OSTEOARTHRITIS

Dr Surya Darma, SpPD

Bagian Penyakit Dalam

FK Unsri/RSMH Palembang
 Tingkat Kompetensi

3A. Bukan gawat darurat

Lulusan dokter mampu membuat diagnosis klinik dan
memberikan terapi pendahuluan pada keadaan yang
bukan gawat darurat.
Lulusan dokter mampu menentukan rujukan yang paling
tepat bagi penanganan pasien selanjutnya.
Lulusan dokter juga mampu menindaklanjuti sesudah
kembali dari rujukan.
 Osteoarthritis
1. Introduction
Definition
Epidemiology
Risk factor
2. Pathophysiology
3. Diagnosis
4. Treatment
Nonpharmacology
Pharmacology
Surgery
 Definition

Evolved from being considered a natural part of

the aging process and noninflammatory

The result of a complex process involving

genetic susceptibility, mechanical force and

variable inflammation of the synovium, leading to
degradation of the articular cartilage.
 Definition

Osteoarthritis (OA) is a degenerative joint disease,

occurring primarily in older persons, characterized
by erosion of the articular cartilage, hypertrophy of
bone at the margins (i.e., osteophytes),
subchondral sclerosis, and a range of biochemical
and morphologic alterations of the synovial
membrane and joint capsule.

Paul E Dicesare, Kelleys Textbook of Rheumatology, 9th ed. 2013

 Epidemiology

OA is the most common articular disease, affecting

indonesian people.

No wide epidemiological study to know about

prevalence OA.

It predicted one to two million elder indonesian will

be suffer from disability cause by OA in next ten
years
 Chronic Disease in Indonesian People
( man and women, 50 yo)

Diseases Semarang* Denpasar** Singosari***

Rheumatic 40.0 % 56.0 % 61.0 %
CV disease 17.3 % 14.9 % 15.3 %
Respiratory 7.4 % 6.1 % 9.2 %
Diabetes 3.3 % 4.1 % 3.6 %
Neurologic 2.1 % 1.1 % 1.9 %
Malignancy 0.7 % 0.8 % -

* Budi Darmoyo, 1991; ** Dwi Sutanegara, 1993; *** Kalim dkk, 1994
 Classification

Primary or idiopatic
Localized form; affect one to two joint group.
ie DIP, PIP, CMC, cervical or lumbar spine,
MTP, knee or hip joint.

Generalized form; affect three or more

joints group. Frequently associated with
Herbedens node and or Bouchard s node
 Classification

Secondary
If a patient develops OA in atypical joints,
such as MCP, wrist, ankles, shoulder or
elbows
Assessment should be made for previous
trauma, metabolic disease, blood dyscrasias
or neuropathic joint
Erosive OA
Inflammatory OA, affect DIP and PIP joints
of hand
 Risk factors

Risk factors for primary OA

Age
Gender
Obesity
High bone mass
Mechanical factors
Genetic
 Risk factors

Risk factors for secondary OA

Injured or damaged joints
Metabolic/infiltrative disease
Hemarthrosis
Neuropatic pain
 Pathophysiology

Chondrocytes are responsible for balancing the

anabolic and catabolic processes in the joint.

Biomechanical stressors cause condrocytes to

trigger matrix metalloproteinases and synthesis of
matrix protein including fibrillar type II collagen
 Pathophysiology

The triggering of various metalloproteinases lead

to cartilage degradation. Synthesis of matrix
proteins lead to new bone growth resulting in
osteophyte formation

Over years, this process of cartilage degradation

and osteophyte formation results in the bone-on-
bone grinding sensation (crepitation), and
sometimes even instability of the joint use.
Pathophysiology
 Diagnosis

Diagnosis is based on history and physical

examination

If the clinical presentation is confusing, synovial

fluid analysis, inflammatory marker and
radiographs can be used to assist in diagnosis
 Diagnosis

History
Patients complain of pain or locking of affected
joints that are mechanical in nature and
worsening with activity.
Stiffness can become a manifestation but is
typically less than 30 minutes.
 Diagnosis

Phisycal examination
the joints most commonly involved are knee,
hip, ankle, vertebrae, spine and manus (PIP,
DIP and 1st CMC)
mild tenderness to palpation, usually without
evidance inflammation
crepitus
bony enlargement
decrease ranged of motion
joint effusion
 Diagnostic criteria

Knee OA
Knee pain plus three of the following: age > 50 yo,
ESR < 20 mm/hr, stiffness < 30, crepitus, bony
hypertrophy and no palpable warmth

Hip OA
Hip pain plus two of the following ESR < 20 mm/hr,
radiographic acetabular or femoral osteophyte and
joint space narrowing.
 Diagnostic criteria

Hand OA
Hand pain or stiffness plus at least three of the
following:
hard tissue enlargement of more than one of the
selected joints 2nd and 3rd DIP or PIP joint or 1st
CMC of each hand
Hard tissue enlargement of more than one DIP
joint
deformity of at least one of ten selected
joints
fewer than three swollen MCP joints
Radiograph of a hand showing osteoarthritis of the distal interphalangeal
(DIP), proximal interphalangeal (PIP), and first carpometacarpal (CMC)
joints.
 Differential diagnosis

Rheumatoid arthritis (RA)

Spondyloarthropathies sero negative ie.
Psoriatic arthritis, reactive arthritis, ankylosing
spondylitis, enteropathic arthritis
Crystalline arthropathies
Infection arthritis
Hemarthrosis
Referred pain from a different joint
 Diagnostic testing

Laboratories
No laboratory test confirming the diagnosis
Imaging
Radiographic

Typical feature seen on radiograph include: joint

space narrowing, subchondral sclerosis,
osteophytes at the periphery of joints and
subcondral cyst.
Radiograph of knee OA
 Diagnostic testing

Synovial fluid analysis

ifthe patients has an effusion and the clinical
picture is confusing, joint aspiration can be
performed.
Synovial fluid has a few WBCs (< 200 WBCs/ml)
 Treatment

Medication
nonpharmacologic modalities
pharmacologic agents

Surgery
 Treatment

Nonpharmacologic modalities
Physical therapy Insoles
Aerobic Thermal modalities
Weight reduction Transcutaneus
Walking aids electrical nerve
Knee brace stimulation
Acupuncture
Foot wear
Education
Knee brace
 Treatment

Pharmacologic agents
First line
Acetaminophen 2 3 gr/day up to 4 gr/day
Second line
Nonsteroid anti-inflamatory drug (NSAID)
ie. Ibuprofen 3 x 200-600 mg/day, sodium
diclofenac 2-3 x 25-50 mg/day, piroxicam 1 x 10-
20 mg/day and meloxicam 1x7,5-15 mg/d
 Treatment

Pharmacologic agents
Third line
opioid theraphy, ie. Codein 3-4 x 10-30
mg/day, tramadol 2-3 x 50-100 mg/day

Fourth line
corticosteroid injection
hyaluronic acid injection
 Treatment

Pharmacologic agents
Topical therapies
Capsaicin cream 0,025%, four times a day
Diclofenac solution (1,5% w/w), four times a day

Novel therapy
Diacerein 2 x 50 mg/day

Tanezumab, a humanized mab againts nerve

growth factor
 Treatment

Surgical management
Arthroscopic irrigation
Knee and hip arthroplasty or total joint replacements
Prosthetic joints
QUESTIONS
Sites of hand or wrist involvement and their potential disease
associations.