OSTEOARTHRITISOSTEOARTHRITIS

Blondina Marpaung

Rheumatology DivisionInternal MedicineDepartment

Medical Faculty Sumatera Utara University

The most common degenerative joint had been seen in :

•human

•Rats

• whales

•Dinosaur fossil

It had been recognice since 5000 years ago

* Over 40 years old

* Woman : man = 4 : 1

• The most common joint disease

in Indonesia

* Weight bearing joints

Chronic disease due to articular Chronic disease due to articular cartilage damage with a new bone cartilage damage with a new bone

formation.formation.

OsteoarthritisOsteoarthritis

• degenerative joint disease

• cartilage and sub chondral damage

• imbalance between synthesa and

degradation

• cartilage erosives, cyst formation, osteophytes formation

• synovial inflammation

FUNCTONAL IMPAIRMENT:

Restricted movement

Intermitten

Mild at early phase

Joint stiffness : - localized / temporary

- in the morning before activity - weather alteration

Crepitation :-The sensation of bone rubbing against bone

- palpable at knee joint

Helpful for diagnosis

GAIT DISORDER

* ANTALGIC GAIT (PAIN AT WEIGHT BEARING JOINT)

* TRENDELENBURG GAIT ( HIP )

* STIFF KNEE GAIT

* LUMBAR CLAUDICATION (VERTEBRA LUMBAL)

RISK FACTOR

Knee joint: * Body weight- linier association- obese woman 7 x fold risk

* Activity- menekuk sendi lutut- weight bearing

Panggul : * obesitas kurang berperan* hubungan erat dgn aktivitas (petani)

* Race Kaukasia >> Asia (orang Asia sering jongkok)

Joint Predilection Joint Predilection Most common : weight bearing joint - knee - lumbal - cervical

Generalized OA DIP ( Heberden node )

thickening capsule

OA KNEENORMAL KNEE

Cyst formationSubchondral

bone sclerosisCartilge articular

fibrillation

Synovium hypertrophyOsteofphyte formation

capsule

cartilageArticular

Synovium

bone

ACRFP

NORMAL versus OA JOINT

Clinical featuresClinical features

OA of HandsOA of HandsHeberden’s and Bouchard’s NodesHeberden’s and Bouchard’s Nodes

Chondrocyte : Play role in collagen and proteoglycan

synthesis

Articular Cartilage

MATRIX EXTRACELLULER : Water (65-85 %) Collagen type I (15-25 %) Proteoglycan (10 %) Collagen type VI, IX, XI and XIV Connective Protein etc

Mature chondrocyte cell

Produces Collagen & proteoglycan

CHONDROCYTE

Function : produces syntheses and degradates articular cartilage enzymes

Stabil and balance articular cartilage

COLLAGEN

a protein with strenght and elastic fibre Play role as tissue skeleton

Function : perekat yang membangun matriks rawan

sendi

PROTEOGLYCANMacromolecule yang dibangun oleh protein & gula

Terdiri dari : Inti protein Glycosaminoglycan Chondroitin sulphate Keratan sulphate

menyokong stabilitas dan kekuatan rawan sendiProteoglikan membentuk kesatuan dgn asam hialuronat

Fungsi :

menghisap dan mengeluarkan air sesuai dgn gerakan sendi

Evaluation Konventional Radiology

cant assess early OA

because : cartilage thickening can assessbut surface alteration cant

- Cartilage thinning / narrowing joint cleave

OA process had been 10 year

Clinical Presentation of OA

Symptoms*Pain–initially with useStiffnessLimitation of motion

SignsCrepitusBony hypertrophyBony tendernessLimitation of range

of motion

MalalignmentAltered gait*Insidious onset

Risk factor for osteoarthritisRisk factor for osteoarthritisNon-modifiable

Age Race Genetics (Col 2A1 gene) Female sex Metabolic and endocrine

disease Congenital defect Neurological defect

Modifiable Major trauma Repetitive stress Inflammatory joint

disease Obesity Smoking Hormone Quadriceps muscle

weakness

Hochberg MC. J Rheumatol 1991; 18: 1438-40.

Therapy principle

• Pain Reduction / elimination

•Functional impairment prevention/

reduction

•Disability prevention

Management of OsteoarthritisManagement of Osteoarthritis

Non-pharmacological therapyNon-pharmacological therapy Pharmacological therapyPharmacological therapy

SurgerySurgery

Non-pharmacological therapyNon-pharmacological therapy

Patients education, self-management program Weight control Physical therapy, occupational therapy Exercise program Assistive devices Joint protection Appropriate foot ware

Modified from ACR subcommittee. A&R 2000; 43:1905-15.

Pharmacologic Management of OAPharmacologic Management of OA

Systemic therapySystemic therapy Nonopioid analgesicsNonopioid analgesics NSAIDs / Cox 2 inhibitorNSAIDs / Cox 2 inhibitor Opioid analgesics Opioid analgesics DMOAD’s / SYSADOA’s: DMOAD’s / SYSADOA’s:

Chondroitin & Glucosamine Chondroitin & Glucosamine DoxicyclineDoxicyclineChloroquine Chloroquine visco suplementvisco suplement

Diacerine Diacerine

Local therapyLocal therapyTopical agents Topical agents Intra-articular Intra-articular

agentsagents

CAUSAL DRUGS / DMOADS

• Visco supplementation

Hyaluronan / Hyalgan Intra articular

- Main molecule of proteoglycan - Activates repairing cartilage process.

- Normalyzed synovial fluid quality.

* Intra articular inj. 20 mg (1 amp) weekly, 5-7 weeks

• Chloroquin

- inhibits IL-1 expression

- inhibits supression of prostaglandin synthese-Slowing progression of OA stage-Repairs OA pathology

• Chondroitin Sulphate

- matrix proteoglycan formation-Dose : per-oral 400 mg , 3 x / day

OA: Intra-articular TherapyOA: Intra-articular Therapy

• Intra-articular steroid• Good pain relief • Most often used in knees,

up to q 3 mo• With frequent injections,

risk infection, worsening diabetes, or CHF

• Joint lavage• Significant symptomatic

benefit demonstrated

• Hyaluronate injection• Symptomatic relief • Improved function• Expensive• Require series of injections• No evidence of long- term

benefit• Limited to knees

* Altman, et al. J Rheumatol. 1998;25:2203.

Surgical Therapy for OASurgical Therapy for OA• ArthroscopyArthroscopy

• May reveal unsuspected focal abnormalitiesMay reveal unsuspected focal abnormalities• Results in tidal lavageResults in tidal lavage

• Osteotomy: May delay need for TKR for 2 to 10 yearsOsteotomy: May delay need for TKR for 2 to 10 years

• Total joint replacement: When pain severe and Total joint replacement: When pain severe and function significantly limitedfunction significantly limited

PHARMACOLOGICAL THERAPY OF PHARMACOLOGICAL THERAPY OF OSTEOARTHRITISOSTEOARTHRITIS

EULAR Recommendation(Ann Rheum Dis 2003;62:1145-55)

Analgesics Acetaminophen NSAIDs and COX-2 inhibitors Tramadol and opioids

Topical Capsaicin and topical NSAIDs

Intra-articular Corticosteroids Hyaluronan

Symptomatic slow acting drugs Glucosamine sulfate Chondroitin sulfate Diacerein

Treatment of osteoarthritis Treatment of osteoarthritis (of the knee)(of the knee)

Education, PT, OT, weight reduction, topic analgesics

Simple analgesicsIA co

rtico

stero

ids, IA hya

luronan

SurgeryExercise, assistive devices

NSAIDs or specific COX-2 inhibitors, or tramadol, or

opioids analgesics

SYSADOAs

Glucosamin:o Stimulates chonrocytes to produces more

and faster collagen and proteoglycan o Normalyzed metabolism of cartilage articularo Eliminates of pain o Supports joint movement

GLUCOSAMIN & KONDROITIN GLUCOSAMIN & KONDROITIN FUNCTIONFUNCTION

Chondroitin:

o Role as liquid magnet membantu menarik cairan ke dalam molekul-molekul proteoglikan sehingga membantu jalannya nutrisi kartilago dan juga berperan sebagai Spongy Shock Absorber

o Mempercepat penyembuhan luka dan tukak

IL1

DNA

mRNA

iNOS

NO

apoptosis

Cartilago Degradation

Inhibitor sitokin( diacerhein, kloroquin ? )

Terapi gen

Inhibitor NOS

Inhibitor protease

CollagenProteoglican

Autolytic Enzyme

ChondroitinGlucosamine

Hyaluronate

Teori kerja beberapa obat pada Osteoartritis

Tetracyklin, ASA, SA

Cyclosporin,Metothrexat

ASA

COX2 NSAID ?

Inflammation

Thank You . . . .

Dr. Blondina Marpaung, SpPD - KR