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Osteoarthritis David Hunter MBBS, PhD Chief of Research New England Baptist Hospital.

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Presentation on theme: "Osteoarthritis David Hunter MBBS, PhD Chief of Research New England Baptist Hospital."— Presentation transcript:

1 Osteoarthritis David Hunter MBBS, PhD Chief of Research New England Baptist Hospital

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3 Osteoarthritis: Future Shock 20 million currently affected 40 million affected in 2020 Aging of the population Increasing obesity Increased sports related injuries

4 Prevalence of Knee Pain and Osteoarthritis in Persons Age 55 and Over Population of adults aged 55+ years 160* * The proportion with radiographic evidence in this category is not known, though seems likely to be high Shading represents the proportion in each category with radiographic evidence of knee osteoarthritis.

5 Disease Burden Most common joint disease in the world Most common joint disease in the world Affects the majority of people over the age of 65 Affects the majority of people over the age of 65 Prevalence increases with age; 80% of people over the age of 75 are affected. Prevalence increases with age; 80% of people over the age of 75 are affected. Females affected twice as commonly. Females affected twice as commonly. <50% of those with radiographically demonstrated OA have symptoms. <50% of those with radiographically demonstrated OA have symptoms. Klippel et al. Rheumatology. 1998; Brandt. Harrison’s Principles of Internal Medicine. 1998;

6 Social and Economic Impact In the elderly, accounts for more lower extremity disability than any other disease. In the elderly, accounts for more lower extremity disability than any other disease. One in eight days of restricted activity in U.S. elderly. One in eight days of restricted activity in U.S. elderly. Accounted for 140 million MD visits, 185 million bed days and 68 million work days lost per year (as of 1983). Accounted for 140 million MD visits, 185 million bed days and 68 million work days lost per year (as of 1983). Total annual cost about $46 billion (U.S., 1990), 25% direct. All arthritis costs equal 2.5% GNP in 1988 and rising Total annual cost about $46 billion (U.S., 1990), 25% direct. All arthritis costs equal 2.5% GNP in 1988 and rising Accounts for most total knee and hip replacements Accounts for most total knee and hip replacements

7 What is osteoarthritis?

8 William Hunter ( ) Hunter W. Of the structure and diseases of articular cartilages. Phil Trans 1744;42:514–21.

9 What is osteoarthritis? Myth: Osteoarthritis is a disorder of hyaline articular cartilage. Myth: Osteoarthritis is a disorder of hyaline articular cartilage. A disease of the whole joint: A disease of the whole joint: Cartilage loss Cartilage loss Bone remodeling and sclerosis Bone remodeling and sclerosis Capsular thickening and distension Capsular thickening and distension Synovial inflammation Synovial inflammation Muscle atrophy and weakness Muscle atrophy and weakness

10 Why does it hurt?

11 Conscious Neurosensory Mapping of the Internal Structures of the Human Knee Without Intraarticular Anesthesia. The American Journal of Sports Medicine 26: (1998)

12 Pain sensitive structures in the normal knee Joint capsule Joint capsule Ligaments Ligaments Outer third of meniscus, especially near capsule Outer third of meniscus, especially near capsule Periosteal and subchondral bone Periosteal and subchondral bone Synovium Synovium Soft tissues including fat around and deep to patellar tendon Soft tissues including fat around and deep to patellar tendon *from Dye, Kellgren and others

13 Characteristics of OA Pain Pain with use (e.g. knee pain with climbing stairs) Pain with use (e.g. knee pain with climbing stairs) Pain relieved with rest Pain relieved with rest Onset usually insidious Onset usually insidious AM stiffness absent or <30 minutes AM stiffness absent or <30 minutes If severe OA, pain can be present at night and at rest (late disease) If severe OA, pain can be present at night and at rest (late disease)

14 Multiple Locations of Pathology

15 Diego Valazquez Old Woman Frying Eggs. 1618

16 Hand Osteoarthritis Symptomatic hand osteoarthritis- Symptomatic hand osteoarthritis- 26% of women 26% of women 13% of men aged over % of men aged over 70. Leads to reduced grip strength, difficulty writing, and carrying weight. Leads to reduced grip strength, difficulty writing, and carrying weight. Multifactorial Genetic predisposition Mechanical Factors Obesity Prior inflammatory joint disease Zhang Y et al. Am J Epidemiol 2002; 156:

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18 Risk Factors for OA Vulnerable Joint Genetic Predisposition Age Gender Ethnicity Dietary Factors Malalignment Structural abnormality (BML, meniscal tear, ACL) Bridging Muscle Weakness Proprioceptive Deficiencies Laxity

19 Obesity Increased BMI has been associated with an increased prevalence of knee, hip, and hand OA. Increased BMI has been associated with an increased prevalence of knee, hip, and hand OA. Weight loss of 5kg is associated with a 50% reduction in chance of developing OA, and also slows progression. Weight loss of 5kg is associated with a 50% reduction in chance of developing OA, and also slows progression. Adjusted OR (95% CI) Risk Factor Male Female Age (per 5-year)0.9 ( )1.3 ( ) BMI (per 5-unit)1.0 ( )1.8 ( ) Weight change (per 10-lb) 0.9 ( )1.6 ( )

20 Injury

21 Aims of Management Patient education about both the disease and its management Pain control Improvement of function Alteration of the disease process and its consequences

22 Algorithm for OA Management

23 Current Research Agenda David Hunter

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25 Knee MRI Relation of MRI features to symptoms. Relation of MRI features to symptoms. Improvement of scoring methods. Improvement of scoring methods.

26 Clinical Trials Outcome measurement- function and structure Outcome measurement- function and structure Responsiveness of cartilage volume, dGEMRIC, biomarkers. Responsiveness of cartilage volume, dGEMRIC, biomarkers. Knee Brace ± Orthosis. Knee Brace ± Orthosis T1 (sec) 1.2

27 Relationship between peri-articular bone changes and initiation and progression of OA CHICKEN (bone) EGG (cartilage) WHICH COMES FIRST?

28 Intervention-Realignment Study

29 Intervention-PF Bracing Trial CONTROL ARM Q Brace without T strap. ACTIVE Stratus Q Brace.

30 Acknowledgements

31 Thank-you for your attention Raphael. The School of Athens


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