LECTURELECTUREDEGENERATIVE DISEASES OF THE DEGENERATIVE DISEASES OF THE

JOINTS AND SPINE COLUMN JOINTS AND SPINE COLUMN (OSTEOARTHRITIS, (OSTEOARTHRITIS,

OSTEOCHONDROSIS).OSTEOCHONDROSIS).

DefinitionDefinition Also known as Also known as

degenerative joint degenerative joint disease or “wear and disease or “wear and tear arthritis”.tear arthritis”.

Progressive loss of Progressive loss of cartilage with cartilage with remodeling of remodeling of subchondral bone subchondral bone and progressive and progressive deformity of the joint deformity of the joint (s). (s).

Cartilage destruction Cartilage destruction may be a result of a may be a result of a variety of etiologiesvariety of etiologies

Osteoarthritis (OA) - Osteoarthritis (OA) - DefinitionDefinition•The repair mechanisms of tissue

absorption and synthesis get out of balance and result in osteophyte formation (bone spurs) and bone cysts

A case of the, “Which came first? The chicken or the egg?”

Osteoarthritis (OA)Osteoarthritis (OA) OA is the OA is the most common most common

form of arthritis and the form of arthritis and the most common joint most common joint diseasedisease

Most of the people who Most of the people who have OA are older than have OA are older than age 45, and women are age 45, and women are more commonly affected more commonly affected than men.than men.

OA most often occurs at OA most often occurs at the ends of the fingers, the ends of the fingers, thumbs, neck, lower back, thumbs, neck, lower back, knees, and hips.knees, and hips.

AgeAge Age is the strongest risk factor for OA. Although OA can start in Age is the strongest risk factor for OA. Although OA can start in

young adulthood, if you are over 45 years old, you are at higher risk.young adulthood, if you are over 45 years old, you are at higher risk.

Female genderFemale gender In general, arthritis occurs more frequently in women than in men. In general, arthritis occurs more frequently in women than in men.

Before age 45, OA occurs more frequently in men; after age 45, OA Before age 45, OA occurs more frequently in men; after age 45, OA is more common in women. OA of the hand is particularly common is more common in women. OA of the hand is particularly common among women. among women.

Joint alignmentJoint alignment People with joints that move or fit together incorrectly, such as bow People with joints that move or fit together incorrectly, such as bow

legs, a dislocated hip, or double-jointedness, are more likely to legs, a dislocated hip, or double-jointedness, are more likely to develop OA in those joints. develop OA in those joints.

OA – Risk Factors

Hereditary gene defectHereditary gene defect A defect in one of theA defect in one of the genes responsible for the cartilage genes responsible for the cartilage

component collagen can cause deterioration of cartilage. component collagen can cause deterioration of cartilage.

Joint injury or overuse caused by physical labor or Joint injury or overuse caused by physical labor or sportssports

Traumatic injury (ex. Ligament or meniscal tears) to the knee Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip increases your risk for developing OA in these joints. or hip increases your risk for developing OA in these joints. Joints that are used repeatedly in certain jobs may be more Joints that are used repeatedly in certain jobs may be more likely to develop OA because of injury or overuse. likely to develop OA because of injury or overuse.

ObesityObesity Being overweight during midlife or the later years is among Being overweight during midlife or the later years is among

the strongest risk factors for OA of the knee. the strongest risk factors for OA of the knee.

OA – Risk Factors

OA – SymptomsOA – Symptoms OA usually occurs slowly OA usually occurs slowly

- It may be many years - It may be many years before the damage to before the damage to the joint becomes the joint becomes noticeablenoticeable

Only a third of people Only a third of people whose X-rays show OA whose X-rays show OA report pain or other report pain or other symptoms:symptoms:

– Steady or intermittent pain in a joint – Stiffness that tends to follow periods of inactivity, such as sleep or

sitting – Swelling or tenderness in one or more joints [not necessarily

occurring on both sides of the body at the same time] – Crunching feeling or sound of bone rubbing on bone (called crepitus)

when the joint is used

Asymmetrical joint space narrowing from loss of articular cartilage

The medial (inside) part of the knee is most commonly affected by osteoarthritis. 

OA – Radiographic Diagnosis

Normal knee anatomyNormal knee anatomy

left: Normal x-rayleft: Normal x-ray Right: worn away cartilage reflected by Right: worn away cartilage reflected by

decreased joint spacedecreased joint space

OA – Radiographic Diagnosis•Asymmetrical joint space narrowing

•Periarticular sclerosis

•Osteophytes

•Sub-chrondral bone cysts

Joint space Joint space narrowing where narrowing where there is more there is more stressstress

Subchondral bone Subchondral bone has thickenedhas thickened

bony overgrowthbony overgrowth

significant joint space narrowing as well as proliferative significant joint space narrowing as well as proliferative bone formation around the femoral neck (arrows) bone formation around the femoral neck (arrows)

Left: normal hipLeft: normal hipRight: There is some joint space medially but the superior portion is Right: There is some joint space medially but the superior portion is

completely destroyed. Supralateral aspects affected most because completely destroyed. Supralateral aspects affected most because the weight is transfered through the roof of the acetabulum. the weight is transfered through the roof of the acetabulum.

Note the sclerosis and oseophyte formation (arrow). Note the sclerosis and oseophyte formation (arrow).

painful bone on bone contact at the CMC joint and the large painful bone on bone contact at the CMC joint and the large bone spurs -- osteophytes. bone spurs -- osteophytes.

What to look for in an x-rayWhat to look for in an x-ray Radiographic changes visible Radiographic changes visible

relatively late in the diseaserelatively late in the disease Subchondral sclerosisSubchondral sclerosis Joint space narrowing esp where Joint space narrowing esp where

there is stressthere is stress Subchondral cystsSubchondral cysts OsteophytesOsteophytes Bone mineralization should be Bone mineralization should be

normalnormal

X-ray shows lateral osteophytes, varus deformity, narrow joint X-ray shows lateral osteophytes, varus deformity, narrow joint space in a 70 yr old female with OAspace in a 70 yr old female with OA

Clinical features and diagnosisClinical features and diagnosis PainPainSourcesSources

– Joint effusion and stretching of the joint capsule Joint effusion and stretching of the joint capsule – Torn menisci Torn menisci – Inflammation of periarticular bursaeInflammation of periarticular bursae– Periarticular muscle spasm Periarticular muscle spasm – Psychological factors Psychological factors

Deep, aching localized to the jointDeep, aching localized to the joint Slow in onsetSlow in onset Worsened with activity in initial stagesWorsened with activity in initial stages Occurs at rest with advanced diseaseOccurs at rest with advanced disease

May be referred eg hip pain referred May be referred eg hip pain referred to the thigh, groin, knee. to the thigh, groin, knee.

Pain may be aggravated with Pain may be aggravated with weather changesweather changes

ExamExam

Joint line Joint line tendernesstenderness

Bony enlargement Bony enlargement of jointof joint

+/- effusion+/- effusion Crepitus Crepitus Decreased range of Decreased range of

motionmotion

Joint examJoint exam Joint line pain can Joint line pain can

indicate tear of the indicate tear of the lining of the lining of the capsule or the capsule or the meniscus.meniscus.

Where is the Where is the patella?patella?

Joint examJoint exam In the evaluation of joint In the evaluation of joint

line pain, perform a line pain, perform a varus or or valgus stress test. .

Apply stress across the Apply stress across the joint, place fingers joint, place fingers directly over the joint directly over the joint line to assess for pain, a line to assess for pain, a clunk may indicate a clunk may indicate a meniscal tear, or , or crepitus may indicate crepitus may indicate cartilage damage.cartilage damage.

Have the patient to lie supine on the Have the patient to lie supine on the exam table with leg muscles relaxed exam table with leg muscles relaxed

Press the patella downward and Press the patella downward and quickly release it. quickly release it.

the patella visibly rebounds.the patella visibly rebounds. What does this mean? What does this mean? a large knee effusiona large knee effusion Ballotable patellaBallotable patella

Have the patient lie supine Have the patient lie supine with leg muscles relaxedwith leg muscles relaxed

Compress the Compress the suprapatellar pouch with suprapatellar pouch with your thumb, palm, and your thumb, palm, and index finger. index finger.

"Milk" downward and "Milk" downward and laterally so that any excess laterally so that any excess fluid collects on the medial fluid collects on the medial side. side.

Tap gently over the Tap gently over the collected fluid and observe collected fluid and observe the effect on the lateral the effect on the lateral side side

A fullness on the lateral A fullness on the lateral side indicates the presence side indicates the presence small knee effusion small knee effusion

Involved jointsInvolved joints

DIP, PIPDIP, PIP 11stst carpometacarpal carpometacarpal cervical/lumbar facet jointscervical/lumbar facet joints 11stst metatarsophalangeal metatarsophalangeal HipsHips KneesKnees

UncommonUncommon Wrist, elbows, shoulders, Wrist, elbows, shoulders,

anklesankles

11stst metatarso-phalangeal most commonly metatarso-phalangeal most commonly affected in OA of the foot. affected in OA of the foot.

OA – Arthroscopic Diagnosis

Normal Articular Cartilage

Ostearthritic degenerated cartilage with exposed subchondral bone

Arthroscopy allows earlier diagnosis by demonstrating the more subtle cartilage changes that are not visible on x-ray

•OA is a condition which progresses slowly over a period of many years and cannot be cured•Treatment is directed at decreasing the symptoms of the condition, and slowing the progress of the condition

•Functional treatment goals:•Limit pain•Increase range of motion•Increase muscle strength

OA – Disease Management

TreatmentTreatment Non-pharmacokineticNon-pharmacokinetic No proven medication-based disease No proven medication-based disease

modifying intervention exists. modifying intervention exists. Analgesics (acetominophen)Analgesics (acetominophen) NSAIDSNSAIDS Help pain symptoms but controversial for Help pain symptoms but controversial for

long term use in non-inflammatory OA long term use in non-inflammatory OA because of risks vs benefitsbecause of risks vs benefits

NarcoticsNarcotics Intra-articular steroidsIntra-articular steroids Chondroprotective agentsChondroprotective agents Anti-depressantsAnti-depressants

Intra-articular corticosteroidsIntra-articular corticosteroids May be used if NSAIDS are contraindicated, May be used if NSAIDS are contraindicated,

persistent pain despite use of other persistent pain despite use of other medications.medications.

(not > 4 injections per year per joint)(not > 4 injections per year per joint) 2004 meta-analysis of controlled trials (w/ 2004 meta-analysis of controlled trials (w/

placebo) showed short term improvement in placebo) showed short term improvement in knee pain, but efficacy in other joints is knee pain, but efficacy in other joints is uncertain.uncertain.

saline vs steroid injection?saline vs steroid injection? A study comparing the two in knee OA A study comparing the two in knee OA

showed no effect on joint space narrowing or showed no effect on joint space narrowing or significant difference in pain at the end of significant difference in pain at the end of the study, but over a 2 yr period saline the study, but over a 2 yr period saline injections has less pain relief.injections has less pain relief.

Intra-articular hyaluronansIntra-articular hyaluronans Evidence shows they have a small Evidence shows they have a small

advantage in terms of pain control, advantage in terms of pain control, compared to intra-articular placebos or compared to intra-articular placebos or NSAIDS.NSAIDS.

No evidence for improvement in No evidence for improvement in functionfunction

Two studies comparing intra-articular Two studies comparing intra-articular steroids to hyaluronans have come to steroids to hyaluronans have come to opposite conclusions-more trials are opposite conclusions-more trials are needed.needed.

Intra-articular Intra-articular CorticosteroidsCorticosteroids

Beneficial in KNEEBeneficial in KNEE– LOE 1aLOE 1a

Beneficial in HIPBeneficial in HIP– LOE 1bLOE 1b

Short-duration benefits: 2-4 weeksShort-duration benefits: 2-4 weeks Every 3 mos OK; not effective at 2 Every 3 mos OK; not effective at 2

yearsyears

Very effective in knee and hip Very effective in knee and hip – LOE 1a for knee pain, fxn, & stiffnessLOE 1a for knee pain, fxn, & stiffness

Effective in ankle, shoulder (LOE lower)Effective in ankle, shoulder (LOE lower) Delayed effect (4 weeks)Delayed effect (4 weeks) Long duration (6 months)Long duration (6 months) 1-5 weekly injections1-5 weekly injections

Intra-Articular Hyaluronic Acid Intra-Articular Hyaluronic Acid (IAHA)(IAHA)

“viscosupplement”“viscosupplement”

IAHA: Mechanism of ActionIAHA: Mechanism of Action Increased synovial fluid HA conc.Increased synovial fluid HA conc. Increased cartilage lubrication/elasticityIncreased cartilage lubrication/elasticity Chondrocyte proliferationChondrocyte proliferation Chondrocyte stimulation Chondrocyte stimulation matrix matrix Decreased inflammatory mediatorsDecreased inflammatory mediators Inhibition of nociceptorsInhibition of nociceptors MAY BE DISEASE-MODIFYINGMAY BE DISEASE-MODIFYING HIGH-M.W. prep’s have higher effects HIGH-M.W. prep’s have higher effects in vitroin vitro

Devine, Shaffer. Use of viscosupplementation for knee osteoarthritis: an update. Curr Sports Med Rep 2011

OA – Non-operative Treatments

•Pain medications•Physical therapy•Walking aids•Shock absorption•Re-alignment through orthotics•Limit strain to affected areas

Summary and ReviewSummary and Review Low-impact exercise and strength exercise Low-impact exercise and strength exercise

effectively treat OAeffectively treat OA Minimize use of chronic NSAIDsMinimize use of chronic NSAIDs Viscosupplement injections give long-Viscosupplement injections give long-

lasting pain reductionlasting pain reduction Consider use of multiple treatments Consider use of multiple treatments

simultaneouslysimultaneously Arthroscopic lavage & debridement no Arthroscopic lavage & debridement no

better than conservative mgmtbetter than conservative mgmt

Arthroscopy Arthroscopy Cartilage Cartilage

transplantationtransplantation Joint replacementJoint replacement

SurgerySurgery

•Osteoarthritis usually affects the inside half (medial compartment) of the knee more often than the outside (lateral compartment).

•This can lead to the lower extremity becoming slightly bowlegged, or in medical terms, a genu varum deformity

Proximal Tibial Osteotomy

Rt: varus deformity of the kneeRt: varus deformity of the knee

Proximal Tibial Osteotomy•The result is that the weight bearing line of the lower extremity moves more medially (towards the medial compartment of the knee).

•The end result is that there is more pressure on the medial joint surfaces, which leads to more pain and faster degeneration.

•In some cases, re-aligning the angles in the lower extremity can result in shifting the weight-bearing line to the lateral compartment of the knee. This, presumably, places the majority of the weight-bearing force into a healthier compartment. The result is to reduce the pain and delay the progression of the degeneration of the medial compartment.

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.

OsteotomyOsteotomy Realignment of JointsRealignment of Joints Transfer Weight to Transfer Weight to

less involved part of less involved part of jointjoint

60s and 70s60s and 70s Less popularLess popular Does not provide Does not provide

good long term good long term resultsresults

The ultimate solution for osteoarthritis of the knee is to replace the joint surfaces with an artificial knee joint:•Usually only considered in people over the age of 60•Artificial knee joints last about 12 years in an elderly population

•Not recommended in younger patients because:•The younger the patient, the more likely the artificial joint will fail•Replacing the knee the second and third time is much harder and much less likely to succeed.•Younger patients are more active and place more stress on the artificial joint, that can lead to loosening and failure earlier•Younger patients are also more likely to outlive their artificial joint, and will almost surely require a revision at some point down the road.

•Younger patients sometimes require the surgery (simply because no other acceptable solution is available to treat their condition)

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

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Photographs of total knee components on model bone

Total Knee Replacement

Total Joint ReplacementTotal Joint Replacement Considered last Considered last

Solution for ArthritisSolution for Arthritis Improved Improved

AmbulationAmbulation Decreased PainDecreased Pain Increased ROMIncreased ROM 90%+ good to 90%+ good to

excellent resultsexcellent results

Unicompartmental Knee Replacement

•When only one part of the knee joint is arthritic, it may be possible to replace just this part of the joint

•The procedure is similar to a total knee replacement, but only one side of the joint is resurfaced

•A metal component is fit onto the femur and a plastic bearing is inserted either directly onto the tibia or onto a metal tray which has been fit onto the tibia

•Recovery time is generally slightly shorter following this kind of surgery.

LOE IIILOE III Universally Universally

recommended to recommended to improved pain, improved pain, function, QOLfunction, QOL– UnicompartmentalUnicompartmental– Total joint replacementTotal joint replacement

Knee Joint Knee Joint ReplacementReplacement

OA – Arthroscopic Treatment•In addition to being the most accurate way of determining how advanced the osteoarthritis is:•Arthroscopy also allows the surgeon to debride the knee joint

•Debridement essentially consists of cleaning out the joint of all debris and loose fragments. During the debridment any loose fragments of cartilage are removed and the knee is washed with a saline solution. •The areas of the knee joint which are badly worn may be roughened with a burr to promote the growth of new cartilage - a fibrocartilage material that is similar scar tissue. •Debridement of the knee using the arthroscope is not 100% successful. If successful, it usually affords temporary relief of symptoms for somewhere between 6 months - 2 years.

•Arthroscopy also allows access for surgical treatment of articular cartilage: graft-transplantation, micro-fracture techniques, sub-chondral drilling

NO BENEFIT for unselected NO BENEFIT for unselected OA (mechanical or OA (mechanical or inflammatory causes), Ibinflammatory causes), Ib– Moseley JB et al. A controlled trial Moseley JB et al. A controlled trial

of arthroscopic surgery for of arthroscopic surgery for osteoarthritis of the knee. osteoarthritis of the knee. N Engl N Engl J MedJ Med 2002 Jul 11; 347(2):81-8. 2002 Jul 11; 347(2):81-8.

– Kirkley A et al. A randomized trial Kirkley A et al. A randomized trial of arthroscopic surgery for of arthroscopic surgery for osteoarthritis of the knee. osteoarthritis of the knee. NEJMNEJM Sep 2008;359:1097.Sep 2008;359:1097.

– Two other RCTsTwo other RCTs

Arthroscopy with Arthroscopy with Lavage and DebridementLavage and Debridement

Left: View of normal elbow cartilage through Left: View of normal elbow cartilage through an arthroscope - white, glistening, smooth an arthroscope - white, glistening, smooth

Right: severe elbow osteoarthritis - cartilage Right: severe elbow osteoarthritis - cartilage is lost and the bone underneath is exposed is lost and the bone underneath is exposed

SurgerySurgeryArthroscopyArthroscopy Least InvasiveLeast Invasive Remove partially Remove partially

damaged cartilagedamaged cartilage Remove dead Remove dead

cartilage and cartilage and enzymes that enzymes that cause inflammationcause inflammation

Arthroscope

Portals

Damaged cartilage

Abrasion / DrillingAbrasion / Drilling Abrasion and DrillingAbrasion and Drilling Healing responseHealing response Fibrocartilage= Scar Fibrocartilage= Scar

CartilageCartilage Inferior mechanical Inferior mechanical

properties to properties to articular cartilagearticular cartilage

Less advanced OALess advanced OA Focal arthritisFocal arthritis

Focal, localized lesionFocal, localized lesion

Surgical: arthroscopySurgical: arthroscopy arthroscopy is not recommended for arthroscopy is not recommended for

nonspecific "cleaning of the knee“.nonspecific "cleaning of the knee“. Used to fix specific structural Used to fix specific structural

damage on imaging (repairing damage on imaging (repairing meniscal tears, removing fragments meniscal tears, removing fragments of torn menisci that are producing of torn menisci that are producing symptoms). symptoms).

Mosaicplasty / OATSMosaicplasty / OATS Localized focal Localized focal

arthritis/defectarthritis/defect Traumatic arthritisTraumatic arthritis Small to medium Small to medium Transferring Transferring

healthy healthy plug of plug of bone and cartilagebone and cartilage to defect in weight to defect in weight bearing areabearing area

Small Large

ACIACI Articular Cartilage Articular Cartilage

ImplantationImplantation ““Pot hole in the road”Pot hole in the road” Two operationsTwo operations Cartilage harvested and Cartilage harvested and

sent to Lab, to grow in sent to Lab, to grow in CultureCulture

Cartilage cells Cartilage cells transplanted into the transplanted into the defectdefect

In future may be In future may be applicable to large applicable to large lesions/primary OAlesions/primary OA

SummarySummary Accurate Diagnosis importantAccurate Diagnosis important Understand the nature of this Understand the nature of this

ProblemProblem Many treatment Options availableMany treatment Options available Benefits and limitations Benefits and limitations Choose the right treatment for youChoose the right treatment for you Get back into the gameGet back into the game

The degree of osteoarthritis has been classified by N. S. The degree of osteoarthritis has been classified by N. S. Kosinskaya as shown in Table 2.Kosinskaya as shown in Table 2.

Table 2Table 2 Classification of degree of osteoarthritisClassification of degree of osteoarthritis..GradeGrade PainPain Level of activityLevel of activity The range of The range of

movementmovementRadiological changesRadiological changes

Grade Grade 11

Slight and Slight and occasional occasional pain. pain. Weight Weight bearing is bearing is possible.possible.

A patient may A patient may able to able to perform perform certain certain activities of activities of daily living.daily living.

The range of movement The range of movement in the joint is not in the joint is not limited or there is limited or there is loss of part of the loss of part of the range of movements range of movements in the joint.in the joint.

Slight narrowing of joint Slight narrowing of joint space. Small marginal space. Small marginal osteophytes.osteophytes.

Grade Grade 22

Moderate Moderate pain, but a pain, but a patient patient may be may be able to able to weight weight bear albeit bear albeit with pain.with pain.

There is There is increasing increasing difficulty in difficulty in walking and walking and standing. standing.

Moderate limitations of Moderate limitations of movement, movement, contractures and contractures and fixed flexion fixed flexion deformities with deformities with apparent shortening apparent shortening of the affected limb. of the affected limb. There are pain and There are pain and crepitus on crepitus on movement.movement.

Gross narrowing of joint Gross narrowing of joint space. Moderate space. Moderate marginal osteophytes marginal osteophytes and cysts. and cysts. Subchondral bone Subchondral bone sclerosis. An alteration sclerosis. An alteration of the joint contours.of the joint contours.

Grade Grade 33

Moderate or Moderate or severe severe pain. pain.

A patient has had A patient has had to modify or to modify or give up give up activities or activities or both because both because of pain and of pain and progressive progressive loss of loss of movement.movement.

Great stiffness in the Great stiffness in the affected joint affected joint (rigidity). (rigidity).

Loss of joint space. Loss of joint space. Massive marginal Massive marginal osteophytes. osteophytes. Osteoporosis of the Osteoporosis of the articular end of the articular end of the bone. Areas of new bone. Areas of new bone formation round bone formation round the joint.the joint.