Osteoarthritis of joints and related treatment
- 1. Osteoarthritis Rupal Patel, MD Assistant prof, VCU orthopedic C.O.R.E lecture series, VCU CMH, South hill, VA January 23, 2018
- 2. Disclosure • no financial relationship with any of the company implants or products mentioned in this talk • Exparel (liposomal bupivacaine) – received compensation in the past for being one of the consultants
- 3. Articular cartilage and joint anatomy • Joint is made up of two or more bones • Articular cartilage at the end of bones. Up to 4 mm thick in larger joints • Joint fluid – contains hyaluronic acid • Smooth surfaces with viscous joint fluid in between makes it smooth movements comparable to ice-on-ice • Changes in articular cartilage with osteoarthritis - Increase in water content - Decrease stiffness - Chondrocytes (cartilage cells) clumps up in cluster - Decrease GAG (joint vitamins like keratan sulfate and glucosamine) - Collagen fibers gets disorganized
- 4. Types of arthritis • Osteoarthritis Wear and tear arthritis • Inflammatory arthritis - Rheumatoid arthritis - Psoriatic arthritis - Gout, pseudogout - Arthritis secondary to Lyme’s disease - Lupus, juvenile arthritis • Secondary arthritis - Post traumatic - Avascular necrosis • Septic arthritis
- 5. Osteoarthritis •Osteoarthritis - wear & tear type - loss of articular cartilage •It is non inflammatory disease but inflammation can set up in later stage of the disease •most common type of arthritis after the age of 50 •used to be known as “crippling disease” - not anymore
- 6. Risk factors for osteoarthritis • Age: increasing age with wear and tear • Genetics: hereditary • Obesity: increase stress to weight bearing joints like knee and hip • Injury: previous injury with damage to cartilage or change in alignment
- 7. Risk factors for osteoarthritis • Leg mal-alignment or deformity (congenital/trauma): wear in one side of joint - bow legs or knock knee • Occupation: increase stress on certain joints - mechanics, sports professionals, surgeons • Persistent wrong posture or wrong foot ware
- 8. Symptoms of osteoarthritis • Pain - Dull aching - Good days and bad days - Cold weather • Stiffness – in the morning, after period of inactivity • Loss of range of motion - Prevents full extension, loss of flexion
- 9. Symptoms of osteoarthritis •Swelling - increase in joint fluid (baker's cyst in knee) - spurs •Popping/grating sensation
- 10. Commonly involved joints and associated symptoms • Knee • hip • Spine - Lower back (lumbar) - Neck (cervical spine) • basal joint of the thumb • shoulder • big toe MTP joint • joints of fingers
- 11. Commonly involved joints: Knee-symptoms - Hinge joint - Three bones… - most common joint to develop OA - Diffuse or localized pain - Worse after prolonged inactivity or overactivity - Stairs, getting in & out of chair - Giving out of knee (instability) - Popping - Deformity (knock knee/bow legs)
- 12. Commonly involved joints: Hip-symptoms - Ball and socket joint - Pain in groin and front of the thigh - Knee pain (sometimes only knee pain) - Difficulty in raising from toilet, getting in and out of car - Difficulty in wearing sox & shoe - Shortening of the leg in extreme arthritis is bone destruction.
- 13. Commonly involved joints: lumbar spine - symptoms - Degeneration of disc - Facet joint degeneration - Spondylolisthesis • Lower Back pain • Spasm kind of pain • Radiating pain in legs – pinch nerve in lumbar spine - Sciatica • tingling and/or numbness • Muscle weakness in extreme cases
- 14. Commonly involved joints: cervical spine - symptoms - Degeneration of disc - Facet joint degeneration - Spondylolisthesis • Neck pain • Spasm kind of pain • Crepitus with neck movement • Radiating pain in arms to fingers • tingling and/or numbness • Muscle weakness in extreme cases
- 15. Commonly involved joints: basal joint of thumb-symptoms - Trapezium (carpal) metacarpal joint - Pain at the base of the thumb - Difficulty in turning the door knob - Difficulty in opening the jar - Deformity in severe cases
- 16. Commonly involved joints – symptoms • Shoulder - Ball and socket joint - Pain around shoulder - Radiating to arm - Difficulty in overhead work or reaching the back - Crepitus • Great toe MTP joint - pain at the base of the toe - Pain with walking - Pain in certain shoe - Bunion deformity in severe cases
- 17. Commonly involved joints: finger joints - symptoms • Interphalangeal joints • Metacarpo-phalangeal joint - Nodules (spur) - Swelling of finger joints - Difficulty in fine activities - Deformity - lesser amount compared to rheumatoid arthritis
- 18. Diagnosis • Medical history - symptoms - slowly worsening pain - pain with certain movements - stiffness after inactivity • Physical exam - joint specific • x-rays - most important • other diagnosis - usually don't require advanced imaging like CT scan or MRI except for spine
- 19. X-ray findings •Joint space narrowing •Sclerosis •Osteophytes (spurs) •Joint/bone erosion •Subchondral cyst Sclerosis
- 20. X-ray findings • Joint space narrowing • Sclerosis • Osteophytes (spurs) • Joint/bone erosion • Subchondral cyst - No advanced imaging like MRI or CT scan needed to diagnose arthritis.
- 23. How to prevent or slow down osteoarthritis? • Activity modification - Prevent activities which make joint hurt more (avoid stress on joint) - Knee: avoid squatting, pounding of joint (running, jumping), prolonged sitting. - Hip: use elevated toilet seat, use cane, install grab bar in bathroom - Hand/fingers: avoid repeated activities. Use door knob extension and key turners. Use of electric can openers or jar openers - Spine: avoid weight lifting, avoid bad posture
- 24. Do’s and Don’ts for spine
- 25. How to prevent or slow down osteoarthritis? • Weight reduction - Each pound of weight loss decreases 4 pound of stress from knee joint • Muscle strengthening exercises - Strong muscles and ligaments around the joint will take some load/stress off of the joint – decreases the pain and slows wearing of the cartilage • Joint vitamins - Vit D and Calcium: soft subchondral bone (bone underneath the cartilage) leads to early arthritis. - Glucosamine and chondroitin sulfate (?): questionable role. Studies suggested no added benefits in treatment or prevention of osteoarthritis
- 26. Treatment of osteoarthritis Non operative treatment • Activity modification • Exercises / physical therapy • Heat or cold, icy hot (mostly heat) • weight reduction • topical cream • oral pain meds • Brace • cane • shoe wedges • Intra-articular injections - cortisone - hyluronic acid Surgical/operative treatment • Arthroscopic surgery • Osteotomies • Fusion • Joint replacement
- 27. Treatment - activity modification Limit activities which causes/aggravate the pain - Knee: avoid squatting, limit stair, avaoid prolonged sitting with flexed knees. - Hip: use elevated toilet seat, use cane, install grab bar in bathroom - Hand/fingers: avoid repeated activities. Use door knob extension and key turners. Use of electric can openers or jar openers - Spine: avoid weight lifting, avoid bad posture
- 28. Treatment - exercise or physical therapy - Helps strengthening of muscles around joint - decrease stress on joint - keeps joint mobile, avoid stiffness • knee - quad sets, balance • hip - hip girdle muscles - water therapy can help with joint arthritis pain • spine - back and core strengthening - Physical therapy - key for long term pain relief of back pain due to arthritis
- 29. spine - exercise or physical therapy • back and core strengthening exercises • have to do it regularly
- 30. Treatment – weight reduction • Each pound of weight loss decreases 4 pound of stress from knee joint • Peri-operative risks for complications increases in obese patients (infection, wound healing problems, blood clot, loosening of implants) • VA hospitals denied knee or hip replacement surgery to patients with BMI above 35 • Medicare and Medicaid also asks for explanation if joint replacement planned in patient above BMI 40 • Diet, joint protective exercises , bariatric surgery for morbid obesity
- 31. Treatment - cane, heel wedges • Walking aid and support help reducing stress on joint • Cane should be used in opposite hand • shoe insert or wedges - for knock knees (valgus) and bow legs (varus)
- 32. Treatment - Brace • Unloader brace for bow legs or knock knee • Thumb brace • Lumbar support brace • Soft cervical collar • Ankle brace - shouldn’t use regularly, weakens muscles.
- 33. Treatment - topical cream - relieves pain with less side effects - Work as counter-irritants, local anti- inflammatory or local anesthetic • Capsaicin – derived from cayenne peppers • Bengay – Methyl salicylate or menthol • Voltaren gel – Diclofenac (need Rx – insurance) • Lidocaine patch • Aspercreme (Trolamine) • Icy hot • Biofreeze
- 34. Treatment - oral pain meds • Acetaminophen (Tylenol) • NSAID (Aleve, Ibuprofen - Motrin, Advil) - stomach burn, kidney problem • Combining Tylenol with Aleve/ibuprofen – synergistic effect (less side effects than taking one type of medicine in excess) • COX-2 inhibitor (Celebrex)- less stomach burn • Cymbalta (Duloxetine) – off label use • opioid medications - should be avoided for arthritis pain
- 35. Treatment – Intra-articular injections Cortisone (steroid) Injection - Mixture of depo-medrol (steroid) and numbing medicine - Acts within hours, lasts 6 weeks to 3 months depending on severity of arthritis - Commonly used for knee, shoulder and thumb arthritis – can be done in office/clinic - Hip and back/neck injections needs fluoroscopic/x-ray guidance - Can be repeated every 3 – 4 months but decrease efficacy with subsequent injections - Multiple injections can damage remaining cartilage - Tolerable (does it hurt?)
- 36. Treatment – Intra-articular injections Hyluronic acid (gel) injection - synthetic joint fluid - Joint lubrication - Does not regrow the worn cartilage but possibly slow down further degenration - Works in only 50% of patients - Acts slow, lasts longer if works - Series of 3 injections - Insurance denial (AAOS has no positive recommendation) Platelet rich plasma (PRP) injection - Largest study published in 2013 suggests it decrease pain by 3 to 6 months - Insurance payment issue due to cost and questionable long term efficacy
- 37. Surgical treatment • Surgical advancement - no longer have to “live” with arthritis • Consider surgical treatment once non operative treatment exhausted • In my practice, patient makes the decision when they are ready for the surgery • Joint preservative versus joint replacement surgery • Sophisticated joint replacement started in early 70s in USA, it has advanced significantly now • No longer crippling disease 1969
- 38. Surgical options for hip osteoarthritis • Arthroscopic surgery rarely work for hip osteoarthritis • Fusion is almost obsolete • Hip replacement - Partial hip replacement is mostly for fracture only - Total hip replacement (arthroplasty) - Surface replacement arthroplasty (metal-on-metal) – found to have metal toxicity - failed
- 39. Total hip replacement (arthroplasty) • Replace socket and head ball • Medicare/federal health have announced it as second most successful surgery in restoring quality of life next to the cataract surgery. • Types or bearing surfaces options - Metal or ceramic on plastic (polyethylene) – best option in current time - Ceramic on ceramic – less wear but squeaking and fracture - Metal on metal – failed due to metal ions release and causing severe soft tissue reaction.
- 40. Total hip replacement (arthroplasty) • Different approaches - Posterior (back) - Direct anterior (front) - Lateral/antero-lateral (side) Posterior approach (traditional hip replacement) - Time tested, used for years - More dislocation - precautions - Have to cut and reattach muscles – longer recovery - Implant position may not be consistently accurate
- 41. Total hip replacement (arthroplasty) • Direct anterior approach - no need to cut muscles – faster recovery - Less dislocation - Done under x-ray, so more accurate implants placement and restoration of leg length - Difficult to do surgery - Learning curve for surgeon, more complications during learning curve
- 42. Surgical options for knee osteoarthritis • Knee arthroscopic surgery - temporary pain relief, helps more in mild to moderate OA - AAOS doesn’t have strong recommendation for it - Speeds up process of osteoarthritis • Osteotomy - High tibial osteotomy for bow legs - Distal femoral osteotomy for knock knees - For one compartment arthritis only in younger patients
- 43. Surgical options for knee osteoarthritis Partial knee replacement Retain ACL and PCL – feeling of natural stable knee - Unicompartmental knee arthroplasty - Patellofemoral knee arthroplasty - Bicompartmental knee arthroplasty
- 44. Surgical options for knee – total knee replacement • 500,000 knee replacement per year in USA • Scarifies ACL and sometimes PCL • Good pain relief – 95% happy patients depending on their expectation • VCU CMH joint replacement program
- 45. Surgical treatment of thumb osteoarthritis • Arthroscopic surgery • Excisional arthroplasty with tendon interposition • Arthrodesis (fusion) • Joint replacement
- 46. Surgical treatment of shoulder osteoarthritis • Arthroscopic surgery – minimum role in osteoarthritis • Hemiarthroplasty (partial shoulder replacement) • Total shoulder replacement • Reverse total shoulder replacement
- 47. Surgical treatment of toe MTP joint osteoarthritis • Fusion (arthrodesis) • Joint replacement
- 48. Treatment for spine (back and neck) arthritis • Regular back and core strengthening exercises • Heat pad • Pain meds • Steroid (prednisone) for acute pain • Muscle relaxer • Brace (for short duration) • Epidural steroid injection • surgery
- 49. Treatment for spine (back and neck) arthritis • Regular back and core strengthening exercises • Heat pad • Pain meds • Steroid (prednisone) for acute pain • Muscle relaxer • Brace (for short duration) • Epidural steroid injection • Surgery - Nerve decompression (Laminectomy/discectomy) + fusion - Disc replacement surgery
- 50. Surgical treatment of hand joints osteoarthritis • Bone spur removal • Joint replacement
- 51. Surgical treatment of ankle joints osteoarthritis • fusion • Joint replacement