OSTEOARTHRlTIS

Dr.H.Djumadi Achmad, SpPA(K)

Definition

Chronic, localized joint disorder with no systemic effects Progressive degeneration of the cartilage Hyperthrophy & remodeling of the subchondral bone Secondary inflammation of the synovial membrane

Synonims

Osteoarthrosis Degenerative joint disease Degenerative arthritis Senescent arthritis Hyperthrophic arthritis

Incidence

Increases with aging process Found mainly at age of over 50 years Young people can develop OA history of articular cartilage injury Wear & tear mechanism most common in weight bearing synovial joints, e.g. spine, hip, knee & interphalangeal jonts

Etiology

Disparity between the stress applied to articular cartilage & the ability of the articular cartilage to withstand that stress
Increased stress Weak cartilage Abnormal support from the subchondral bone

Primary: idiopathic Secondary: injury, deformity & diseases capable of producing cartilage lesion

Pathogenesis & Pathology

Biomechanical Theory
Excessive joint loading

Altered stress

Abnormal chondrocyte function

Imbalance between matrix mobilization/synthesis Release of degradative enzymes

Cartilage breakdown

Biochemical Theory
Aging Impaired matrix maintenance

Synovitis

Release of degradative enzymes

Death of chondrocytes

Cartilage breakdown

Articular Cartilage

Loss of proteoglycan from the matrix Chondromalacia Collagen fibrils rendered more susceptible to the friction of joint Fissuring & fibrillation Clustering & mitoses of chondrocytes Peripheral areas: chondrophyte endochondral ossification osteophyte Joint incongruity

Subchondral Bone

Central area: eburnation, hyperthrophy, becomes radiographically dense (sclerotic) Peripheral areas: atrophy, becomes radiographically less dense (osteoporotic) Cystic lesions Increased vascularity/congestion pain Remodelling joint incongruity

Synovial Membrane & Fibrous Capsule

Fragments of abraded cartilage loose bodies Synovial hyperplasia, hyperemia & lymphocytic infiltration effusion Fibrous capsule thickened & fibrotic, limiting joint motion Interphalangeal joints Heberdens nodes/Bouchards nodes

Muscles

Develop spasm/contracture in response to pain Joint deformity Restriction of motion Contribute to the vicious cycle of degeneration

Symptoms

Use related pain affecting one or a few joints Stiffness after rest or in the morning Functional limitation Joint instability Joint deformity Joint crepitation

Physical Examination

Chronic monoarthritis or asymmetric oligo/polyarthritis Firm swelling of the joint margins e.g. Heberdens nodes/Bouchards nodes Mild synovitis with effusion Crepitance Deformity e.g. varus/valgus deformity Restriction of movement Spine involvement neurologic abnormality

Diagnosis

Clinical manifestation Radiographic features:

Narrowing of the cartilage space Subchondral sclerosis Cystic lesions Osteophyte formation Joint remodeling or joint incongruity

Laboratory exams: usually normal Synovial fluid: increased mucin & viscosity

Treatment

Patient education, weight reduction, supportive tools, appropriate exercises Analgetics: acetaminophen, salycilates or NSAIDs Intraarticular glucocorticoids Tidal irrigation Glucosamine & chondroitin Surgery

Operative Treatment

Osteotomy Arthroplasty Arthrodesis Soft tissue operations Transplantation of partial joint

Prognosis

Virtually everyone who reaches old age has some degree of OA Many experience only mild discomfort Continuous use of severely affected joints may lead to progressive deterioration with increasing pain & loss of motion Lower limbs continuing demands put on the affected joint relative bad prognosis