1. LECTURE DEGENERATIVE DISEASES OF THE JOINTS AND SPINE COLUMN (OSTEOARTHRITIS, OSTEOCHONDROSIS).

2. Definition Also known as degenerative joint disease or “wear and tear arthritis”. Also known as degenerative joint disease or “wear and tear arthritis”. Progressive loss of cartilage with remodeling of subchondral bone and progressive deformity of the joint (s). Progressive loss of cartilage with remodeling of subchondral bone and progressive deformity of the joint (s). Cartilage destruction may be a result of a variety of etiologies Cartilage destruction may be a result of a variety of etiologies

3. Osteoarthritis (OA) - Definition The repair mechanisms of tissue absorption and synthesis get out of balance and result in osteophyte formation (bone spurs) and bone cysts A case of the, “Which came first? The chicken or the egg?”

4. Osteoarthritis (OA) OA is the most common form of arthritis and the most common joint disease OA is the most common form of arthritis and the most common joint disease Most of the people who have OA are older than age 45, and women are more commonly affected than men. Most of the people who have OA are older than age 45, and women are more commonly affected than men. OA most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips. OA most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.

5. Age Age is the strongest risk factor for OA. Although OA can start in young adulthood, if you are over 45 years old, you are at higher risk. Age is the strongest risk factor for OA. Although OA can start in young adulthood, if you are over 45 years old, you are at higher risk. Female gender In general, arthritis occurs more frequently in women than in men. Before age 45, OA occurs more frequently in men; after age 45, OA is more common in women. OA of the hand is particularly common among women. In general, arthritis occurs more frequently in women than in men. Before age 45, OA occurs more frequently in men; after age 45, OA is more common in women. OA of the hand is particularly common among women. Joint alignment People with joints that move or fit together incorrectly, such as bow legs, a dislocated hip, or double-jointedness, are more likely to develop OA in those joints. People with joints that move or fit together incorrectly, such as bow legs, a dislocated hip, or double-jointedness, are more likely to develop OA in those joints. OA – Risk Factors

6. Hereditary gene defect A defect in one of the genes responsible for the cartilage component collagen can cause deterioration of cartilage. A defect in one of the genes responsible for the cartilage component collagen can cause deterioration of cartilage. Joint injury or overuse caused by physical labor or sports Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for developing OA in these joints. Joints that are used repeatedly in certain jobs may be more likely to develop OA because of injury or overuse. Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for developing OA in these joints. Joints that are used repeatedly in certain jobs may be more likely to develop OA because of injury or overuse.Obesity Being overweight during midlife or the later years is among the strongest risk factors for OA of the knee. Being overweight during midlife or the later years is among the strongest risk factors for OA of the knee. OA – Risk Factors

7. OA – Symptoms OA usually occurs slowly - It may be many years before the damage to the joint becomes noticeable OA usually occurs slowly - It may be many years before the damage to the joint becomes noticeable Only a third of people whose X-rays show OA report pain or other symptoms: Only a third of people whose X-rays show OA report pain or other symptoms: –Steady or intermittent pain in a joint –Stiffness that tends to follow periods of inactivity, such as sleep or sitting –Swelling or tenderness in one or more joints [not necessarily occurring on both sides of the body at the same time] –Crunching feeling or sound of bone rubbing on bone (called crepitus) when the joint is used

8. Asymmetrical joint space narrowing from loss of articular cartilage The medial (inside) part of the knee is most commonly affected by osteoarthritis. OA – Radiographic Diagnosis

9. Normal knee anatomy

10. left: Normal x-ray left: Normal x-ray Right: worn away cartilage reflected by decreased joint space Right: worn away cartilage reflected by decreased joint space

11. OA – Radiographic Diagnosis Asymmetrical joint space narrowing Periarticular sclerosis Osteophytes Sub-chrondral bone cysts

12. Joint space narrowing where there is more stress Joint space narrowing where there is more stress Subchondral bone has thickened Subchondral bone has thickened bony overgrowth bony overgrowth

14. significant joint space narrowing as well as proliferative bone formation around the femoral neck (arrows)

15. Left: normal hip Right: There is some joint space medially but the superior portion is completely destroyed. Supralateral aspects affected most because the weight is transfered through the roof of the acetabulum. Note the sclerosis and oseophyte formation (arrow).

16. painful bone on bone contact at the CMC joint and the large bone spurs -- osteophytes.

17. What to look for in an x-ray Radiographic changes visible relatively late in the disease Radiographic changes visible relatively late in the disease Subchondral sclerosis Subchondral sclerosis Joint space narrowing esp where there is stress Joint space narrowing esp where there is stress Subchondral cysts Subchondral cysts Osteophytes Osteophytes Bone mineralization should be normal Bone mineralization should be normal

18. X-ray shows lateral osteophytes, varus deformity, narrow joint space in a 70 yr old female with OA

19. Clinical features and diagnosis Pain PainSources – Joint effusion and stretching of the joint capsule – Torn menisci – Inflammation of periarticular bursae – Periarticular muscle spasm – Psychological factors Deep, aching localized to the joint Deep, aching localized to the joint Slow in onset Slow in onset Worsened with activity in initial stages Worsened with activity in initial stages Occurs at rest with advanced disease Occurs at rest with advanced disease

20. May be referred eg hip pain referred to the thigh, groin, knee. May be referred eg hip pain referred to the thigh, groin, knee. Pain may be aggravated with weather changes Pain may be aggravated with weather changes

21. Exam Joint line tenderness Joint line tenderness Bony enlargement of joint Bony enlargement of joint +/- effusion +/- effusion Crepitus Crepitus Decreased range of motion Decreased range of motion

23. Joint exam Joint line pain can indicate tear of the lining of the capsule or the meniscus. Joint line pain can indicate tear of the lining of the capsule or the meniscus. Where is the patella? Where is the patella?

24. Joint exam In the evaluation of joint line pain, perform a varus or valgus stress test. In the evaluation of joint line pain, perform a varus or valgus stress test.varusvalgus stress testvarusvalgus stress test Apply stress across the joint, place fingers directly over the joint line to assess for pain, a clunk may indicate a meniscal tear, or crepitus may indicate cartilage damage. Apply stress across the joint, place fingers directly over the joint line to assess for pain, a clunk may indicate a meniscal tear, or crepitus may indicate cartilage damage.meniscal tearmeniscal tear

25. Have the patient to lie supine on the exam table with leg muscles relaxed Have the patient to lie supine on the exam table with leg muscles relaxed Press the patella downward and quickly release it. Press the patella downward and quickly release it. the patella visibly rebounds. the patella visibly rebounds. What does this mean? What does this mean? a large knee effusion a large knee effusion Ballotable patella Ballotable patella

26. Have the patient lie supine with leg muscles relaxed Have the patient lie supine with leg muscles relaxed Compress the suprapatellar pouch with your thumb, palm, and index finger. Compress the suprapatellar pouch with your thumb, palm, and index finger. "Milk" downward and laterally so that any excess fluid collects on the medial side. "Milk" downward and laterally so that any excess fluid collects on the medial side. Tap gently over the collected fluid and observe the effect on the lateral side Tap gently over the collected fluid and observe the effect on the lateral side A fullness on the lateral side indicates the presence small knee effusion A fullness on the lateral side indicates the presence small knee effusion

27. Involved joints DIP, PIP DIP, PIP 1 st carpometacarpal 1 st carpometacarpal cervical/lumbar facet joints cervical/lumbar facet joints 1 st metatarsophalangeal 1 st metatarsophalangeal Hips Hips Knees Knees Uncommon Uncommon Wrist, elbows, shoulders, ankles Wrist, elbows, shoulders, ankles

29. 1 st metatarso-phalangeal most commonly affected in OA of the foot. 1 st metatarso-phalangeal most commonly affected in OA of the foot.

30. OA – Arthroscopic Diagnosis Normal Articular Cartilage Ostearthritic degenerated cartilage with exposed subchondral bone Arthroscopy allows earlier diagnosis by demonstrating the more subtle cartilage changes that are not visible on x-ray

31. OA is a condition which progresses slowly over a period of many years and cannot be cured Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition Functional treatment goals: Limit pain Increase range of motion Increase muscle strength OA – Disease Management

32. Treatment Non-pharmacokinetic Non-pharmacokinetic No proven medication-based disease modifying intervention exists. No proven medication-based disease modifying intervention exists. Analgesics (acetominophen) Analgesics (acetominophen) NSAIDS NSAIDS Help pain symptoms but controversial for long term use in non-inflammatory OA because of risks vs benefits Help pain symptoms but controversial for long term use in non-inflammatory OA because of risks vs benefits Narcotics Narcotics Intra-articular steroids Intra-articular steroids Chondroprotective agents Chondroprotective agents Anti-depressants Anti-depressants

33. Intra-articular corticosteroids May be used if NSAIDS are contraindicated, persistent pain despite use of other medications. May be used if NSAIDS are contraindicated, persistent pain despite use of other medications. (not > 4 injections per year per joint) (not > 4 injections per year per joint) 2004 meta-analysis of controlled trials (w/ placebo) showed short term improvement in knee pain, but efficacy in other joints is uncertain. 2004 meta-analysis of controlled trials (w/ placebo) showed short term improvement in knee pain, but efficacy in other joints is uncertain. saline vs steroid injection? saline vs steroid injection? A study comparing the two in knee OA showed no effect on joint space narrowing or significant difference in pain at the end of the study, but over a 2 yr period saline injections has less pain relief. A study comparing the two in knee OA showed no effect on joint space narrowing or significant difference in pain at the end of the study, but over a 2 yr period saline injections has less pain relief.

34. Intra-articular hyaluronans Evidence shows they have a small advantage in terms of pain control, compared to intra-articular placebos or NSAIDS. Evidence shows they have a small advantage in terms of pain control, compared to intra-articular placebos or NSAIDS. No evidence for improvement in function No evidence for improvement in function Two studies comparing intra-articular steroids to hyaluronans have come to opposite conclusions-more trials are needed. Two studies comparing intra-articular steroids to hyaluronans have come to opposite conclusions-more trials are needed.

35. Intra-articular Corticosteroids Beneficial in KNEE Beneficial in KNEE – LOE 1a Beneficial in HIP Beneficial in HIP – LOE 1b Short-duration benefits: 2-4 weeks Short-duration benefits: 2-4 weeks Every 3 mos OK; not effective at 2 years Every 3 mos OK; not effective at 2 years

36. Very effective in knee and hip Very effective in knee and hip – LOE 1a for knee pain, fxn, & stiffness Effective in ankle, shoulder (LOE lower) Effective in ankle, shoulder (LOE lower) Delayed effect (4 weeks) Delayed effect (4 weeks) Long duration (6 months) Long duration (6 months) 1-5 weekly injections 1-5 weekly injections Intra-Articular Hyaluronic Acid (IAHA) “viscosupplement”

37. IAHA: Mechanism of Action Increased synovial fluid HA conc. Increased synovial fluid HA conc. Increased cartilage lubrication/elasticity Increased cartilage lubrication/elasticity Chondrocyte proliferation Chondrocyte proliferation Chondrocyte stimulation  matrix Chondrocyte stimulation  matrix Decreased inflammatory mediators Decreased inflammatory mediators Inhibition of nociceptors Inhibition of nociceptors MAY BE DISEASE-MODIFYING MAY BE DISEASE-MODIFYING HIGH-M.W. prep’s have higher effects in vitro HIGH-M.W. prep’s have higher effects in vitro Devine, Shaffer. Use of viscosupplementation for knee osteoarthritis: an update. Curr Sports Med Rep 2011

38. OA – Non-operative Treatments Pain medications Physical therapy Walking aids Shock absorption Re-alignment through orthotics Limit strain to affected areas

39. Summary and Review Low-impact exercise and strength exercise effectively treat OA Low-impact exercise and strength exercise effectively treat OA Minimize use of chronic NSAIDs Minimize use of chronic NSAIDs Viscosupplement injections give long- lasting pain reduction Viscosupplement injections give long- lasting pain reduction Consider use of multiple treatments simultaneously Consider use of multiple treatments simultaneously Arthroscopic lavage & debridement no better than conservative mgmt Arthroscopic lavage & debridement no better than conservative mgmt

40. Arthroscopy Arthroscopy Cartilage transplantation Cartilage transplantation Joint replacement Joint replacement Surgery

41. Osteoarthritis usually affects the inside half (medial compartment) of the knee more often than the outside (lateral compartment). This can lead to the lower extremity becoming slightly bowlegged, or in medical terms, a genu varum deformity Proximal Tibial Osteotomy

42. Rt: varus deformity of the knee

43. Proximal Tibial Osteotomy The result is that the weight bearing line of the lower extremity moves more medially (towards the medial compartment of the knee). The end result is that there is more pressure on the medial joint surfaces, which leads to more pain and faster degeneration. In some cases, re-aligning the angles in the lower extremity can result in shifting the weight-bearing line to the lateral compartment of the knee. This, presumably, places the majority of the weight-bearing force into a healthier compartment. The result is to reduce the pain and delay the progression of the degeneration of the medial compartment.

44. Proximal Tibial Osteotomy In the procedure to realign the angles, a wedge of bone is removed from the lateral side of the upper tibia. A staple or plate and screws are used to hold the bone in place until it heals. This converts the extremity from being bow-legged to knock-kneed. The Proximal Tibial Osteotomy buys some time before ultimately needing to perform a total knee replacement. The operation probably lasts for 5-7 years if successful.

45. Osteotomy Realignment of Joints Realignment of Joints Transfer Weight to less involved part of joint Transfer Weight to less involved part of joint 60s and 70s 60s and 70s Less popular Less popular Does not provide good long term results Does not provide good long term results

46. The ultimate solution for osteoarthritis of the knee is to replace the joint surfaces with an artificial knee joint: Usually only considered in people over the age of 60 Artificial knee joints last about 12 years in an elderly population Not recommended in younger patients because: The younger the patient, the more likely the artificial joint will fail Replacing the knee the second and third time is much harder and much less likely to succeed. Younger patients are more active and place more stress on the artificial joint, that can lead to loosening and failure earlier Younger patients are also more likely to outlive their artificial joint, and will almost surely require a revision at some point down the road. Younger patients sometimes require the surgery (simply because no other acceptable solution is available to treat their condition) Total Knee Replacement

47. The ends of the femur, tibia, and patella are shaped to accept the artificial surfaces. The end result is that all moving surfaces of the knee are metal against plastic Total Knee Replacement

56. Photographs of total knee components on model bone

57. Total Knee Replacement

58. Total Joint Replacement Considered last Solution for Arthritis Considered last Solution for Arthritis Improved Ambulation Improved Ambulation Decreased Pain Decreased Pain Increased ROM Increased ROM 90%+ good to excellent results 90%+ good to excellent results

59. Unicompartmental Knee Replacement When only one part of the knee joint is arthritic, it may be possible to replace just this part of the joint The procedure is similar to a total knee replacement, but only one side of the joint is resurfaced A metal component is fit onto the femur and a plastic bearing is inserted either directly onto the tibia or onto a metal tray which has been fit onto the tibia Recovery time is generally slightly shorter following this kind of surgery.

60. LOE III LOE III Universally recommended to improved pain, function, QOL Universally recommended to improved pain, function, QOL – Unicompartmental – Total joint replacement Knee Joint Replacement

61. OA – Arthroscopic Treatment In addition to being the most accurate way of determining how advanced the osteoarthritis is: Arthroscopy also allows the surgeon to debride the knee joint Debridement essentially consists of cleaning out the joint of all debris and loose fragments. During the debridment any loose fragments of cartilage are removed and the knee is washed with a saline solution. The areas of the knee joint which are badly worn may be roughened with a burr to promote the growth of new cartilage - a fibrocartilage material that is similar scar tissue. Debridement of the knee using the arthroscope is not 100% successful. If successful, it usually affords temporary relief of symptoms for somewhere between 6 months - 2 years. Arthroscopy also allows access for surgical treatment of articular cartilage: graft-transplantation, micro-fracture techniques, sub-chondral drilling

62. NO BENEFIT for unselected OA (mechanical or inflammatory causes), Ib NO BENEFIT for unselected OA (mechanical or inflammatory causes), Ib – Moseley JB et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002 Jul 11; 347(2):81-8. – Kirkley A et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM Sep 2008;359:1097. – Two other RCTs Arthroscopy with Lavage and Debridement

63. Left: View of normal elbow cartilage through an arthroscope - white, glistening, smooth Right: severe elbow osteoarthritis - cartilage is lost and the bone underneath is exposed

64. Surgery Arthroscopy Least Invasive Least Invasive Remove partially damaged cartilage Remove partially damaged cartilage Remove dead cartilage and enzymes that cause inflammation Remove dead cartilage and enzymes that cause inflammation Arthroscope Portals Damaged cartilage

65. Abrasion / Drilling Abrasion and Drilling Abrasion and Drilling Healing response Healing response Fibrocartilage= Scar Cartilage Fibrocartilage= Scar Cartilage Inferior mechanical properties to articular cartilage Inferior mechanical properties to articular cartilage Less advanced OA Less advanced OA Focal arthritis Focal arthritis Focal, localized lesion

66. Surgical: arthroscopy arthroscopy is not recommended for nonspecific "cleaning of the knee“. arthroscopy is not recommended for nonspecific "cleaning of the knee“. Used to fix specific structural damage on imaging (repairing meniscal tears, removing fragments of torn menisci that are producing symptoms). Used to fix specific structural damage on imaging (repairing meniscal tears, removing fragments of torn menisci that are producing symptoms).

67. Mosaicplasty / OATS Localized focal arthritis/defect Localized focal arthritis/defect Traumatic arthritis Traumatic arthritis Small to medium Small to medium Transferring healthy plug of bone and cartilage to defect in weight bearing area Transferring healthy plug of bone and cartilage to defect in weight bearing area SmallLarge

68. ACI Articular Cartilage Implantation Articular Cartilage Implantation “Pot hole in the road” “Pot hole in the road” Two operations Two operations Cartilage harvested and sent to Lab, to grow in Culture Cartilage harvested and sent to Lab, to grow in Culture Cartilage cells transplanted into the defect Cartilage cells transplanted into the defect In future may be applicable to large lesions/primary OA In future may be applicable to large lesions/primary OA

69. Summary Accurate Diagnosis important Accurate Diagnosis important Understand the nature of this Problem Understand the nature of this Problem Many treatment Options available Many treatment Options available Benefits and limitations Benefits and limitations Choose the right treatment for you Choose the right treatment for you Get back into the game Get back into the game

70. The degree of osteoarthritis has been classified by N. S. Kosinskaya as shown in Table 2. Table 2 Classification of degree of osteoarthritis. Classification of degree of osteoarthritis.GradePain Level of activity The range of movement Radiological changes Grade 1 Slight and occasional pain. Weight bearing is possible. A patient may able to perform certain activities of daily living. The range of movement in the joint is not limited or there is loss of part of the range of movements in the joint. Slight narrowing of joint space. Small marginal osteophytes. Grade 2 Moderate pain, but a patient may be able to weight bear albeit with pain. There is increasing difficulty in walking and standing. Moderate limitations of movement, contractures and fixed flexion deformities with apparent shortening of the affected limb. There are pain and crepitus on movement. Gross narrowing of joint space. Moderate marginal osteophytes and cysts. Subchondral bone sclerosis. An alteration of the joint contours. Grade 3 Moderate or severe pain. A patient has had to modify or give up activities or both because of pain and progressive loss of movement. Great stiffness in the affected joint (rigidity). Loss of joint space. Massive marginal osteophytes. Osteoporosis of the articular end of the bone. Areas of new bone formation round the joint.