Osteoarthritis is a chronic degenerative disorder of synovial joints in which there is progressive softening and erosion/disintegration of the articular cartilage. In the presentation, I will deal in detail about the condition in every dimension with the most recent evidence.

1. OSTEOARTHRITIS
PRESENTED BY:
Dr. Aryan
(Anish Dhakal)

2. Components of
Synovial Joint
Articular cartilage
Subchondral bone
Synovial membrane
Synovial fluid
Joint capsule
Synovial Joint

3. Joint Stability

4. It is the most common joint disease
It is a chronic degenerative disorder of synovial joints in
which there is progressive softening and erosion/disintegration
of articular cartilage
a frequent, if not inevitable, part of aging
Osteoarthritis

5. Prevalence
More prevalent in high income countries comparatively
25% with osteoarthritis have multiple joints involvement
Prevalence
1% < 30 years of age
0ver 50%  >60 years of age
80% over 80 years of age have radiographic evidence

6. Risk Factors for Osteoarthritis
Age (strongest predictor)
Gender (females are more prone)
Genetics (no single gene implicated)
Joint injury (post traumatic OA)
Anatomic factors (joint shape and alignment)
Obesity (weight bearing joints)
Lifestyle (occupational, higher paced physical activity)
Smoking, muscle weakness, physical activity, bone density, etc.

7. Pathophysiology of Osteoarthritis
formerly considered to be simply a degenerative "wear and
tear" process and therefore often misnamed as degenerative
joint disease (an absolute misnomer)
Pathogenesis of OA is much more complex
"-itis" is indicative of an inflammatory process is actually
correct
Destruction and loss of the articular cartilage is a central
component of OA, all joint tissues are affected in some way

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10. Pathophysiology

11. Morphology
At early OA, water content of matrix increases and
concentration of proteoglycans decreases
Proteoglycan content of the cartilage matrix
provides turgor and elasticity
Vertical and horizontal fibrillation and
cracking of the matrix
Eventually chondocyte die and
full thickness of cartilage are
sloughed.

13. Pathology

14. 1. Eburnated articular surface
2. Subchondral cyst
3. Residual articular cartilage

15. Osteoarthritic Changes

17. 17

18. Primary Osteoarthritis
 more common
 occurs in joint de novo
 occurs in old age
 mainly in weight bearing joints (knee, hip)
Secondary Osteoarthritis
 there is underlying primary disease of joint
 occurs in any age after adolescence
 occurs mainly in the hip
Classification

20. Localized OA (Monoarticular or Pauciarticular)
Classic form of OA
Pain & dysfunction of one or more large weight bearing joints
Nodal OA, Hip OA, Knee OA
Generalized OA (Polyarticular)
Most common form of OA
Erosive OA (Rapidly Destructive OA)
Rapid progression of bone destruction occurs
Occurs in elderly women
Associated with deposition of calcium pyrophosphate crystals
Clinical Variants of Osteoarthritis

21. 21

22. Signs and Symptoms
Primary symptoms of osteoarthritis (OA) are joint pain,
stiffness, and locomotor restriction
On clinical grounds:
Persistent usage-related joint pain in one or few joints
Age ≥ 45 years
Morning stiffness ≤ 15 minutes
Imaging and laboratory investigations are reserved for patients
presenting with atypical symptoms and signs

24. Usually a middle aged women who
presents with pain, swelling &
stiffness of the finger joints
The following joints are affected at
almost same time:
1st carpometacarpal joint
Big toe
Meta-tarsophalangeal
Knee joints
Lumbar facet joints
Generalized Osteoarthritis

25. Progressive Vs Non-progressive

27. Heberden’s & Bouchard’s nodes
(Osteophytes)

28. Clinical Findings

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Thumb-base OA: prominence and "squaring" of the thumb base: Osteophyte formation
and subluxation at the first CMC joint

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Erosive hand OA: marked radial deviation and fixed flexion deformity in the left middle PIP joint, radial
deviation with restriction in the index PIP joint, and bony swelling

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Unilateral knee OA: swollen left knee with varus and fixed flexion deformity history of knee trauma. On
palpation, there was marked crepitus, restricted flexion, bony swelling, and a small effusion.

32. 32
Right hip OA with painful restriction with internal rotation in flexion. “Tight-pack" position for the hip (when
the capsule is at its tightest) and is the first movement to be affected.

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Patient with right hip OA, showing fixed flexion and external rotation deformity

34. Investigations
 Serum Uric acid and RF to rule out specific disorders.
 Radionuclide scanning with 99MTc-HDP: increased activity over subchondral regions: increased vascularity and new
bone formation

35. X-ray Findings

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Complete loss of the articular cartilage at all four DIP joints, large osteophytes, and ankylosis of the DIP joint
of the middle finger

39. Differential Diagnosis
Rheumatoid arthritis (symmetric, atrophic rather than hypertrophic arthritis)
Psoriatic arthritis (may be in one finger as dactylitis, and characteristic nail changes are usually present)
Avascular necrosis (articular cartilage loss precedes bone destruction in OA)
Crystalline arthritis (urate or CPP crystals in synovial fluid, tophi on imaging in gout)
Hemochromatosis (targets the MCP joints and wrists, predominates in men, squared-off bone ends and
hook-like osteophytes in the MCP joints)
Infectious arthritis : RA, Ankylosing spondylitis, Reiter disease (inflammatory signs effusion, increased
warmth, erythema), culturing the pathogen from the synovial fluid or from the blood
Diffuse Idiopathic Skeletal Hyperostosis (bony spurs in pelvic apophyses and vertebral column, usually
asymptomatic)
Soft tissue abnormalities (bursitis, tendinitis, enthesitis, etc.)

41. Depends on:
Joint involved
Age of patient
Patient’s functional needs
Management of Osteoarthritis

42. Pain (5 items)
Stiffness (2 items)
Physical Function (17 items)
None (0), Mild (1), Moderate (2), Severe (3), and Extreme (4)
0-20 for Pain, 0-8 for Stiffness, and 0-68 for Physical Function
Activities of daily living, functional mobility, gait, general health, quality of life

43.  Symptoms characteristically wax and wane, and pain may
subside spontaneously for long periods
 Some forms of OA actually become less painful with the
passage of time and the patient may need no more than
reassurance and a prescription for pain killers
 At the other extreme, the recognition (from serial x-rays) that
the patient has a rapidly progressive type of OA may warrant
an early move to reconstructive surgery before bone loss
compromises the outcome of any operation
Management of Osteoarthritis

44. Symptomatic treatment
Tailored to the patient according to individual needs, goals,
and values and should be patient-centered, stall progress
Patient preferences for certain types of therapies should
also be assessed. Compliance must be assessed.
Principles:
maintain movement and muscle strength
protect the joint from ‘overload’
relieve pain
modify daily activities (quality of life)
Management of Osteoarthritis

45. Counseling (patient education)
Physical Therapy (massage, aerobic and muscle strengthening
exercises, local heat application)
Load Reduction
weight reduction in obese patients
wearing shock-absorbing shoes
avoiding activities like climbing stairs, standing and running or sitting
cross legged and squatting in knee osteoarthritis
braces and foot orthoses
Non Pharmacological Therapy

46. Pharmacological Therapy Most Recent Evidence
Topical NSAIDs Initial treatment one or few joints affected,
especially knee and/or hand OA
Topical capsaicin Use may be limited by common local side effects
Oral NSAIDs Inadequate symptom relief with topical NSAIDs,
patients with symptomatic OA in multiple joints,
and/or patients with hip OA (lowest dose, shortest
duration)
Duloxetine Contraindicated oral NSAIDs and for patients with
knee OA who have not responded satisfactorily to
other interventions
Intraarticular glucocorticoid Short duration of its effects (i.e. approximately four
weeks). Not recommended for regular use.
Opioids Strong analgesics. Potential side effects (e.g., nausea,
dizziness, drowsiness), especially for long-term use
and in the older adult population
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47. Other Therapies (Uncertain Benefits)
Nutritional supplements such as glucosamine, chondroitin, vitamin D,
diacerein, avocado soybean unsaponifiables (ASU), and fish oil
Curcumin (active ingredient of turmeric) and/or Boswellia serrata
might be beneficial, but the data are limited
Insoles and footwear
Hyaluronans viscosupplementation weekly injection
Platelet-rich plasma (PRP)
Transcutaneous electrical nerve stimulation (TENS)
Acupuncture
Local heat

50. Progressive joint destruction, with increasing pain,
instability and deformity usually requires reconstructive
surgery
Realignment osteotomy (joint with deformities like high tibial
osteotomy for OA knee). Major part of articular cartilage is
still preserved. Dramatic pain relief.
Vascular decompression of subchondral bone
Redistribution of load towards less damaged part of the joint
Operative Modalities

52. Debridement
synovectomy, excision of osteophytes, removal of loose bodies,
chondroplasty, and removal of damaged menisci
painful and often requires 6 months of postoperative rehabilitation
Arthroscopic treatments of osteoarthritis of the knee include simple
lavage, debridement, and abrasion chondroplasty (less postoperative pain
and shorter rehabilitation)
Success rate about 70%, placebo effect is also evident
Arthroscopic debridement procedures cannot alter the natural
progression of osteoarthritis

53. Arthroscopic view of the removal of cartilaginous loose body

54. 54
Dervin et al.: 126 arthroscopic debridement procedures done for OA knee
44% of patients had significant pain relief at 2 years after surgery
Three variables were significantly associated with improvements in symptoms:
(1) medial joint line tenderness
(2) positive Steinmann test (forced external and internal rotation of a knee flexed to 90 degrees and pain
that is referable to either joint line)
(3) an unstable meniscal tear identified at arthroscopy

55. Operative Modalities
Arthrodesis, still a reasonable choice if the stiffness
is acceptable and neighboring joints are not
compromised (small joints that are prone to OA, e.g.
the carpal and tarsal joints and the large toe
metatarsophalangeal joint)

56. Operative Modalities
Total joint arthroplasty (replacement) is reserved for patients with
severe symptomatic OA who have failed to respond to non
pharmacologic and pharmacologic management (intolerable
symptoms, marked loss of function and severe restriction of daily
activities)
Alternatives to total knee arthroplasty for selected patients with knee
OA include unicompartmental knee arthroplasty and knee osteotomy
Alternatives to total hip arthroplasty for selected patients with hip OA
include hemiarthroplasty, hip osteotomy, and perhaps, for a very
specific group, hip resurfacing

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59. 59

60. Capsular Herniation (Baker’s cyst)
Loose bodies (cartilage and bone fragments: intermittent locking)
Rotator cuff dysfunction (OA of AC joint: impingement, tendinitis
and cuff tears)
Spinal stenosis (lumbar apophyseal joints OA)
Spondylolisthesis (degenerative spondylolisthesis at L4/L5)
Complications of Osteoarthritis

61. Natural History and Prognosis
Great variability among individuals and among different phenotypes
Courses of pain and physical functioning have been found to be
predominantly stable
No single biochemical or imaging markers to predict progressive course
Predominantly characterized by minimum/slow rather than marked
worsening over time
Certain poor prognostic factors have been identified which include
higher pain intensity at baseline, presence of depressive symptoms,
presence of bilateral knee symptoms

62. References
Solomon L, Warwick D, Nayagam S. Apley’s system of orthopedics and fractures, 9th edition
Leticia Alle Deveza et al., Overview of the management of osteoarthritis, https://www.uptodate.com/contents/overview-of-the-
management-of-osteoarthritis
Michael Doherty et al., Clinical manifestations and diagnosis of osteoarthritis, https://www.uptodate.com/contents/clinical-
manifestations-and-diagnosis-of-osteoarthritis
Leticia Alle Deveza et al., Management of knee osteoarthritis, https://www.uptodate.com/contents/management-of-knee-osteoarthritis
Lyn March, AM et al., Epidemiology and risk factors for osteoarthritis, https://www.uptodate.com/contents/epidemiology-and-risk-
factors-for-osteoarthritis
Lisa A Mandl et al., Overview of surgical therapy of knee and hip osteoarthritis, https://www.uptodate.com/contents/overview-of-
surgical-therapy-of-knee-and-hip-osteoarthritis
Karine Louati et al., Comorbidities that impact management of osteoarthritis, https://www.uptodate.com/contents/comorbidities-that-
impact-management-of-osteoarthritis
Campbells Operative Orthopedics, 14th edition
Maheshwari J, Essential Orthopedics, 6th Edition
Review of Orthopedics, Mark D. Miller, 8th Edition