OA: Management Summary (cont d) Second-line approach NSAIDs if acetaminophen fails Intra-articular agents Other agents Opioids Third-line Osteotomy Total joint replacement
42 Additional Source Information for more information see: Slide 4: Help Your Bilateral Knee Osteoarthritis by soni2006, Hubpages.com, Slide 5: American College of Rheumatology Slide 6: Source Undetermined Slide 8: American College of Rheumatology Slide 9: A. Kierszenbaum. Histology and Cell Biology. Mosby, Inc Slide 10: Source Undetermined Slide 11:Rheumatology Image Bank, Slide 14: Source Undetermined Slide 17: Source Undetermined Slide 19: J. Klippel. Primer on the Rheumatic Diseases. 13 th Ed. Springer Science+Media Business, LLC. 2008; Source Undetermined Slide 20: Source Undetermined Slide 22: American College of Rheumatology (both Images) Slide 23: American College of Rheumatology Slide 24: American college of Rheumatology (Both Images) Slide 25: Rheumatology Image Bank, Slide 26: American College of Rheumatology Slide 27: American College of Rheumatology Slide 28: Source Undetermined Slide 29: American College of Rheumatology Slide 31: Goldman: Cecil Medicine, 23rd ed., 2007 Slide 34: Regents of the University of Michigan; Aqua Fit by GWSA, Flickr, CC:BY-NC- SA,
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