Download degenerative diseases of the joints and spine column

LECTURE
DEGENERATIVE DISEASES OF THE JOINTS
AND SPINE COLUMN (OSTEOARTHRITIS,
OSTEOCHONDROSIS).
Definition
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Also known as
degenerative joint
disease or “wear and
tear arthritis”.
Progressive loss of
cartilage with
remodeling of
subchondral bone and
progressive deformity
of the joint (s).
Cartilage destruction
may be a result of a
variety of etiologies
Osteoarthritis (OA) - Definition
•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)
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OA is the most common form
of arthritis and the most
common joint disease
Most of the people who have
OA are older than age 45, and
women are more commonly
affected than men.
OA most often occurs at the
ends of the fingers, thumbs,
neck, lower back, knees, and
hips.
OA – Risk Factors
Age
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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.
Female gender
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In general, arthritis occurs more frequently in women
than in men. 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
among women.
Joint alignment
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People with joints that move or fit together
incorrectly, such as bow legs, a dislocated hip, or
double-jointedness, are more likely to develop OA in
OA – Risk Factors
Hereditary gene defect
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A defect in one of the genes responsible for the
cartilage component collagen can cause deterioration
of cartilage.
Joint injury or overuse caused by physical labor
or sports
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Traumatic injury (ex. Ligament or meniscal tears) to
the knee or hip increases your risk for developing OA
in these joints. Joints that are used repeatedly in
certain jobs may be more likely to develop OA
because of injury or overuse.
Obesity
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Being overweight during midlife or the later years is
among the strongest risk factors for OA of the knee.
OA – Symptoms
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OA usually occurs slowly
- It may be many years
before the damage to the
joint becomes noticeable
Only a third of people
whose X-rays show OA
report pain or other
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
OA – Radiographic Diagnosis
Asymmetrical joint space narrowing from loss
of articular cartilage
The medial (inside) part of the knee is most commonly affected by osteoarthritis.
Normal knee anatomy
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left: Normal x-ray
Right: worn away cartilage reflected by
decreased joint space
OA – Radiographic Diagnosis
•Asymmetrical
joint space
narrowing
•Periarticular
sclerosis
•Osteophytes
•Sub-chrondral
bone cysts
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Joint space narrowing
where there is more
stress
Subchondral bone has
thickened
bony overgrowth
significant joint space narrowing as well as proliferative
bone formation around the femoral neck (arrows)
Left: normal hip
Right: There is some joint space medially but the superior portion is
completely destroyed. Supralateral aspects affected most because
the weight is transfered through the roof of the acetabulum.
Note the sclerosis and oseophyte formation (arrow).
painful bone on bone contact at the CMC joint and the large bone
spurs -- osteophytes.
What to look for in an x-ray
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Radiographic changes visible relatively late
in the disease
Subchondral sclerosis
Joint space narrowing esp where there is
stress
Subchondral cysts
Osteophytes
Bone mineralization should be normal
X-ray shows lateral osteophytes, varus deformity, narrow joint space in
a 70 yr old female with OA
Clinical features and diagnosis
Pain
Sources
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Joint effusion and stretching of the joint capsule
Torn menisci
Inflammation of periarticular bursae
Periarticular muscle spasm
Psychological factors
Deep, aching localized to the joint
Slow in onset
Worsened with activity in initial stages
Occurs at rest with advanced disease
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May be referred eg hip pain referred to
the thigh, groin, knee.
Pain may be aggravated with weather
changes
Exam
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Joint line tenderness
Bony enlargement of
joint
+/- effusion
Crepitus
Decreased range of
motion
Joint exam
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Joint line pain can
indicate tear of the
lining of the capsule
or the meniscus.
Where is the patella?
Joint exam
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In the evaluation of joint
line pain, perform a varus
or valgus stress test.
Apply stress across the
joint, place fingers
directly over the joint line
to assess for pain, a clunk
may indicate a meniscal
tear, or crepitus may
indicate cartilage
damage.
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Have the patient to lie supine on the exam
table with leg muscles relaxed
Press the patella downward and quickly
release it.
the patella visibly rebounds.
What does this mean?
a large knee effusion
Ballotable patella
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Have the patient lie supine
with leg muscles relaxed
Compress the suprapatellar
pouch with your thumb, palm,
and index finger.
"Milk" downward and laterally
so that any excess fluid
collects on the medial side.
Tap gently over the collected
fluid and observe the effect on
the lateral side
A fullness on the lateral side
indicates the presence small
knee effusion
Involved joints
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DIP, PIP
1st carpometacarpal
cervical/lumbar facet joints
1st metatarsophalangeal
Hips
Knees
Uncommon
Wrist, elbows, shoulders,
ankles
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1st metatarso-phalangeal most commonly
affected in OA of the foot.
OA – Arthroscopic Diagnosis
Arthroscopy allows earlier diagnosis by
demonstrating the more subtle
cartilage changes that are not visible
on x-ray
Normal Articular Cartilage
Ostearthritic degenerated cartilage
with exposed subchondral bone
OA – Disease Management
•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
Treatment
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Non-pharmacokinetic
No proven medication-based disease modifying
intervention exists.
Analgesics (acetominophen)
NSAIDS
Help pain symptoms but controversial for long
term use in non-inflammatory OA because of
risks vs benefits
Narcotics
Intra-articular steroids
Chondroprotective agents
Anti-depressants
Intra-articular corticosteroids
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May be used if NSAIDS are contraindicated,
persistent pain despite use of other medications.
(not > 4 injections per year per joint)
2004 meta-analysis of controlled trials (w/
placebo) showed short term improvement in
knee pain, but efficacy in other joints is
uncertain.
saline vs steroid injection?
A study comparing the two in knee OA showed
no effect on joint space narrowing or significant
difference in pain at the end of the study, but
over a 2 yr period saline injections has less pain
relief.
Intra-articular hyaluronans
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Evidence shows they have a small
advantage in terms of pain control,
compared to intra-articular placebos or
NSAIDS.
No evidence for improvement in function
Two studies comparing intra-articular
steroids to hyaluronans have come to
opposite conclusions-more trials are
needed.
Intra-articular Corticosteroids
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Beneficial in KNEE
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Beneficial in HIP
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LOE 1a
LOE 1b
Short-duration benefits: 2-4 weeks
Every 3 mos OK; not effective at 2 years
Intra-Articular Hyaluronic Acid (IAHA)
“viscosupplement”
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Very effective in knee and hip
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LOE 1a for knee pain, fxn, & stiffness
Effective in ankle, shoulder (LOE lower)
Delayed effect (4 weeks)
Long duration (6 months)
1-5 weekly injections
IAHA: Mechanism of Action
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Increased synovial fluid HA conc.
Increased cartilage lubrication/elasticity
Chondrocyte proliferation
Chondrocyte stimulation  matrix
Decreased inflammatory mediators
Inhibition of nociceptors
MAY BE DISEASE-MODIFYING
HIGH-M.W. prep’s have higher effects
in 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 Review
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Low-impact exercise and strength
exercise effectively treat OA
Minimize use of chronic NSAIDs
Viscosupplement injections give longlasting pain reduction
Consider use of multiple treatments
simultaneously
Arthroscopic lavage & debridement no
better than conservative mgmt
Surgery
 Arthroscopy
 Cartilage
transplantation
 Joint replacement
Proximal Tibial Osteotomy
•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
Rt: 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.
Osteotomy
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Realignment of Joints
Transfer Weight to
less involved part of
joint
60s and 70s
Less popular
Does not provide
good long term
results
Total Knee Replacement
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
Photographs of total knee
components on model bone
Total Knee Replacement
Total Joint Replacement
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Considered last
Solution for Arthritis
Improved Ambulation
Decreased Pain
Increased ROM
90%+ good to
excellent 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.
Knee Joint Replacement
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LOE III
Universally recommended
to improved pain,
function, QOL
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Unicompartmental
Total joint replacement
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
Arthroscopy with
Lavage and Debridement
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NO BENEFIT for unselected
OA (mechanical or
inflammatory causes), Ib
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Moseley JB et al. A controlled trial
of arthroscopic surgery for
osteoarthritis of the knee. N Engl J
Med 2002 Jul 11; 347(2):81-8.
Kirkley A et al. A randomized trial
of arthroscopic surgery for
osteoarthritis of the knee. NEJM
Sep 2008;359:1097.
Two other RCTs
Left: View of normal elbow cartilage through an
arthroscope - white, glistening, smooth
Right: severe elbow osteoarthritis - cartilage is lost
and the bone underneath is exposed
Surgery
Portals
Arthroscopy
 Least Invasive
 Remove partially
damaged cartilage
 Remove dead
cartilage and enzymes
that cause
inflammation
Arthroscope
Damaged
Abrasion / Drilling
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Abrasion and Drilling
Healing response
Fibrocartilage= Scar
Cartilage
Inferior mechanical
properties to articular
cartilage
Less advanced OA
Focal arthritis
Focal, localized lesion
Surgical: arthroscopy
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arthroscopy is not recommended for
nonspecific "cleaning of the knee“.
Used to fix specific structural damage on
imaging (repairing meniscal tears,
removing fragments of torn menisci that
are producing symptoms).
Mosaicplasty / OATS
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Localized focal
arthritis/defect
Traumatic arthritis
Small to medium
Transferring healthy
plug of bone and
cartilage to defect in
weight bearing area
Small
Large
ACI
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Articular Cartilage
Implantation
“Pot hole in the road”
Two operations
Cartilage harvested and
sent to Lab, to grow in
Culture
Cartilage cells
transplanted into the
defect
In future may be
applicable to large
lesions/primary OA
Summary
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Accurate Diagnosis important
Understand the nature of this Problem
Many treatment Options available
Benefits and limitations
Choose the right treatment for you
Get back into the game
The degree of osteoarthritis has been classified by N. S. Kosinskaya as
shown in Table 2.
Table 2
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Classification of degree of osteoarthritis.
Pain
Level of activity
The range of
movement
Grade
1
Slight and
occasional
pain. Weight
bearing is
possible.
A patient may able
to
perform
certain activities
of daily living.
The range of movement in
the joint is not limited
or there is loss of part
of
the
range
of
movements in the joint.
Slight narrowing
space. Small
osteophytes.
Grade
2
Moderate pain,
but
a
patient may
be able to
weight bear
albeit with
pain.
There is increasing
difficulty
in
walking
and
standing.
Moderate limitations of
movement, contractures
and fixed flexion
deformities with
apparent shortening of
the affected limb. There
are pain and crepitus on
movement.
Gross narrowing of joint
space. Moderate marginal
osteophytes and cysts.
Subchondral
bone
sclerosis. An alteration of
the joint contours.
Moderate
or
severe pain.
A patient has had to
modify or give
up activities or
both because of
pain
and
progressive loss
of movement.
Great stiffness in the Loss of joint space. Massive
marginal
osteophytes.
affected
joint
Osteoporosis
of
the
(rigidity).
Grade
Grade
3
Radiological changes
of joint
marginal
articular end of the bone.
Areas of new bone
formation round the joint.