Osteoarthritis

Chronic, degenerative disorder of multifactorial

etiology, characterised by loss of articular cartilage and
periarticular bone remodelling, particularly large
weight-bearing joints.
Typically affects the fingers, spine, hips and knees.
Common in older patients but can occur in younger
patients ( genetic mechanism , previous joint trauma).

Pathophysiology

Degenerative alterations primarily begin in the

articular cartilage
Enzymatic destruction increases cartilage degradation
proteoglycans and collagen synthesis
Loss of cartilage results in the loss of the joint space
Subchondral bone responds with vascular invasion
and increased cellularity, at areas of pressure may
undergo cystic degeneration
At nonpressure areas along the articular margin
irregular outgrowth of new bone (osteophytes)

Anatomy of The Knee

Anatomy of The Knee

 Surface layer of cartilage

break down and wears
away, causes the bones
under the cartilage to rub
together
Pain, swelling, and loss of
motion result
Formation of bone spurs

Incidence
Incidence increases with age, after age 55 years, the
prevalence increases in women in comparison with men
USA approximately 80-90% of individuals older than 65
years have evidence of primary osteoarthritis
No significant correlation exists between incidence of
OA and race

Risk Factors
Age
Female
Obesity (most important modifiable)
Previous knee injury
Lower extremity malalignment
Repetitive knee bending
High impact activities
Muscle weakness

Causes
Primary OA
Idiopathic
Defective gene

Causes
Secondary OA

Obesity
Repetitive use (ie, jobs requiring heavy labor and bending)
Previous trauma (ie, posttraumatic OA)
Infection

History
Insidious throbbing arthralgias with activity
Initially, resting relieves the pain
Eventually, the pain occurs even at rest
Morning stiffness 30 minutes
Intermittent joint swelling

Symptoms
Pain
Stiffness
Gelling
Instability

Signs
Pain
Tenderness
Swelling
Effusion
Crepitus
Limitation of movement and muscle wasting

Physical
Early
Joints may appear normal
Gait may be antalgic if weight-bearing joints are involved

Physical
Later

Visible osteophytes may be noted

Joints may be warm to palpation
Palpable osteophytes frequently are noted
Joint effusion frequently is evidenced in superficial joints
Range-of-motion limitations, because of bony restrictions
and/or soft tissue contractures, are characteristic
Crepitus with range of motion is not uncommon

Imaging

X-rays (3 views)

Weight-bearing AP
Lateral
Tangential Patellar (Sunrise)

X-ray findings
Joint space narrowing
Subchondral cysts : fluidfilled sacs which extrude fr
om the joint
Osteophytes
Subchondral sclerosis :
bone density, frequently f
ound adjacent to joint spa
ce

Diagnosis
On the basis of the initial history and examination
X-rays

Goals of managing OA
Controlling pain
Maintaining and improving the range of movement and
stability of affected joints
Limiting functional impairment

Management: Algorithm
Lifestyle Modifications

NSAIDs

Steroid Injections

Acetaminophen

Celecoxib

Opioids

Hyaluronan Injections

Surgical Referral

Treatment
Education and behavioural intervention
Aim is to provide patients with an understanding of the
disease process, its prognosis and the rationale and
implications of managing their condition
Weight loss
Weight loss (<5kg) has significant short-term and longterm reduction in symptoms of OA

Treatment
Mechanical aids
Wear shock-absorbing footwear with good mediolateral
support, adequate arch support and calcaneal cushion
Exercise
Aim of exercise is to reduce pain and disability by
strengthening muscle, improving joint stability,
increasing the range of movement and improving
aerobic fitness

Treatment
Medication
Acetaminophen (Tylenol) is a mild pain reliever with
few side effects
Anti-inflammatory medication, such as ibuprofen and
aspirin
COX-2 inhibitors
Glucosamine and Chondroitin sulfate

Treatment
Intra-articular injection
- Glucocorticoids injection
- Hyaluronic Acid (HA) and similar hyaluronan
preparations (eg, Synvisc)

Treatment
Surgery
Arthroscopy (including debridement,and
lavage/irrigation)
Proximal Tibial Osteotomy
Artificial Knee Replacement
Osteotomy
Arthroplasty or Joint Replacement