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Block 2 - MSK > WEEK 5 - MINI LECTURES - OSTEOARTHRITIS > Flashcards

WEEK 5 - MINI LECTURES - OSTEOARTHRITIS Flashcards

1
Q

What is OA

A
  • progressive disease
  • failed repair of joing damage that has been triggered by abnormal intra-articular stress
  • synovial inflammation in OA may be secondary to breakdown of cartilage and bone
  • all tissues of joint are involved
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2
Q

OA disease vs OA illness

A
  • disease: radiographic OA: 30% of adult population

- Illness: pain: 10% of adults

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3
Q

Criteria for hand diagnosis of OA

A
  • hand pain, aching, stiffness

3 or more of

  • hard tissue enlargement of 2 or more of 10 selected joints
  • hard tissue enlargement of 2 or more DIP joint
  • fewer than 3 swollen MCP joint
  • deformity of at least 1/10 joints
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4
Q

ACR criteria for diagnosis of knee OA: clinical and laboratory

A
  • knee pain plus at least 5 of the following
    1) >50 yo
    2) stiffness for less than 30 min
    3) crepitus
    4) bony tenderness
    5) bony elargement
    6) no palpable warmth
    7) ESR
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5
Q

ACR criteria for diagnosis of knee OA: clinical and radiographic

A

Knee pain + 1+ of the following:

  • age 50+
  • stiffness
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6
Q

ACR criteria for the diagnosis of knee OA: Clinical

A
  • knee pain + at least 3 of the following
    1) age 50+
    2) stiffness
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7
Q

Criteria for hip OA diagnosis

A
  • hip pain + 2+ of these features

1) ESR

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8
Q

Knee joint

A
  • largest, most complex joint in the body
  • synovial, modified hinge joint
  • articular surfaces: patellar surface of femur to patella, and femoral condyles to tibial plateau
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9
Q

KNEE JOINT collateral ligaments

A
  • fibular collateral ligament: round, cord like, separate from capsule, limits adduction
  • Tibial collateral ligament: broad and flat, blends with joint capsule, attaches to medial meniscus and limits movement, limits abduction movement, more commonly damaged
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10
Q

Knee joint also stabilised by

A
  • biceps femoris and ITT on lateral side

- sartorius, gracillis, semitendenosis, semimembranosus on medial side

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11
Q

Knee joint menisci

A
  • fibrocarilage
  • lateral meniscus more mobile
  • medial mniscus more commonly injured
  • thicker laterally
  • outer part more supplied
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12
Q

Knee joint - synovial joint

A
  • synovial joint caviry is the largest in the body -> communicates with suprapatellar bursae
  • cruciate ligaments are outside the synovial joint cavity
  • Bursae: 11 in knee joint: reduce friction between adjacent structures
  • bursae in the anterior of the knee may become inflammed
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13
Q

Ligaments of the hip joint

A
  • 3 major stabilising ligaments: iliofemoral, pubofemoral, ischiofemoral
  • are thickenings of capsule
  • taut on extension -> more stable
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14
Q

Synovial joints: normal morphology and function

A
  • different tissues functioning together to enable movement, provide frictionless bearing and transmit load
  • have proprioceptive function
  • are able to adapt to different physiological requirements/loads
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15
Q

Bone morphology and function

A
  • continuum from diaphysis to metaphysis to subchondral plate
  • absorb and translate load
  • rapidly adaptable - remodelling
  • really about load bearing capacity
  • 1st affected in OA
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16
Q

Cartilage normal morphology and function

A
  • calcified and non calcified
  • different morphology, biochemistry, metabolism and function deep to superficial and topographially
  • compression resistant, frictionless
  • surface: parallelly oriented
  • deeper: more vertically oriented
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17
Q

Joint capsule, synoviu, synovial fluid: morphology and function

A
  • filtration barrier: protein, cells: reduce cell influx
  • immune privileged
  • lubrication
  • nutrition
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18
Q

Meniscus: morphology and function

A
  • load translation, lubrication, proprioception
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19
Q

Ligaments and capsule: morphology and function

A
  • ligaments (and capsule)
  • constrain and regulate range of motion
  • proprioception
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20
Q

OA - a disease of the joint organ - BONE

A
  • increased bone formation: subchondral thickening, osteophytes, enthesophyte
  • lower bone mineral density, increased turnover
  • increased vascularity
  • BML - necrosis, microfractute
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21
Q

OA - a disease of the joint organ - CARTILAGE

A
  • loss of aggrecan early on (reversible)
  • Collagen breakdown in late stages (irreparable)
  • cartilage loss is an autplytic process: the cells taht lay down cartilage also produce proteins that break it down (ADAMTS)
  • hypertrophic differentiation and apoptosis
  • recapitulates grown plate
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22
Q

OA: a disease of the joint organ: JOINT CAPSULE, MENISCUS, LIGAMENT

A
  • capsule fibrosis, loss of SF HA and lubricin
  • inflammation - innate and adaptive
  • altered biochemistry , loss of biomechanics
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23
Q

OA is NOT just a wear and tear - its an active disease

A
  • respond to external signals
  • drive the pathology and pain pathwyas
  • interactions between structures
  • extrinc factors
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24
Q

Study if you target one system

A
  • different OA models compared in same GM strain
  • 70% had same outcome
  • 30% have a different outcome
  • molecular pathophysiology differs with OA phenotype
  • makes it difficult to find a treatment
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25
Q

4 general pathways of OA

A
  • cartilage matrix degradation
  • chondrocyte hypertrophic differentiation and apoptosis
  • inflammation/synovitis
  • bone turnover
26
Q

Pain sensitive structures in the normal knee

A
  • joint capsule
  • ligaments
  • outer third of meniscus, especially near capsule
  • periosteal and subchondral bone
  • synovium
  • soft tissues including fat around and deep to patellar tendon
    (LAST 3 MOST IMPORTANT)
27
Q

Other reasons for pain

A
  • pain behavior, distress, disability
  • SES
  • psychosocial comorbidity
  • altered cortical processing, spinal cord gating, PNS…
28
Q

Prevalence of kneee pain and OA in persons age 55+

A
  • 25% of adults above 55 have had more than 4 weeks of knee pain, half of them had radiographic evidence of OA
29
Q

Characteristic symptoms of OA

A
  • pain is mechanical in nature - occurs with activity and is relieved with rest
  • insiduous onset of pain
  • morning stiffness absent or lasts
30
Q

Other symptoms of OA

A
  • limited function or disability
  • joint swelling
  • feeling of giving way
  • reduced ROM
31
Q

Physical examination of OA

A
  • tenderness over joint line
  • crepitus
  • bony enlargement
  • reduced ROM
  • joint swelling/deformity
  • instability/laxity of joint
32
Q

Other types of arthritis that may involve hip, knee or hand

A
  • RA
  • Psoriatic arthritis
  • otehr seronegative spondyloarthripathies
  • crystal arthropathy
  • sarcoidosis
33
Q

Diseases that can predispose to OA

A
  • metabolic diseases
  • endocrine diseases
  • hypermobility
  • crystal arthropathy (gout)
  • neuropathic joint
  • chondrodysplasia
34
Q

Other common causes of hip pain

A
  • trochaneric bursitis
  • iliopsoas tendonitis
  • referred pain from lumbosacral spine
  • avascular necrosis
  • inguinal hernia
  • hip fracture
35
Q

Radiographic patterns of OA

A

1) patellofemoral: most common
2) medial tibiofemoral (50% cooccur with patellofemoral)
3) lateral tibiofemoral: less common

36
Q

Other common causes of knee pain

A
  • pes anserine bursitis
  • ITT friction sundrome
  • patella tendonitis
  • PFPS
  • prepatellar bursitis
  • semimembranosous bursitis
37
Q

HEberden’s and bouchard’s nodes

A
  • most commonly affected by OA
  • Heberden’s node: distal IP of third finfer
  • Bouchard node: middle IP of second finger
  • base of thumb also prevalent: squaring deformithy
38
Q

Other common causes of hand pain

A
  • De Quervain’s tenosynovitis
  • Carpal tunnel syndrome
  • flexor tenosynovitis
  • Ulnar nerve compression
39
Q

Lab test and OA

A
  • non contributory as OA is a non-inflammatory arthritis
  • aspiration if another diagnosis is feared
  • synovial fluid in OA should be clear and viscous with a WCC
40
Q

Role of radiography in OA

A
  • confirm clinical suspicion and exclude other conditions

- can see osteophyte formation, joing space narrowing, subchondral sclerosis, sunchondral cyst

41
Q

X ray of hand and wrist principles

A
  • bone more than soft tissue
  • centred on important part, close to film
  • joint surgace in multiple projections
  • often useful to include both hands to compare
  • need good spatial detail
42
Q

Osteoarthritis X ray changes - general changes

A
  • cartilage loss
  • non uniform joint space thinning
  • subchondral bone sclerosis, cyst formation, intraarticular lose bodies
  • reactive proliferative changes; sclerosis, osteophytes
  • weakening: isntabilities, malalignment, capsular tears ganglia
  • absence of erosive changes
43
Q

OA specific changes on XRAY

A
  • symmetrical
  • DIP 2 and 3
  • IP thumb
  • MC thumb
  • deformities: heberden, bouchard
44
Q

Geodes

A
  • subchondral cysts

- lucent space in subchondral bone formation

45
Q

Ganglia and mucous cysts

A
  • common at the back of the wrist

- localised collection of joint fluid

46
Q

OA: aims of management

A
  • patient education about both the disease and its management
  • pain control
  • improvement of function
  • alteration of the disease process and its consequence: disease modification
47
Q

Algorhythm for OA management

A

1) Non pharmacological management (education, exercise, weight loss, appropriate footwear)
2) physiotherapy, braces, simple analgesic
3) pharmacological management: NSAIDS, opioids
4) Surgery: osteotomy, total joint replacement

48
Q

Concomitant morbidities

A
  • 90% overweight/obese
  • 60% have hypertension
  • 20% have depression
  • 20% have diabedeteied
49
Q

Knee osteoarthritis

  • prevention
  • progression
  • palliation
A

1) Prevention: obesity, joint injury
2) progression: reduce load, disease modification
3) palliation: analgesia, joint replacement

50
Q

What is the most important intervention for OA

A
  • weight loss

- those that lost 10% of their body weight improved by 50% in their symptoms

51
Q

EWxercise

A
  • generally ineffective at home because exercise trechnique not appropriate
  • exercise leads to improvement in strength, proprioception, pain and function
  • combination of strength training and aerobic conditioning - low impact exercises
52
Q

ConclusionOA management

A
  • adequate pain control still unmet need
  • dichotomy between guidelines and clinical practice
  • focus management on risk factors
  • reduce compressive load
  • recognize those at risk and encourage them to lose weight
53
Q

OA epidemiology and prevention

A

1: 8 australians are affected by OA
2: 1 F:M
- disease of old age, but 2/3 are still in working age

54
Q

Risk factors for OA

A
  • Susceptible joint: injury, alignment, limp length inequality, structural abnormality, muscle eweakness…
  • susceptible individual: obesity, age, gender, race, genetic predisposition, dietary
55
Q

Surgical options for OA

A
  • arthroscopic surgery
  • chondrocyte implantation
  • relaignment osteotomy
  • joint replacement
56
Q

Arthroscopic surgery

A
  • no direct benefit for OA -> not indicated if symptoms are mostly related to OA
  • possible role in significant displaced meniscus tears or early OA
57
Q

Joint replacement

A
  • commonly performed
  • mostly for old patients
  • for advanced OA clinically and radiologically
  • failure of non operative treatment
  • severe pain and disability
58
Q

Total knee replcement especially for

A
  • more than one compartment affected
  • fixed deformity
  • stiffness
  • all joint surfaces replaces with metal and plastic components
  • computer navigation
  • postoperatively
59
Q

Contraindications to joint replacement

A
  • active infection
  • knee: absent extensor mechanism
  • hip: absent abductor mechanism
  • medically unfit
60
Q

Outcomes of joint replacement

A
  • reduced pain
  • increase activity level
  • improved fitness and longevity
  • improved quality of life
  • not normal but not much improved
  • hips surgery slightly more successful than knees
  • approximately 5% revision surgery over 10 years

Block 2 - MSK (38 decks)

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