1. 1 IN THE NAME OF GOD

2. 2 OSTEOARTHRITIS

3. 3 EPIDEMIOLOGY

4. 4 EPIDEMIOLOGY Most common type of arthritis Most common type of arthritis A leading cause of disability in elderly A leading cause of disability in elderly Prevalence: Prevalence: - Aging - Aging - Obesity - Obesity

5. 5 EPIDEMIOLOGY Common in: Common in: Knee, hand, spine… Spared: Spared: Wrist, elbow, shoulder, ankle Symptomatic knee OA: Symptomatic knee OA: >30y 6% >60y 12%

6. 6 EPIDEMIOLOGY Symptomatic hand OA: Symptomatic hand OA: 10% of elderly Hand OA >50% of person >70y Correlate strikingly with age: Correlate strikingly with age: - <40y Uncommon - <40y Uncommon Sex: Sex: More common in women Sex differences with age Sex differences with age

7. 7 JOINT PROTECTORS

8. 8 PROTECTORS Capsule and ligaments: Capsule and ligaments: Limits excursion Muscles and tendons: Muscles and tendons: Key protector Function: - Appropriate power - Appropriate power - Focal stress by: - Focal stress by: - Decelerate joint - Decelerate joint - Distribute across joint surface - Distribute across joint surface

9. 9 PROTECTORS Mechanoreceptor: Mechanoreceptor: In ligament, skin and tendon Assume appropriate tension Synovial fluid: Synovial fluid: Friction Friction Lubricin: secreted by fibroblasts Subchondral bone Subchondral boneShock-absorber

10. 10 PROTECTORS Cartilage: Cartilage: A thin rim of tissue Function: - Frictionless surface - Frictionless surface - Absorbing capacity - Absorbing capacityComponent: - Chondrocyte - Chondrocyte - Matrix - Matrix

11. 11 PROTECTORS Chondrocyte: Chondrocyte: Synthesize all element of matrix Secret: - Growth factors - Growth factors - Cytokines (MMP…) - Cytokines (MMP…) Matrix: Matrix: Type 2 collagen Tensile strength Proteoglycans (aggrecan) Compressive strength

12. 12 PATHOPHYSIOLOGY

13. 13 PATHOPHYSIOLOGY Joint failure Joint failure Initial step: failure of protective mechanisms Initial step: failure of protective mechanisms Pathologic change in all structures of joint Pathologic change in all structures of joint Hallmark: hyaline cartilage loss Hallmark: hyaline cartilage loss

14. 14 PATHOPHYSIOLOGY Chondrocytes: Chondrocytes: Metabolic activity, catabolic activity PG Metabolic activity, catabolic activity PG Apoptosis Apoptosis Chondrocytes and synovium: Chondrocytes and synovium: IL1 and TNFa Chondrocyte PROTEINASE MATRIX SYNTHESIS PG E2 NO PROTEINASE ACTIVITY AGGRECAN SYNTHESIS

15. 15

16. 16 PATHOPHYSIOLOGY OA cartilage OA cartilage Aggrecan and Collagen Aggrecan and Collagen Compressive and Tensile strength Compressive and Tensile strength

17. 17 RISK FACTORS

18. 18 RISK FACTORS AGE: AGE: Most potent Mechanisms: Matrix synthesis Thin cartilage Matrix synthesis Thin cartilage Muscles: - Weaker - Weaker - Less quickly response - Less quickly response Slow sensory impute Ligament

19. 19 RISK FACTORS FEMALE FEMALE GENETIC (OA in member): GENETIC (OA in member): Hand & Hip 50% Knee 30% Generalized Rare

20. 20 RISK FACTORS JOINT: JOINT:DevelopmentalFracture AVN (Avascular necrosis) Tear of ligament MeniscMalalignment Bone density Bone density

21. 21 RISK FACTORS OBESITY: OBESITY: Knee in stance 3-6 times of weight Knee OA and less for hip and hand OA Knee OA and less for hip and hand OA Women: Stronger (linear) Symptom Symptom Mechanisms: - Loading - Metabolic - Metabolic

22. 22 RISK FACTORS REPEATED USE: REPEATED USE: Farmers: Hip Miners: Knee and Spine Shipyards: Knee and Finger Runners: Hip Elite runner: Hip and Knee

23. 23 PATHOLOGY

24. 24 PATHOLOGY

25. 25 PATHOLOGY

26. 26 PATHOLOGY

27. 27 PATHOLOGY

28. 28 SOURSE OF PAIN

29. 29 SOURSE OF PAIN Cartilage Aneural Cartilage Aneural Innervated structures: Innervated structures: Synovium, Ligaments, Capsule, Muscle, Bone( Sub.) NOT VISUALIZED BY X RAY NOT VISUALIZED BY X RAY X RAY CHANGES AND PAIN SEVERITY X RAY CHANGES AND PAIN SEVERITY POORLY CORRELATION

30. 30 CLINICAL FEATURES

31. 31 CLINICAL FEATURES Mechanical pain Mechanical pain Gelling pain Gelling pain Night pain Night pain

32. 32 CLINICAL FEATURES KNEE: KNEE:BucklingLockingCatching

33. 33 PHYSICAL EXAMINATION

34. 34

35. 35 PHYSICAL EXAMINATION

36. 36 PHYSICAL EXAMINATION

37. 37 PHYSICAL EXAMINATION

38. 38 DIAGNOSIS CLINICAL CLINICAL No blood test routinely indicated No blood test routinely indicated Synovial fluid Synovial fluid

39. 39 DIAGNOSIS X Ray: X Ray: Hand and hip pain knee if: - Not typical symptom - Not typical symptom - Pain persists after effective treatment - Pain persists after effective treatment Poorly correlation with pain severity MRI: Not indicated MRI: Not indicated - Meniscal tear in most patients - Meniscal tear in most patients

40. 40 RADIOLOGY

41. 41 HAND OA

42. 42 HAND OA

43. 43 HIP OA

44. 44 KNEE OA

45. 45 SPINE OA

46. 46 HALLUS RIGIDUS

47. 47 TREATMENT

48. 48 TREATMENT NON PHARMACOTHERAPY NON PHARMACOTHERAPY Mainstay of therapy 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. 49 TREATMENT NON PHARMACOTHERAPY NON PHARMACOTHERAPY Avoiding overload the joint - Knee & Hip Cane in opposite hand - Knee & Hip Cane in opposite handExercise: - Age - Age - Disuse - Disuse - Arthrogenous inhibition - Arthrogenous inhibition

50. 50 TREATMENT NON PHARMACOTHERAPY NON PHARMACOTHERAPY Degree of weakness correlate strongly with: - Severity of pain - Severity of pain - Physical limitation - Physical limitation Correction of malalignment

51. 51 TREATMENT PHARMACOTHERAPY PHARMACOTHERAPYAcetaminophenNSAIDInjection

52. 52

53. 53

54. 54 PATHOLOGY SYNOVIUM: SYNOVIUM: Edematous and inflamed Enzymes CAPSULE: CAPSULE: Stretch, edematous and fibrotic BCP AND CPPD: BCP AND CPPD: Most joints with end-stage OA