07-Jul-14

1

นพ. สหธช งามอโฆษ

ภาควชา ออรโธปดกส

คณะแพทยศาสตร จฬาลงกรณมหาวทยาลย

Some illustrations are from the internet and intended for educational purpose only

Synonym

Osteoarthritis (OA)

Hip osteoarthritis

Knee osteoarthritis

Arthrosis (use in ICD coding)

M 16.0 Coxathrosis

M 17.0 Gonarthorsis

Chronic disorder of SYNOVIAL joints

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Mobile

Adequate range of motion (ROM)

Stable

No subluxation/dislocation

Stability from ligaments/ joint

Painless

Complex extracellular matrix 95%

Water: 65-80%

Collagen 10-20%

Type II 90-95%

Type V, VI, IX, X and XI

Proteoglycans 10-15%

Cellular component 5%

Water Deformation of cartilage surface due to stress

Nutrition

Collagen Framework, tensile strength

Proteoglycans Negative-charged hydrophilic molecule

Compressive strength

Chondrocytes Matrix and collagen production

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Avascular

Nutrients from

Diffusion

Synovial fluid

Aneural

Alymphatic

Chains of glycosaminoglycans (GAGs) attached to a linear core protein

Produced by chondrocyte

Disaccharide polymer

Chondroitin sulfate

Keratan sulfate

Dermatan sulfate

Heparan sulfate

Hyaluronic acid

Load distribution

Minimizing loads on subchondral bone

Reduce friction

Smooth joint motion

Resistance to compressive, tensile, and shear forces

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Very poor

High ratio of matrix/ cellular components

Poor ability of cartilage to repair

Low mitotic activity of chondrocytes

Negligible healing of Hyaline cartilage

May form fibrocartilage (scar) instead

Diminished cellularity

Reduced proteoglycan production

Loss of water & elasticity

Decrease strength

Cartilage breakdown

Osteoarthritis

OSTEOARTHRITIS (OA)

Chronic disorder of SYNOVIAL joints Progressive softening and disintegration

of articular cartilage New growth of bone at the joint margins

(osteophytes) Sclerosis from pressure overload in the

subchondral bone Subchondral cyst formation Mild synovitis and capsular fibrosis

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Progressive destruction of the joints leading to joint dysfunction

Stiffness, decrease motion

Painful

Deformity (angulation/shortening)

Loss of joint stability

Ligament injury, subluxation, dislocation

Localized increase in loading stress

Angular deformity,

malunion of intraarticular fracture

Increased stiffness of the cartilage

Decrease amount of proteoglycans

Inflammatory (enzymatic) degradation

Inflammatory joint disease

Restriction of free joint movement

Decrease nutrient from pumping mechanism

Sclerosis in the subchondral bone

Poorer stress distribution than cancellous bone

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OA: Gross Pathology

Articular cartilage Progressive loss

(joint space narrowing)

Subchondral bone Remodeling,

sclerotic change Bone cysts/

osteophytes formation

OA: Gross Pathology

Ligament

Ligament attenuation

Elongation (convex side)

Synovium and capsule

Thickening

Inflammation (synovitis)

Older age

Female sex

Obesity

Repetitive stress and joint overload

Genetic factors

Major trauma

Prior inflammatory joint disease

Metabolic disorder

Proprioceptive defects

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Symptoms

Stiffness

Initial (morning) stiffness

Pain with movement and activity

Improve with rest

Deformity

Angulation, shortening

Abnormal sound

Signs

Joint swelling

Effusion

Enlargement from osteophyte

Deformity

Angulation, shortening

Localized tenderness

Instability

Ligament laxity

Symptoms and signs Joint pain

Restriction of motion

Crepitus with motion

Joint effusions

Deformity

Instability

Radiography Plain X-ray

Radiographic findings

Subchondral bone changes

Osteophyte

Cyst formation

Sclerosis

Narrowed joint spaces

Deformity

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Joint space narrowing

Subchondral sclerosis

Marginal osteophytes

Subchondral cysts

Bone remodelling

Primary OA or Idiopathic

No identifiable etiology

Some relevant risk factors exist

Secondary OA

Underlying causes

Disease, congenital, trauma

Primary OA

Idiopathic

Strong family history

Alterations in structural macromolecules

Mutations in the type II collagen gene

Progressive wear and tear degenerative condition

Common joints

Knee

Spine

Hip

IPJ of hand

IPJ of foot

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Primary OA: knee OA Spine: Spondylosis

Joints of Spine

Synovial joint

Facet joint

Non-synovial joint

Intervertebral disc

OA: Hip OA: Thumb & Fingers

Thumb

1st Metacarpophalangeal joint

Finger

Interphalangeal joint (DIP>PIP)

Heberden's nodes

Bouchard's nodes

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Secondary OA: Etiology

Intra-articular Fx

High intensity impact joint loading

Ligament injury

Joint dysplasia

Aseptic necrosis

Joint infection

Crystal deposition

Ochronosis

Hemochromatosis

Hemophilia

Acromegaly

Paget’s disease

Ehlers-Danlos syndrome

Gaucher’s disease

Stickler’s syndrome

Neuropathic arthropathy

Secondary OA

Secondary OA

Post-traumatic OA Rheumatoid Arthritis

Goal of treatments Decrease pain

Muscle strengthening

Improve or maintain joint function Activity of daily living

Sports activity

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Activity modification Physical therapy Weight loss Low impact exercise

Medications Analgesics NSAIDs SySADOA (Symtomatic Slow-Acting Drugs

For Osteoarthritis)

Arthrodesis (fusion) Reduce pain, no motion

Joint resection Reduce pain, limited motion, no stability

Realignment osteotomy Correct deformity, maintain motion, joint

unloading

Arthroplasty (joint replacement) Correct deformity, improve motion & stability Concerns of longevity

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Knee Realignment Osteotomy

Degenerative change of synovial joint

Cartilage destruction & loss of joint function

Pain & Stiffness

Progressive joint deformity

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Conservative treatment of OA

Activity modification

Conservative treatment of OA

Conservative treatment of OA

SySADOA

Symptomatic Slow Acting Drug for Osteoarthritis Glucosamine

Chondroitin

Diacerein

Hyalulonic acid injection

Conservative treatment of OA

Intra-articular administration of hyaluronic acid

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Surgical treatment of OA

Arthroscopy

Early symptom

Mild pathology –less deformity

Mechanical causes

Surgical treatment of OA

Realignment osteotomy

Normalizes the biomechanical loads on the involved joint

Surgical treatment of OA

Autogenous chondrocyte

transplantation

Isolated, limited size (2- 7 cm2)

chondral defects

Osteochondral autografts

"mosaicplasty”

Autografts of up to 10 mm is

transferred into prepared defects

Surgical treatment of OA

Knee arthroplasty

Unicompartmental knee arthroplasty

Total knee arthroplasty

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ยาลดการอกเสบในกลมสเตยรอยด แบบฉด

มกใชผสมกบยาชาเพอฉดเขาในขอเขา ประสทธภาพด ราคาถก อาจท าใหเกดการตดเชอในขอได ไมควรใชบอย

แบบเมด มผลขางเคยงสง ไมนยมใชในโรคเขาเสอม

อาจพบใน ยาชด ยาหมอ ยาลกกลอน

Loss of joint stability

Localized increase in loading stress

Increased stiffness of the cartilage

Inflammatory (enzymatic) degradation

Restriction of free joint movement

Sclerosis in the subchondral bone

Primary OA: other joints