1. Osteoarthritis and Related Conditions Brian J. Keroack, MD

2. Clinical Features of Osteoarthritis Onset as young as mid 30’s (usually>40) Onset as young as mid 30’s (usually>40) Early OA (1-2 years): Early OA (1-2 years): Inflammatory symptoms prominent: Morning stiffness (<1hr). “If I just keep going I’m OK.” Inflammatory symptoms prominent: Morning stiffness (<1hr). “If I just keep going I’m OK.” Red, prominent PIP, DIP joints Red, prominent PIP, DIP joints Normal Radiographs Normal Radiographs Later: Later: AM stiffness <30 min. AM stiffness <30 min. ‘Mechanical’ symptoms: Worse with use. “I really pay for what I do.” “I just don’t have the strength I use to.” (e.g. jars, doors) ‘Mechanical’ symptoms: Worse with use. “I really pay for what I do.” “I just don’t have the strength I use to.” (e.g. jars, doors) Joint abnormalities preclude normal use Joint abnormalities preclude normal use

3. Clinical Features of Late OA: continued Little Evidence of Inflammation Little Evidence of Inflammation Deformities more prominent (angulation, bony proliferation) Deformities more prominent (angulation, bony proliferation) Radiographs abnormal Radiographs abnormal Some patients actually get LESS symptomatic in non-weight bearing joints. You will see many patients with hand deformities that are asymptomatic Some patients actually get LESS symptomatic in non-weight bearing joints. You will see many patients with hand deformities that are asymptomatic “My hands really don’t bother me like the use to.” “Once they deformed, they stopped hurting.” “My hands really don’t bother me like the use to.” “Once they deformed, they stopped hurting.” Weight bearing joint symptoms usually progress. Weight bearing joint symptoms usually progress.

4. Risk Factors for Osteoarthritis Weight Weight Trauma Trauma Genetics?—Amino acid substitutions in Type II Collagen. Genetics?—Amino acid substitutions in Type II Collagen. Secondary Osteoarthritis (later) Secondary Osteoarthritis (later)

5. Consequences of OA: Spinal Stenosis

6. Erosive Osteoarthritis More aggressive Destructive Persistent symptoms Inflammatory findings on exam

7. Secondary Osteoarthritis Trauma Trauma Congenital deformity Congenital deformity Endocrinopathies Endocrinopathies Neuropathic Arthropathy Neuropathic Arthropathy Avascular Necrosis Avascular Necrosis Padget’s Disease Padget’s Disease Diffuse Idiopathic Skeletal Hyperostosis (DISH) Diffuse Idiopathic Skeletal Hyperostosis (DISH) Hemophilia Hemophilia Crystals (CPPD, Hydroxyapetite) Crystals (CPPD, Hydroxyapetite)

8. Illnesses Associated with Neuropathic Arthropathy (Charcot Joint) Diabetes Diabetes Alcoholism Alcoholism Tabes Dorsalis Tabes Dorsalis Syrinx (meningomyelocele—cord compression) Syrinx (meningomyelocele—cord compression)

9. Therapy Joint Conservation Joint Conservation Exercise Exercise Weight Loss (Wt Bearing Joints) Weight Loss (Wt Bearing Joints) NSAIDS (Cough medicine analogy: not disease modifying) NSAIDS (Cough medicine analogy: not disease modifying) Not benign: Ulcers 4%, greater with risk factors (age>60, coumadin, past ulcer, prednisone use). Hypertension, ACE+Diuretic+NSAID=trouble (e.g. CHF, Renal failure) Not benign: Ulcers 4%, greater with risk factors (age>60, coumadin, past ulcer, prednisone use). Hypertension, ACE+Diuretic+NSAID=trouble (e.g. CHF, Renal failure) COX-2: Safer for those at risk for ulcer (>65, coumadin, prednisone, previous ulcer) similar renal effects. Cardiovascular effects? 2.5 X increase in MI or CVA. Mechanisms—1. Increase Thromboxane A2 (platelets stickier).---2. Vascular remodeling (18 months)-- Hypertension COX-2: Safer for those at risk for ulcer (>65, coumadin, prednisone, previous ulcer) similar renal effects. Cardiovascular effects? 2.5 X increase in MI or CVA. Mechanisms—1. Increase Thromboxane A2 (platelets stickier).---2. Vascular remodeling (18 months)-- Hypertension

10. Therapy: Continued ??DMARDS—not yet ??DMARDS—not yet The problem: Sclerosis of subchondral bone in mid thirties, apoptosis of chondrocytes in late thirties The problem: Sclerosis of subchondral bone in mid thirties, apoptosis of chondrocytes in late thirties If DMARDS are to succeed they will have to be studied a decade before symptoms start If DMARDS are to succeed they will have to be studied a decade before symptoms start Remind me not to volunteer for a medicine that might work that I will have for take for 10 years without knowing the long term effects Remind me not to volunteer for a medicine that might work that I will have for take for 10 years without knowing the long term effects Joint Replacement/Fusion Joint Replacement/Fusion Medical vs Surgical Disease? Medical vs Surgical Disease? Bone on Bone (X-rays never told me about symptoms) Bone on Bone (X-rays never told me about symptoms) Night Pain Night Pain “As soon as I step on the knee it hurts and it is all down hill from there.” “As soon as I step on the knee it hurts and it is all down hill from there.”