Osteoarthritis. RA Hughes

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1 Osteoarthritis RA Hughes

2 Osteoarthritis (OA) OA is the most common form of arthritis and the most common joint disease Most of the people who have OA are older than age 45, and women are more commonly affected than men. OA most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.

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5 Primary versus secondary Primary not associated with any other underlying risk of OA. Primary nodal Secondary resulting from another disease that predisposes DM Haemochromatosis Hypermobility

6 OA Nodal osteoarthritis Note bony enlargement of distal and proximal interphalangeal joints (Heberden's nodes and Bouchard's nodes, respectively).

7 OA OA is a disease of joints that affects all of the weightbearing components of the joint: Articular cartilage Menisci Bone Synovium

8 Age OA Risk Factors Age is the strongest risk factor for OA. Although OA can start in young adulthood age brings increased prevalence. Female gender Before age 45, OA occurs more frequently in men; after 45, OA is more common in women. Primary nodal OA of the hand is particularly common among women. Joint alignment People with joints that move or fit together incorrectly, such as bow legs, a dislocated hip, or hypermobility are more likely to develop OA in those joints.

9 Hereditary gene defect OA Risk Factors A defect in one of the genes responsible for the cartilage component collagen Joint injury or overuse caused by physical labor or sports Traumatic injury (Ligament or meniscal tears) to the knee or hip increases your risk for developing OA in these joints Obesity Being overweight during midlife or the later years is among the strongest risk factors for OA of the knee.

10 OA usually occurs slowly - It may be many years before the damage to the joint becomes clinically noticeable Only a third of people whose X-rays show OA report any symptoms OA Symptoms Pain Steady or intermittent in a joint - flares Stiffness that tends to follow periods of inactivity, such as sleep or sitting Swelling or tenderness in one or more joints Crepitus - Crunching feeling or sound of bone rubbing on bone on activity Functional disability especially weight bearing joints and hand OA (CMC joint)

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14 Osteoarthritis (OA) Osteoarthritis may result from wear and tear or damage to the joint (injury) The normal cartilage lining is gradually worn away and the underlying bone is exposed.

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16 Osteoarthritis The repair mechanisms of tissue absorption and synthesis get out of balance and result in osteophyte formation (bone spurs) and bone cysts

17 OA Articular Cartilage Articular cartilage is a target tissue in OA Increased tissue swelling Change in color Cartilage fibrillation Cartilage erosion down to subchondral bone

18 OA Articular Cartilage

19 OA Articular Cartilage A) Normal articular cartilage from 21-year old adult (3000X) B) Osteoarthritic cartilage (3000X) The surface changes alter the distribution of biomechanical forces further triggering changes in the tissue

20 OA Articular Cartilage Cartilage damage causes chondrocyte cloning in an attempt to restore articular surface (Normal adult chondrocytes are fully differentiated and do not proliferate) (A) Normal articular cartilage (B) Osteoarthritic cartilage

21 OA Articular Cartilage Newly dividing chondrocytes do not differentiate fully and cannot effectively synthesize the elements needed for matrix maintenance This results in a net loss of matrix components Collagen content stays constant but fibrils are thinner and more disorganized with decreased tensile strength

22 OA Articular Cartilage Proteoglycan loss results in an inability to hold on to water content Decreased resistance to compression especially with repeated stress

23 OA as an inflammatory disease Inflammatory mediators Lack of association with levels of joint use Presence of synovitis in OA Central role for IL-1 in OA

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28 OA vs. Aging Unlike aging, OA is progressive and a significantly more active process

29 OA Overall Changes Osteoarthritis with lateral osteophyte, loss of articular cartilage thickness and subchondral bony sclerosis

30 OA Radiographic Diagnosis Asymmetrical joint space narrowing from loss of articular cartilage

31 OA Radiographic Diagnosis Asymmetrical joint space narrowing Periarticular sclerosis Osteophytes Sub-chrondral bone cysts

32 OA Arthroscopic Diagnosis Arthroscopy allows early diagnosis by demonstrating cartilage change not visible on x-ray

33 Treatment Lifestyle Weight loss Exercise And stretch quads building Conservative Physiotherapy Splints and aids Drugs NSAID oral and topical Injections Steroids by mouth Supplements

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41 Surgery Arthroscopy and lavage Joint replacement

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43 Drugs for OA

44 Approach to the pharmacologic management of osteoarthritis. Stanos S J Am Osteopath Assoc 2013;113: Published by American Osteopathic Association

45 Topical NSAIDs Topical NSAIDs Cochrane review Sept 2012 Topical provide equal pain relief when compared to oral NSAIDS Effective in Knee and hand OA Fewer side effects Some topical irritation

46 Choices Personal view Topical NSAIDs / oral NSAIDs Low dose steroids orally / IM steroids Supplements

47 Supplements Likely to be low harm Hard to study using conventional study design Use for three months trial Evidence supports 1. Rose hip GOPO 2. Glucosamine SO4 or HCl