Etiology, Diagnosis and Treatment

1. OsteoarthritisOsteoarthritis
Etiology, Diagnosis and TreatmentEtiology, Diagnosis and Treatment

2. DisclosuresDisclosures
• None (except)
• Except I like talking
about osteoarthritis

3. OA: prevalenceOA: prevalence
• In a lifetime of 80
years most people will
walk 200 million
steps!
• Wonderful joint
durability!

4. OA prevalenceOA prevalence
• Over age 65 10%
(men) and almost
20% (women) have
symptomatic OA

5. Osteoarthritis: PretestOsteoarthritis: Pretest
Choose False statement:
1. OA not seen onXray often
2. OA occurs after RA
3. Most patients with OA on Xrays are
symptomatic
4. Woman suffer more than men

6. OA: Pre testOA: Pre test
All false except
1. OA always caused by injury
2. Most common presentation- heberdens
nodes
3. Ginger extract useful for Rx
4. All NSAIDS share same safety profile

7. Pretest OAPretest OA
• All true except
• 1. knee injections can be safely done by
you
• 2. steroids effective RX
• 3. Viscosupplementation doesn’t work
• 4. PRP shown to be effective

8. Pretest: true or falsePretest: true or false
• Regarding DMOADS and OA
• 1. There are no Dmoads for OA
• 2. Dmoads for RA are effective for OA
• 3. Some nutraceuticals have Dmoad
activitiy in OA.

9. Osteoarthritis: PathologyOsteoarthritis: Pathology
• Normal joint surface
is smooth with a hard
rubbery surface.
Made up of hyaline
cartilage.

10. Osteoarthritis: PathologyOsteoarthritis: Pathology
• Osteoarthritis starts
by the breakdown of
the smooth normal
articular surface

11. Osteoarthritis: PathologyOsteoarthritis: Pathology
• Degenerative
changes can be mild

12. Osteoarthritis: PathologyOsteoarthritis: Pathology
• Changes can be
severe (bone on
bone)

13. Osteoarthritis: pathologyOsteoarthritis: pathology
• Cartilage breakdown
affects whole joint
• Secondary
development of
osteophytes,
ligamentous laxity etc

14. OA mechanical causesOA mechanical causes
• Any process that
damages the articular
surface causes
arthritis
• injuries

15. OA : mechanical causesOA : mechanical causes
• Overload of joint
• For every extra 10 kg
weight there is a
100% increase in
osteoarthritis
• BMI >30 had 7 times
OA as BMI <25

16. OA: Residual of InflammatoryOA: Residual of Inflammatory
ArthritisArthritis
• Inflammatory disease
damages joint
• RA
• Gout
• OA is what is left

17. OA: Genetic causesOA: Genetic causes
• Any condition that
genetically makes the
articular cartilage
weaker
• Eg.
hemachromatosis

18. Osteoarthritis-causesOsteoarthritis-causes
• Heberdens nodes
associated with
increased general
osteoarthritis
• ? Marker, hand
arthritis a risk factor
for later hip and knee
arthritis

19. Cause OA: bottom lineCause OA: bottom line
• Any single or multiple
factors that lead to
damage to that nice
smooth articular
surface

20. Arthritis: progressionArthritis: progression
• Once the joint has a
rough surface, the
moving surface is
rough and the
roughess will
progress at variable
speeds
• Intrinsic process
continues as well

21. OA: Clinical AssessmentOA: Clinical Assessment
• History
• Physical
• Diagnostic imaging

22. OA: HistoryOA: History
• OA classically pain
increasing with
activity and improving
with rest
• (but) any
presentation possible

23. OA: historyOA: history
• History of any
condition that leads to
OA
• Injury, gout, other
inflammatory
conditions, family
history

24. Osteoarthritis-HistoryOsteoarthritis-History
• The presence of OA
pathology does not
mean there will be
symptoms
• This guy says he has
no pain!

25. Osteoarthritis-HistoryOsteoarthritis-History
• This asymptomatic
patient’s knee may
look like this

26. Osteoarthritis- HistoryOsteoarthritis- History
• This guy says he has
pain all the time and
cannot work

27. Osteoarthritis-PhysicalOsteoarthritis-Physical
• Objective
• Muscle wasting

28. Osteoarthritis: physicalOsteoarthritis: physical
• Objective
• Effusion

29. Osteoarthritis-PhysicalOsteoarthritis-Physical
• Deformity
• Cmc arthritis

30. Osteoarthritis-physicalOsteoarthritis-physical
• stiffness

31. Osteoarthritis -XrayOsteoarthritis -Xray
• Joint space narrowing
• Osteophytes
• Sclerosis
• Cystic change
• (implies advanced
changes)

32. Radiological OARadiological OA
• Only symptomatic
about one third to one
half the time
• The “je ne sais quoi?
disease

33. Osteoarthritis- XrayOsteoarthritis- Xray
• Early arthritis will
have normal xray

34. Osteoarthritis - xrayOsteoarthritis - xray
• For knee always
order all weight AP
xray

35. Xrays stork viewXrays stork view
• All weight ap

36. Kellgren-lawrence gradesKellgren-lawrence grades

37. Osteoarthritis- CT scanOsteoarthritis- CT scan
• Not very helpful for
OA
• harmful rads and
wasted rads time
• Wasted money

38. Osteoarthritis-mriOsteoarthritis-mri
• Xray better for more
advanced oa
• Mri may or may not
show early oa

39. OsteoarthritisOsteoarthritis
• Knee osteoarthritis is
the most common
type you will see

40. Knee Osteoarthritis: diff dxKnee Osteoarthritis: diff dx
• Knee pain may be
from mechanical
problems
• ie, meniscal tear

41. Knee OA- DiagnosisKnee OA- Diagnosis
• Old fashioned History
is best to differentiate
mechanical from non
mechanical pain

42. Knee OA Mechanical DiagnosisKnee OA Mechanical Diagnosis
• Symptoms of locking
or catching in flexion
(meniscal) or in
extension
(patellofemoral)
• History of injury

43. Knee OA: Arthritic diagnosisKnee OA: Arthritic diagnosis
• Long term symptoms
• Ache and Pain
• Increase with activity

44. Hip OA: DiagnosisHip OA: Diagnosis
• Most hip pain caused
by arthritis

45. Hip OA: DiagnosisHip OA: Diagnosis
• Much like knee the
hip can have a
mechanical diagnosis
• Torn labrum
• Rare compared to
knee

46. Thumb CMC ArthritisThumb CMC Arthritis
• Very common
• Can diagnosis by
clinical exam and
Xray

47. Hallux Rigidus: DiagnosisHallux Rigidus: Diagnosis
• Pain and enlargement
of big toe
• Clinically has stiffness
and palpable
osteophytes

48. Hallux Rigidus: DiagnosisHallux Rigidus: Diagnosis
• Xray shows nice
straight but arthritic
mtp joint

49. Hallux Rigidus vs BunionHallux Rigidus vs Bunion
• Bunions most usually
do not develop
arthritis
• Mtp joint unloads into
valgus

50. Hallux Rigidus vs BunionHallux Rigidus vs Bunion
• Bunion caused by
metarsus varus and
secondary hallux
valgus

51. OA -TreatmentOA -Treatment
• Weight loss
• Patients think u
should be involved
• Only 42% obese
patients had this
addressed
• Average time spent
was 42 seconds

52. OA : weight lossOA : weight loss
• Recent RCT showed 10% weight
reduction improved knee function by 28%
• Catch 22- “I can’t exercise because my
knee hurts so much”

53. OA- Physical TherapyOA- Physical Therapy
• Done by our own
professionals already

54. OA: CMC splintingOA: CMC splinting
• “Overall splinting was found to be a well
tolerated and effective conservative
treatment to diminish, but not elimate
symptoms from thumb CMC arthritis”
• Eaton et al Journal hand surgery 1999

55. OA: CMC splintingOA: CMC splinting
• Splints can be made
by your friendly local
OT
• OTC splint (push
splint) available for 60
$

56. OA: knee unloader bracesOA: knee unloader braces
• “The preponderance of evidence suggests
that off loader braces are effective in
reducing pain, increasing stability and
diminish the risk of falling in patients with
oa and varus or valgus instability.”
• Sports Health 2009 (81 references)

57. OA: Braces and splintsOA: Braces and splints
• Custom knee
unloader braces for
unicompartment oa
• 25% still wearing
them at 2 years
(CORR 2013)

58. OA: Knee unloader bracesOA: Knee unloader braces
• Reasonable option for
patients with
unicompartmental oa
of knee.
• Doesn’t work well for
the obese

59. OA: acetaminophenOA: acetaminophen
• Is first line of non
prescription
pharmacotherapy
• Must consider dose
and comorbidities, eg
liver disease

60. OA: acetaminophen toxicityOA: acetaminophen toxicity
• 290 patients treated with 4 grams of
acetaminophen for 3 to 12 months.
• “no patient developed hepatic failure or
dysfunction, aminotransferase levels
greater than 2 times upper limit, or renal
problems”
• Clinical therapeutics 2006

61. OA: NSAIDSOA: NSAIDS
• More effective as a
general class than
acetominophen
• Non prescription
included in this class
• All about the same
efficacy

62. OA: NSAIDS –GI risk factorsOA: NSAIDS –GI risk factors
• Age
• Hx of GI problems
• Use of ASA

63. OA: NAIDS GI toxicityOA: NAIDS GI toxicity
• Celecoxib has less GI
toxicity
• No different than non
selective NSAID
combined with ppi

64. OA: NSAIDS – CV riskOA: NSAIDS – CV risk
• All NSAIDS except
• Naproxen
• Celecoxib less than
200 mg dose

65. OA: NSAIDS CV riskOA: NSAIDS CV risk
• 1 % per year have
serious vascular
event
• Best guess

66. NSAIDS: Renal DiseaseNSAIDS: Renal Disease
• All NSAIDS inhibit
prostaglandins
• Will exacerbate
underlying renal
disease
• NSAIDS cause 15%
of drug induced renal
failure

67. NSAIDS: RENAL DISEASENSAIDS: RENAL DISEASE
• Nsaid users had 3
times chance of
developing acute
renal failure
compared to those
not taking nsaids
• Huerta et al 2005

68. NSAIDS: toxicity followupNSAIDS: toxicity followup
• 291 patients taking 750 mg naproxen for 3
to 12 months
• No patient developed renal failure or
serum creatinine levels greater than or
equal to 1.5 times the upper limit. One
patient developed gi bleed.
• Clinical Therapeutics 2006

69. Principles of MedicinePrinciples of Medicine
• First do no harm

70. OA: Low risk treatmentsOA: Low risk treatments
• Topical nsaids
• Derry et al 2012
Cochrane
• Effective treatment for
knee and hand
• Skin side effects only

71. OA: injectablesOA: injectables
• Steroid injection
• Effective (cochrane)
• Short term
• inexpensive

72. OA: injectablesOA: injectables
• Hyaluronic acid
• Effective (Cochrane)
• Expensive
• Only those with high
molecular weight and
crosslinking

73. OA: injectablesOA: injectables
• Maybe be as effective
or more than
hyaluronic acid
• ( in younger with mild
disease)

74. OA treatmentOA treatment
• Prolotherapy, using 20% dextrose and
water has be shown to improve symptoms
for significant periods of time
• Robago et al Annals of Family practice
2013
• More studies recommended
• I have no experience here

75. OA: nutraceuticalsOA: nutraceuticals
• I will try to give big
picture

76. OA: Glucosamine SulphateOA: Glucosamine Sulphate
Numerous good studies demonstrate pain
reduction.
• (glucosamine hydrochloride not proven)
• Rovati t al 2012
• Therapeutic advances MSK disease

77. OA: Chondroitin sulphateOA: Chondroitin sulphate
• Chondroitin :
evidence in several
trials shown to be
effective. Often in
combination with GS

78. OA: gingerOA: ginger
• two double blind
studies demonstrated
ginger statistically
reduced symptoms of
knee arthritis

79. OA: avocado-soybeanOA: avocado-soybean
• Placebo controlled
trial demonstrated
mild efficacy of
avocado-soybean
unsaponifiables in
knee oa
• Cochrane (2014)
approves

80. OA: Boswellia serrataOA: Boswellia serrata
• Cochrane (2014)
recommends for
further investigation

81. Tumeric (circuminoids)Tumeric (circuminoids)
• “scientific evidence
that 8 to 12 weeks of
tumeric extracts
(1000 mg per day)can
reduce arthritis
symptoms and
inflammation to a
similar degree as
ibuprofen and
diclofenac”

82. Cannabinoid Rx for OACannabinoid Rx for OA
• Body has a
endocannabinoid
system (ECS)
• This system has been
shown to decrease all
pain types

83. Cannaboid Rx OACannaboid Rx OA
• “there is a growing
body of scientific
evidence which
supports the
analgesic potential of
cannabinoids to treat
OA”
• Current opinion
pharmacology 2018

84. Topical CBD oilTopical CBD oil
• Transdermal
cannabidiol reduces
inflammation and pain
related behaviours in
…
• European Pain
Journal 2016

85. OA: Disease Modifying AgentsOA: Disease Modifying Agents
• You will be surprised!

86. OA: DMOADOA: DMOAD
Glucosamine sulphate
Natural constituent of
glyosaminolyans of
normal articular
cartilage
Crystalline form best
1500 mg od

87. OA:DMOAD glucosamineOA:DMOAD glucosamine
• “1500 mg of glucosamine sulphate has
been shown in 2 studies to prevent the
joint space narrowing observed in the
knee in patients with mild to moderate
arthritis.” double blind Xray study
Reginster 2001
• Pavelka et al Annals Int Med 2002

88. OA: DMOAD-glucosamineOA: DMOAD-glucosamine
• “Glucosamine sulphate reduces both
cartilage volume loss and bone marrow
lesions in knee OA starting as early as 6
months after initiation of treatment. A
randomized, double blind, placebo
controlled pilot study using MRI”
• Wildi et al Ann. Rheum. Dis 2011

89. OA glucosamineOA glucosamine
• American journal of sports medicine
March 2015
• Meta analysis of 13 studies
• Both glucosamine sulphate and
chondroitin sulphate may slow
osteoarthritis progression
• (Is it the sulphate?cjp)

90. OA Glucosamine SulphateOA Glucosamine Sulphate
• See summary, Current Medical research
and Opinion at
• DOU:10.1185/03007995.2016.1154521
• Crystalline glucosamine sulpate 1500 mg
per day
• Trade names Viatril, Arthryl, Osaflexan
and Xicyl are some trade names
recommended

91. OA glucosamineOA glucosamine
• Followup of patients
on gs or placebo
• At 5 years placebo
group more than
twice as likely to need
TKR
• Pavelka 2008

92. OA: surgeryOA: surgery
• Arthroscopic
debridement shown to
have no benefit when
only diagnosis is
arthritis

93. OA surgeryOA surgery
• HOT OFF THE
PRESS CMAJ OCT
14
• DEGENERATIVE
MENISCAL TEAR
NOT HELPED BY
SURGERY
• (knew that)

94. OA: surgery TKROA: surgery TKR
• Total knee
replacement for
advanced disease
• 85% happy
• Results worse for
early disease than for
advanced

95. OA : surgery THROA : surgery THR
• For advanced disease
• 90% happy with
surgery

96. OA: TSROA: TSR
• Total shoulder
replacement 85%
plus good to excellent
results
• For servere disease

97. OA: CMC arthroplastyOA: CMC arthroplasty
• Trapeziectomy
• High success rate in
advanced disease

98. OA: Hallux RigidusOA: Hallux Rigidus
cheilectomycheilectomy
• Debridement
arthroplasty
successful for
advanced disease
• Fusion for backup
procedure

99. Post TestPost Test
• Choose false statement
• 1. OA not seen on Xray often
• 2. OA occurs after RA
• 3. Most patients with OA on Xrayh are
symptomatic
• 4. Woman suffer more than men

100. Post TestPost Test
All false except:
1. OA always caused by injury
2. Most common presentation heberdens
nodes
3. Ginger extract useful for RX
4. All NSAIDS share same safety profile

101. Post TestPost Test
• All true except
1. Knee injections can be safely done by
you
2. Steroids effective rx
3. Viscosupplementation doesn’t work
4. PRP shown to be effective for OA

102. Post TestPost Test
• Regarding DMOADS and OA
1. There are no DMOADS for OA
2. DMOADS for RA are effective for OA
3. Some nutaceuticals have DMOAD
activity

103. OsteoarthritisOsteoarthritis
• Question period