Osteoarthritis Medicine PDF

11-Nov-20 Prof. Amir Youssef  Osteoarthritis AMIR A YOUSSEF MD ,PhD (LONDON). RPROFESSOR OF REUMATOLOGY AND REHABILITATION MANSOURA UNIVERSITY e-mail : amiram7@ hotmail.com 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef ...

11-Nov-20 Prof. Amir Youssef  Osteoarthritis AMIR A YOUSSEF MD ,PhD (LONDON). RPROFESSOR OF REUMATOLOGY AND REHABILITATION MANSOURA UNIVERSITY e-mail : amiram7@ hotmail.com 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Normal diarthrodial joint (Synovial joint) (e.g. Knee Joint ) The articulating surfaces are covered by a smooth layer of hyaline cartilage and are enclosed in a fibrous capsule. The fibrous capsule merges externally with periosteum, tendons, ligaments, and fascia and internally with the synovial membrane which lines the joint cavity. Articular cartilage is not covered by synovial membrane A small amount of synovial fluid is normally present within the joint cavity. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Articular cartilage Articular cartilage has low metabolic activity; no blood supply, no lymphatic drainage, no nerve supply, poor regenerative capacity. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef Historical considerations Osteoarthritis (OA) occurs in all mammalian species. It is the earliest documented human disease Human skeleton from 2 million years ago show evidence of the effect of OA 11-Nov-20 Prof. Amir Youssef  ? 11-Nov-20 Prof. Amir Youssef  Definition of Osteoarthritis Osteoarthritis (OA) is a degenerative joint disease, occurring primarily in older persons It is characterized by focal degeneration of articular cartilage leading to breaks in it through which synovial fluid enters to bone and forms cysts. Cysts weaken bone so new bone formation occurs at the base of the cartilage lesion (subchondral sclerosis) and at the joint margins (osteophytes) but it is weak bone. OA is not accompanied by any systemic illness. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Epidemiology & Burden Osteoarthritis is the most common form of arthritis in clinical rheumatologic practice Radiographic evidence of osteoarthritis is present in the majority of people over age 65; 80% of them over 75. Approximately 11% of those over 65 have symptomatic osteoarthritis of the knee. OA is associated with considerable burden ,second only to cardiovascular disease in causing severe disability 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Classification 1- Primary OA ( occurs in old age : more than 50 years) (Nodal: localized" or generalized OA) There is a strong inherited pattern 1- Localized ( nodal) OA : Heberden’s nodes at DIP joints. Bouchard’s nodes at PIP joints 2- Generalized OA: Three or more joint involvement or joint groups (all PIP in a hand is considered as a group) and Later OA knee, hip and apophyseal joints of the cervical or lumbar spine 11-Nov-20 Prof. Amir Youssef  Classification 2- Secondary OA (Premature onset OA) Under age of 50 years Affect any joint at any age. Occurs secondary to: Local mechanical factors : e.g. : Trauma, menisectomy. Joint disease: RA, septic arthritis Systemic diseases: Hyperparathyroidism, Acromegally, Ochronosis, (accumulation of homogentisic acid in connective tissue ) Hemochromatosis 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Risk factors of 1ry OA 1- Age With advancing age Gradual loss of Glycosaminoglycan from cartilage Leaving unsupported cartilage collagen fibers. 11-Nov-20 Prof. Amir Youssef  Risk factors 2- Genetic Factor May be present especially in 1ry generalized OA Heberden’s nodes denote generalized form of OA. Also obesity especially in knee OA 3- Sex Both sexes are affected But generalized OA is most common in women especially after menopause (post-menopausal OA). 11-Nov-20 Prof. Amir Youssef  Risk factors 4- Mechanical factors Wear and Tear Accumulated micro-trauma causes changes in subchondral bone that affects a joint’s ability to absorb force of loading. This factor appears mainly in occupational OA. e.g. OA of MCP joints of boxers Knees of housewives Spine of coal miners. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Pathology Manifested first by fibrillation of the surface of the articular cartilage then thinning Clefts in the cartilage surface then develop and eventually loss of cartilage can be seen. Subchondral sclerosis and hypertrophy. Sclerosis is weak bone so causes osteophytes formation and so. Fibrosis and contracture of the capsule. Synovial hypertrophy 11-Nov-20 Prof. Amir Youssef  Pathology 11-Nov-20 Prof. Amir Youssef  Pathology 11-Nov-20 Prof. Amir Youssef  Pathology 11-Nov-20 Prof. Amir Youssef  Pathology 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Distribution The most Common affected joints are : Knee joints Hip joints Lumbar vertebrae (Lumber spondylosis) Cervical vertebrae ( Cervical spondylosis ). Spondylosis is OA of vertebrae Hands : PIP with Boucharde’s nodes, DIP joints with Heberden’s nodes, First CMC joint Feet: first MTP joint. Rarely affected joints are : Ankle Shoulders Elbow Lateral MTP joints of the feet. 11-Nov-20 Prof. Amir Youssef  Symptoms 1- Pain Pain is aching and poorly localized and arising from several structures such as: Bone. Synovium. Ligaments. Capsule. Muscles. It is worsened by exercise and weight bearing, and relieved by rest. As disease progresses, pain during rest develops 11-Nov-20 Prof. Amir Youssef  Symptoms 2- Stiffness Inactivity stiffness is a feature of OA It is not usually a prominent feature When present, it lasts no more than 15 minutes. Morning stiffness: less common 3- Limitation of movement Limitation of joint movement and consequently limitation of the patient activity. 11-Nov-20 Prof. Amir Youssef  Signs 1- Swelling Due to Hypertrophy of subchondral bone Effusion Bony swelling (osteophytes). Nodules 11-Nov-20 Prof. Amir Youssef  Signs 2- Muscle wasting Wasting of muscles acting on the affected joints (Disuse wasting) E.g. Quadriceps wasting in knee OA. 11-Nov-20 Prof. Amir Youssef  Signs 3- Joint tenderness Can be assessed using gentle pressure on the joint 4- Joint palpable Cripetus Coarse cripetus can be felt when putting the palm of the hand over the joint during joint movement 11-Nov-20 Prof. Amir Youssef  Signs 4- Deformity Squaring of hand due to involvement of CMC joint of the thumb Flexion deformity of the knee Geno-varus deformity (bow legs ) Flexion of DIP joint of fingers. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Investigations 1- Routine Laboratory Features All the basic laboratory tests are within the reference range ESR less than 40 mm /h 11-Nov-20 Prof. Amir Youssef  investigations 2- Synovial Fluid Characteristic features of degenerative synovial fluid : Clear synovial fluid high viscosity ( positive string test )  Synovial fluid when dripped from the syringe forms a string of greater than 10 – 15 cm  Inflammatory synovial fluid drips like water forming small drops. Firm mucin clot during test of synovial fluid precipitation in acetic acid. _Slight increase in white cells (< 2000 cell/mm³ ) 11-Nov-20 Prof. Amir Youssef  Investigations 3- Radiography : gold standard Asymmetrical Joint space narrowing Subchondral sclerosis. Subchondral bone cysts. Osteophytes. _Deformity and sublaxation of opposite side of deformity _Central erosions and seal Gull appearance in erosive OA _Irregular articulating surface _ In OA, medial compartment of joints is the most commonly affected. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef Radiographic Classification Kellgren and Lawrence grading system of OA of the knee Grades: 0 (none) 1 (doubtful) 2 (minimal) 3 (moderate) 4 (severe) 11-Nov-20 Prof. Amir Youssef  Cervical spondylosis & disc disease There is narrowing of the interspace between C5 and C6, with osteophytes arising from adjacent bony margins both anteriorly and posteriorly. The remaining intervertebral spaces and posterior articulations are normal. The term spondylosis refers to the formation of osteophytes in response to degenerative disc disease. 11-Nov-20 Prof. Amir Youssef  Lumbar vertebrae, advanced stages This anteroposterior projection of the lumbar spine shows scoliosis and narrowing of the intervertebral spaces on the concave side where extensive osteophyte formation is present. The osteophytes are thick and project laterally Adjacent bony margins are sclerosed. 11-Nov-20 Prof. Amir Youssef  Hips: early disease The left hip joint demonstrates narrowing with sclerosis and osteophyte formation of adjacent bony margins. The right hip is normal. 11-Nov-20 Prof. Amir Youssef  Hips: advanced disease An anteroposterior view shows almost complete loss of joint space in the hip on the right that is associated with sclerosis, osteophyte formation, and extensive cyst formation on adjacent margins of the head and acetabulum. The hip on the left shows only mild sclerosis and early osteophyte formation. 11-Nov-20 Prof. Amir Youssef  Hand There is irregular narrowing of all interphalangeal joints, with osteophyte formation and sclerosis of articulating margins. Subluxation has caused deviation at the distal interphalangeal joints. Similar narrowing and subluxation have occurred in the first metacarpophalangeal joint. 11-Nov-20 Prof. Amir Youssef  First carpometacarpal joint There is marked narrowing of the first carpometacarpal joint space, with extensive sclerosis of adjacent bony margins. Osteophyte formation and subchondral cysts are present. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Treatment Goals of treatment : Patient education Alleviate pain Optimize function Modify progression 11-Nov-20 Prof. Amir Youssef  Before treatment ….  Confirm the diagnosis  Identify risk factors  Assess function  Assess co morbidities  Assess patient goals 11-Nov-20 Prof. Amir Youssef  Current Treatment of OA Patient education Physical & Occupational therapy treatment Medical treatment (pharmacologic treatment) Surgical treatment Psychosocial treatment 11-Nov-20 Prof. Amir Youssef  American College of Rheumatology Guidelines: Non-pharmacologic Management of OA  Patient education  Psychosocial support  Weight loss (if necessary)  Aerobic exercise programs  Physical therapy  Occupational therapy 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Patient education Studies suggest that patient education is around 20% as effective as NSAIDs, and can have a synergistic effect with other treatments Patient information and self- management strategies can empower patients to take control of their arthritis 11-Nov-20 Prof. Amir Youssef What is the best method of patient education ? 11-Nov-20 Prof. Amir Youssef  A- Many patients do well with reading materials. B- some prefer attending lectures D- still other learn best from one to one discussions. C- viewing films and other audio- visual presentations & web sites 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Instructions for joint protection Don’t lie or sit too long in one position. Lose weight if you are over weight Don’t use low chairs. Don’t stand in the same position or walk for long periods. Don’t over exercise the affected joint. Don’t use faulty posture that places stress on the affected joint. (Squatting position for knee OA ) Don’t load the joint when it is very painful 11-Nov-20 Prof. Amir Youssef Does Losing Weight Affect Risk in OA ? For a woman of normal height, weight loss of only 5kg reduces the risk of OA by more than 50%. It is estimated that substantial weight loss e.g. obese to overweight, or overweight to normal weight, could prevent 33% of OA in women and 20% in men. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Therapeutic exercise in OA Isometric exercises for strengthening quadriceps and gluteals are important in reducing pain and disability from large joint OA (knee and hip) Proprioception and standing balance are also improved secondary to improvement in muscle strength Exercises should be included in gradual program increased gradually and tailored to the individual 11-Nov-20 Prof. Amir Youssef  Therapeutic exercise in OA (cont.) However, vigorous prolonged weight - bearing exercise may worsen the articular cartilage and subchondral bone An ideal exercise is swimming, when done in a warm pool )hydrotherapy) Simple gradual home exercise program is readily taught and also effective 11-Nov-20 Prof. Amir Youssef  Therapeutic exercise in OA (cont.) A specific exercise program play a significant role in improving joint ROM and function and reducing pain Clinical studies have shown that a supervised program of fitness walking resulted in improvement of pain, joint function and psychological well-being 11-Nov-20 Prof. Amir Youssef  Other physiotherapy measures Application of heat or cold packs TENS for pain relief Mid Laser therapy (low power laser) 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  Weight relieving measures & splints Walking aids : Crutches & Canes (contra laterally to the affected knee joint ) Walkers Support pillows & Splinting : CMJ splint, Cervical collars knee support: Therapeutic taping of the knee towards the medial side 11-Nov-20 Prof. Amir Youssef  Weight relieving measures & splints Lateral or medial heel wedged insoles : Wear medially wedged insoles if they have lateral compartment OA Wear laterally wedged subtalar strapped insoles if they have medial compartment OA These measures are designed to relive weight on medial compartment or lateral compartment of the knee by mechanically decreasing the varus or valgus torque. Shock absorbing insoles : Made of sponge or silicone 11-Nov-20 Prof. Amir Youssef  Psychosocial Management Psychological status of the patient with OA including anxiety ,depression ,and social support is an important determinant of symptomatic and functional outcome. Providing social support, even just regular telephone contact can ameliorate symptoms. It is important to patients to know that: OA is not invariably progressive Many things can be done to them The patients are not on their own. 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef Pharmacological treatment: 1- Analgesics: paracetamol NSAIDS: glafenine and floctafenine Opioids 2- Antiinflammatory: Conventional NSAIDs (oral short course) Topical NSAIDs or COX-2 selective (When old age, GIT\renal problems) 3- IA steroids when NSAID ineffective. 4- Local application of capsaicin 5- Symptomatic slow acting drugs for OA ( SYSADDA): Diacerein: blocks IL-1B (anti-inflammatory) Visco chondroprotective supplementations: IA hyaluronic acid Hydrated collagen: (ch-alpha plus) Disease modifying drugs: GAGs like keratan sulphate and glucosamine sulphate and chondoriotin Soya and Avocado oils.  A suggested Scheme for Pain Management in OA A patient with OA can start with acetaminophen (Paracetamol ) 1000mg every 8 hours as needed or low dose NSAID Combination of a NSAID and an analgesic is sometimes necessary during painful attack Alternating treatment comprising two weeks of analgesic therapy followed by two weeks of NSAID is recommended 11-Nov-20 Prof. Amir Youssef  A suggested Scheme for Pain Management in OA (cont.) NSAID's with specificity for COX 2 may be considered for those at higher risk for GI ulceration (and my be given with a proton pump inhibitor. Topical NSAIDs are strongly recommended by the ACR, particularly for patients 75 years or older Narcotic analgesia (Tramadol) is indicated for acute exacerbations unresponsive to conventional therapy. 11-Nov-20 Prof. Amir Youssef A suggested Scheme for Pain Management in OA (cont.) However , It is preferable not to adopt a routine approach but to adapt the prescription in accordance with the clinical course of the OA and the individual therapeutic response of each patient ,bearing in mind the primary risk of GI and kidney side effects. 11-Nov-20 Prof. Amir Youssef Avoid polypharmacy 11-Nov-20 Prof. Amir Youssef  Intra-articular steroid injection Indications For hot inflamed joint with effusion After joint aspiration If no response to conventional NSAIDs. 11-Nov-20 Prof. Amir Youssef Symptomatic slow-acting drugs of OA (SYSADOA) Example : Chondroitin & Glucosamine Sulphate Oral preparations of Avocado and Soya unsaponifiable ( AUS) Diacerein ( It blocks interleukin-1 Beta ) Visco supplementation (IA Injection of Hyaluronic acid) 11-Nov-20 Prof. Amir Youssef  1. Efficacy OF Glucosamine & Chondroitin. It is thought to stimulate chondrocytes to make proteoglycans. It is also thought to possibly inhibit cartilage catabolic enzymatic activity. Combination of Glucosamine and Chondroitin may be more effective in patients with moderate-to-severe knee pain Dose of Glucosamine : 500mg caps TDS Dose of Chondroitin : 400mg Caps TID Duration of treatment : 6-8 weeks 11-Nov-20 Prof. Amir Youssef  Diacerein in Osteoarthritis? Diacerein is an anti-inflammatory medication that blocks interleukin-1Beta Clinical studies concluded that diacerein had an effect in improving pain and slowing progression of osteoarthritis compared to standard treatment with NSAIDs or placebo The most common side effect associated with diacerein was diarrhea. Dose : 50 mg twice /day 11-Nov-20 Prof. Amir Youssef Oral preparations of avocado and soya oils: They inhibit MMPs and NO which degrdae cartilage. _Pioscledine: Unsaponifiable ( doesn't dissolve with water and don't make sapons): mix od Avcado and soya oils of ratio 1:2. _Spondex: wheat germ oil+ soya bean oil 11-Nov-20 Prof. Amir Youssef  Surgical Management in OA The decision to use surgery depends on: The patient's level of disability The intensity of pain The interference with the patient's lifestyle The patient's age The patient’s occupation. 11-Nov-20 Prof. Amir Youssef  Indications for Arthroscopy Severe symptomatic OA that has failed to respond to non-surgical management. Evidence on clinical assessment of either: Loose bodies OR Mechanical symptoms such as : locking, Giving way, or Catching. 11-Nov-20 Prof. Amir Youssef  Total Joint Replacement (Arthroplasty) Sugary is most often employed in hip & knee OA, but may be helpful in OA involving CMC & MTP joints and less commonly the DIP & PIP joints Approximately 90% of patients who undergo total joint replacement acquire pain relief and satisfactory function Failure rates are variable (10 to 30% at 10 years) 11-Nov-20 Prof. Amir Youssef 11-Nov-20 Prof. Amir Youssef  New Techniques to Restore Articular Cartilage Autogenous Cartilage implantation : The grafting of cell populations derived from cartilage : Chondroblasts, Chondrocytes, undifferentiated Chondrocytes Autogenous Osteochondral grafting : It is a technique whereby cylinders of bone and autogenous cartilage from a lesser weight bearing position on the distal femur are transferred into prepared tunnels on the articular defect of the femur 11-Nov-20 Prof. Amir Youssef  New Techniques to Restore Articular Cartilage Somatic Gene therapy : Somatic Gene therapy is the introduction of normal genes into cells that contain defective genes to reconstitute a missing protein product Stem cell transplantation : Stem cells are undifferentiated cells that give rise to all of the body cells and organs Three sources of stem cells: embryonic, adult and fetal. Stem cells can differentiate & develop into one of the different types of cells that comprise the living organism 11-Nov-20 Prof. Amir Youssef  Thank you ! 11-Nov-20 Prof. Amir Youssef