Osteoarthritis. Dr Anthony Feher. With special thanks to Dr. Tim Williams and Dr. Bhatia for allowing me to use some of their slides

Transcription

1 Osteoarthritis Dr Anthony Feher With special thanks to Dr. Tim Williams and Dr. Bhatia for allowing me to use some of their slides

2 No Financial Disclosures

3 Number one chronic disability in the United States 54 million Americans ( 22.7% adults) IN 1.39 million with 599K reporting activity limitations. By 2040 about 78.4 million Americans Arthritis

4 Indiana Statistics General statistics Adults with arthritis 1,336,000 1,385,000 1,390,000 Adults limited by arthritis a 605, , ,000 Percentage of adults with arthritis Percentage of women and men with arthritis 32/23 32/24 30/25 Percentage of whites, blacks, and Hispanics with arthritis 28/27/10 29/25/13 30/23/ b Percentage of 18- to 44-year olds with arthritis Percentage of 45- to 64-year olds with arthritis Percentage of adults aged 65 years or older with arthritis Percentage of adults with arthritis who are inactive Percentage of arthritis among adults with diabetes Percentage of arthritis among adults with hypertension Percentage of arthritis among adults with obesity

5 Arthritis The incidence of osteoarthritis and gout increased significantly between 1995 and 2005, while that of rheumatoid arthritis declined in part because of more restrictive classification criteria. Source: Helmick CG et al. Arthritis Rheum. 2008;58:15-35

6 Osteoarthritis Non-inflammatory degenerative joint disease Multifactorial - Ageing - Genetics - Hormones - Mechanics - Trauma affects several joints

7 EPIDEMIOLOGY Affects all ethnic groups in all geographic locations By age of 40, 90% have some DJD in weight bearing joints, asymptomatic. >1/3 of people >45yr report joint symptoms Most common cause of long term disability in >65 yrs F>M; <45 yrs males more affected, >55 females more affected Obesity increases incidence

8 MOLECULAR BIOLOGY IL-1 leads to catabolic effect stromelysin and plasmin, both secreted by chondrocytes, have degradative action against cartilage Tissue inhibitor of metalloproteinase inhibits the degradative action of stromelysin

9 CARTILAGE DESTRUCTION IN OSTEOARTHRITIS Increase in water content 90%(as a result of the disruption in architecture of the matrix molecules)(different than decreased water content seen with normal aging process) interleukin-1 chondrocyte activity and proliferation metalloproteinase levels cathepsins B and D levels stiffness of articular cartilage Proteoglycan synthesis and degradation

10 CARTILAGE DESTRUCTION IN OSTEOARTHRITIS Decrease in proteoglycan quantity and size quantity of collagen cross-linking Keratan sulfate concentration reduced Modulus of elasticity Chondrocyte size and number collagen abnormalities

11 Characteristic histology shows loss of superficial chondrocytes replication and breakdown of the tidemark fissuring cartilage destruction with eburnation of subchondral bone Histology

12 Pain Stiffness Loss of motion Crepitus Joint tenderness Palpable osteophytes Deformity Muscle atrophy Effusion Presentation

13 IMAGING Radiographs are typically the most useful 1) Joint space narrowing 2) Bone eburnation, subchondral sclerosis 3) Subchondral cysts 4) Osteophytes 5) Loose bodies 6) Deformity and malalignment

14 IMAGING MRI sensitive in early stage. cartilage thinning, patchy or complete loss shown well NM scan sensitive but not specific CT not routinely utilized

15 Hip Arthritis

16 Hip OA

17 Hip OA

18 Joint Pain Stiffness SYMPTOMS Usually anterior groin / trochanteric Can radiate posteriorly Concurrent bursitis common (due to mechanical abnormalities) Usually less than 30 min of stiffness Stinchfield sign + Forced Internal Rotation painful and restricted

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26 AMERICAN COLLEGE OF RHEUMATOLOGY Clinical Criteria Clinicoradiographic 1) Hip Pain 2a) Internal Rotation <15 deg 2b) ESR <44 Or 3a) Internal Rotation >15 deg 3b) Morning Stiffness <60 min 3c) Age >50 3d) Pain on internal Rotation 1) Hip pain + 2 of: 2a) ESR <20 2b) Osteophytes 2c) Joint space narrowing

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30 Medical Management

31 AAOS Guidlines

32 AAOS guidlines

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34 Cane in opposite hand reduces joint reactive force by 30-60%

35 ROM & Strengthening Ex Aquatic Ex esp for obese Manual therapy Aerobic ex Relaxation ex Biofeedback Stress management Weight loss

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37 OPERATIVE MODALITIES Valgus extension Osteotomy Resurfacing arthroplasty Total Hip Arthroplasty Arthrodesis limited option Excision arthroplasty not a good option

38 Knee Osteoarthritis

39 ACL INJURY AND PATTERN OF OA Varus knees with intact ACL more wear on anterior and middle aspect of medial tibial plateau. Absence of ACL leads to more posterior wear on medial tibial plateau in varus knees. Contrary valgus knees with or without ACL insufficiency caused wear posterior to the center of the lateral tibial plateau.

40 PCL INJURY AND PATTERN OF OA Increased contact forces on MFC and patella Increased deterioration over time over medial and patellofemoral cartilage Effect of isolated PCL injury over DJD varies, combined Quadriceps and presence of meniscal damage rapidly causes degeneration

41 TREATMENT Nonoperative supportive measures weight loss has the strongest supporting evidence as an effective nonoperative treatment for osteoarthritis of the knee (Pts who have BMI>25, should lose >5% body weight)aaos Guidelines Walking better than running Self management techniques-activity, exercises and lifestyle modification Acetaminophen /NSAIDS

42 AAOS Guidlines

43 TREATMENT AAOS RECOMMENDATIONS Low impact aerobic exercises-effect of pain relief in symptomatic OA of knee statistically significant Quadriceps strengthening Patellar taping-no use Lateral Heel wedges- not of help Braces do NOT help Acupuncture with no proven benefit Glucosamine /chondroitin sulphates -? Benefit Gl/Ch arthritis Intervention trial

44 AAOS Guidlines

45 MEDICAL TREATMENT IN PTS WITH GI UPSET Acetaminophen [not to exceed 4 grams per day] Topical NSAIDs Nonselective oral NSAIDs plus gastroprotective agent Cyclooxygenase-2 (COX-II) inhibitors

46 TREATMENT Intra-articular corticosteroids for short-term pain relief Operative Arthroscopic partial meniscectomy or loose body removal is an option in patients with symptomatic OA of the knee with mechanical symptoms total joint replacement TKA UKA, Bicompartmental Arthroplasty Arthrodesis- selected limited patients

47 OPERATIVE TREATMENT Realignment osteotomy is an option in active patients with symptomatic unicompartmental OA of the knee with malalignment. Others : Soft tissue grafts- Periosteal/perichondral graft Chondrocyte transplantation- med femoral condyle defects Artificial matrix- Collagen, bone matrix, polylactic acid used to create matrix to allow cartilage to grow Fresh osteochondral grafts /OATS

48 Thank you! Dr. Williams will now discuss total joint arthroplasty.