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OSTEOARTHRITIS - GENERAL

Introduction

Osteoarthritis (OA) is a degenerative disease characterized by progressive destruction of the extracellular matrix (ECM) of articular cartilage, synovial inflammation, subchondral bone sclerosis and osteophyte formation. OA is most common in the knee; the hip and fingers also are frequently affected. In general, weight-bearing joints are the most severely affected. OA is one of the most common chronic diseases in the elderly. There are no approved disease-modifying drugs for OA; pain and inflammation are managed using analgesics, corticosteroids and NSAIDs.

Pathophysiology

Structural damage, even minor injury, to cartilage manifests as an inability to heal. Aging also leads to changes in ECM composition and alters chondrocyte activity. Compared with normal aging chondrocytes, those isolated from OA cartilage show different patterns of protein expression (Table). After cartilage in OA-affected joints begins to degenerate, ECM degradation products are released into the synovial fluid, which in turn, stimulates the release of pro-inflammatory cytokines. These molecules increase the expression of various catabolic enzymes, including matrix metalloproteinases (MMPs).

Table. Changes in cartilage properties with aging versus osteoarthritis

Property

Aging

Osteoarthritis

Water content

Decreased

Increased

Collagen

Relatively unchanged
(some increased in type VI)

Relative concentration increased Content decreased in severe cases

Matrix becomes disordered

Proteoglycan concentration

Decreased

Decreased

Proteoglycan synthesis

Unchanged

Increased

Proteoglycan degradation

Decreased

Increased

Total chondroitin sulfate concentration

Decreased

Increased

Chondroitin-4-sulfate concentration

Decreased

Increased

Keratin sulfate concentration

Increased

Decreased

Chondrocyte size

Increased

Unchanged

Chondrocyte number

Decreased

Unchanged

Modulus of elasticity

Increased

Decreased

 

Incidence and Related Conditions

  • OA is the most prevalent joint disorder in the United States.
  • The knee is the most frequently affected joint and occurs in 10% of men and 13% of women aged ≥60 years.
  • The incidence and prevalence of OA is likely to increase owing to the aging population and the prevalence of obesity.
  • Risk factors include advancing age, gender, genetics, poor nutrition, joint injury and/or instability

Differential Diagnosis

  • Gout
  • Rheumatoid arthritis
  • Infection
Clinical Presentation Photos and Related Diagrams
  • Arthritic wrist secondary to scapholunate advanced collapse (SLAC Wrist)
    Arthritic wrist secondary to scapholunate advanced collapse (SLAC Wrist)
  • Arthritic thumb CMC joint with swelling and subluxation
    Arthritic thumb CMC joint with swelling and subluxation
Basic Science Photos and Related Diagrams
  • Normal and abnormal cartilage histology;A = Superficial zone; B = Transitional zone; C = Radial zone; D = Calcified zone; E = Cancellous bone; F = Cartilage matrix; G = Necrotic tissue with clustered chondrocytes
    Normal and abnormal cartilage histology:A = Superficial zone; B = Transitional zone; C = Radial zone; D = Calcified zone; E = Cancellous bone; F = Cartilage matrix; G = Necrotic tissue with clustered chondrocytes
Symptoms
Joint pain and swelling
Joint stiffness; difficulty making a fist
Limited mobility
Pain with pinch and grasp
Typical History
  • A patient typically presents insidious onset and progression of joint pain and stiffness.  Patients with osteoarthritis are usually older and frequently have a history of overuse, diabetes, excessive alcohol use, obesity and/or previous joint trauma. In the upper extremity the most frequently involved joints are the DIP joints of the fingers, the thumb CMC joint and the wrists. 
Positive Tests, Exams or Signs
Grip Strength
Range of Motion: Active
Range of Motion: Passive
Scapho-Trapezial-Trapezoid (STT) Tenderness
Tenderness
Thumb (Grind) Compression Test
Watson Scaphoid Shift Test
Work-up Options
Radiology studies - X-ray
Magnetic resonance imaging - MRI without contrast
Sonographic studies - Ultrasound
Images (X-Ray, MRI, etc.)
  • Normal wrist and arthritic wrist (Hover over right edge to see more images)
    Normal wrist and arthritic wrist (Hover over right edge to see more images)
  • Normal and arthritic thumb
    Normal and arthritic thumb
  • Normal and arthritic DIP joints
    Normal and arthritic DIP joints
Treatment Options
Conservative: 
  • Modification of activity
  • Placement of orthosis
  • NSAIDs or corticosteroid injections
Operative: 

Thumb CMC Osteoarthritis:

In a recent Cochrane Systematic review,1 11 randomized/quasi-randomized trials of surgery for thumb OA were included (N=670 patients), and 7 surgical procedures were identified:

  • Trapeziectomy
  • Trapeziectomy with interpositional arthroplasty
  • Trapeziectomy with ligament reconstruction
  • Trapeziectomy with ligament reconstruction and tendon interposition (LRTI)
  • Artelon joint resurfacing
  • Arthrodesis
  • Swanson joint replacement

DIP Osteoarthritis of the Finger:

  • Although rarely needed DIP arthrodesis can solve severe DIP arthritic pain 

Wrist osteoarthritis such as sccapholunated advanced collapse (SLAC) wrist:

  • Proximal row carpectomy
  • Partial wrist fusion
  • Complete wrist fusion
  • Rarely wrist arthroplasty
Complications
  • As reported in the Cochrane review, the AE rate was 10% after trapeziectomy and 19% after trapeziectomy with LRTI, corresponding to a risk increase of 9% (95% CI 0%, 28%).
Outcomes

As reported in the Cochrane review, the AE rate was 10% after trapeziectomy and 19% after trapeziectomy with LRTI, corresponding to a ris    As reported in the Cochrane review, trapeziectomy with LRTI may not confer additional benefits or result in more adverse events (AEs) versus trapeziectomy.

- On a visual analog scale (VAS) from 0 (no pain) to 100 mm, mean pain was 26 mm for trapeziectomy; trapeziectomy with LRTI reduced pain by 2.8 mm (95% confidence interval [CI] -9.8, 4.2).

- On a scale of 0 (no disability) to 100, physical function was 31.1 after trapeziectomy; trapeziectomy with LRTI resulted a worsening in physical function of 0.2 points (95% CI −5.8, 6.1).k increase of 9% (95% CI 0%, 28%).

Key Educational Points
  • The 3 major components of extracellular matrix (ECM) are water, collagen and proteoglycans
  • The primary cell in hyaline cartilage is the chondrocytye. 
  • Cartilage is composed of 4 layers:1. Tangential layer (zone 1, superficial disease); 2. Transitional layer (zone 2, middle); 3. Deep (zone 3, radial); 4. Calcified cartilage layer attached to subchondral bone (zone 4)
  • Cartilage is composed of extracellular matrix (95%) and chondrocytes (5%)
  • Cartilage changes seen in osteoarthritis include loss of proteoglycans, disorganized collagen with decreased modulus of elasticity,  dying chondrocytes, increased water content and increased proteolytic enzymes activated enhanced by cytokines.
Practice and CME
References

Cited

  • Wajon A, Vinycomb T, Carr E, et al. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane database Syst Rev 2015:CD004631. PMID: 25702783

New Articles

  1. Burke J, Hunter M, Kolhe R, et al. Therapeutic potential of mesenchymal stem cell based therapy for osteoarthritis. Clin Transl Med 2016;5:Epub. PMID: 27510262
  2. Kulkarni P, Deshpande S, Koppikar S, et al. Glycosaminoglycan measured from synovial fluid serves as a useful indicator for progression of osteoarthritis and complements Kellgren-Lawrence Score. BBA Clin 2016;6:1-4. PMID: 27331021

Reviews

  1. Berenbaum F, Meng QJ. The brain-joint axis in osteoarthritis: nerves, circadian clocks and beyond. Nat Rev Rheumatol 2016;12:508-16. PMID: 27305851
  2. Berger AJ, Meals RA. Management of osteoarthritis of the thumb joints. J Hand Surg Am 2015;40:843-50. PMID: 25754790

Classics

  1. Stecher, RM. Heberden’s notes: the importance of osteoarthritis of the fingers to the practicing physician. Practitioner 1948;161(963):176-9. PMID: 18879550
  2. Spender, JK. On some hitherto undescribed symptoms in the early history of osteoarthritis: the so-called rheumatoid arthritis. Br Med J 1888;1(1424):781-3. PMID: 20752255