Osteoarthritis Dr Anthony Feher With special thanks to Dr. Tim Williams and Dr. Bhatia for allowing me to use some of their slides
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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
Indiana Statistics General statistics 2011 2013 2015 Adults with arthritis 1,336,000 1,385,000 1,390,000 Adults limited by arthritis a 605,000 632,000 599,000 Percentage of adults with arthritis 27 28 28 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 10 11 9 Percentage of 45- to 64-year olds with arthritis 38 36 38 Percentage of adults aged 65 years or older with arthritis 54 55 54 Percentage of adults with arthritis who are inactive 41 45 41 Percentage of arthritis among adults with diabetes 54 55 51 Percentage of arthritis among adults with hypertension 46 46 48 Percentage of arthritis among adults with obesity 37 39 36
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
Osteoarthritis Non-inflammatory degenerative joint disease Multifactorial - Ageing - Genetics - Hormones - Mechanics - Trauma affects several joints
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
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
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
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
Characteristic histology shows loss of superficial chondrocytes replication and breakdown of the tidemark fissuring cartilage destruction with eburnation of subchondral bone Histology
Pain Stiffness Loss of motion Crepitus Joint tenderness Palpable osteophytes Deformity Muscle atrophy Effusion Presentation
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
IMAGING MRI sensitive in early stage. cartilage thinning, patchy or complete loss shown well NM scan sensitive but not specific CT not routinely utilized
Hip Arthritis
Hip OA
Hip OA
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
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
Medical Management
AAOS Guidlines
AAOS guidlines
Cane in opposite hand reduces joint reactive force by 30-60%
ROM & Strengthening Ex Aquatic Ex esp for obese Manual therapy Aerobic ex Relaxation ex Biofeedback Stress management Weight loss
OPERATIVE MODALITIES Valgus extension Osteotomy Resurfacing arthroplasty Total Hip Arthroplasty Arthrodesis limited option Excision arthroplasty not a good option
Knee Osteoarthritis
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.
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
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
AAOS Guidlines
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
AAOS Guidlines
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
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
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
Thank you! Dr. Williams will now discuss total joint arthroplasty.