DEFINITION n n n Osteoarthritis OA is a

DEFINITION n n n Osteoarthritis OA is a degenerative disease of diarthrodial (synovial) joints, characterized by Breakdown of articular cartilage and proliferative changes of surrounding bones

Epidemiology n n Incidence : hand OA (symptomatic) 100 per 100, 000 per year hip OA (symptomatic)88 per 100, 000 per year knee OA (symptomatic)240 per 100, 000 per year

n n n demographics females more commonly affected than males incidence rates increase with age racial disparities exist in the treatment of osteoarthritis African American males are the least likely to receive total joint replacement when compared to whites and Hispanics

LIMITED FUNCTION n n n OA may cause functional loss Activites of daily living Most important cause of disability in old age Major indication for joint replacement surgery

Risk Factors n n n modifiable obesity trauma occupation, hard labor muscle weakness metabolic syndrome

Risk Factors n n n non-modifiable gender females at increased risk age genetics race some Asian populations at lower risk

STRUCTURE OF JOINT CARTILAGE n n Collagen (Type 2) Proteoglycan - Hyaluronic acid - Glycoseaminoglycan Water Condrocyte Regeneration and Degeneration

cell biology n n n proteolytic enzymes matrix metalloproteases (MMPs) responsible for cartilage matrix digestion tissue inhibitors of MMPS (TIMPs) : control MMP activity preventing excessive degradation imbalance between MMPs and TIMPs has been demonstrated in OA tissues

What factor(s) is responsible for inducing metalloprotease synthesis n n n IL-1 is a potent pro-inflammatory cytokine that, in vitro, is capable of inducing chondrocytes and synovial cells to synthesize MMPs. IL-1 suppresses the synthesis of type II collagen and proteoglycans, and inhibits transforming growth factor-ß stimulated chondrocyte proliferation. IL-1 may not only actively promote cartilage degradation, but may also suppress attempts at repair, in OA. In addition to these effects, IL-1 induces nitric oxide production, chondrocyte apoptosis, and prostaglandin synthesis, which further contribute to cartilage deterioration.

Pathology n n n n changes in osteoarthritic cartilage increased water content alterations in proteoglycans eventual decrease in amount of proteoglycans collagen abnormalities organization and orientation are lost binding of proteoglycans to hyaluronic acid

Presentation Symptoms : n joint pain often worse in morning n swelling n stiffness Physical exam : n decreased range of motion n malalignment n Effusion n Crepitation

Radiographic findings n n n joint space narrowing osteophytes eburnation of bone subchondral sclerosis subchondral cysts

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

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

LABORATORY FINDINGS OF OA n n There are no pathognomonic laboratory findings for OA Laboratory analysis is performed for differential diagnosis

DIAGNOSIS OF OA CLINICAL FINDINGS + RADIOLOGIC FINDINGS

ACR 2000 Guidelines— Pharmacologic/Surgical Therapy Mild to Moderate Pain • Simple analgesics (eg, acetaminophen) • OTC NSAIDs • Topical creams Moderate to Severe Pain • Rx NSAIDs plus gastroprotective agent, or COX-2–selective inhibitors Additional Therapies • IA hyaluronans • IA steroids Surgical Intervention • Total knee replacement American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000; 43: 1905 -1915.

Non operative : n n n NSAIDs : Indications : first line treatment for all patients with symptomatic arthritis NSAID selection should be based on physician preference, patient acceptability and cost AAOS guidelines strongly recommende

weight loss n n n Indications : patients with symptomatic arthritis and BMI > 25 AAOS guidelines moderate strength of recommendation

Exercise program/physical therapy n n n Indications: first line treatment for all patients with symptomatic arthritis technique combination of supervised exercises and home program has shown best results benefits lost after 6 months if exercises are stopped AAOS guidelines : strongly recommended by the AAOS

Bracing n n n Indications : unicompartmental disease in patients who wish to delay arthroplasty technique varus/valgus unloading braces AAOS guidelines : unable to recommend for or against the use of a brace

Joint injection n n corticosteroid joint injections AAOS guidelines : cannot recommend for or against (inconclusive) viscoelastic joint injections AAOS guidelines : cannot recommend based on strong evide

Operative n n n Arthroscopic debridement indications : degenerative meniscal tears , loose bodies. AAOS guidelines : in the absence of meniscal symptoms, arthroscopic debridement is strongly recommended against High tibial osteotomy indications: Younger patients with unicompartmental disease AAOS guidelines : "limited" strength of recommendation Unicompartmental arthroplasty (knee) indications isolated unicompartmental disease Total joint replacement indicated for advanced disease

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.

Total Knee Replacement • 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

Total Knee Replacement

Rheumatoid Arthritis n n A chronic systemic autoimmune disease with a genetic predisposition Epidemiology : most common form of inflammatory arthritis affects 3% of women and 1% of men

Pathophysiology n n n Immunology : cell-mediated (T cell-MHC type II) immune response against soft tissues (early), cartilage (later), and bone (later) Rheumatoid factor : an Ig. M antibody which recognizes and attacks native Ig. G antibodies Immune complex is then deposited in end tissues like the kidney as part of the pathophysiology Mononuclear cells are the primary cellular mediator of tissue destruction in RA IL-1, TNF-alpha are part of cascsade that leads to joint damage immune response thought be related to infectious etiologyor HLA locus

pathoanatomy n n n cascade of events includes : Antigen-antibody and antibody-antibody reactions > Microvascular proliferation and obstruction > Synovial pannus formation (histology shows prominent intimal hyperplasia) > Joint subluxation, chondrocyte death/joint destruction, and deformity > Tendon tenosynovitis and rupture

Presentation n n n n Symptoms : insidious onset of morning stiffness and polyarthropathy usually affects hands and feet , DIP joint of hand is usually spared may also affect knees, cervical spine, elbows, ankle and shoulder Physical exam : subcutaneous nodules in 20% (strong association with RF in serum) ulnar deviation with metacarpophalangeal (MCP) subluxation, swan neck deformity hallux valgus, claw toes, metatarsophlanageal (MTP) subluxation

Radiographs n n n Periarticular erosions and osteopenia Protrusio acetabuli : medial migration of femoral head past the radiographic teardrop joint space narrowing

Labs n n n n anti-CCP (most sensitive and specific test) elevated ESR elevated CRP positive RF titer (most commonly Ig. M) joint fluid testing decreased complement may have elevated RF levels

Symptoms and Signs Morning stiffness lasting ≥ 1 hour* n Swelling in ≥ 3 joints* n Swelling in hand joints* n Symmetric joint swelling* n Erosions or declacifications on xray of hand n Rhematoid nodules n Abnormal serum RF *Must be present ≥ 6 weeks n

Nonoperative treatment n n n n pharmacologic treatment indications mainstay of treatment medications first line of medications includes NSAIDS, antimalarials, remittent drugs (gold, sulfasalazine, methotrexate), steroids, cytotoxic drugs more aggressive approach with is now favored over pyramid approach Outcomes ; significant advances in pharmocologic management have significantly changes prognosis of disease

Operative treatment n n Indictation: by specific condition significant advances in pharmocologic management have led to a decrease in surgical intervention important to obtain preoperative cervical spine radiographs

Cervical Spondylitis n n Cervical spondylitis includes : atlantoaxial subluxation basilar invagination subaxial subluxation

Rheumatoid nodules n n n n n Epidemiology : most common extra-articular manifestation of RA seen in 25% of patients with RA and associated with aggressive disease an extraarticular process found over IP joints, over olecranon, and over ulnar border of the forearm. erosion through skin may lead to formation of sinus tract Presentation : patients complain of pain and cosmetic concerns Treatment : non operative : steroid injection Operative : surgical excision Indications : cosmetic concerns, pain relief, diagnostic biopsy

n n n Ulnar drift at MCP joint volar subluxation associated with ulnar drifting of digits Treatment , operative early disease: synovectomy, extensor tendon centralization, and intrinsic release Late disease: MCP arthroplasty

n n Boutonneire deformity treat with PIP arthrodesis Swan neck deformity treat with proximal Fowler tenotomy or intrinsic release and MCP reconstruction if PIp flexion is limited

n n n Extensor Tendon Rupture Treatment : tendon transfer, interposition graft,

Rheumatoid elbow n n Treatments: synovectomy and radial head excision interposition arthroplasty total elbow arthoplasty

Knee Conditions n n synovectomy of knee total knee arthroplasty

Foot & Toe Conditions n n Toe hyperextension deformity arthrodesis of the 1 st MTP joint and lesser MTP joint resections