OA Lamongan

Osteoarthritis of Osteoarthritis of Knee Knee

Diagnosis and ManagementDiagnosis and Management

Agus Adiantono, MDAgus Adiantono, MD

Lamongan, Oktober 2010 Lamongan, Oktober 2010

Definition :Definition :

No universal agreementNo universal agreement Current working definition :Current working definition :

A condition of synovial joints A condition of synovial joints charaterised by cartilage loss charaterised by cartilage loss (chondropathy) and evident of (chondropathy) and evident of periarticular bone response.periarticular bone response.

Classification :Classification :

Type I :Type I :

Polyarticular degenerative arthritisPolyarticular degenerative arthritis Unknown originUnknown origin Rarely occurs before 35 yearsRarely occurs before 35 years

Classification :Classification :

Type II :Type II : Monoarticular arthritisMonoarticular arthritis Reaction to some condition that has Reaction to some condition that has

produced incongruity of joint surfacesproduced incongruity of joint surfaces Pyogenic infectonPyogenic infecton Congenital anomalyCongenital anomaly Coxa planaCoxa plana Ligamentous instabilityLigamentous instability Physeal separationPhyseal separation fracturefracture

Risk factor of OA :Risk factor of OA :

Generalized susceptibilityGeneralized susceptibility Genetic factors :Genetic factors :

HLA1,B8 (Heberden’s node)HLA1,B8 (Heberden’s node) α1 α1 antitrypsin phenotypeantitrypsin phenotype

Aging :Aging : Does not cause OADoes not cause OA Increase the risk of degenerationIncrease the risk of degeneration Decrease ability of articular cartilage to Decrease ability of articular cartilage to

prevent progressionprevent progression

ObesityObesity


Local mechanical factors :Local mechanical factors : Trauma :Trauma :

Intra articular Intra articular Alter mechanical loadingAlter mechanical loading

Joint shape :Joint shape : Perthes diseases Perthes diseases Slipped capital epiphysisSlipped capital epiphysis CDHCDH

Abnormal load transmission across jointAbnormal load transmission across joint


Local mechanical factors :Local mechanical factors : Occupational and recreational activitiesOccupational and recreational activities

Repetitive impact loading and micro traumaRepetitive impact loading and micro trauma Wear and tear Wear and tear

e.g. : miners (OA knee, spine)e.g. : miners (OA knee, spine)

cotton workers (Dip joint)cotton workers (Dip joint)

PathologyPathology

ChondropathyChondropathy

Periarticular bone responsePeriarticular bone response

PathologyPathology ChondropathyChondropathy

Early :Early : Surface irregularities (fibrilation)Surface irregularities (fibrilation) Small cleft beyond the superficial zoneSmall cleft beyond the superficial zone Slight hypercellularitySlight hypercellularity Minimum loss of proteoglycan, not Minimum loss of proteoglycan, not

extending beyond the transitional zoneextending beyond the transitional zone Moderately Advance :Moderately Advance :

More extensive loss of surfaceMore extensive loss of surface Clefts extend into middle zoneClefts extend into middle zone Loss of proteoglycan extend to middle Loss of proteoglycan extend to middle

zonezone HypercellularHypercellular

PathologyPathology

ChondropathyChondropathy

Advance :Advance : Reduce of cartilage thicknessReduce of cartilage thickness Reduce proteoglycan throughout entire Reduce proteoglycan throughout entire

thicknessthickness Complete loss of articular cartilage Complete loss of articular cartilage

(eburnated of sub chondral bone)(eburnated of sub chondral bone) Focal pressure necrosisFocal pressure necrosis

PathologyPathology

Periarticular bone response :Periarticular bone response :

New bone formation in sub chondral New bone formation in sub chondral bone bone

New cartilage formation and New cartilage formation and enchondral ossificationenchondral ossification

Release degrading cytokines /enzymes by chondrocyte

(Interleukin - 1.etc)

Collagen alteration

Proteoglycan alteration

Mineralization Cartilage alteration

Cartilage destruction

Synovial inflamation

OA

Local mechanical factorsGeneralize suscepbility

Pathogenesis

MacroscopicMacroscopic

OA KneeOA Knee

Symptoms :Symptoms : Pain Pain

Chief complainChief complain Mechanism of pain :Mechanism of pain :

Stimulation of capsule pain fibers and Stimulation of capsule pain fibers and mechanorecepters by : intra articular mechanorecepters by : intra articular hypertensionhypertension

Imflammatary mediators stimulating pain fibers in Imflammatary mediators stimulating pain fibers in the synovium and capsule.the synovium and capsule.

Stimulation of periostal nerve fibers by Stimulation of periostal nerve fibers by intraosseous hypertension, osteofit formationintraosseous hypertension, osteofit formation

Subchondral micro fractureSubchondral micro fracture Bursitis, muscle spasm,Bursitis, muscle spasm, Instability Instability

Pain characteristicPain characteristic On usage : mechanicalOn usage : mechanical At rest : inflamationAt rest : inflamation At night : intra osseous hypertensionAt night : intra osseous hypertension

Symptoms :Symptoms :

Joint stiffnessJoint stiffness

Functional impairment, due to :Functional impairment, due to :Pain Pain Reduce range and control of Reduce range and control of movementmovement

DeformityDeformity

Signs :Signs :

Crepitus :Crepitus :• Irregulat articular surfaceIrregulat articular surface

Bony enlargement :Bony enlargement :• OsteophyteOsteophyte• Remodelling DeformityRemodelling Deformity

InstabilityInstability Restricted movementRestricted movement Muscle weaknessMuscle weakness Massive joint effusionMassive joint effusion

Laboratory testLaboratory test

Non specificNon specific Increase inflammatory mediators on Increase inflammatory mediators on

synovial fluidsynovial fluid Urine CTX II increasingUrine CTX II increasing

(C-Telopeptide fragments of type II (C-Telopeptide fragments of type II collagen)collagen)

RadiographyRadiographycorrelates with pathological changescorrelates with pathological changes

Pathological changePathological changeCartilage fibrilation, erosionCartilage fibrilation, erosion

Subchondral new bone Subchondral new bone formationformation

New cartilage formation and New cartilage formation and endochondral ossificationendochondral ossification

Fibrous-walled pseudocysts Fibrous-walled pseudocysts reulting from fluid instrusion reulting from fluid instrusion or myxoid degenerationor myxoid degeneration

Trabecular compressionTrabecular compression

Fragmentation of osteochondral Fragmentation of osteochondral surface; cartilage and bone surface; cartilage and bone metaphasia in synovium metaphasia in synovium

Radiograhic Radiograhic abnormalityabnormality

Decrease in interosseous Decrease in interosseous distance (localized)distance (localized)

SclerosisSclerosis

OsteophyteOsteophyte

Subchondral cytsSubchondral cyts

Bone collapse / attrition Bone collapse / attrition

Osseous (‘loose’) bodiesOsseous (‘loose’) bodies

RadiographyRadiography


RadiographyRadiographyClassification Kellgren and Lawrence Classification Kellgren and Lawrence

(1957)(1957)

Grade 0 : normalGrade 0 : normalGrade I : minimal osteophyte Grade I : minimal osteophyte

normal joint spacenormal joint spaceGrade II : definite osteophyteGrade II : definite osteophyte

possible joint space narrowing possible joint space narrowing Grade III : definite osteophyte and joint Grade III : definite osteophyte and joint

space narrowingspace narrowingGrade IV : definite osteophyte and joint Grade IV : definite osteophyte and joint

space narrowing with sclerosis space narrowing with sclerosis and abnormal joint contour.and abnormal joint contour.


Classification AhlbClassification Ahlbääck (1968)ck (1968)

Grade I : joint space narrowing (joint Grade I : joint space narrowing (joint space < 3mm)space < 3mm)

Grade II : joint space obliterationGrade II : joint space obliteration

Grade III : minor bone attrition (0-5mm)Grade III : minor bone attrition (0-5mm)

Grade IV : moderate bone attrition (5-Grade IV : moderate bone attrition (5-10mm)10mm)

Grade V : severe bone attrition (>10mm)Grade V : severe bone attrition (>10mm)

Arthroscopic Arthroscopic AppearenceAppearence

Stage I : SofteningStage I : Softening


Stage II : FibrilationStage II : Fibrilation


Stage III : FragmentationStage III : Fragmentation


Stage IV : EburnationStage IV : Eburnation

DiagnosisDiagnosis Based on clinical and radiological Based on clinical and radiological American Collage of Rheumatology :American Collage of Rheumatology :

Traditional format :Traditional format : Knee pain and radiographic osteophytes and at Knee pain and radiographic osteophytes and at

least 1 of the following 3 items :least 1 of the following 3 items : Age >40 yearsAge >40 years Morning stiffness <30min in durationMorning stiffness <30min in duration Crepitus on motionCrepitus on motion

Modified :Modified : Knee pain and radiographic osteophytes orKnee pain and radiographic osteophytes or Knee pain and age >40 years and morning Knee pain and age >40 years and morning

siffness <30 min in duration and crepitus on siffness <30 min in duration and crepitus on motion.motion.

ManagementManagement

Not known cure of OANot known cure of OA Goal of OA treatment :Goal of OA treatment :

Control pain and other symptomsControl pain and other symptoms Maintain and / or improve joint mobilityMaintain and / or improve joint mobility Minimize disability / functional Minimize disability / functional

impairmentimpairment Education of patient and his or her Education of patient and his or her

familyfamily


Multi modal management of patient Multi modal management of patient with OA of the knee :with OA of the knee :

Pharmacologic Pharmacologic therapytherapy

Surgical treatmentSurgical treatment

Non Non Pharmacologic Pharmacologic therapytherapy

ManagementManagement Non pharmacologic therapy :Non pharmacologic therapy :- Patient education Patient education - Weight reducingWeight reducing- RestingResting- Exercise :Exercise :

Muscle strenghtening exerciseMuscle strenghtening exercise Physical therapy range of motion exercisePhysical therapy range of motion exercise Aerobic exercise programAerobic exercise program

- Joint protection and energy Joint protection and energy conservation :conservation :

Assistive device for ambulationAssistive device for ambulation Bracing Bracing Reduce weightReduce weight

- Occupational therapyOccupational therapy

Arthritis Exercise Arthritis Exercise According to the Degree of According to the Degree of

InflammationInflammation

ROM & ROM & stretchinstretchingg

IsometriIsometricc

IsotonicIsotonic

AerobicAerobic

RecreatioRecreationalnal

Exercise Exercise PrescriptionPrescription

HigHighh

LoLoww

Infl

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ati

Infl

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on

ManagementManagementPharmacologic therapyPharmacologic therapy Oral :Oral :

Analgesic / anti inflamatory agentAnalgesic / anti inflamatory agent Nutritional supplementNutritional supplement Anti catabolic cytokines agentAnti catabolic cytokines agent

Intra articular :Intra articular : Carticosteroid ?Carticosteroid ? ““Visco” therapy (hyaluronan)Visco” therapy (hyaluronan)

Topical :Topical : Capsaicin Capsaicin Methyl salicylateMethyl salicylate Transdermal Glucosamine SulphateTransdermal Glucosamine Sulphate


Pharmacologic therapyPharmacologic therapy AnalgesicAnalgesic

AcetaminophenAcetaminophen Cox-2-specific inhibitor :Cox-2-specific inhibitor :

Celecoxib, Rofecoxib, ValdecoxibCelecoxib, Rofecoxib, Valdecoxib Non selectiv NSAIDS :Non selectiv NSAIDS :

Naproxen, Iboprofen, DiclofenacNaproxen, Iboprofen, Diclofenac Non acetylated salicylateNon acetylated salicylate Opioid :Opioid :

Codein, Morphin, TramadolCodein, Morphin, Tramadol

American Pain Society 2004American Pain Society 2004Treatment of Chronic Pain Treatment of Chronic Pain

in OAin OAMild pain Mild pain Little / no Little / no

inflammationinflammationAcetaminopAcetaminop

hen hen Continued Continued

painpain

Conduct GI Conduct GI riskrisk

Factor Factor analysisanalysis

Moderate-to-Moderate-to-severe painsevere pain

inflammationinflammationCOX-2 COX-2

sp.inhibitorsp.inhibitorContinued Continued

painpain

High riskHigh riskNSAID + NSAID +

protectiveprotective

Low Low riskrisk

NSAIDNSAID

Continued Continued painpain

Hyaluronic acid Hyaluronic acid injectioninjection

Glucocorticoid Glucocorticoid injectioninjection


Pharmacologic therapyPharmacologic therapy

Nutritional supplementNutritional supplement GlucosamineGlucosamine Chodroitine sulfateChodroitine sulfate


Pharmacologic therapyPharmacologic therapy

Anti catabolic cytokines agent :Anti catabolic cytokines agent : Diacerin : Diacerin :

Interleukine-1 inhibitorInterleukine-1 inhibitor

Intra-Articular Intra-Articular “Visco”therapy“Visco”therapy

Hyaluronan (hyaluronic acid ): Hyaluronan (hyaluronic acid ): Attempts to restore synovial fluid protective, Attempts to restore synovial fluid protective,

lubricating, shock absorbing, barrier and lubricating, shock absorbing, barrier and rheologic affects. rheologic affects.

The agents are :The agents are : Non immunologicNon immunologic Permeabel to metabolites and macromolecules.Permeabel to metabolites and macromolecules. Qualitatively similar to human synovial fluid. Qualitatively similar to human synovial fluid. Retained longer than endogenus hyaluronic acid.Retained longer than endogenus hyaluronic acid.

Effects on joint pain and mobility last longer Effects on joint pain and mobility last longer than the agent is retained in the joint (improved than the agent is retained in the joint (improved endogenous production?)endogenous production?)

ManagementManagementSurgical therapy :Surgical therapy :

Minimally invasive arthroscopic :Minimally invasive arthroscopic : LavageLavage Debridement Debridement Resurfacing Resurfacing

Surgical debridement :Surgical debridement : Synovectomy Synovectomy Excision of osteophytes Excision of osteophytes Removal of loose bodiesRemoval of loose bodies Chondroplasty of cartilageChondroplasty of cartilage Removal of damaged menisci Removal of damaged menisci

ManagementManagementSurgical therapy :Surgical therapy : Biological resurfacing :Biological resurfacing :

Marrow stimulationMarrow stimulation Autologos transplantationAutologos transplantation

Realignment osteotomy :Realignment osteotomy : High Tibial OsteotomyHigh Tibial Osteotomy Distal Femoral OsteotomyDistal Femoral Osteotomy

Arthroplasty :Arthroplasty : Uni compartemental Knee ArthroplastyUni compartemental Knee Arthroplasty Total Knee ArthroplastyTotal Knee Arthroplasty

ArthrodesisArthrodesis

Biological ResurfacingBiological Resurfacing

Marrow Marrow stimulation :stimulation :


Cartilage graft : Cartilage graft :


Cartilage Cartilage transplantation :transplantation :

Realignment OsteotomyRealignment Osteotomy

High tibial osteotomyHigh tibial osteotomy

ArthroplastyArthroplasty

Total knee Total knee arthroplastyarthroplasty

Staging System for Establishing the Severity Staging System for Establishing the Severity of OA of the Knee.(Robert W. Jackson)of OA of the Knee.(Robert W. Jackson)

Based on :Based on : Clinical SymptomsClinical Symptoms X-ray findingsX-ray findings

Correlated with :Correlated with : ArthroscopyArthroscopy

Severity Grading of OA of Severity Grading of OA of KneeKnee

Stage I :Stage I : Minimum SymptomsMinimum Symptoms

pain-swellingpain-swelling X-rayX-ray

normal, ornormal, or minimal changeminimal change

ArthroscopyArthroscopy Softening or fibrilationSoftening or fibrilation


Stage II :Stage II : Mild SymptomsMild Symptoms

pain-swelling, decreased ROMpain-swelling, decreased ROM Respond well to NSAIDS or Respond well to NSAIDS or

analgesicanalgesic X-rayX-ray

Decreased joint space on weight-Decreased joint space on weight-bearing filmbearing film

ArthroscopyArthroscopy FibrilationFibrilation


Stage III :Stage III : Symptoms ModerateSymptoms Moderate

pain-swelling, decreased ROMpain-swelling, decreased ROM Minimally respond to NSAIDS or Minimally respond to NSAIDS or

analgesicanalgesic X-rayX-ray

Decreased joint space Decreased joint space Osteophyte formationOsteophyte formation

ArthroscopyArthroscopy FragmentationFragmentation


Stage IV :Stage IV : Severe SymptomsSevere Symptoms

Decreased ROMDecreased ROM Deformity, instabilityDeformity, instability Rest painRest pain

X-rayX-ray Decreased / lost of joint spaceDecreased / lost of joint space OsteophytesOsteophytes Sclerosis Sclerosis MalalignmentMalalignment

ArthroscopyArthroscopy Eburnated boneEburnated bone

Recommended Recommended TreatmentTreatment

Stage I :Stage I :

Conservatif :Conservatif : Non-medicationNon-medication MedicationMedication

Stage II :Stage II :

Minimally invasive Minimally invasive arthroscopic arthroscopic surgerysurgery LavageLavage DebridementDebridement

Recommended Recommended TreatmentTreatment

Stage III :Stage III :Biological resurfacing Biological resurfacing

techniquestechniques Marrow stimulationMarrow stimulation

Penetration of Penetration of subchondral bone subchondral bone (abrasion, drilling, (abrasion, drilling, microfracture) microfracture) arthroscopicarthroscopic

Autologous transplantationAutologous transplantation Chondrocyte Chondrocyte

transplantationtransplantation

Stage IV :Stage IV :

AnalgesicAnalgesic RealignmeRealignme

nt nt osteotomyosteotomy

ArthroplastArthroplastyy

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OA Lamongan