Download - IN THE NAME OF GOD

1

IN THE NAME OF GOD

2

OSTEOARTHRITISOSTEOARTHRITIS

3

EPIDEMIOLOGYEPIDEMIOLOGY

4


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

5


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%

6


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

7

JOINT PROTECTORSJOINT PROTECTORS

8

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

9


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

10


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

11


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

12

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

13


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

14


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

16


OA cartilageOA cartilage

Aggrecan and CollagenAggrecan and Collagen

Compressive and Tensile strengthCompressive and Tensile strength

17

RISK FACTORSRISK FACTORS

18


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

19


FEMALE FEMALE

GENETIC (OA in member):GENETIC (OA in member):Hand & Hip 50%Hand & Hip 50%

Knee 30%Knee 30%

Generalized Rare Generalized Rare

20


JOINT:JOINT:

Developmental Developmental

FractureFracture

AVN (Avascular necrosis) AVN (Avascular necrosis)

Tear of ligamentTear of ligament

Menisc Menisc

Malalignment Malalignment

Bone densityBone density

21


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

22


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

23

PATHOLOGYPATHOLOGY

24

PATHOLOGYPATHOLOGY

25

PATHOLOGYPATHOLOGY

26

PATHOLOGYPATHOLOGY

27

PATHOLOGYPATHOLOGY

28

SOURSE OF PAINSOURSE OF PAIN

29

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

30

CLINICAL FEATURESCLINICAL FEATURES

31


Mechanical painMechanical pain

Gelling painGelling pain

Night painNight pain

32


KNEE:KNEE:BucklingBuckling

LockingLocking

Catching Catching

33

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

35


36


37


38

DIAGNOSISDIAGNOSIS

CLINICALCLINICAL

No blood test routinely indicatedNo blood test routinely indicated

Synovial fluidSynovial fluid

39

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

40

RADIOLOGYRADIOLOGY

41

HAND OAHAND OA

42

HAND OAHAND OA

43

HIP OAHIP OA

44

KNEE OAKNEE OA

45

SPINE OASPINE OA

46

HALLUS RIGIDUSHALLUS RIGIDUS

47

TREATMENTTREATMENT

48

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

49

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

50

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

51

TREATMENTTREATMENT

PHARMACOTHERAPYPHARMACOTHERAPYAcetaminophenAcetaminophen

NSAIDNSAID

Injection Injection

54

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