1. Osteoarthritis

2. Objectives Describe prevalence, etiology & pathogenesis of ( O.A. ) .
Take proper history, considering Pt.'s ICE.
List the risk factors for developing O.A.
Conduct knee examination .
Describe the radiological findings .
Identify different modalities of management for O.A.
Recommend lifestyle changes & educational strategies as part of treatment .

3. Case Scenario - Saied, healthy & active 54 years old carpenter.
- C/O: Bilateral knee pain . He used Acetaminophen & local diclofenac gel. He had partial relief .
He is unable to do his job comfortably .He does his prayers sitting on a chair.
PMH: GERD & hernia repair 10 years ago.
O/E: BP = 130/85 mmHg , Temp °C.
Weight = 98 Kg, Height = 175 cm
Knees Examination:
X-Rays of both knees:

4. Definition
OA refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life.
OA is a common degenerative disorder of the articular cartilage associated with hypertrophic bone changes.
It is characterised pathologically by localised loss of cartilage, remodelling of adjacent bone and associated inflammation.
It is the most common form of arthritis, and one of the leading causes of pain and disability worldwide.
The most commonly affected peripheral joints are the knees, hips and small hand joints.

6. The pathogenesis of joint damage
Articular cartilage.
molecular level
gradual proteolytic degradation of the matrix
increased synthesis of the matrix components by the chondrocytes
morphological changes
cartilage surface fibrillation
cleft formation
loss of cartilage volume

7. The pathogenesis of joint damage
Bone :less well understood,
development of osteophytes at the joint margin
ossification of cartilage outgrowths
major changes in the vascularity and turnover of the subchondral bone.
Cytokines and other signalling molecules released from the cartilage, synovium, and bone affect chondrocyte function.
Role for inflammation in O.A. , at least in some patients and in some phases of the disease.

8. Differential diagnosis
Condition
Differentiating signs/symptoms
Differentiating Investigations
Gout
More acute onset(few Hours), the affected joint is usually red, hot, and acutely tender. Commonly involves the (MTP) joint
Joint fluid analysis shows leukocytes >2000, and the presence of sodium monourate crystals. RA
symmetrical small joint in the hands, the MCP joints and sparing the DIP joints. More prolong morning stiffness than OA. Patients feel generally unwell, with fatigue and low mood.
In RA, ESR and CRP are abnormal and RF is positive. Typical RA erosive changes are seen on x-ray, MRI, or ultrasound.

9. Differentiating signs/symptoms Differentiating Investigations
Condition
Differentiating signs/symptoms
Differentiating Investigations
Psoriatic Arthritis
often affects the DIP joints.
In psoriatic arthritis, the joint involvement is usually asymmetrical
x-ray shows typical erosive changes.
Avascular Necrosis
This is common in the hip and knee joints. The onset is subacute and there is usually a risk factor such as corticosteroid use.
MRI is the most sensitive test in AVN. In the early stages, localised subchondral oedema is characteristic. In 50% of all cases, accompanying joint effusion may be found.

10. Common clinical Features that allow Bedside Diagnosis
Increased age
Pain
Stiffness
Reduces movement
Swelling &
Crepitus

11. Diagnosis
The diagnosis is based on a history of joint pain worsened by movement, which can lead to disability in activities of daily living.
Plain radiography may help in the diagnosis, but laboratory testing usually does not.

12. Finding in Plain X-ray Mnemonic L: loss of joint space O: osteophytes
S: subchondral cysts
S: subchondral sclerosis
Osteophyte is the most specific radiographic marker for OA although it is indicative of relatively advanced disease.

13. Diagnosis differentiation from referred pain
periarticular (soft-tissue) conditions
somatisation (regional pain in the absence of any local pathological cause)

14. Diagnosis
Diagnose osteoarthritis clinically without investigations if a person:
Is 45 or over and
Has activity-related joint pain and
Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30minutes,unlike rheumatoid arthritis, which causes stiffness for 45 minutes or more.

15. Risk Factors Female sex, Past trauma, Advancing age, and Obesity.
Genetics,
Female sex,
Past trauma,
Advancing age, and
Obesity.

16. Involve Joints The joints most commonly affected are The hands, Knees,
Hips, and
Spine,
But almost any joint can be
involved.

17. The pathogenesis of joint pain
Synovitis
Subchondral bone changes
Peripheral pain sensitisation
Central pain sensitisation
Finally, the experience of pain will be modulated by psychological, social, and other contextual factors

18. Signs and Symptoms of OA
Hand
Pain on range of motion
Hypertrophic changes at distal and proximal interphalangeal joints (Heberden nodes and Bouchard nodes)
Tenderness over carpometacarpal joint of thumb

19. Typical findings Heberden’s nodes Bouchard’s nodes1 2 2
Hand affected by osteoarthritis.
(1) Heberden nodes. (2) Bouchard nodes.

20. Radiograph of a hand affected by OA2
(1) joint space narrowing, (2) osteophytes, and (3) joint destruction. Also note changes at carpometacarpal joint (4), which are very common in osteoarthritis. 3 1 4

21. Shoulder Pain on range of motion
Limitation of range of motion, especially external rotation
Crepitus on range of motion

22. Knee Pain on range of motion Joint effusion
Crepitus on range of motion
Presence of popliteal cyst (Baker cyst)
Lateral instability
Valgus or varus deformity

23. KNEE/(1) joint space narrowing and (2) osteophyte formation.

24. Hip Pain on range of motion Pain in buttock
Limitation of range of motion, especially internal rotation

25. Radiograph of the hips showing (1) joint space narrowing and (2) osteophyte formation.

26. Foot Pain on ambulation, especially at first metatarsophalangeal joint
Limited range of motion of first metatarsophalangeal joint, hallux rigidus
Hallux valgus deformity

27. Spine Pain on range of motion Limitation of range of motion
Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement
Pseudoclaudication caused by spinal stenosis

28. Physical examination Important in making the diagnosis.
Pain and limitation of range of motion are common
Each joint has unique physical examination findings

29. Laboratory testing Usually is not required to make the diagnosis.
ESR & CRP are typically normal.
Immunologic tests, such as ANA & RF (only if evidence of joint inflammation or synovitis)
uric acid level (only if gout is suspected).

30. Holistic approach to OA assessment and management
Offer advice on the following core treatments to all people with clinical osteoarthritis.
Access to appropriate information.
Activity and exercise.
Interventions to achieve weight loss if the person is overweight or obese

31. Treatment

32. Treatment Four main categories: Nonpharmacologic, Pharmacologic,
Complementary and alternative, and
Surgical.
Begin with the safest and least invasive therapies
All patients with OA should receive at least some treatment from the first two categories.

33. NONPHARMACOLOGIC
Exercise: Muscle strengthening and range-of-motion exercises.
Thermotherapy: local heat or cold should be considered as an adjunct to core treatments.
Swimming, elliptical training, and cycling are exercise options for patients with osteoarthritis in weight-bearing joints.
Weight reduction
Bracing and splinting to help support painful or unstable joints.

34. PHARMACOLOGIC Acetaminophen NSAIDs Opoids
Intra-articular injections of corticosteroids or hyaluronic acid
combination of glucosamine and chondroitin

35. COMPLEMENTARY AND ALTERNATIVE MEDICINE
Acupuncture – LBP
glucosamine and chondroitin (GAIT).
Balneotherapy (spa therapy or mineral baths).
Capsaicin cream
S-adenosylmethionine (SAM-e)

36. SURGICAL
Indication is continued pain and disability despite conservative treatment.
The most effective is total joint replacement.
Excellent outcomes for hip, knee, and shoulder.

37. Follow-up and review
Monitoring the symptoms and the ongoing impact of the condition on everyday activities and quality of life.
Monitoring the long-term course of the condition
Discussing person's knowledge & concerns
Personal preferences and ability to access services
Reviewing effectiveness & tolerability of all treatments
Support for self-management.

38. Annual Review For any person with one or more of the following:
troublesome joint pain
more than one joint with symptoms
more than one comorbidity
taking regular medication for their osteoarthritis.