IN THE NAME OF GOD
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Transcript of IN THE NAME OF GOD
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IN THE NAME OF GOD
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OSTEOARTHRITISOSTEOARTHRITIS
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EPIDEMIOLOGYEPIDEMIOLOGY
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EPIDEMIOLOGYEPIDEMIOLOGY
Most common type of arthritisMost common type of arthritis
A leading cause of disability in elderlyA leading cause of disability in elderly
Prevalence:Prevalence:
-- Aging Aging
-- Obesity Obesity
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EPIDEMIOLOGYEPIDEMIOLOGY
Common in:Common in:Knee, hand, spine…Knee, hand, spine…
Spared:Spared:Wrist, elbow, shoulder, ankleWrist, elbow, shoulder, ankle
Symptomatic knee OA:Symptomatic knee OA:>30y 6%>30y 6%
>60y 12%>60y 12%
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EPIDEMIOLOGYEPIDEMIOLOGY
Symptomatic hand OA:Symptomatic hand OA:10% of elderly10% of elderlyHand OA >50% of person >70yHand OA >50% of person >70y
Correlate strikingly with age:Correlate strikingly with age: -- <40y Uncommon <40y Uncommon
Sex:Sex:More common in womenMore common in women Sex differences with ageSex differences with age
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JOINT PROTECTORSJOINT PROTECTORS
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PROTECTORSPROTECTORS
Capsule and ligaments:Capsule and ligaments:Limits excursion Limits excursion
Muscles and tendons:Muscles and tendons:Key protectorKey protector
Function:Function:
- - Appropriate powerAppropriate power
-- Focal stress by: Focal stress by:
-- Decelerate joint Decelerate joint
-- Distribute across joint surface Distribute across joint surface
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PROTECTORSPROTECTORS
Mechanoreceptor:Mechanoreceptor:In ligament, skin and tendonIn ligament, skin and tendon
Assume appropriate tensionAssume appropriate tension
Synovial fluid:Synovial fluid: FrictionFriction
Lubricin: secreted by fibroblasts Lubricin: secreted by fibroblasts Subchondral boneSubchondral bone
Shock-absorber Shock-absorber
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PROTECTORSPROTECTORS
Cartilage:Cartilage:A thin rim of tissueA thin rim of tissue
Function:Function:
-- Frictionless surface Frictionless surface
-- Absorbing capacity Absorbing capacity
Component:Component:
-- Chondrocyte Chondrocyte
- - MatrixMatrix
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PROTECTORSPROTECTORS
Chondrocyte:Chondrocyte:Synthesize all element of matrixSynthesize all element of matrix
Secret:Secret:
- - Growth factorsGrowth factors
- - Cytokines (MMP…)Cytokines (MMP…)
Matrix:Matrix:Type 2 collagen Tensile strengthType 2 collagen Tensile strength
Proteoglycans (aggrecan) Compressive strengthProteoglycans (aggrecan) Compressive strength
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PATHOPHYSIOLOGYPATHOPHYSIOLOGY
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PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Joint failureJoint failure
Initial step: failure of protective mechanismsInitial step: failure of protective mechanisms
Pathologic change in all structures of jointPathologic change in all structures of joint
Hallmark: hyaline cartilage lossHallmark: hyaline cartilage loss
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PATHOPHYSIOLOGYPATHOPHYSIOLOGY
Chondrocytes:Chondrocytes: Metabolic activity, catabolic activity PGMetabolic activity, catabolic activity PG
Apoptosis Apoptosis
Chondrocytes and synovium:Chondrocytes and synovium:IL1IL1 and TNFaand TNFa
Chondrocyte
PROTEINASE
MATRIX SYNTHESIS
PG E2
NOPROTEINASE ACTIVITY
AGGRECAN SYNTHESIS
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PATHOPHYSIOLOGYPATHOPHYSIOLOGY
OA cartilageOA cartilage
Aggrecan and CollagenAggrecan and Collagen
Compressive and Tensile strengthCompressive and Tensile strength
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RISK FACTORSRISK FACTORS
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RISK FACTORSRISK FACTORS
AGE:AGE:Most potent Most potent Mechanisms:Mechanisms:
Matrix synthesis Thin cartilageMatrix synthesis Thin cartilage
Muscles:Muscles: -- Weaker Weaker - - Less quickly response Less quickly response
Slow sensory imputeSlow sensory impute
Ligament Ligament
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RISK FACTORSRISK FACTORS
FEMALE FEMALE
GENETIC (OA in member):GENETIC (OA in member):Hand & Hip 50%Hand & Hip 50%
Knee 30%Knee 30%
Generalized Rare Generalized Rare
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RISK FACTORSRISK FACTORS
JOINT:JOINT:
Developmental Developmental
FractureFracture
AVN (Avascular necrosis) AVN (Avascular necrosis)
Tear of ligamentTear of ligament
Menisc Menisc
Malalignment Malalignment
Bone densityBone density
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RISK FACTORSRISK FACTORS
OBESITY:OBESITY:Knee in stance 3-6 times of weightKnee in stance 3-6 times of weight
Knee OA and less for hip and hand OAKnee OA and less for hip and hand OA
Women: Stronger (linear)Women: Stronger (linear)
SymptomSymptom
Mechanisms: Mechanisms: -- Loading Loading
-- Metabolic Metabolic
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RISK FACTORSRISK FACTORS
REPEATED USE:REPEATED USE:Farmers: Hip Farmers: Hip
Miners: Knee and Spine Miners: Knee and Spine
Shipyards: Knee and FingerShipyards: Knee and Finger
Runners: HipRunners: Hip
Elite runner: Hip and Knee Elite runner: Hip and Knee
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PATHOLOGYPATHOLOGY
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PATHOLOGYPATHOLOGY
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PATHOLOGYPATHOLOGY
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PATHOLOGYPATHOLOGY
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PATHOLOGYPATHOLOGY
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SOURSE OF PAINSOURSE OF PAIN
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SOURSE OF PAINSOURSE OF PAIN
Cartilage AneuralCartilage Aneural
Innervated structures:Innervated structures:Synovium, Ligaments, Capsule, Muscle, Bone( Sub.)Synovium, Ligaments, Capsule, Muscle, Bone( Sub.)
NOT VISUALIZED BY X RAYNOT VISUALIZED BY X RAY
X RAY CHANGES AND PAIN SEVERITY X RAY CHANGES AND PAIN SEVERITY
POORLY POORLY CORRELATIONCORRELATION
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CLINICAL FEATURESCLINICAL FEATURES
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CLINICAL FEATURESCLINICAL FEATURES
Mechanical painMechanical pain
Gelling painGelling pain
Night painNight pain
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CLINICAL FEATURESCLINICAL FEATURES
KNEE:KNEE:BucklingBuckling
LockingLocking
Catching Catching
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
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DIAGNOSISDIAGNOSIS
CLINICALCLINICAL
No blood test routinely indicatedNo blood test routinely indicated
Synovial fluidSynovial fluid
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DIAGNOSISDIAGNOSIS
X Ray:X Ray:Hand and hip painHand and hip painknee if:knee if:
-- Not typical symptom Not typical symptom -- Pain persists after effective treatment Pain persists after effective treatment
Poorly correlation with pain severityPoorly correlation with pain severity
MRI:MRI: Not indicated Not indicated - - Meniscal tear in most patientsMeniscal tear in most patients
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RADIOLOGYRADIOLOGY
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HAND OAHAND OA
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HAND OAHAND OA
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HIP OAHIP OA
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KNEE OAKNEE OA
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SPINE OASPINE OA
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HALLUS RIGIDUSHALLUS RIGIDUS
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TREATMENTTREATMENT
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TREATMENTTREATMENT
NON PHARMACOTHERAPYNON PHARMACOTHERAPYMainstay of therapyMainstay of therapy
Weight loss: Weight loss:
-- Each Kg of weight: Load in knee 3-6 fold Each Kg of weight: Load in knee 3-6 fold
-- Symptom of Knee & Hip OA Symptom of Knee & Hip OA
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TREATMENTTREATMENT
NON PHARMACOTHERAPYNON PHARMACOTHERAPYAvoiding overload the jointAvoiding overload the joint
-- Knee & Hip Cane in opposite hand Knee & Hip Cane in opposite hand
Exercise:Exercise:
-- Age Age
-- Disuse Disuse
-- Arthrogenous inhibition Arthrogenous inhibition
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TREATMENTTREATMENT
NON PHARMACOTHERAPYNON PHARMACOTHERAPYDegree of weakness correlate strongly with:Degree of weakness correlate strongly with:
-- Severity of pain Severity of pain
-- Physical limitation Physical limitation
Correction of malalignment Correction of malalignment
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TREATMENTTREATMENT
PHARMACOTHERAPYPHARMACOTHERAPYAcetaminophenAcetaminophen
NSAIDNSAID
Injection Injection
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PATHOLOGYPATHOLOGY
SYNOVIUM:SYNOVIUM:Edematous and inflamed Enzymes Edematous and inflamed Enzymes
CAPSULE:CAPSULE:Stretch, edematous and fibroticStretch, edematous and fibrotic
BCP AND CPPD:BCP AND CPPD:Most joints with end-stage OAMost joints with end-stage OA