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Osteoarthritis Definition

• Joint symptoms and signs occur due to articular cartilage degeneration.
• These symptoms are related to changes in the underlying bone and the joint margin.

Classification

• Primary osteoarthritis affects certain joints and is related to old age.
• The cause of primary osteoarthritis is unknown.
• Secondary osteoarthritis can affect any joint at any age.
• Local mechanical factors like trauma or menisectomy can cause secondary OA.
• Joint diseases like RA or septic arthritis can cause secondary OA.
• Systemic diseases like hyperparathyroidism can cause secondary OA.

Primary Osteoarthritis Risk Factors

• Advancing age leads to a loss of glycosamino-glycan.
• This loss leaves unsupported cartilage collagen fibers.
• Genetics may be present, especially in generalized OA.
• Both sexes are affected, but generalized OA is more common in females, especially after menopause.
• Obesity predisposes individuals to knee OA.
• Repeated overload is another risk factor.

Pathology of Osteoarthritis

• Fibrillation occurs on the cartilage articular surface.
• This leads to clefts in the cartilage surface and subsequent loss of cartilage.
• Hypertrophy is observed in the synovial membrane.
• Fibrosis and contracture of the capsule occur.
• Subchondral sclerosis occurs in the bone.
• Marginal osteophytes are observed in bone changes.

Clinical Picture - Distribution of Joints

• Common joints affected include:
  • Knee joint
  • Lumbar and cervical vertebrae
  • Hand (PIP joints/Bouchard's nodes, DIP joints/Heberden's nodes, 1st CMC joint)
  • Feet (1st MTP joint)
  • Hip joint.
• Rarely affected joints include:
  • Ankle
  • Shoulders
  • Lateral MTP joints of the feet.
• Heberden's nodes are located on the distal interphalangeal joint.
• Bouchard's nodes are located on the proximal interphalangeal joint.

Symptoms of Osteoarthritis

• Pain sources include Bone, Synovium, Ligaments, Capsules and Muscle.
• Pain is worsened by exercise and weight bearing.
• The character of the pain is aching.
• Pain is poorly localized.
• As the disease progresses, pain occurs during rest.
• Inactivity stiffness is present for a few minutes.
• Morning stiffness is not a prominent feature and lasts no more than 1/4 hour.
• There is a limitation of movement and activity.

Signs of Osteoarthritis

• Swelling is due to Synovial thickening, Effusion, or Bony swelling.
• Heberden's nodes over distal interphalangeal joints
• Bouchard's nodes over proximal interphalangeal joints
• Wasting of muscles acting on the affected joints.
• Deformity:
  • Flexion deformity of the knee
  • Genu varum
  • Genu valgum
• Joint tenderness occurs.
• Joint crepitus is coarse.

Investigations - Plain X-ray

• Plain X-ray is the most useful showing:
  • Joint space narrowing
  • Subchondral bone sclerosis
  • Subchondral bone cysts
  • Osteophytes (bone spurs)
  • Central bone erosions in erosive OA
• Black arrows point to subchondral sclerosis.
• White arrows point to osteophytes.
• Black arrowheads point to joint narrowing in the medial compartment.

Investigations - Laboratory & Synovial Fluid

• Laboratory features are normal.
• Synovial fluid:
  • Good viscosity
  • Normal mucin clot
  • Slight increase in cell count

Treatment - Joint Protection and Physiotherapy

• Instructions for joint protection to avoid overstressing the affected joints.
  • Do not lie or sit too long in one position.
  • Do not use low chairs.
  • Do not stand in the same position or walk for long periods.
  • Do not over exercise the affected joints.
  • Do not use faulty postures that place stress on affected joints.
  • Do not load the joint when it is very painful.
  • Reduction of body weight in obese patients.
• Physiotherapy types:
  • Heat
  • Cold
  • Electric stimulation
  • Laser
  • Massage
  • Exercise
• Physiotherapy benefits:
  • Reduce pain, stiffness, and muscle spasm
  • Improve joint range of motion
  • Strengthen peri-articular structures to improve joint support
  • Improve blood supply and metabolism.

Treatment - Medication and Assistive Devices

• Medication:
  • Use simple analgesics for pain.
  • Use short courses of NSAIDS to control symptoms.
  • Use chondro-protective drugs and visco-supplements.
• Assistive devices:
  • Knee brace
  • Stick
  • Benefit: Partially unload the joint

Treatment - Surgical

• Osteotomy corrects deformity.
• Arthroplasty is a partial or total joint replacement.