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Degenerative Joint Diseases:Degenerative Joint Diseases:
OsteoartritisOsteoartritis
BY
Manal Y TayelProf OF Internal Medicine And
Rheumatology
2009-2010.
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DefinitionDefinition Osteoarthritis (OA) is the leading cause
of arthritis in the adult American
population and affects an estimated 20million people in the United States.
Joint pain is a frequent symptom that
often prompts a patient to seek medical
attention
Synonymous with degenerative joint
disease.
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Essentials of DiagnosisE
ssentials of Diagnosis Joint pain brought on and exacerbated by
activity and relieved with rest.
Stiffness that is self-limited upon
awakening in the morning or when rising
from a seated position after an extended
period of inactivity. Absence of prominent constitutional
symptoms.
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Clinical PresentationC
linical Presentation Characteristic sites of involvement in the
peripheral skeleton include the hand (distal
interphalangeal joint, proximal interphalangeal joint, and first carpometacarpal joint]), knee andhip .
Constitutional symptoms are absent
Erythrocyte sedimentation rate normal for age. Non-inflammatory synovial fluid (<1000
WBC/mm3)
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Clinical PresentationC
linical Presentation Negative serologic tests for antinuclear
antibody and rheumatoid factor
Radiographic evidence of osteoarthritis(non-uniform joint space narrowing,
osteophyte [spur] formation,subchondral cysts, and eburnation[bony sclerosis])
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adiograph of a hand showingRadiograph of a hand showing
osteoarthritis of the distalosteoarthritis of the distalinterphalangeal (DIP),interphalangeal (DIP),
proximal interphalangeal (PIP), proximal interphalangeal (PIP),
and first carpometacarpaland first carpometacarpal
(CMC) joints. Note the joint(CMC) joints. Note the joint
space narrowing of the DIPspace narrowing of the DIPand PIP joints compared to theand PIP joints compared to the
metacarpophalangeal joints, asmetacarpophalangeal joints, as
well as the bony sclerosiswell as the bony sclerosis
(eburnation) of all joints(eburnation) of all joints
involved by the osteoarthritisinvolved by the osteoarthritis
process. process.
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The base of the
first finger with
OA affection of
the CMC joint
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K nee osteoarthritis with medial joint spaceK nee osteoarthritis with medial joint space
narrowing and osteophytes.narrowing and osteophytes.
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OA of the hip joints
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Factors That Predispose Persons To OA.Factors That Predispose Persons To OA.
Age, gender and race, joint injury, andObesity
Age: Although the clinical manifestations of OA can begin
as early as the fourth and fifth decades of life, theincidence of OA continues to increase with each decade of aging.
Gender : Women in their 50s, 60s, and 70s have a greater prevalence of OA in the hands and knees than do men.
Race: There is evidence that OA among African Americansis more severe and has greater impact on disability than inwhites.
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Risk factors for OARisk factors for OA
Trauma: to a joint such as a ruptured anterior cruciate ligament or torn meniscus increases
the risk of later osteoarthritis. Obesity: women and men are at high risk of
knee osteoarthritis and have a modest increasein hip OA risk. This increase in risk is due
mostly to the excess load across weight-bearing joints conferred by obesity, and at least for women, the risk is proportional to the degree of
overweight.
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Causes Of Causes Of OsteoarthritisOsteoarthritis
1- Primary
2- Secondary
Congenital disorder (hip) : Legg-Calvé-Perthes
disease, Acetabular dysplasia , Slipped capital femoralepiphysis
Inborn error of connective tissue : Ehlers-Danlossyndrome, Marfan syndrome
Post traumatic (knee): Anterior cruciate ligament
tear, Meniscus tear . Metabolic disorders : Hemochromatosis , Wilson disease
History of a septic joint: Post-inflammatory
Underlying rheumatoid arthritis
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TreatmentTreatment
The goals of medical therapy are to:
1- control pain
2- improve function
3- minimize disability
4- enhance health-related quality of life.
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Non Non--pharmacologic Treatments pharmacologic Treatments
They have demonstrated efficacy and can often
help relieve pain and improve function. For
example, an assistive device, such as a properly-
used cane or walker, can unload an affectedknee or hip and diminish pain with walking.
Similarly, quadriceps strengthening and aerobic
exercise are effective in the management of
osteoarthritis at the knee. For exercise therapy,referral to a physical therapist is often helpful,
as they will evaluate function and craft the right
mix of exercises.
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Weight loss should be encouraged for all persons
with knee or hip osteoarthritis.Pharmacological Treatment:
A front-line approach to medicinal therapy for osteoarthritis includes use of acetaminophen. This
drug improves pain and function and has a safer toxicity profile, particularly with regard to thegastrointestinal tract, than NSAIDs.
NSAIDs have been widely used in the management
of OA. Via their inhibition of cyclooxygenase,symptomatic benefit is achieved. NSAIDs aremodestly more efficacious than acetaminophenfor the pain of osteoarthritis.
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Ways To Diminish NSAIDWays To Diminish NSAID ToxicityToxicity
Gastroprotective drugs especially proton
pump inhibitors
Administration of cyclooxygenase-2
isoenzyme inhibitors ( recent forms of
NSAIDs ) reduces GIT upset, but has no
effect on renal toxicity.
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TreatmentTreatment
The efficacy of glucosamine sulfate in the
medical management of osteoarthritis is
controversial. Glucosamine sulfate is acomponent of human articular cartilage
that is administered orally.
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TreatmentTreatment
Chondroitin sulfate (also commerciallyavailable) is similarly controversial.
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TreatmentTreatment Intra-articular hyaluronic acid is a
controversial FDA-approved
treatment for knee OA.
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Future DirectionsFuture Directions
Biomechanical TreatmentsBiomechanical Treatments
The aim is to identify biomarkers²of bone
and cartilage turnover²that may identifythose at risk for osteoarthritis and those
at risk for disease progression.
In the future, availability of drug therapy
that may inhibit the adverse effects of
degradative enzymes or promote the
growth of deficient cartilaginous.
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