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MSK 3 final > Arthritis - OA > Flashcards

Arthritis - OA Flashcards

1
Q

___ is the most common form of arthritis

A

OA

1 in 4 people in US

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2
Q

Leading cause of disability in older adults:

A

OA

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3
Q

Most commonly affected joints (but can impact ANY synovial joint):

A

Hips
Knees
Hands

*shoulder, ankle,

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4
Q

OA: Clinical Features

A

Loss of Articular Cartilage
Synovitis
Boney Changes
Ligamentous Changes
Meniscal Changes

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5
Q

OA: Patient Impact

A

Pain
Swelling
Stiffness
Loss of Function

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6
Q

Bone responds by laying down more bone:

A

*osteophyte is one way

*sclerosis is the other way (bright white new layer)

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7
Q

Ligamentous changes = what the osteophyte is responding to

A

ligaments become more lax (take away some of the stretch they are under)

*osteophytic lipping occurs

*LCL and MCL more lax - lipping happens to make deeper bowl

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8
Q

OA Pathophysiology

A

Degenerative process of the whole joint with different phenotypes emerging

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9
Q

Primary OA:

A

Idiopathic

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10
Q

Secondary OA:

A

Underlying cause or event (trauma)

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11
Q

Risk factors for primary OA:

A

Age
Obesity/Metabolic Disease
Sex (60% female)

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12
Q

Cartilage Major Components:

A

Water

Extracellular Matrix (ECM) & Proteoglycans

Chondrocytes (Responsible for both catabolism and anabolism)

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13
Q

Cartilage Function:

A

Withstand highly repetitive compressive and shear loads, maintain a near frictionless joint surface environment, allow force transmission between articulating bones

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14
Q

collagen arrangement of articular cartilage:

A

articular surface

superficial tangetial zone: 10-20%

middle transitional zone: 40-60%

deep zone: 30%

calcified cartilage
subchondral bone
cancellous bone

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15
Q

Review of normal cartilage physiology and biomechanics:

A

Uses hydrodynamics- water flows out in response to compression

Proteoglycans are hydrophilic, attract water to flow back into cartilage following water loss

Combination of hydrodynamics and ECM structure allow compressive forces to be converted to shear at the calcified cartilage/bone interface

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16
Q

Cartilage Regeneration:

A

Chondrocytes repair ECM (very slow process) -> poor healing potential

Chondrocytes are mechanosensitive, regenerative process is stimulated in response to loading

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17
Q

What’s happening with OA - Impairment of cartilage regeneration

A

Regeneration is too slow to keep up with damage repair AND/OR regeneration pathway is altered

Presence of inflammation impacts chondrocyte function

Produce more pro-inflammatory markers and matrix degrading enzymes

Early chondrocyte senescence

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18
Q

Proteoglycan loss occurs first, followed by ___

A

eventual ECM breakdown

Loses ability to handle loads via hydrodynamics (less water), placing more stress on ECM

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19
Q

Articular Cartilage Breakdown:

A

This process is going on for YEARS/DECADES before we can see cartilage breakdown

Translation: By the time we start to see cartilage breakdown its far too late

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20
Q

Cartilage response to loading in controls vs OA:

A

More ECM deformation and more water loss in OA

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21
Q

Primary OA Phenotypes:

A

1) overweight/obesity
*poor diet indirectly impacts

2) ageing

3) lifestyle choices

all 3 lead to inflammaging ->chondrosenescene -> OA

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22
Q

Secondary OA:

A

OA due to associated event

The normal joint structure and biomechanics are impacted resulting in both inflammatory environment and changes to loading environment

Slow cartilage metabolism does not adapt quickly enough to joint changes

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23
Q

Joint Injury: PTOA

A

Knee injury: 6x risk increase

Abnormal Alignment or Geometry (Congenital, tumor, etc)

Malalignment of the knee is an independent risk factor of OA progression

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24
Q

___ is an independent risk factor of OA progression

A

Malalignment of the knee

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25
Q

PTOA: The major issue:

A

Huge cohort of young individuals with old knees

Lots of years left in the medical system

Downstream healthcare impacts of physical inactivity and/or disability

Joint arthroplasty only lasts~ 20 yrs
* These people may need multiple arthroplasties in their lifetime = $$$$$

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26
Q

post ACL: ~50% will have radiographic OA within ___

A

10-20 yrs

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27
Q

Much more complex than originally thought (not just wear and tear)

A

Cartilage regeneration is unable to keep up with microdamage

Impacted by biomechanics and/or inflammatory environment

Impacts the whole joint (not just articular cartilage)

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28
Q

We don’t fully understand what causes symptoms - OA Pathophysiology

A

Worse radiographic OA more likely to have symptoms

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29
Q

Primary OA: Intersection between ____

A

aging, genetics, metabolic syndrome/obesity, lifestyle choices

30
Q

Secondary OA: Intersection between _____

A

joint biomechanics and inflammation

31
Q

Common Imaging Features:

A

Loss of joint space width

Osteophyte formation

Sclerosis of subchondral bone

32
Q

Imaging Modality:

A

Radiographs (gold std)
MRI
CT

33
Q

OA Grading System:

A

0-4

34
Q

OA: grade 0

A

no OA
no osteophytes
no JSN

35
Q

OA: grade 1

A

doubtful OA
possible osteophytes
doubtful JSN

36
Q

OA: grade 2

A

mild OA
definite osteophytes
possible JSN

37
Q

OA: grade 3

A

moderate OA
moderate osteophytes
definite JSN

38
Q

OA: grade 4

A

severe OA
large osteophytes
great JSN

39
Q

Curveball:

A

Up to 50% of people with radiographic OA have no associated symptoms

We do not currently understand why some are symptomatic and others are asymptomatic

40
Q

Advanced Imaging Techniques:

A

New promising imaging sequences that allow us to assess cartilage physiology before cartilage damage is evident

MRI T1rho

MRI T2*

41
Q

MRI T1rho:

A

Associated proteoglycan content/concentration

42
Q

MRI T2*:

A

Associated with ECM orientation and free vs bound water

43
Q

We currently have ___ treatments that have been proven effective at reversing OA or stopping its progression

A

zero

44
Q

The treatments we do have:

A

Treat the symptoms (reduce pain)

Promote function

Prevent OA from happening in the first place

45
Q

Prevent OA from happening in the first place:

A

Injury prevention (Secondary OA)

Lifestyle (Primary OA)
* Moderate Activity
* Weight Management

46
Q

Pharm interventions:

A

NSAIDs
Corticosteroids
Hyaluronic Acid
Biologics

47
Q

Surgery interventions:

A

Debridement
Cartilage Repair
Joint Replacement

48
Q

Common NSAIDs:

A

Ibuprofen
Naproxen
Diclofenac

49
Q

NSAIDs Treatment:

A

Effective at reducing pain and targeting synovitis

Cheap

Cons: Some with comorbidities unable to use

Some have topical versions available

Con: Treats symptoms, no impact on disease

50
Q

Common Corticosteroids:

A

Cortisone Injection

51
Q

Corticosteroid Treatment:

A

Effective at reducing short-term pain and inflammation

Intended to be an adjunct

More localized treatment

Cons: Some with comorbidities unable to use

Con: Treats symptoms, no impact on disease

Con: Limited dosage schedule, infection risk

52
Q

Hyaluronic Acid
Common: (Viscosupplementation)

A

Synvisc
Hyalgen
Euflexxa

53
Q

Hyaluronic Acid Treatment:

A

Can improve symptoms and function in mild/moderate OA (high bias evidence)

“lubricates” the joint

Cons: Expensive (limited insurance coverage)

Con: Treats symptoms, no impact on disease

Con: Limited dosage schedule

54
Q

Common Biologics:

A

Stem Cell Therapy

Platelet Rich Plasma (PRP)

55
Q

Biologics treatment:

A

Promising basic science results

Some mixed results but mostly poor findings of effectiveness in vivo

No Standardization

Cons: Expensive (not covered by insurance)

Cons: Travel to special clinic

56
Q

Disease-Modifying Osteoarthritis Drugs (DMOADs)

A

Corticosteroids have short-term symptomatic benefits and should be adjuncts

Placebo effect from injections

57
Q

Surgery:

A

Joint replacement is highly effective but still considered a salvage procedure

Reduces pain, reduces disability, improves QOL

57
Q

Viscosupplementation studies that show benefit have ___

A

high risk of bias

Recommendation: try it if the patient had little to no effect from steroid or can’t have steroid

58
Q

Rehab Interventions:

A

Weight Management
Exercise
Bracing

59
Q

Weight Management:

A

9-76% reduction in pain following gastric bypass

Pain scores reduced, functional scores improve

Improved joint space associated with weight loss

Con: Poor adherence to interventions

Dose response exists (More weight loss more symptomatic improvement)

60
Q

Physical Activity and OA:

A

Maintain and/or improve functional capacity

Supplement diet for weight loss

No specific recommendations:
*No evidence to support a hierarchy of types of exercise
*Whatever the patient likes to do will improve adherence

61
Q

Rehab programs:

A

Decrease pain, improve function, improve QOL

Quad strength/power = Function

PT had better outcomes through 1 year follow up vs corticosteroid injection

62
Q

Bracing:

A

Unloader braces have some symptomatic benefit

Other braces: Likely placebo/tactile

Braces are generally bulky, uncomfortable, and/or not aesthetically pleasing

63
Q

In general, running was not associated with OA

A

Running at a recreational level was associated with
lower odds of hip/knee OA compared to those 
running competitively and more sedentary,
non running individuals

Recreational runners have the lowest incidence of OA

64
Q

The Debate:

A

Don’t Unnecessarily Load

Don’t Change Activity

swinging pendulum

65
Q

Not all OA is the same:

A

Primary vs secondary with phenotypes of each

It is unlikely there will be one blanket recommendation, each subset will need its own specific recommendations that is also adjusted to the individual patient

66
Q

The most basic principle of treatment is the ___

A

risk reward benefit to the patient

67
Q

Promote physical activity for weight management, joint health maintenance, pain/mental health

A

Weigh the risk reward for whether higher loading activity is appropriate

Use irritability as a guide

68
Q

Quad strength and power to maintain function

A

Combination of open and closed chain depending on joint irritability and compensations

69
Q

OA PT Management

A

Assistive device use for significant gait deviations

Self-management focus

Booster visits currently being explored, watch for evidence

70
Q

The future:

A

Harness mechanosensitivity of chondrocytes to promote regeneration

Can we identify specific loading inputs to optimize cartilage health after injury and surgery

Likely in combination with pharm

Use of biologics to regenerate damaged cartilage

71
Q

Our current post-injury and post-op treatments are focused on short term goals of ___ and have little focus on ___

A

return to sport and function

long-term joint health

MSK 3 final (9 decks)

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