1. Dr.Farzad Ravari M.D Specialist Orthopedic Surgeon Cedars J.A Int.Hospital

2. Histology of cartilage

4. Kinds of Cartilages Hyaline(white) cartilages -Articular cart.eg joints,minuiscus -Costal Cart. Xyphoid,nose,trachea Elastic (yellow)Cartilages -epiglotis -ear …..

5. Classification of joints SYNARTHROSIS( immovable) AMPHIARTHROSIS (slightly movable) DIARTHROSIS ( free movable)

6. SYNARTHROSIS SUTURA…… skull SCHINDYLESIS….maxilla+pa latine GOMPHOSIS…. Teeth+mandible SYNCHONDROSIS…epiphisi s+metaphysis

7. AMPHIARTHROSIS SYMPHYSIS…….pubis, body of vertebra SYNDESMOSIS….. Distal tibio +fibular

8. DIARTHROSIS HINGE (GINGLYMUS)… IP,Humero+ulnar PIVOT(TROCHOID)..odontoid CONDYLOID…wrist SADDLE…..CMCJ thumb BALL &SOCKET (ENARTHROSIS)….hip,shoulder GLIDING(ARTHRODIA)…carpal,tarsal, facet joints

9. Anatomy of joints

10. Synovial fluid is formed through a serum ultrafiltration process by cells that form the synovial membrane (synoviocytes). Synovial cells also manufacture the major protein component of synovial fluid, hyaluronic acid (also known as hyaluronate). Synovial fluid supplies nutrients to the avascular articular cartilage; it also provides the viscosity needed to absorb shock from slow movements, as well as the elasticity required to absorb shock from rapid movements.

11. P athophysiology When friction increase Cytokines metaloprotein Matrix degeneration Cartilage swelling Increase proteoglycan to repair cartilage hypertrophy Subchondral erosion &cyst Osteophyte formation effusion Joint collapse

12. Pain mechanisms in osteoarthritis Osteophytic periosteal elevation Vascular congestion of subchondral bone, leading to increased intraosseous pressure Synovitis with activation of synovial membrane nociceptors Fatigue in muscles that cross the joint Overall joint contracture Joint effusion and stretching of the joint capsule Torn menisci Inflammation of periarticular bursae Periarticular muscle spasm Psychological factors Crepitus (a rough or crunchy sensation)

13. Epidemiology 20 mil. Population in USA White>black Female >male At 18 24 years old=7% OA hand At 55-64 YO= 28% knee,23% hip At 65-74 YO= 39% knee,23% hip At 75-79 YO=100% sign of OA

14. Etiology Risk factors for osteoarthritis include the following Age Obesity (increases mechanical stress) Trauma Genetics Sex hormones Muscle weakness Repetitive use (ie, jobs requiring heavy labor and bending) Infection Crystal deposition Acromegaly Previous rheumatoid arthritis (ie, burnt-out rheumatoid arthritis) Heritable metabolic causes (eg, alkaptonuria, hemochromatosis, Wilson disease) Hemoglobinopathies (eg, sickle cell disease, thalassemia) Neuropathic disorder leading to a Charcot joint (eg, syringomyelia, tabes dorsalis, diabetes) Underlying orthopedic disorders (eg, congenital hip dislocation, slipped femoral capital epiphysis) Disorders of bone (eg, Paget disease, avascular necrosis)

15. Physical exam. Tenderness over joint lines Crepitation of joint effusion Malalignment Muscle atrophy Limitation of motion Heberden nodes esp at IPJ

16. Progression of Osteoarthritis Stage 1:proteolytic breakdown of cartilage matrix Stage 2:fibrillation +erosion of cartilage that increase proteoglycan & collagen into synovium Stage 3:chronic inflammatory response in synovium

17. Differentials Diagnosis Crystal deposition disease Pseudogout Inflammatory arthritis Seronegative spondyloarthropathies Infected joint Underlying mechanical pain Reactive arthritis Abdominal Aortic Aneurysm Imaging Ankylosing Spondylitis Avascular Necrosis Avascular Necrosis, Femoral Head Calcium Pyrophosphate Deposition Disease Imaging in Neuropathic Arthropathy (Charcot Joint) Lyme Disease Patellofemoral Arthritis Patellofemoral Syndrome Prepatellar Bursitis Psoriatic Arthritis Rheumatoid Arthritis Rheumatoid Arthritis, Hands Rhinosporidiosis

18. Rhinosporidiosis is a disease caused by the organism Rhinosporidium seeberi, which was once thought to be a fungus but is now believed to be a rare aquatic protistan parasite of fish. First described in 1900 by Guillermo Seeber, it generally presents as swollen, pink or red polyps in the nasal cavity or the ocular conjunctivae. Other sites of infection are rare. Infection generally occurs after swimming in stagnant freshwater ponds, lakes, or rivers, but is also suspected to occur from dust or air. The disease is most often seen in individuals ages 15-40, with preferential occurrence in boys. R. seeberiprogresses through several stages of development and can be easily diagnosed via traditional fungal stains. Although there is no effective antibiotic therapy, surgical excision of the polyps is often successful in treating the disease. R. seeberi has a worldwide distribution with a proclivity for warm, tropical environments. It is most prevalent in southern India, Sri Lanka, and southeast Asia, although cases have been reported in South America, Africa, and the U.S. There are no alternate synonyms for the disease.

19. Synovial fluid analysis

20. Imaging in Osteoarthritis X-ray MRI CT-Scan Bone Scan

21. Conservative therapy ========= =========== Sodium Hyaluronate Acetaminophen Nonsteroidal anti-inflammatory drugs (NSAIDs) Muscle relaxants Glucocorticoids Nonpharmacologic interventions Patient education Temperature-based modalities Weight loss Exercise Physical therapy Occupational therapy Unloading in certain joints (eg, knee, hip)

22. Sodium hyaluronate injections Mechanisms of action : Increased endogenous production of hyaluronate and aggrecan by the joint A mechanical barrier to the activation of nociceptors The inhibition of pain mediators (eg, PGE, bradykinin) An anti-inflammatory effect (eg, inhibition of proinflammatory cytokine activity, inhibition of inflammatory cell function) A beneficial effect on immune cells An antioxidant effect Restoration of the synovial fluid's physical characteristics (viscoelasticity)

23. Electromagnetic field stimulation and TENS device (Bionicare) has been FDA-approved for use in patients with knee osteoarthritis. Pulsed electromagnetic field stimulation is believed to act at the level of articular cartilage by maintaining proteoglycan composition of chondrocytes via down- regulation of its turnover

24. Acupuncture It is effective to decrease pain not for treatment

25. The treatment focuses on reducing the symptoms and chronic effects of osteoarthritis. The mechanism of action for stem cell therapy is believed to be due to stem cells' ability to down-regulate inflammation and promote tissue healing through regeneration Results Most patients treated with stem cell therapy for osteoarthritis require only a single application to obtain relief in contrast to PRP treatment that typically requires 3 injections or viscosupplementation that requires 3-5 injections.PRP treatment viscosupplementation Stem Cell Treatment for Osteoarthritis and other Painful Joint Conditions

26. Surgical therapy Artheroscopy Osteotomy to correct malalignment Debridment of miniscus, cartilage, loose bodies

27. Arthroplasty Uni-Compartmental Bi- Compartmental Tri-Compartmental

29. Indication Contraindication Severe disabling pain esp at night that reduce quality of life Absolute contraindications to total knee replacement include the following: Knee sepsis A remote source of ongoing infection Extensor mechanism dysfunction Severe vascular disease Recurvatum deformity secondary to muscular weakness Presence of a well-functioning knee arthrodesis Relative contraindications include medical conditions that preclude safe anesthesia and the demands of surgery and rehabilitation. Other relative contraindications include the following: Skin conditions within the field of surgery (eg, psoriasis) Past history of osteomyelitis around the knee Neuropathic joint Obesity

30. Other treatments Resection arthroplasty Resection arthroplasty consists of the removal of the joint and allowing the scar to separate the bones and to help in reducing pain. This procedure is sometimes used after the failure of hip replacements if there is extensive bone destruction or persistent infection. Fusion Fusion consists of the union of bones on either side of the joint. This procedure relieves pain but prevents motion and puts more stress on surrounding joints. Fusion is sometimes used after knee replacements fail or as a primary procedure for ankle or foot arthritis. Joint lavage Closed-needle joint lavage may benefit a small subgroup of patients with osteoarthritis.

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