Loyola-Provident-Cook County Family Medicine Residency Osteoarthritis Emanuel Diaz MD Loyola-Provident-Cook County Family Medicine Residency

Objectives To identify economic and physical impact of OA in a patient’s life. To understand proposed etiology of OA and its pathophysiology. To understand modalities and treatments available. To get a glimpse of a new experimental modality undergoing research.

Demographics Affects over 20 million individuals in the United States alone. Estimated cost in medical care of 15.5 billions. Up to 65 billions if we add days of work lost.

Morbidity The prevalence of osteoarthritis differs among different ethnic groups. Equally common among men and women aged 45- 55 years. More common in women after 55. 30% of affected individuals aged 45-65 years. More than 80% by their eighth decade of life. http://www.eorthopod.com/images/ContentImages/hip/hip_osteoarthritis/hip_oa_intro01.jpg

Etiology Unknown Yet Risk Factors Increasing age Obesity Female sex Trauma Infection Repetitive occupational trauma Genetic factors History of inflammatory arthritis Neuromuscular disorder Metabolic disorder http://www.eorthopod.com/images/ContentImages/arthritis/arthritis_osteoarthritis/arthritis_osteo_intro01.jpg

Pathophysiology Stages Proteolytic breakdown of the cartilage matrix occurs by metalloproteinases. Fibrillation and erosion of the articular cartilage. http://me.queensu.ca/people/deluzio/KneeOsteoarthritis.php

Pathophysiology Stage 3 Chronic inflammatory response in the synovium. Production of IL-1, TNF-a , metalloproteinases and NO. More joint destruction. Loss of architecture. Bone overgrowth. http://myhealth.ucsd.edu/library/healthguide/en-us/images/media/medical/hw/h9991217.jpg

With this in mind. It is important to understand that new evidence might show that OA is an inflammatory disease. Compared to what we once believed.

Symptoms Symptoms Physical Findings Pain Joint Stiffness Morning Stiffnes s Less than 30 minutes. Instability (severe) Malalignment with a bony enlargement . Sometimes effusion No erythema or warmth Limitation of joint motion or muscle atrophy (severe) Crepitus Bouchard and or Heberden nodes. (Common in women)

OA http://www.poandpo.com/s208/osteoarthritis_5.jpg http://medicineworld.org/images/blogs/10-2006/osteoarthritis-late-6180.jpg

http://www.thecamreport.com/images/hipFracture.jpg http://www.riversideonline.com/source/images/image_popup/ww5r003.jpg http://www.eorthopod.com/images/ContentImages/ankle/ankle_osteoarthritis/ankle_osteoarthritis_diagnosis01.jpg

Treatment AAOS and ACR Pharmacologic Surgical Arthroplasty (knee) Acetaminophen Max 4g/day NSAIDS (inflammation present) Lowest dose possible Can add PPI or Misoprostol for GI disturbances prevention. Cox-2 selective Meloxicam, Piroxicam Can use topicals. Tramadol For moderate to severe Intraarticular Steroids Viscous supplement (Sinvisc, Hyalgan) Narcotics if severe. Arthroplasty (knee) Can last up to 15 years Osteotomy

Treatment AAOS and ARC Mechanical Knee taping Good evidence

Treatment AAOS and ACR Education Lifestyle Stay informed Follow Arthritis Foundation recommendations. Loose weight (at least 5% of bodyweitgh) if overweight BMI >25

Treatment AAOS Mechanical CAM Bracing Not good evidence Acupuncture inconclusive Glucosamine and chondroitin Not recommended in symptomatic patients. Tai Chi Needs more evidence DMSO Promising but needs more studies Boron Promising but needs more studies. S-Adenosylmethionine- Antioxidant Studies not randomized well or blinded. Exercise : Low impact aerobics Level 1 Grade A Muscle strenghtening Flexibility and ROM exercises. Level V Grade C

Treatment ACR Nonpharmacologic therapy for patients with osteoarthritis Personalized social support through telephone contact Assistive devices for ambulation Appropriate footwear Lateral-wedged insoles (for genu varum) Bracing (recent article says no benefit***) Occupational therapy Bracing Joint protection and energy conservation Assistive devices for activities of daily living

Treatment ACR Pharmacologic Topical Capsaicin Methylsalicylate

Experimental CAM Yoga

Prognosis The prognosis of osteoarthritis depends on joints involved and severity. No proven disease/structure-modifying drugs for osteoarthritis currently exist. Goal is symptoms relief.

References http://www.aaos.org/research/guidelines/OAKguideline.pdf http://emedicine.medscape.com/article/330487-overview http://www.rheumatology.org/publications/guidelines/oa-mgmt/oa- mgmt.asp?aud=mem