OSTEOARTHRITIS OF THE                                  October 2010; 52: 8
                                               ...
contents
                                                                                                                 ...
contents
#115–1665 West Broadway, Vancouver, BC, Canada V6J 5A4
Tel: 604 638-2815 or 604 638-2814 Fax: 604 638-2917
E-mail...
editorials

      Patient self-management

           recently attended a patient self-            for your health and I a...
editorials

Type 2 diabetes in youth
         ntil recently, type 2 diabetes       today’s children will become the first ...
personal view

                                                                                                    “wash y...
personal view

cian has no authority to have the dri-    plaining about the doctor who took         ers, the driver’s medi...
personal view

      Continued from page 387                           spent $375 000 to date in direct costs    Re: Poten...
comment

All in a day’s work (or perhaps a couple of weeks)
“        o, are you enjoying being         short notice becaus...
comment

      Continued from page 389                           brain injury. All sport has its own inher-
      meeting....
worksafebc

Research team explores new bone and tendon-related treatments

Platelet-rich plasma offers                Shoc...
Guest editorial




                                                        Osteoarthritis of the hip and
                ...
Manal Hasan, MBBS, MD, Rhonda Shuckett, MD, FRCPC, Diplomate ABIM




                                        Clinical fea...
Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees




                                ...
Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees




proves the ability to diagnose m...
Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees




                                ...
Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees




should not be surprising that ob...
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
British Columbia Medical Journal, October 2010 issue: Full Issue
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British Columbia Medical Journal, October 2010 issue: Full Issue

  1. 1. OSTEOARTHRITIS OF THE October 2010; 52: 8 Pages 381- 428 HIP AND KNEE—PART 1 Pathogenesis and nonsurgical management Clinical features and pathogenetic mechanisms Evidence-based guidelines for nonpharmacological treatment Pharmacological treatment Good Guys: Hammy and Hector Proust: Ari Giligson Research team explores new bone and tendon-related treatments Health Canada allows 10 000 unproven remedies onto shelves Screening renal failure patients for tuberculosis www.bcmj.org
  2. 2. contents October 2010 Volume 52 • Number 8 Pages 381–428 A R T I C L E S OSTEOARTHRITIS OF THE HIP AND KNEE—PART 1 392 Guest editorial Pathogenesis and nonsurgical management Established 1959 B.A. Masri, MD 393 Clinical features and pathogenetic mechanisms of osteoarthritis of the hip and knee Manal Hasan, MD, Rhonda Shuckett, MD 399 Evidence-based guidelines for the nonpharmacological treatment of osteoarthritis of the hip and knee J. Hawkeswood, MD, R. Reebye, MD ON THE COVER: Hip and 404 Pharmacological treatment of osteoarthritis of the hip and knee knee osteoarthritis places Stephen Kennedy, MD, Michael Moran, MBBS a huge burden on society because of the disability associated with it. In Part 1 O P I N I O N S of this double-issue series, we explore the pathogene- sis and nonsurgical man- agement of OA of the hip 384 Editorials Patient self-management, David R. Richardson, MD (384); Type 2 diabetes and knee. In Part 2 (Novem- ber), we examine the surgi- in youth, Susan E. Haigh, MD (385) cal options. Artwork by Jerry Wong. 386 Personal View Nosocomial or iatrogenic infections, Jim Battershill, MD (386); Re: Driver assessment, Robert Shepherd, MD (386); Re: AGM article, Jim Busser, MD (387); Re: Potential allergic drug reaction from residual antibiotics present 30% in livestock, H.C. George Wong, MD (388) 389 Comment All in a day’s work (or perhaps a couple of weeks), Ian Gillespie, MD Cert no. SW-COC-002226 410 Good Guys Hammy and Hector, Sterling Haynes, MD ECO-AUDIT: Environmental benefits of using recycled paper Using recycled paper made with post- 426 Back Page Proust questionnaire: Ari Giligson, MD consumer waste and bleached without the use of chlorine or chlorine compounds results in measurable environmental benefits. We are pleased to report the following savings. 1399 pounds of post-consumer waste used instead of virgin fibre saves: • 8 trees • 760 pounds of solid waste • 837 gallons of water Enter to Win an iPad from • 1091 kilowatt hours of electricity (equivalent: 1.4 months of electric power required by the average home) • 1382 pounds of greenhouse gases (equivalent: www.bcmj.org 1119 miles traveled in the average car) • 6 pounds of HAPs, VOCs, and AOX combined • 2 cubic yards of landfill space 382 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  3. 3. contents #115–1665 West Broadway, Vancouver, BC, Canada V6J 5A4 Tel: 604 638-2815 or 604 638-2814 Fax: 604 638-2917 E-mail: journal@bcma.bc.ca Web: www.bcmj.org D E P A R T M E N T S 390 Recently Deceased Physicians 391 WorkSafeBC Research team explores new bone and tendon-related treatments EDITOR David R. Richardson, MD Kukuh Noertjojo, MD, Craig Martin, MD EDITORIAL BOARD David B. Chapman, MBChB Brian Day, MB 411 Council on Health Promotion Health Canada allows 10 000 unproven remedies onto shelves Susan E. Haigh, MD Lindsay M. Lawson, MD Lloyd Oppel, MD Timothy C. Rowe, MB Cynthia Verchere, MD EDITOR EMERITUS Willem R. Vroom, MD 412 Guidelines for Authors MANAGING EDITOR Jay Draper 413 BC Centre for Disease Control Screening renal failure patients for tuberculosis PRODUCTION COORDINATOR James Johnston, MD, Kevin Elwood, MB Kashmira Suraliwalla EDITORIAL ASSISTANT Tara Lyon 414 Pulsimeter Stephen Lewis AIDS Foundation AfriGrand Caravan (414) COPY EDITOR Barbara Tomlin MWIA conference, Pamela Verma, BSc, Kristin DeGirolamo, BSc Pharm (414) Call for nominations: BCMA and CMA special awards (415) PROOFREADER Ruth Wilson Core-Plus Plan reminder (416) COVER CONCEPT & ART Peaceful Warrior Arts 416 Advertiser Index DESIGN AND PRODUCTION Olive Design Inc. PRINTING 417 Calendar Mitchell Press ADVERTISING 420 Classifieds OnTrack Media Tel: 604 375-9561 bcmj@ontrackco.com 427 Club MD 302–70 E. 2nd Ave. Vancouver, BC V5T 1B1 ISSN: 0007-0556 Advertisements and enclosures carry no endorsement of the BCMA or BCMJ. © British Columbia Medical Journal, 2010. All rights reserved. No part of this journal may be re- Subscriptions produced, stored in a retrieval system, or transmitted in any form or by any other means—elec- Single issue ................................................................................................................................$8.00 tronic, mechanical, photocopying, recording, or otherwise—without prior permission in Canada per year........................................................................................................................$60.00 writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any Foreign (surface mail) ..............................................................................................................$75.00 form for any purpose, send an e-mail to journal@bcma.bc.ca or call 604 638-2815. Postage paid at Vancouver, BC. Canadian Publications Mail, Product Sales Agreement #40841036. The BCMJ is published 10 times per year by the BC Medical Association as a vehicle for Return undeliverable copies to BC Medical Journal, 115-1665 West Broadway, Vancouver, BC V6J continuing medical education and a forum for association news and members’ opinions. The BCMJ 5A4; tel: 604 638-2815; e-mail: journal@bcma.bc.ca is distributed by second-class mail in the second week of each month except January and August. Prospective authors should consult the “Guidelines for Authors,” which appears regularly in the Jour- US POSTMASTER: BCMJ (USPS 010-938) is published monthly, except for combined issues Janu- nal, is available at our web site at www.bcmj.org, or can be obtained from the BCMJ office. ary/February and July/August, for $75 (foreign) per year, by the BC Medical Association c/o US Agent- Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not nec- Transborder Mail 4708 Caldwell Rd E, Edgewood, WA 98372-9221. Periodicals postage paid at essarily those of the BCMA or the institutions they may be assoicated with. The BCMA does not as- Puyallup, WA. USA and at additional mailing offices. POSTMASTER: Send address changes sume responsibility or liability for damages arising from errors or omissions, or from the use of to BCMJ c/o Transborder Mail, PO Box 6016, Federal Way, WA 98063-6061, USA. information or advice contained in the BCMJ. The BCMJ reserves the right to refuse advertising. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 383
  4. 4. editorials Patient self-management recently attended a patient self- for your health and I am concerned I management seminar. The idea is to involve patients in their own care, thereby increasing the chance about you.”) Next, I got Bob thinking about the issue while encouraging him to be an active part of the solution. I wanted to tell Bob that they will actually make appropri- “Bob, there are two basic factors that he was the only ate lifestyle changes. After complet- involved in weight control. Do you living creature on the ing the course, filled with religious know what they are?” self-management fervor, I was unleash- “No.” planet capable of ed upon my unsuspecting patients. I was taken aback, but sometimes creating mass . . . I found the most applicable issue more groundwork is required. “Well, in my practice to be weight control, so Bob, the two factors are how many when faced with an obese middle- calories you consume—diet—and aged man I launched into action. First how many you burn off—exercise.” I established rapport. “Bob, you are Now it was time to give control back ing, is there any other type of exercise really fat and are going to die.” (I actu- to the patient. “Which of these would you like?” ally started with, “Bob, there is lots of you like to talk about?” “I love to exercise.” evidence that being overweight is bad “We can talk about diet but I don’t “I notice you live by the pool. How eat anything.” about swimming?” “Bob, you’re 5'9" and 300 pounds “I don’t like to get wet.” but you don’t eat anything?” “There’s a gym at the pool, how “That’s right Doc. You would be about using the stationary bike?” surprised by how little I eat and what “My thighs rub.” I do eat is all healthy.” “Elliptical trainer?” I think Bob and I would both be “I get dizzy.” surprised by what he eats. If the patient “Rowing machine?” isn’t ready to talk reasonably about “I don’t like the sound they make, one item then it’s probably better to it creeps me out.” try a different approach, “Well, Bob, In the seminar they did say that since your diet is so good how about sometimes you have to accept that some we talk about your activity level?” patients just aren’t ready to change. “I walk everywhere.” However, I have a problem with this “Everywhere?” whole self-management thing. It feels “Yes, everywhere.” a little like babysitting. Who doesn’t “So let’s get this straight. You know that being overweight isn’t good don’t eat anything and walk every- for you? Have any of you ever had a where but continue to gain weight?” I conversation with a patient like this? wanted to tell Bob that he was the only “Hey Bob, probably no one ever told living creature on the planet capable you this before but being overweight of creating mass and that I wanted to is bad for you.” study him in the lab, but I remember “Really, you’re kidding. Shut the the kind people at the seminar stating front door! Bad for you? I’ve been see- that ridicule isn’t an effective self- ing doctors for years and you’re the management technique. “Well, Bob, first one to tell me. Well, if it’s bad for if you can’t improve your diet and me then I’ll lose weight and take bet- you’re already walking everywhere, ter care of myself. Thanks Doc.” the only solution is to increase your Another life saved. activity a little more. Other than walk- —DRR 384 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  5. 5. editorials Type 2 diabetes in youth ntil recently, type 2 diabetes today’s children will become the first ing the importance of preventing obe- U mellitus was almost unheard of in children, but over the past few years there has been a signif- generation in some time to potentially have a shorter life expectancy than their parents! sity and promoting health. It was esta- blished in 2005 as a cross-government health promotion initiative and their icant increase in incidence of this con- Currently, the economic costs re- mandate involved achieving five goals dition in children and adolescents. It lated to obesity and its consequences by 2010. Three of these related to has occurred too rapidly to be solely are not insignificant but relatively healthier food and exercise habits and attributable to genetic predisposition, small. Without effective intervention, resulted in new guidelines for food indicating that environmental factors though, they may well become stag- and beverage sales in public schools are likely to play a key role in its devel- gering in the future. in BC. These were developed with opment. Preventing childhood obesity in registered dietitians and implemented The hallmark of type 2 diabetes is the first place is obviously the goal in 2008. New recommendations for insulin resistance and the most com- and comes down to a need for com- physical activity in schools were also mon cause of this is overweight and prehensive changes in dietary and introduced in 2008. Their web sites obesity (overweight is defined by a lifestyle habits. This is a very complex and links for parents and families try- body mass index of 25 to 29.9 or waist issue and intervention must take place ing to adopt a healthier lifestyle are circumference of > 80 cm in females at a number of levels—the family, excellent tools. and > 94 cm in males and obesity as a schools and community, the food and There is promise that we can begin BMI > 30 or waist circumference of entertainment industry, policymakers, to stem the tide of childhood obesity, > 88 cm in females and > 102 cm in and government agencies. but it will take a massive shift in our males). About 50% of the Canadian The fast food industry in particu- current habits. Little steps can start at population is overweight or obese. lar needs to get on side and make rad- home! The proportion of obese children has ical changes. For the most part, unfor- —SEH almost tripled in the last 25 years in tunately, they offer “bad” foods. Bad both females and males in all age foods are cheap, heavily promoted, groups except preschoolers. Children and engineered to taste good. They are Liquid Nitrogen of obese parents have a 66% risk of loaded with calories, sugars or refined for Medical Use being obese before adulthood. It is carbohydrate, fat, and salt. Portion Westgen has been providing Liquid Nitrogen estimated that 26% of Canadians age sizes have exploded. “Supersized” to doctors for the past 10 years. We have 2 to 17 (more than 1 in 4) are over- portions of fries, burgers, and pop established a reputation for prompt, quality weight or obese, up from 15% in 1978. are typically two to five times larger service at a reasonable price. We also offer MVE Cryogenic Refrigera- Ninety-five percent of children with than when first introduced. Some fast tors in 10 and 20 litre sizes. These can be type 2 diabetes are obese. food chains have introduced healthier acquired on a one year LEASE TO OWN With the seemingly unabated in- meals, but they are generally more option, a system that allows you to own your crease in prevalence of obesity, type 2 expensive than the standard burger tank after a year of low monthly payments diabetes in youth is emerging as a seri- and fries. which includes free liquid nitrogen for the ous public health concern. It is associ- Regular physical activity is key to lease period. ated with increases in morbidity and achieving and maintaining a healthy MVE Cryogenic mortality from both microvascular weight. It’s recommended that chil- Refrigerators and macrovascular disease, and we dren get at least 60 minutes of physi- • No Stop Charge are now seeing these complications, cal activity daily, and sadly this is • No Cartage Fees • No Dangerous particularly coronary artery disease, often not achieved. Goods Handling appearing in young adults. This child- On a positive note, the ActNowBC Charges hood obesity epidemic means that initiative has led the way in recogniz- • Lease to own option Service provided to practitioners on Vancouver Island, Lower Mainland and Okanagan area. For more information contact Westgen at: 1-800-563-5603 Ext. 150 or 778-549-2761 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 385
  6. 6. personal view “wash your hands in front of each Letters for Personal View are welcomed. patient before examining them.” Also They should be double-spaced and less “get offices on the main floor so older than 300 words. The BCMJ reserves the patients are considered.” Many of our right to edit letters for clarity and length. teachers had seen the 1918 influenza Letters may be e-mailed (journal@bcma .bc.ca), faxed (604 638-2917), or sent epidemic and were still scared stiff of it. through the post. I fully realize that the world moves on, but perhaps we should look back once in a while at what we are leaving Nosocomial or behind. iatrogenic infections For example, we all had a small —Jim Battershill, MD, FRCPC booklet called The Control of Com- North Vancouver ne hears frequently through the municable Disease, which listed meas- O press about nosocomial (hos- pital) or iatrogenic (doctor- induced) diseases these days. I find ures for the practitioner such as immu- nization, placarding, or isolation. Surgical infection (it used to be called Re: Driver assessment this frustrating because when I entered “surgical scarlet fever”) was a cause doctor who never examines medicine in 1946 the antibiotic era was just beginning and we were still indoctrinated in the older measures for horror and embarrassment by all the staff of the hospital. One of my fondest memories is of A his or her patients is doing a poor job. The Office of the Superintendent of Motor Vehicles for disease control. One wonders if practical advice such as “the first thing (OSMV) tests young drivers repeat- some may have been abandoned too the patient does when he/she enters edly. The OSMV does not test older quickly. the office is to look to your hands” and drivers. Dr Jensen wrote, “The physi- The EMR for BC Specialists 7% of General Surgeons 7% of Internists 8% of Dermatologists Implement Accuro®EMR 8% of Neurosurgeons 9% of Otolaryngologists Alternative Specialist Funding Program 10% of Neurologists 13% of Surgical Specialists 13% of Urologists 13% of Ophthalmologists Accuro® EMR will enable physicians to meet the 19% of Endocrinologists 21% of Thoracic Surgeons 22% of Obstetricians & Gynecologists 25% of Orthopaedic Surgeons Alternative Specialist Funding Program (ASFP) 29% of Plastic Surgeons of $5,000 one-time and $250/month 35% of Gastroenterologists 42% of Nephrologists info@optimedsoftware.com 1-866-454-4681 * percentage of BC Specialists www.optimedsoftware.com for Accuro® Demonstration using Accuro®EMR 386 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  7. 7. personal view cian has no authority to have the dri- plaining about the doctor who took ers, the driver’s medical examination, ver’s licence cancelled. The decision away his driver’s licence. He almost destroys the trust between patient and to… deny a licence to operate a motor never comes to see me, so I cannot doctor. The OSMV should require vehicle rests solely with OSMV” examine him. older drivers to have their vision [“Driver assessment and the duty to On the OSMV “Driver’s medical checked by an optometrist by the auto- report.” BCMJ 2010;52:122]. examination” is a request that the doc- mated static perimetry. The OSMV Patients do not understand this. tor check a box “cognitive impairment should examine older drivers and do a The only contact older patients have MMSE score.” The Folstein Mini screen of cognitive ability. The only with the OSMV is a letter requiring Mental Status Examination does not test that assures that a person can drive them to get a medical exam. As far as evaluate executive function. It is pos- safely is a road test. the patients are concerned, this exam sible for a person to score well on the —Robert Shepherd, MD is a routine visit that they happen to MMSE, but have sufficient loss of Victoria have to pay for. Several patients have executive function that he or she left my practice because I required should not drive. References them to have an evaluation at Drive- The OSMV “Driver’s medical 1. Kerr NM, Chew SS, Eady EK, et al. Diag- ABLE (www.driveable.com). examination” requires the doctor to nostic accuracy of confrontation visual One such patient is Mr B., a gen- evaluate visual field. Kerr and col- field tests. Neurology 2010;74:1184- tleman who enjoyed driving. I used to leagues demonstrated that “most 1190. look forward to his visits, and he en- confrontation visual field tests were joyed his visits with me when he insensitive to the identification of Re: AGM article would tell me about the history books field loss.”1 he had been reading. When I asked The current method by which the he Journal’s feature on the An- him to go to DriveABLE, he scored far below normal on “Identification of driving situations.” Now his wife tells OSMV evaluates older drivers is inad- equate to assure safe driving. The cur- rent method by which the OSMV T nual General Meeting [BCMJ 2010;52:290-293] hinted at problems that warrant expansion. me that he sits around at home com- gathers information about older driv- Continued on page 388 “MCI takes care of everything without telling me how to run my practice”. heal thyself. MCI means freedom: I remain independent MCI Medical Clinics Inc. Toronto – Calgary – Vancouver www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 387
  8. 8. personal view Continued from page 387 spent $375 000 to date in direct costs Re: Potential allergic While the segue to Zafar Essak and pertaining to Dr Wang. No reference was drug reaction from Caroline Wang bears no comment, to made to her provision of facts, which write that their business took “a lot of she clearly wished accessible to mem- residual antibiotics time” risks losing the merit of the busi- bers. No mention was made of Past present in livestock ness inside its treatment. Highly signifi- President Ian Courtice’s appeal to the agree with the concern about anti- cant to my view were repeated ad homi- nem objections levied by one director at Dr Essak. Those objections, later Board to quickly resolve this matter. On low attendance, Dr Lloyd Op- pel asserted that it was the norm for I biotic use in our livestock ex- pressed in Dr Bill Mackie’s COHP column [BCMJ 2010;52:309]. built upon by other directors, were coun- associations everywhere. The BCMJ’s In addition to the problem of tered by Past President John Turner. managing editor proposed that given antibiotic-resistant organisms, there I found it was this fruitless antag- the many opportunities for input that is a potential of sensitization from onism, more than anything else, that people now have (phone, e-mail, reg- the residual antibiotics in the livestock frustrated remaining attendees. To my ular surveys, elections), the AGM has resulting in subsequent antibiotic view, the standing rules of our AGMs become obsolete, “a dinosaur on the allergy in patients. There could be a should provide that the demeanor of brink of extinction.” With all due res- potential cause of chronic urticaria or any speaker and any items they raise, pect to such opinion holders, the Asso- idiopathic anaphylaxis due to ingestion once criticized, not be subject to repeat ciation might better take low atten- of the livestock containing the resid- objection by the same person. Further dance as a failure to convince members ual antibiotics by sensitive patients objection should have to be levied by that attending matters. This hinges on later on. Research in this area should some other attendee. whether and how well those in charge be carried out. It was learnt that the Association show themselves to be open, account- Antibiotic-resistant organisms and able, and responsive, and to accord potential allergic drug reaction from regular members a meaningful voice. the residual antibiotics in our live- The social program, while important, stock should be of great concern to cannot compensate for the entrenched Health Canada. business portion that I maintain us to —H.C. George Wong, MD have evolved. Vancouver Our recent AGMs return to ques- tions of transparency, accountability, and function. I shall have asked the Enter to Win Board to answer these squarely at its an iPad from September meeting. www.bcmj.org —Jim Busser, MD BCMA Delegate, District 3 Your forum to advance… Specialist Issues Representing BCMA specialists 388 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  9. 9. comment All in a day’s work (or perhaps a couple of weeks) “ o, are you enjoying being short notice because of reporter dead- see more brain injury prevention pro- S BCMA president? What is it like?” To frequent questions such as this, lines. It can be quiet for several weeks and then there will be a flurry of act- ivity all in one day, usually when an grams and more effective methods of assessing brain injury in our emer- gency departments. Regarding the lat- I would say “fascinating, satisfying, issue grabs the media’s attention. ter, I am working on a pilot project challenging, and more.” The BCMA Most reporters are respectful, howev- intended to improve the quality and is a well-integrated group of teams er they do like to polarize the news to consistency of the assessment patients including the Executive Office, Pro- increase the level of audience interest. receive when they present in BC hospi- fessional Relations, Policy and Eco- tal emergency departments after trau- nomics, Negotiations, Communica- matic brain injury. Our small group tions, Finance, Benefits, and Member Most reporters are has met with interested and knowl- Services. The work is varied and can respectful, however they edgeable experts, including represen- change on very short notice. tatives from ICBC, and a second meet- do like to polarize the My practice is compressed into 2 ing is forthcoming to discuss a draft days per week with the remaining time news to increase the assessment flowchart, intake forms, spent at the BCMA office. My patients level of audience patient information forms, and how to and my office assistant, Rosemary, ensure good communication with the interest. have been very understanding and patient’s family doctor. We will then supportive of my taking a turn at this decide on the appropriate terms of ref- leadership. While president-elect, I was invit- erence for any committee work that Once weekly, I meet with the sen- ed to speak to the BCMA staff. During will be carried forward and report that ior staff of the BCMA to keep abreast the question period, someone asked if to the Board of Directors. of Association issues, plus I have other I had a special project to undertake With respect to brain injury pre- meetings with staff, physician mem- during my presidency. For some time vention, the BCMA’s resolution sup- bers, government officials, and indi- I have had an interest in the comput- porting a ban on mixed martial arts viduals from stakeholder organiza- erized assessment of cognitive ability (MMA) fighting in Canada somehow tions. Responding to e-mail and phone and have noticed that there is a wide came to the attention of a Vancouver calls usually has to fit in around the variation in findings and that there are newspaper 2 weeks before it was to other tasks. Media interview requests often long delays in the identification be brought to CMA’s General Council can bump other plans and are often on of significant impairment. I’d like to Continued on page 390 GPAC clinical practice guidelines are now available in iPod Touch and iPhone format — FREE! This free application contains over 30 clinical practice guidelines in abridged format. It serves as a condensed, portable companion to the full clinical practice guidelines found at www.BCGuidelines.ca, where over 50 guidelines are available in a range of formats. Download app from: http://itunes.apple.com/us/app/bc-guidelines/id377956292?mt=8 By BC physicians, for BC physicians www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 389
  10. 10. comment Continued from page 389 brain injury. All sport has its own inher- meeting. The story (and subsequent ent risks; however the intent of these ones) generated a visceral reaction from competitive team sports is very differ- Recently many MMA fans and a request to meet ent than the intent of MMA, plus these deceased with an MMA representative. After players are padded and helmeted. And our meeting, in which he wanted us to even though many sanctioned MMA physicians withdraw our resolution, all we could fights have a physician ringside, his or he following physicians agree upon was the common goal that the incidence of brain injuries must be reduced. her presence will not fundamentally reduce the risk of long-term brain damage to a fighter, even if the physi- T have died over the past 9 months; please consid- er submitting a piece for our cian does provide other worthwhile “In Memoriam” section in the The sole intent in an ringside medical care. BCMJ if you knew the deceased With the passing of this resolution well. MMA fight is to disable at CMA’s general council meeting by your opponent, which an 84% majority, it is now up to the Andrews, Dr William John includes by inducing CMA to advocate for a ban with fed- Baldwin, Dr John Henry eral legislators. In Canada, under Sec- Bartok, Dr Katalina a brain injury. tion 83 of the Criminal Code, prize Boxall, Dr Ernest Alfred fighting is illegal with exceptions made Brunton, Dr Lawrence Jackson Not surprisingly, there was debate for boxing (which the CMA voted to Chen, Dr Ferdinand at the BCMA caucus meeting when call for a national ban in 2002) and Chetwynd, Dr John Brian this resolution was first introduced, events authorized by provincial sports Dudley, Dr John Howard and even more debate at CMA’s Gen- commissions. MMA itself has been Duffy, Dr John Peter eral Council when it was presented banned in six provinces and territo- Findlay, Dr Ian Douglas for discussion. My argument among ries, however Ontario reversed its ban Goh, Dr Anthony Poh Seng media, physicians, and interest groups in August after strong lobbying. Our Kalyanpur, Dr Vasant Raghav has always been the concern with the role will be to provide expert opinion Lewis, Dr David John degree of violence in this sport and the to government about the risks to brain MacDonald, Dr Alan Angus risk for brain injury. The sole intent in health, if and when government de- Mackenzie, Dr Conrad an MMA fight is to disable your oppo- cides to consider the Canadian Med- McAdam, Dr Ronald nent, which includes by inducing a ical Association’s recommendation. McCannel, Dr John Arthur brain injury. We know that repeated Debating this issue has been chal- McDaniel, Dr Bernard Minshull brain injuries have long-term debilitat- lenging, eye opening, and at times Milobar, Dr Tony ing effects. Continuing research also frustrating. But being president of the Penny, Dr Helen Angela confirms the increased risk of neuro- BCMA means you don’t back down Percheson, Dr Peter Brady degenerative disease, and at an earlier when the going gets tough. I am proud Pinkerton, Dr Alexander Clyde age, after repeated concussion. We that I stuck to my principles and per- Puttick, Dr Michael Paul Ernest would not be doing our job if we sisted in working with those who had Queree, Dr Terence Candlish didn’t speak up on behalf of the brain objections, and in the end the position Selwood, Dr Michael health of Canadians. of our caucus was validated by a large Smaill, Dr William Donald Critics have wondered (somewhat majority of physician delegates at the Thomas, Dr Ifor Mackay sardonically) why we haven’t also CMA’s annual meeting. Tucker, Dr Frederick Gordon called for a ban on football, hockey, —Ian Gillespie, MD Van Schie, Dr Lisa or baseball, as they too have a risk of BCMA President 390 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  11. 11. worksafebc Research team explores new bone and tendon-related treatments Platelet-rich plasma offers Shock therapy thought to One cause of shoulder mixed success in treating ease pain from calcified pain is calcific rotator cuff tendinopathies supraspinatus tendinopathy tendinopathy, which occurs The concept of using growth factors One cause of shoulder pain is calcific contained in activated platelets to rotator cuff tendinopathy, which occurs in 7% to 17% of rotator help wound healing dates back to the in 7% to 17% of rotator cuff tendinopa- cuff tendinopathies. early 1980s. More recently, the use of thies. Extracorporeal shock wave ther- platelet-rich plasma (PRP) to treat apy (ESWT) has been promoted as an various musculo skeletal disorders, alternative to surgical intervention in experts have demonstrated a lack of including tendinopathies, has increas- treating rotator cuff tendinopathy that agreement regarding the diagnosis of ed tremendously. fails to respond to conventional and fracture nonunions. Tendon healing is a complex pro- more conservative therapies. While While ultrasound has been applied cess involving many growth factors, the mechanism is still unclear, this in treating fractures for half a century, such as platelet-derived, transform- outpatient procedure is thought to pro- its role in fracture healing is not ing, vascular endothelial, insulin-like, vide long-lasting analgesia and stimu- well understood. In January 2010, the and epidermal growth factors, which late the healing process. WorkSafeBC Evidence-Based Prac- are detected in higher concentrations In June 2010, the WorkSafeBC tice Group investigated the effective- in PRP. To date, the respective role of Evidence-Based Practice Group inves- ness of Exogen low-intensity ultra- each type of growth factor requires tigated the effectiveness of ESWT, sound in treating fracture nonunion further exploration. As well, recent using low- and high-level energy shock and found three high-quality system- evidence suggests varying concentra- waves to treat calcific supraspinatus atic reviews12-14 and one large case tion levels of these growth factors in or rotator cuff tendinopathy in gener- series (n = 1317)15 that showed as fol- PRP, depending on the protocol and al. Their findings included two sys- lows: devices used to spin the blood. tematic reviews, one of high quality6 • No high-level primary studies exist In April 2010, the WorkSafeBC and one of low quality,7 three low- to provide evidence of the effective- Evidence-Based Practice Group con- quality RCTs,8-10 and one low-quality ness of low-level ultrasound. ducted a systematic literature review case-control study.11 This included • Low-level evidence, including large of the effectiveness of PRP in treat- some high- and low-quality evidence case series, showed that low-level ing tendinopathies. They found five to suggest high energy ESWT can ultrasound is effective as an adjunct studies of varying quality and design provide pain relief and increased func- to good immobilization, especially investigating the application of PRP tion, as measured by the Constant- when provided by an external in treating chronic patellar tendinosis1 Murley score, among patients suffering immobilizer. and chronic elbow tendinosis,2 during from calcific rotator cuff tendinopa- • Low-level ultrasound may be effec- arthroscopic rotator cuff repair,3 dur- thy. There was no evidence on the tive among patients aged 31 to 60 ing Achilles tendon surgery to pro- effectiveness of ESWT in treating with long bone or scaphoid frac- mote healing,4 and treating Achilles noncalcific rotator cuff tendinopathy. tures; who had comorbid illnesses; tend ino pathy. 5 Lower-quality and who had been treated with other lower-level studies 1-4 showed the Low-intensity ultrasound for drugs, such as steroids, NSAIDs, effectiveness of PRP in treating vari- nonunion fractures appears anticoagulants; or who are current ous tendinopathies. However, the only effective for some smokers. available high-quality evidence show- Fracture healing is a complex process Other adjunct treatments, yet to ed that PRP injection compared to involving various factors that need to be tested for effectiveness, are also saline injection did not result in sig- occur at a specific time and place. available. These include pulsed elec- nificant improvement in pain and US data show up to 10% of healing tromagnetic field stimulation, direct activity.5 These studies could not dis- fractures develop delayed union, current or capacitative coupling, ex- count the value of co-interventions. and a significant proportion of these tracorporeal shockwave stimulation, become nonunions. At present, some Continued on page 416 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 391
  12. 12. Guest editorial Osteoarthritis of the hip and knee, Part 1: Pathogenesis and nonsurgical management ease and the journey of patients with evidence behind these modalities. OA of the hip or knee from diagnosis This article serves not only as a guide to nonoperative treatment and finally for practitioners, but also as a summa- to surgical intervention. This first part ry for patients who are considering in a two-part theme issue on OA of the each of these modalities. The article hip and knee explores the patholge- demystifies these modalities and netic mechanisms and several aspects allows the physician and patient to of nonsurgical management. understand the relative merits of each In the first article here, Drs Hasan treatment, from footwear and weight and Shuckett discuss the epidemiolo- loss to the use of canes. gy of hip and knee OA and factors in In the third article here, Drs Ken- its genesis. The figures that they in- nedy and Moran continue the discus- clude about the burden of disease are sion of nonoperative management, but indeed sobering. The authors discuss this time from the pharmacological the risk factors for OA, allowing us as point of view. They discuss the role of Dr B.A. Masri practitioners to potentially change oral medications as well as joint injec- patients’ behavior at a young age and tions. This sets the stage for their dis- lessen the likelihood of this disease cussion of the indications for surgical with aging. They also discuss clinical intervention, and when to consider steoarthritis (OA) is the presentation and radiographic find- referral to an orthopaedic surgeon. O most common chronic dis- ease affecting British Col- umbians. Family physicians manage patients with osteoarthritis on a daily basis using strategies that range ings, allowing an easier understand- ing of when to suspect OA in a patient and when to proceed to a radiographic review. The authors clearly delineate the indications for plain radiographs By focusing on the earlier stages of OA and considering diagnosis and nonoperative management, all the articles in Part 1 of this theme issue pave the way for the articles in from reassurance to surgical interven- and MRI. With improved access to Part 2, which will discuss surgical tion. Large joint OA, as exemplified MRI, we often see patients presenting modalities. by hip and knee osteoarthritis, places with OA with an MRI as the initial —B.A. Masri, MD, FRCSC a significant burden on society be- radiographic investigation. The take- Professor and Head, cause of the disability associated with home message is that an MRI should Department of Orthopaedics it. Patients affected by OA of the hip be reserved for use when X-rays do University of British Columbia and knee often require surgical inter- not indicate OA. vention. Many modalities for nonoperative With the increasing emphasis on treatment for OA of the hip and knee joint replacement, it is important to exist. In the second article here, Drs consider the entire spectrum of dis- Hawkeswood and Reebye discuss the 392 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  13. 13. Manal Hasan, MBBS, MD, Rhonda Shuckett, MD, FRCPC, Diplomate ABIM Clinical features and patho- genetic mechanisms of osteo- arthritis of the hip and knee Understanding how osteoarthritis develops is critical to treating this disabling disease. steoarthritis (OA) is a non- tween X-ray findings and symptoms O ABSTRACT: Osteoarthritis is a non- inflammatory form of arthritis that inflammatory form of arth- of OA.1 accounts for 25% of visits to primary ritis. A common miscon- OA accounts for 25% of visits to care physicians. When osteoarthritis ception is that OA is due primary care physicians, and 50% of affects the hip and knee, it can lead solely to wear and tear, since OA is NSAID prescriptions.2 It is estimated to major disability and compromised typically a disease of persons in the that up to 80% of the population will quality of life. Diagnosis relies on sixth decade and beyond. “Degenera- have radiographic evidence of OA by clinical symptoms, physical find- tive arthritis” is often used as a syno- age 65, with 60% of those showing ings, and radiographic findings. The nym for OA, but OA is not the result of symptoms and thereby having clinical interplay between mechanical and a bland degenerative process; rather, OA.3 Another study found that by age systemic factors such as congenital OA involves both degenerative and 70 to 74 years, about 33% of men and abnormalities, obesity, and malalign- regenerative processes. 40% of women will have OA with ment may predispose individuals to OA is common and serves as the clinical and X-ray features.4 The life- osteoarthritis of the hip and knee. main source of chronic joint com- time risk of developing symptomatic We must identify these factors and plaints in adults. The morbidity con- knee OA is about 45%, rising to 66% the underlying causes of osteoarth- ferred by OA of the knee and hip in an in obese persons. While there is vari- ritis if we are to develop more pro- ever-aging population is major. Its ation in these numbers, it is clear that gressive early interventions for this high prevalence and huge impact on the morbidity and disability conferred common affliction. quality of life demand that we engage by OA of the hip and knee is enormous in better understanding of OA by con- and demands our attention.5 sidering diagnostic, epidemiological, clinical, and radiographic features. An Symptoms and understanding of how OA is classified physical findings and OA risk factors is also critical. The main symptoms of OA of the knee or hip are pain, stiffness, and altered Diagnosis and function. Initially this tends to be epidemiology worse with weight bearing and ambu- The diagnosis of OA relies on clinical lation. Eventually this can progress to symptoms, physical findings, and radiographic findings. Not all persons Dr Hasan is a rheumatology fellow in the who have radiographic OA have clin- Division of Rheumatology at the University ical disease. Conversely, not all per- of British Columbia, sponsored by the King- sons who have joint pain demonstrate dom of Saudia Arabia. Dr Shuckett is a clin- plain radiographic findings of OA. ical associate professor in the Division of Thus, there is often discordance be- Rheumatology at UBC. www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 393
  14. 14. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees pain day and night once cartilage loss al compartment OA of the knees. Less leads to bone-on-bone contact. True commonly, patients may present with hip pain is felt in the groin most com- a valgus or knock-knee deformity, monly, but can also present in the but- indicative of more advanced disease tock and often down the anteromedial in the lateral compartment of the knee. thigh to the knee. Not uncommonly, On occasion, and much less common- patients may present solely with knee ly, patients may present with isolated pain when the problem is in the hip. OA in the patellofemoral joint, which Pain arising from osteoarthritis of the can of itself be very symptomatic. knee is felt right around the knee joint, In the case of the hip, a true cap- and unlike pain caused by hip OA, this sular pattern of limitation is found pain does not typically radiate. with groin or buttock pain (or both) In contrast to inflammatory arthri- and particular pain with internal rota- tides such as rheumatoid arthritis, with tion of the hip. Flexion deformity of their prolonged morning stiffness and the involved hip can be present with worsened pain in the morning, OA advanced OA. Patients will often walk Figure 1. Radiograph of osteoarthritis of tends to worsen as the day progresses. with a limp, and a waddling Trende- the hip showing predominant superolateral The stiffness in OA is termed “inac- lenburg gait may be evident in late joint space narrowing, subchondral sclerosis of whitening of the bone adjacent tivity stiffness” and contrasts with stages. to the joint space, and some marginal the prolonged “morning stiffness” of osteophytes. rheumatoid arthritis. Inactivity stiff- X-ray findings ness in osteoarthritic lower limb joints Standard knee X-rays should include lasts about 5 to 10 minutes and occurs a standing anteroposterior (AP) view when the patient gets up and bears of both knees, plus lateral views. In weight after prolonged immobility. patients with suspected posterolateral On physical examination, a small OA with a mild valgus deformity, a effusion with a fluid bulge sign can be 30 degree flexed standing posteroan- present in OA of the knee. Larger effu- terior (PA) view with the beam sions can occur but are less frequent directed 15 degrees from cephalad to than in the inflammatory arthropathies. caudad may be valuable in showing Synovial fluid analysis after aspira- the disease in the posterior aspect of tion of an OA knee effusion reveals the lateral compartment of the knee.6,7 that the fluid is thick and viscous with In early cases, a standard standing AP a low synovial white blood cell count, view may appear normal or indicate most of which are mononuclear cells. very mild OA, whereas the standing On examination, there may be carti- flexed PA view may show bone- laginous crepitus or a crackling feel- on-bone contact. Patellofemoral OA ing on palpation of the knee with mo- of the knee cap is also a common tion. Eventually there may be coarse finding, best diagnosed on a skyline bone-on-bone crepitus whereby the X-ray view. opposing bone ends, denuded of carti- X-rays of the hips to evaluate for lage, seem to grate against one anoth- OA should include a standing AP er. There is often a loss of range of pelvis view and frog-leg views of the motion of the involved knee or hip, suspected hip joint. It is important to Figure 2. Medial compartment particularly with progression of OA. always order standing X-rays of both osteoarthritis of the knee with medial Loss of cartilage of the knee can knees in the case of suspected knee compartment joint space loss.This marked narrowing is between the medial tibial lead to malalignment of the leg with a OA and an X-ray of the pelvis and not plateau and the medial femoral condyle. varus deformity or bow-legged posi- just the affected hip in the case of sus- The fibula can be seen in its lateral tioning of the leg being evident. This pected hip OA. This will allow for location. angulation of the knee applies to medi- comparison between sides and im- 394 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  15. 15. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees proves the ability to diagnose mild to application. MRI has emerged as an Table 1. Traditional classification of OA moderate disease. excellent modality for detection of OA On plain X-ray evaluation, loss of when the plain radiographs indicate Primary osteoarthritis the radiolucent cartilage, termed joint no disease or mild disease, and the • Idiopathic space narrowing, is seen in OA. In the patient’s symptoms are out of keeping • Generalized hip joint the joint space narrowing with the apparent severity of disease. • Erosive tends to be more in the weight-bearing MRI can detect large focal articular Secondary osteoarthritis superolateral aspect of the joint, again cartilage lesions that cannot be detect- • Due to mechanical incongruity of joint, highlighting the role of mechanics in ed on plain films.6-8 congenital or acquired (e.g., acetabular OA ( Figure 1 ). However, there are dysplasia of hip or internal knee different patterns of OA of the hip, and Classification of OA derangement) it is possible to get more central wear, Traditionally OA has been classified • Due to prior inflammatory disease (e.g., rheumatoid arthritis) particularly in patients with deep sock- as primary or secondary ( Table 1 ).9 • Due to endocrine disorders (e.g., ets or protrusio acetabuli. In the knee, Primary OA denotes generalized or diabetes, acromegaly) main involvement is often in the medi- erosive OA with no identifiable cause. • Due to metabolic disorders (e.g., calcium al joint compartment ( Figure 2 ), but Secondary OA denotes OA caused by pyrrophosphate dihydrate crystals, involvement of other compartments an underlying condition, including hemochromatosis) or of the entire joint is also common. those caused by inflammatory dis- • Miscellaneous (e.g., avascular necrosis) On plain X-ray of an osteoarthrit- eases, trauma, and mechanical factors. Source: Adapted from Brandt KD.9 ic joint, in addition to joint space nar- In a large series of cases of so- rowing, there tends to be subchondral called primary osteoarthritis of the sclerosis or an appearance of whiten- hip, some underlying mechanical Table 2. Classification of OA by cause ing of the subchondral bone. Osteo- developmental variation could be found A. Abnormal concentrations of force on phytes, which reflect a regenerative in most cases to account for the onset normal cartilage process with formation of fibrocarti- of the disease.10 For instance, the sub- • Cartilage surface irregularities (e.g., laginous extensions or hooks at the tle presence of a shallow cup of the intra-articular fractures, meniscal tear) joint margins, are common. Interest- hip, called acetabular dysplasia, is a • Malalignment of the joint (e.g., leg length ingly, the presence of osteophytes in common precursor to OA of the hip. disparity, acetabular dysplasia, congenital hip dislocation) one compartment, such as the lateral In middle-aged men, femoroacetabu- • Loss of ligamentous stability (e.g., compartment in a patient with medial lar impingement (FAI) is thought to anterior cruciate ligament tear) compartment OA, is not indicative of be the most common cause of OA of • Loss of protective sensory feedback (e.g., disease in that compartment. It is sim- the hip. FAI of the pincer type occurs diabetic neuropathy) ply indicative of the body’s reparative most often in middle-aged women. On • Other causes (e.g., obesity, occupational) response to the abnormal stresses and occasion, patients may present with B. Normal concentrations of force on presence of disease in the medial com- symptoms of impingement prior to abnormal cartilage partment. the development of advanced OA. It • Pre-existing arthritis (e.g., rheumatoid The identification of OA on plain thus appears that the term “primary or arthritis) X-rays means there is already full idiopathic OA” is probably a mis- • Metabolic abnormalities (e.g., crystal thickness cartilage loss and even nomer as it applies to the hip or knee, arthropathy) bone-on-bone contact. These radi- and that if we look hard enough an • Genetic (e.g., generalized osteoarthritis of hands) ographic findings occur relatively late underlying structural cause will often in the course of OA. It would be ideal be apparent. C. Normal concentrations of force on to be able to identify OA before gross In the 1970s Mitchell and Cruess normal cartilage supported by stiffened subchondral bone changes are apparent on radiographs. proposed a more pathogenetic classi- • Paget disease Earlier OA detection is important in fication of OA ( Table 2 ). This classi- identifying disease before the pro- fication system assumes that osteo- D. Normal concentrations of force on gressive bone-on-bone stage. Joint arthritis can arise from an intrinsic normal cartilage supported by weakened subchondral bone ultrasound has been applied in studies problem of the cartilage as encoun- • Avascular necrosis to identify OA earlier, but this is more tered after years of chronic inflamma- a research tool than a routine clinical tory arthritis.11 Thus, OA can occur Source: Adapted from Mitchell NS, Cruess RL.11 www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 395
  16. 16. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees is gaining increasing recognition as a major structural precursor to hip OA. These are usually asymptomatic before possible progression to OA and can be seen on a screening AP pelvis radi- ograph. Such pre-symptomatic X- rays, however, are not ordered rou- Subtle and asymptomatic anatomic tinely. variations have been associated Genetic factors with hip osteoarthritis. The strongest association between genetic factors and OA applies to gen- eralized osteoarthritis of the hands. Evidence for a correlation between genetics and knee or hip OA is less conclusive.15,16 Physical activity Although the health of cartilage and with (A) normal force on abnormal Gender and the other joint tissues requires regular cartilage. Alternatively, it can occur estrogen connection joint loading, excessive loading may with (B) abnormal concentrations of Women are more likely than men to contribute to OA. While some studies force on normal cartilage. This would have OA, be it generalized OA of the suggest a strong positive relationship implicate mechanical aberrations such hands or OA of the hips and knees.12 between work-related knee bending as malalignment, the post-meniscecto- The increase in OA in menopausal exposure and knee OA, others have my knee, or a cruciate deficient knee. women has led to numerous investi- failed to find a direct relationship The abnormally formed hip mention- gations into the relationship between between the presence of knee OA ed above would fall into this category hormonal factors and OA. The results and habitual physical activity or rec- as well. have been conflicting and inconclu- reational running. 17 A relationship Mitchell and Cruess’s classifica- sive.13,14 Clearly, other health issues between heavy manual work, farming tion system also includes situations are of concern when determining in particular, and hip OA was found in where there is (C) stiffened subchon- whether hormone replacement thera- different studies, but the association is dral bone, as in the case of the rare py is to be considered in the post- still considered a weak one.18 Paget disease, which does indeed pre- menopausal patient. Although it makes sense that high dispose to OA of an involved joint. levels of impact and repeated torsion- Alternatively, they describe situations Congenital/developmental al loading could increase the risk of where (D) weakened subchondreal abnormalities articular cartilage degeneration, this bone, as in avascular necrosis, predis- Local factors that affect the shape of is not borne out consistently in stud- poses to OA. the joint may increase local stress on ies. Still, it would appear prudent to cartilage and contribute to the devel- suggest that anyone with a known Risk factors for OA opment of osteoarthritis, especially in underlying predisposition to OA, such OA is best viewed as the end result of the hip joint. As already mentioned, as abnormal hip or joint anatomy or an interplay between local and sys- subtle and asymptomatic anatomic excessive body weight, avoid repeti- temic factors. Such factors are well variations have been associated with tive impact-loading activities such as outlined in the classification schema hip osteoarthritis. These include ace- jogging. of mechanical factors proposed by tabular dysplasia or epiphysiolysis, Mitchell and Cruess. Several local which are common milder variants of Obesity systemic factors may be operative in congenital hip dislocation and slipped Every step taken in a normal gait places predisposing patients to OA of the hip capital femoral epiphysis, respective- about three times an individual’s body or knee. ly.10 Femoralacetabular impingement weight on lower limb joints. Thus it 396 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org
  17. 17. Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees should not be surprising that obesity tis. An exception to this is the pres- deformity that will challenge accurate and high body mass index have long ence of intra-articular fractures, that leg length measurement. It is key to been recognized as potent risk factors is, fractures that extend though the place the patient’s legs in proper align- for OA, especially medial compart- joint line. The disruption of the carti- ment. There should be an equal dis- ment OA of the knee in females. lage and subchondral bone with an tance between the medial malleoli The Framingham Study found that intra-articular fracture does portend a of the ankles, and the feet should be women who lost about 5 kg had a 50% heightened risk of OA of the involved centred in a neutral position under the reduction in the risk of developing joint in future decades. Trauma of corresponding hips. The apparent leg new symptomatic knee OA.19 Weight- the knees leading to internal knee length is measured from the umbilicus loss interventions have been shown to derangement such as a mensical or to the medial malleolus on each side. decrease pain and disability in estab- major ligamentous tear will predis- A discrepancy usually signals a scol- lished knee OA. The Arthritis, Diet, pose to osteoarthritis. In the case of iosis. The true leg length is measured and Activity Promotion Trial showed the hip, acetabular labral tears, which from the anterior superior iliac spine that weight loss combined with exer- can only be seen on MRI combined to the medial malleolus, and a discrep- cise, but not either weight loss or exer- with an arthrogram, will increase the ancy suggests a true variation between cise alone, was effective in decreasing risk of future OA of the involved hip the two legs. For a true leg length dis- pain and improving function in obese joint. An acetabular labral tear is often crepancy of more than 1 cm, a shoe lift elders who already had symptomatic an indication for hip arthroscopy to or built-up orthotic that adjusts for half knee OA.20 trim the torn fragment. Hip arthros- of the leg length difference is typical- When patients ask their physicians copy is not often done for diagnostic ly recommended. For a large discrep- how they can prevent OA of the knees, purposes because MRI is so effective ancy this may not be readily attainable. weight control is paramount. Unfortu- at picking up lesions. Varus deformities, valgus deform- nately weight loss is challenging in It is thought that blunt trauma such ities, and cruciate ligament tears are established OA of the knee due to the as contact with a dashboard in a motor other factors that can predispose to the limited physical activity possible. vehicle accident can lead to patello- development and progression of knee The relationship between excess femoral syndrome and chondromala- OA. Detailed discussion of such fac- weight and hip OA is less clear. The cia patella. However, whether these tors is beyond the scope of this article. evidence in hip OA is not as compel- pre-OA lesions will progress in future Like the medial compartment and ling as with knee OA.21,22 decades to full thickness confluent the lateral compartment, the patello- In addition, there is evidence that cartilage loss signifying OA has not femoral compartment of the knee is obesity predisposes to osteoarthritis been determined. often afflicted with OA. While injury in non-weight-bearing joints such as is a common factor in medial and lat- the joints of the hand. Clearly excess Alignment, including leg length eral compartment OA, malalignment weight in a biomechanical sense alone Strong evidence suggests that altered is a more common factor in patel- does not explain this finding. Recent mechanics play a role in OA incidence lafemoral OA. Most cases of chon- studies have shown that body fat, par- and progression, and recent studies dromalacia patella that result from ticularly central fat deposits, are bio- are beginning to isolate specific malalignment are nonprogressive, but chemically active and produce sub- mechanical factors that may be of par- some can progress to OA.24 stances such as leptin and adiponectin.23 ticular importance. Such alignment It has also been shown that leptin can problems include a leg length discrep- Conclusions induce the formation of cytokines, ancy of more than 1 cm, which con- OA of the hip and knee is a major such as interleukin-6, which can have fers an increased risk of OA of the hip health care issue in an ever-aging pop- a deleterious effect on chondrocytes on the long leg side. All patients ulation. OA of weight-bearing joints of the cartilage. should be assessed for this. confers major disability and compro- Leg length measurements include mised quality of life. At this time, Trauma the apparent and the true leg length. medical treatment of OA is not as In general, there is a paucity of good To measure leg length, you should sophisticated as the treatment of documentation to support the con- have the patient lie flat on his or her rheumatoid arthritis. All too often we tention that blunt trauma to a joint back on the examining table and en- fail with conservative treatment, and increases the risk of future osteoarthri- sure that there is no hip or knee flexion patients with hip and knee OA progress www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 397

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