Josep Vidal Alaball HCE

1. OSTEOARTHRITIS Josep Vidal Alaball HCE

2. OSTEOARTHRITIS • Commonest condition to affect synovial joints • Single most important cause of locomotor disability • Previously considered a degenerative disease, inevitable consequence of ageing and trauma • Now viewed as a metabolically dynamic, essentially reparative process.

3. Is a condition of synovial joints with focal cartilage loss and accompanying reparative bones response.

4. In most cases this slow but metabolically active process keeps pace with various triggering insults and is non-progressive. • But sometimes it fails to compensate, resulting in joint failure. • Various extrinsic and intrinsic insults cause different patterns of arthritis, and multiple constitutional and environmental factors modify response and outcome.

5. Osteoarthritis targets specific joints, possibly those that have undergone recent evolutionary change in function (relating to bipedal locomotion and precision grip) without yet adapting adequately.

6. ASSESSMENT • For many plain radiograph remains the best means of assessment: • Evidence of cartilage loss (joint space narrowing) • Bone response (osteophytes and sclerosis) • There is often considerable discordance between structural change and clinical outcome

10. RISK FACTORS 1. AGE • NOT and inevitable consequence of ageing, BUT strongly related to age • Uncommon in people under 45 • Prevalence increases up to age 65, when al least 50% of people have RX evidence of OA in at least one joint group • May represent cumulative insult to the joint, possibly aggravated by decline in neuromuscular function

11. 2. SEX • Pronounced FEMALE preponderance in • hands and knee 3. ETHNIC GROUP • Uncommon in Black and Asian populations • This seems to reflect genetic rather than cultural differences

12. 4. INDIVIDUAL RISK FACTORS • Generalised factors • Obesity • Genetic factors • Female • Localised factors E.g.: • Meniscectomy • Instability • Dysplasia

13. TYPES OF OA 1. NODAL GENERALISED OA • Characterised by multiple Heberden´s nodes (distal interphalangeal joint) and Bouchard´s nodes (interphalangeal joint) • Symptoms usually starting around menopause • Aetiology unknown

15. 2. CRISTAL ASSOCIATED OA • Calcium crystals, notably calcium pyrophospate dyhidrate and apatite, may deposit in cartilage. • Predominantly in elderly women, affecting the knee

16. 3. OA OF PREMATURE ONSET • Development of single joint OA after severe trauma is not uncommon • Premature onset in multiple joints may be a presenting feature of other conditions: • Haemochromatosis • Ochronosis • Acromegaly • Thiemann’s disease • Hereditary type II collagen defects • Endemic OA

17. CLINICAL FEATURES • PAIN • Typically sharp pain on using the joint or dull ache which may occur at rest or during the night • Greatly influenced by personality, anxiety, depression and daily activity • GELLING OF JOINTS • Stiffness after immobility, morning stiffness lasting no more than 30 min. • FUNCTIONAL IMPAIRMENT

18. CREPITUS • BONY ENLARGEMENT • DEFORMITY • INSTABILITY • SYNOVITIS • MUSCLE WEAKNESS OR WASTING

19. THERAPEUTIC OPTIONS • Non-pharmacological treatment • Education (patient and spouse or family) • Social support (telephone contact) • Physiotherapy (aerobic exercises, muscle strengthening, and patellar strapping) • Occupational therapy (aids and appliances, joint protection) • Weight loss • Acupuncture • Transcutaneous electrical nerve stimulation (TENS)

20. Pharmacological treatment • Simple analgesia • Non-steroidal anti-inflammatory drugs • COX-2 inhibitors (cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drugs) • Topical (NSAID drugs, capsaicin) • Chondroprotective agents • Intra-articular treatment • Corticosteroids • Hyaluronans • Tidal irrigation

21. PATIENT EDUCATION • Trials contrasting education vs. effects of NSAIDs confirmed a significant beneficial effect on education in joint pain but not on disability. • Any member of the care team can provide education in several forms: literature, audiocassette, computer… • Emphasise weight reduction and exercise

22. In OA of the knee controlled studies have shown that regular telephone contact from healthcare produces significant improvement in pain and function OCCUPATIONAL THERAPY SOCIAL SUPPORT • Walking aids, orthoses, splints

23. PHYSICAL THERAPY • Muscle strengthening programmes • Specific for certain joints • Shown to improve pain and disability in OA of the knee • TENS (transcutaneous electrical nerve stimulation) • Modest pain relief compared with placebo • Acupuncture

24. Changes in lifestyle for patients with OA • General measures • Maintain optimal weight • Encourage activity and regular general exercise • Maintain positive approach • Specific measures • Strengthening of local muscles • Use of appropriate footwear and walking aids • Pay attention to specific problems caused by disability (such as shopping, housework, and job)

25. ANALGESICS, NSAIDs, COX-2 i • PARACETAMOL • It is safe and effective • Slight benefit from addition of dextropropoxyphene • NSAIDs • More effective than placebo in reducing pain and improving function • Few studies have lasted longer than 2 years • No evidence they affect progression of OA

26. Evidence that MISOPROSTOL and PPI reduce risk of upper GI injury • Cost utility of prophylactic use is controversial • Recommended to initiate NSAIDs only after consideration of side effects • Prescription should be reviewed every 6 months • COX-2 INHIBITORS • Published data remains scarce • Trials have shown similar efficacy to NSAIDs with GI toxicity comparable with placebo • Cost effective strategy for their use far from clear

27. Relative contraindications to starting treatment with NSAIDs* Gastrointestinal toxicity. Caution in:- Those aged >65 years - Patients with a history of peptic ulcer disease - Concomitant treatment with corticosteroids and anticoagulants - Smokers - Patients with cardiovascular disease - Heavy alcohol drinkers* Renal toxicity. Caution in:- Those aged >65 years - Patients with hypertension - Patients with congestive cardiac failure - Concomitant medication with ACE inhibitors and diuretics

28. TOPICAL TREATMENT • NSAIDs and CAPSAICIN • Strong evidence that they are effective and safe • Fewer side effects probably should be used more often • However substantial doubt as their superiority over simple rubefacients

29. INTRA-ARTICULAR THERAPY • CORTICOSTEROIDS • Use controversial in uncomplicated OA • Superior short term efficacy to intra-articular placebo • Benefits last 2 to 4 weeks • Indicated in patients with acute crystal associated synovitis and those unfit for or awaiting surgery • Potential for multiple injections to accelerate cartilage damage

30. HYALURONIC ACID • In people with OA there is a reduced concentration of this acid • Trials suggest superior pain relief to placebo and equivalent to corticosteroids injections with greater duration of action • TIDAL IRRIGATION • Irrigation of knee joint with saline • Trials suggest some role in treatment of knee OA

31. CHONDROPROTECTIVE AGENTS • Clinical trials provide some justification for the use of CHONDROITIN and GLUCOSAMINE preparations but only for their analgesic or anti-inflammatory effects

32. SURGERY • JOINT REPLACEMENTS • ARTHROSCOPIC LAVAGE • OSTEOTOMY • ARTHRODESIS

33. THE END