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Introduction
Definition degenerative disease of synovial joints that causes
progressive loss of articular cartilage
Epidemiology
o incidence
hip OA (symptomatic)
88 per 100,000 per year
knee OA (symptomatic)
240 per 100,000 per year
Risk factors
o modifiable
articular trauma
occupation, repetitive knee bending
muscle weakness
large body mass
metabolic syndrome
central (abdominal) obesity, dyslipidemia (high
triglycerides and low-density lipoproteins), high
blood pressure, and elevated fasting glucose
levels.
o non-modifiable
gender
females >males
increased age
genetics
race
African American males are the least likely to
receive total joint replacement when compared to
whites and Hispanics
Pathophysiology
o pathoanatomy
articular cartilage
increased water content
alterations in proteoglycans
eventual decrease in amount of
proteoglycans
collagen abnormalities
organization and orientation are lost
binding of proteoglycans to hyaluronic acid
synovium and capsule
early phase of OA
mild inflammatory changes in synovium
middle phase of OA
moderate inflammatory changes of synovium
synovium becomes hypervascular
late phases of OA
synovium becomes increasingly thick and
vascular
bone
subchondral bone attempts to remodel
forming lytic lesion with sclerotic edges
(different than bone cysts in RA)
bone cysts form in late stages
Cell biology
o proteolytic enzymes
matrix metalloproteases (MMPs)
responsible for cartilage matrix digestion
examples
stromelysin
plasmin
aggrecanase-1 (ADAMTS-4)
tissue inhibitors of MMPS (TIMPs)
control MMP activity preventing excessive
degradation
imbalance between MMPs and TIMPs has been
demonstrated in OA tissues
inflammatory cytokines
secreted by synoviocytes and increase MMP
synthesis
examples
IL-1
IL-6
TNF-alpha
Genetics
o inheritance
non-mendilian
o genes potentially linked to OA
vitamin D receptor
estrogen receptor 1
inflammatory cytokines
IL-1
leads to catabolic effect
IL-4
matrilin-3
BMP-2, BMP-5
Presentation
History
o identify age, functional activity, pattern of arthritic involvement,
overall health and duration of symptoms
Symptoms
o function-limiting knee pain
effect on walking distances
o pain at night or rest
o activity induced swelling
o knee stiffness
o mechanical
instability, locking, catching sensation
Physical exam
o inspection
body habitus
gait
often an increased adductor moment to the limb
during gait
limb alignment
effusion
skin (e.g. scars)
o range of motion
lack of full extension (>5 degrees flexion contracture)
lack of full flexion (flexion <110 degrees)
o ligament integrity
Imaging
Radiographs
o recommended views
weight-bearing views of affected joint
o optional views
knee
sunrise view
PA view in 30 degrees of flexion
o findings
pattern of arthritic involvement
medial and/or lateral tibiofemoral, and/or
patellofemoral
characteristics
joint space narrowing
osteophytes
eburnation of bone
subchondral sclerosis
subchondral cysts
Studies
Histology
o loss of superficial chondrocytes
o replication and breakdown of the tidemark
o fissuring
o cartilage destruction with eburnation of subchondral bone
Treatment
Nonoperative
o non-steroidal anti-inflammatory drugs
indications
first line treatment for all patients with symptomatic
arthritis
technique
Non-steroidal anti-inflammatory drugs (first choice)
selection should be based on physician
preference, patient acceptability and cost
duration of treatment based on effectiveness,
side-effects and past medical history
outcomes
AAOS guidelines: strong evidence for
o rehabilitation, education and wellness activity
indications
first line treatment for all patients with symptomatic
arthritis
technique
self-management and education programs
combination of supervised exercises and home program
have shown the best results
these benefits lost after 6 months if exercises are
stopped
outcomes
AAOS guidelines strong evidence for
o weight loss programs
indications
patients with symptomatic arthritis and BMI > 25
technique
diet and low-impact aerobic exercise
outcomes
AAOS guidelines: moderate evidence for
o controversial treatments
acupuncture
AAOS guidelines: strong evidence against
viscoelastic joint injections
AAOS guidelines: strong evidence against
glucosamine and chondroitin
AAOS guidelines: strong evidence against
needle lavage
AAOS guidelines: moderate evidence againnst
lateral wedge insoles
AAOS guidelines: moderate evidence against
Operative
o high-tibial osteotomy
indications
younger patients with medial unicompartmental OA
technique
valgus producing proximal tibial oseotomy
outcomes
AAOS guidelines: limited evidence for
o unicompartmental arthroplasty (knee)
indications
isolated unicompartmental disease
outcomes
TKA have lower revision rates than UKA in the setting
of unicompartmental OA
o total knee arthroplasty
indications
symptomatic knee osteoarthritis
failed non-operative treatments
techniques
cruciate retaining vs. crucitate sacrificing implants show
no difference in outcomes
patellar resurfacing
no difference in pain or function with or without
patella resurfacing
lower reoperation rates with resurfacing
drains are not recommended