Osteoarthritis

Osteoarthritis (OA)
OA is the most common form of
arthritis and the most common
joint disease
Over 10 million Americans suffer
from OA of the knee alone
Most of the people who have OA
are older than age 45, and women
are more commonly affected than
men.
OA most often occurs at the ends
of the fingers, thumbs, neck,
lower back, knees, and hips.

OA
OA is a disease of
joints that affects all
of the weight-bearing
components of the
joint:

Articular
cartilage
Menisci
Bone

OA
Nodal osteoarthritis
Note bony
enlargement of distal
and proximal
interphalangeal
joints (Heberden's
nodes and
Bouchard's nodes,
respectively).

OA Risk Factors
Age

Age is the strongest risk factor for OA. Although OA can start in young
adulthood, if you are over 45 years old, you are at higher risk.

Female gender

In general, arthritis occurs more frequently in women than in men. Before

age 45, OA occurs more frequently in men; after age 45, OA is more
common in women. OA of the hand is particularly common among
women.

Joint alignment

People with joints that move or fit together incorrectly, such as bow legs, a
dislocated hip, or double-jointedness, are more likely to develop OA in
those joints.

OA Risk Factors
Hereditary gene defect

A defect in one of the genes responsible for the cartilage component

collagen can cause deterioration of cartilage.

Joint injury or overuse caused by physical labor or sports

Traumatic injury (ex. Ligament or meniscal tears) to the knee or hip

increases your risk for developing OA in these joints. Joints that are
used repeatedly in certain jobs may be more likely to develop OA
because of injury or overuse.

Obesity

Being overweight during midlife or the later years is among the

strongest risk factors for OA of the knee.

OA Symptoms

OA usually occurs slowly It may be many years before

the damage to the joint
becomes noticeable
Only a third of people
whose X-rays show OA
report pain or other
symptoms:

Steady or intermittent pain in a joint

Stiffness that tends to follow periods of inactivity, such as sleep
or sitting
Swelling or tenderness in one or more joints [not necessarily
occurring on both sides of the body at the same time]
Crunching feeling or sound of bone rubbing on bone (called
crepitus) when the joint is used

Osteoarthritis (OA) - Definition

Osteoarthritis may result from wear and tear
on the joint
The normal
cartilage lining
is gradually
worn away and
the underlying
bone is
exposed.

Osteoarthritis (OA) - Definition

The repair mechanisms of tissue absorption and

synthesis get out of balance and result in
osteophyte formation (bone spurs) and bone cysts

A case of the, Which

came first? The
chicken or the egg?

OA Articular Cartilage
Articular cartilage is the main tissue affected
OA results in:
Increased tissue swelling
Change in color
Cartilage fibrillation
Cartilage erosion down to subchondral bone

OA Articular Cartilage

OA Articular Cartilage
A) Normal articular
cartilage from 21-year old
adult (3000X)
B) Osteoarthritic cartilage
(3000X)

The surface changes

alter the distribution
of biomechanical
forces further
triggering active
changes by the
tissue

OA Articular Cartilage
The cartilage damage causes chondrocyte cloning in an
attempt to restore articular surface (Normal adult
chondrocytes are fully differentiated and do not proliferate)

(A) Normal articular cartilage (B) Osteoarthritic cartilage

OA Articular Cartilage
Unfortunately, the newly dividing cells do not
differentiate fully and cannot effectively synthesize the
elements needed for matrix maintenance
This results in a net loss of matrix components
Collagen content stays constant but fibrils are thinner
and more disorganized
- Decreased tensile strength

OA Articular Cartilage
Proteoglycan loss
results in an
inability to hold on
to water content:
- Decreased
resistance to
compression
especially with
repeated stress

OA vs. Aging

Unlike aging, OA is progressive and a significantly

more active process

OA Overall Changes

Osteoarthritis with lateral osteophyte, loss of articular cartilage and

some subchondral bony sclerosis- X-ray shows loss of joint space

OA Radiographic Diagnosis

Asymmetrical joint space narrowing from loss of

articular cartilage
The medial (inside) part of the knee is most commonly affected by osteoarthritis.

OA Radiographic Diagnosis
Asymmetrical
joint space
narrowing

Periarticular
sclerosis
Osteophytes
Sub-chrondral
bone cysts

OA Arthroscopic Diagnosis
Arthroscopy allows earlier
diagnosis by demonstrating the
more subtle cartilage changes
that are not visible on x-ray

Normal Articular Cartilage

Ostearthritic degenerated cartilage
with exposed subchondral bone

OA Arthroscopic Treatment
In addition to being the most accurate way of determining how
advanced the osteoarthritis is:
Arthroscopy also allows the surgeon to debride the knee joint
Debridement essentially consists of cleaning out the joint of all debris
and loose fragments. During the debridment any loose fragments of
cartilage are removed and the knee is washed with a saline solution.
The areas of the knee joint which are badly worn may be roughened with
a burr to promote the growth of new cartilage - a fibrocartilage material
that is similar scar tissue.
Debridement of the knee using the arthroscope is not 100% successful. If
successful, it usually affords temporary relief of symptoms for somewhere
between 6 months - 2 years.

Arthroscopy also allows access for surgical treatment of articular

cartilage: graft-transplantation, micro-fracture techniques, subchondral drilling

OA Disease Management
OA is a condition which progresses slowly over a
period of many years and cannot be cured
Treatment is directed at decreasing the symptoms of
the condition, and slowing the progress of the
condition

Functional treatment goals:

Limit pain
Increase range of motion
Increase muscle strength

OA Non-operative Treatments
Pain medications
Physical therapy
Walking aids
Shock absorption
Re-alignment through
orthotics
Limit strain to affected
areas

Proximal Tibial Osteotomy

Osteoarthritis usually
affects the inside half
(medial compartment) of
the knee more often than
the outside (lateral
compartment).
This can lead to the lower
extremity becoming
slightly bowlegged, or in
medical terms, a genu
varum deformity

Proximal Tibial Osteotomy

The result is that the weight bearing line of the lower
extremity moves more medially (towards the medial
compartment of the knee).
The end result is that there is more pressure on the medial
joint surfaces, which leads to more pain and faster
degeneration.
In some cases, re-aligning the angles in the lower extremity
can result in shifting the weight-bearing line to the lateral
compartment of the knee. This, presumably, places the
majority of the weight-bearing force into a healthier
compartment. The result is to reduce the pain and delay the
progression of the degeneration of the medial compartment.

Proximal Tibial Osteotomy

In the procedure to realign the
angles, a wedge of bone is
removed from the lateral side
of the upper tibia.
A staple or plate and screws
are used to hold the bone in
place until it heals.
This converts the extremity
from being bow-legged to
knock-kneed.
The Proximal Tibial Osteotomy buys some time before ultimately
needing to perform a total knee replacement. The operation
probably lasts for 5-7 years if successful.

Total Knee Replacement

The ultimate solution for osteoarthritis of the knee is to
replace the joint surfaces with an artificial knee joint:
Usually only considered in people over the age of 60
Artificial knee joints last about 12 years in an elderly population
Not recommended in younger patients because:
The younger the patient, the more likely the artificial joint will fail
Replacing the knee the second and third time is much harder and much
less likely to succeed.
Younger patients are more active and place more stress on the artificial
joint, that can lead to loosening and failure earlier
Younger patients are also more likely to outlive their artificial joint, and
will almost surely require a revision at some point down the road.

Younger patients sometimes require the surgery (simply because

no other acceptable solution is available to treat their condition)

Total Knee Replacement

The ends of the femur, tibia, and patella are shaped to accept
the artificial surfaces.
The end result is that all moving surfaces of the knee are
metal against plastic

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Total Knee Replacement

Photographs of total knee

components on model
bone

Total Knee Replacement

Unicompartmental Knee Replacement

When only one part of the knee joint is arthritic, it may be
possible to replace just this part of the joint
The procedure is similar to a total knee replacement, but only
one side of the joint is resurfaced
A metal component is fit onto the femur and a plastic bearing
is inserted either directly onto the tibia or onto a metal tray
which has been fit onto the tibia
Recovery time is generally slightly shorter following this
kind of surgery.

The End