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small joints of the hand, lower limb joints and the vertebral column. OA embraces hetero-geneous diseases of different aetiological ori-gin, but with a similar biological, pathologi-cal, radiological and clinical picture. It mani-fests itself by joint dysfunction due to dys-regulation of cartilage metabolism, which leads to changes in the mechanical properties of cartilage. The pathological picture includes focal destruction of the cartilage as well as ar-eas of remodelling in the form of osteosclero-sis and osteophyte formation. OA can be pri-mary or secondary (e.g. due to metabolic, endocrine, haematological diseases).

Risk factors of OA:Heredity, particularly in the polyarticular • form of small joints of the hands,Obesity, where it is associated with knee • osteoarthritis,Hypermobility accompanying collagen ab-• normalities,Post-traumatic conditions,• Sports with risk for joint injuries,• Posture at work.•

Clinical symptoms: Pain is typically associ-ated with exercise, and is associated with brief morning and inactivity stiffness. Gradually reduced function and immobility develop.

The X-ray picture shows loss of joint space, the development of sub-articular cysts, sub-chondral sclerosis, osteophyte formation, and deformities. The course of OA is very vari-able and in most cases progresses very slowly. However, very rapid progression can occur.

Osteoarthritis – hands (Heberden and Bouchard type) A hereditary disease espe-cially affecting women. The DIP (distal inter-phalangeal) joints are affected producing He-berden’s nodes whilst involvement of the PIP (proximal interphalangeal) joints cause Bouchard’s nodes. It commonly manifests it-self between 40 to 60 years of age (menopaus-al).

Clinical symptoms: Cartilaginous stiff nodes gradually grow on the opposite articu-lar surfaces on the dorsal articular margins. The nodes are sore in the course of growth with intermittent inflammatory erythema and swelling. Deviation of the distal and mid-

dle phalanges is frequent. Once growth of the nodes stops, the affected joints become pain-free. Compared with rheumatoid arthritis, hand function usually remains good, though may be a problem in certain jobs or pastimes (e.g. pianist). More often, it only causes cos-metic problems (knobbly looking hands). Initially, the radiographs are normal, but later show unequal narrowing of the articular cav-ity and osteophyte formation. It is very im-portant to emphasise to the patient that it is not rheumatoid arthritis or gout.

Treatment: Non-steroidal anti-inflamma-tory drugs, or intra-articular glucocorticoids, are administered during inflammatory epi-sodes. The use of SYSADOA are other op-tions in more stubborn cases. Treatment may be supplemented by ultrasound administra-tion, thermotherapy (wax, mud) and thera-peutic exercise.

Osteoarthritis (OA) of the first carpo-metacarpal (CMC) joint (Rhizarthro-sis) OA may occur only in the first CMC (OA of the thumb) and the trapeziometacarpal joint. Rhizarthosis is a common problem that affects mainly women in their 50s. The affec-tion may be uni- or bilateral, with different clinical and radiological stages. As the cause is generally unknown it is referred to as idio-pathic. The most common symptom is pain, particularly in everyday movements at using the pinch function (touch the thumb with an-other finger) to turn keys, open a jar, a win-dow, turn a knob. Little by little the joint de-teriorates and later it subluxes. The result is then a characteristic deformation at the base of the thumb. Treatment is the same as in all other forms of OA but if conservative treat-ment is insufficient, surgery may be indicat-ed.

Osteoarthritis (OA) – pharmacological treatment The pharmacological treatment of OA is represented by two large groups of drugs:

SYRADOA (symptomatic rapid-acting 1. drugs of osteoarthritis) can be simple an-algesics such as paracetamol, aspirin, NSAIDs (non-steroidal anti-inflammato-

osteoarthritis – primary generalised nodal osteoarthritis (GNOA) 154

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ry drugs), opioids or intra-articular gluco-corticoids;SYSADOA (symptomatic slow-acting 2. drugs of osteoarthritis) such as intraartic-ular hyaluronate or oral glucosamine sul-phate, chondroitin sulphate, diacerein, etc. (so-called chondroprotective agents).

Initially, simple analgesics usually provide satisfactory pain relief. In advanced disease, in order to suppress the inflammation and ease pain, NSAIDs are prescribed. Treatment with standard NSAIDs is associated with a number of adverse effects, particularly gas-tropathy (gastric ulcer, bleeding). The risk of gastrointestinal complications is increased in elderly patients who often suffer from OA.

In terms of these complications, NSAIDs with strong selectivity to cyclooxygenase 2 (COX-2) have a significantly lower incidence of adverse gastrointestinal effects. In terms of biological and biochemical properties, low dose meloxicam belongs to this group. At the stage of painful OA, it is administered orally in a daily dose of 7.5 mg, but can be increased to 15 mg daily if required.

Another specific COX 2 inhibitor is cele-coxib. Studies have shown that celecoxib is as effective as non-selective NSAIDs, when ad-ministered in a single daily dose of 100–200 mg (Bensen et al. 1999, Pavelka and Štolfa 2005). The safety profile of celecoxib has been extensively tested in comparative trial with diclofenac, ibuprofen and naproxen. These trials confirmed the favourable safety of cele-coxib with less renal adverse effects and no increased cardiovascular risk.

Osteoarthritis – primary generalised nodal osteoarthritis (GNOA) Initially, it manifests by inflammatory episodes of the DIP (distal interphalangeal) and PIP (proxi-mal interphalangeal) joints of the hand in rela-tively young women (around 40 years old), often peri-menopausal. Familial incidence is frequent. It never affects the MCP (metacar-pophalangeal) joints but often affects the knees, hips and intervertebral (facetal) joints. Initially, radiological changes are not visible, but typical osteoarthritic changes develop lat-er. Deviation of the phalanges occurs.

Treatment: Non-steroidal anti-inflamma-tory drugs are administered during inflam-matory episodes. Afterwards, treatment is the same as in other forms of osteoarthrosis.

Osteoarthritis (OA) – surgical treatment Surgical procedures play a key role in the treat-ment of OA. They are indicated when pharma-cological and non-pharmacological treatment fails especially in severe hip and knee arthritis. The indications for surgical treatment include permanent severe pain (including night pain) and greatly reduced function of the affected joint with very limited mobility. At present, to-tal hip or knee joint replacements are the most effective and frequently used procedure. Most patients are able to return to their normal daily activities after surgery. An improvement in the materials used in the development of the pros-theses guarantees their longer durability up to 10 to 15 years.

Osteoblasts Uninuclear cells whose main function is the production of bone tissue (os-teoformation). They develop from a pluripo-tent mesenchymal cell that gradually matures to preosteoblasts and osteoblasts. From a morphological point of view, they have a rounded nucleus localised in the basal part of the cell. In the nucleus, receptors for oestro-gens, vitamin D3, integrins and cytokines can be found. The nucleus is localised on the op-posite side to the position of contact between the osteoblast and the bone surface. The cyto-plasm is heavily basophilic; the Golgi appara-tus lies between the nucleus and the apical part of the cell. The endoplasmic reticulum is pronounced. The plasma membrane of active osteoblasts contains a high concentration of alkaline phosphatase and receptors for para-thormone. Osteoblasts are localised on the surface of trabeculae and in the osteons of compact bone where they are capable of pro-ducing osteoid in the places of active osteo-formation. After completion of the osteofor-mation phase, osteoblasts are transformed into lining cells or osteocytes.

Osteocalcin Osteocalcin, also known as bone Gla-protein (BGP), is a small non-colla-