Osteoarthritis overview

Osteoarthritis of the Medial Side of the Knee.

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'Editor-In-Chief:' C. Michael Gibson, M.S., M.D. [1]

Overview

Osteoarthritis / Osteoarthrosis (OA, also known as degenerative joint disease, degenerative arthritis, arthrosis or in more colloquial terms "wear and tear") is the most common form of arthritis, caused by wearing of the cartilage that covers and cushions joint spaces. As the cartilage wears away, the patient experiences pain with weight bearing, including walking and standing. Due to the movement limitations caused by pain, there might be a regional muscles atrophy, also ligaments may become more lax. This word is derived from the Greek word "osteo", meaning "of the bone", "arthro", meaning "joint", and "itis", meaning inflammation, although inflammation is not a common finding in this regard. OA possesses a great degree of variability in disease onset, progression, and severity.

OA affects nearly 43 million patients in United States and almost 15% of the world population, accounting for 25% of visits to primary care physicians, and half of all NSAID (Non-Steroidal Anti-Inflammatory Drugs) prescriptions. It is estimated that 80% of the population will have radiographic evidence of OA by age 65, although only 60% of those will be symptomatic.[1] Treatment is with NSAIDs, local injections of glucocorticoid or hyaluronan, and in severe cases, with joint replacement surgery. Many physicians have also reported good pain relief by treating ligaments (which is responsible to bone to bone connection) with Prolotherapy. There has been no cure for OA, as cartilage has not been induced to regenerate. However, if OA is caused by cartilage damage (for example as a result of an injury) Autologous Chondrocyte Implantation may be a possible treatment. Clinical trials employing tissue-engineering methods have demonstrated regeneration of cartilage in damaged knees, including those that had progressed to osteoarthritis.[2] Further, in January 2007, Johns Hopkins University was offering to license a technology of this kind, listing several clinical competitors in its market analysis.

Osteoarthritis is capable of influencing any joint in human body; meanwhile, the most common affected joints are: knee and hip given the degree of weight bearing required of these joints. Other joints, such as the distal interphalangeal joints of the fingers and shoulder joints are also commonly affected as well.

Historical Perspective

The earliest descriptions of OA were provided by Heberden and Haygarth in the 19th century. [3] [4] In the 1930s and 1940s, Dr. Stecher showed that there were two forms of OA, idiopathic and post-traumatic. [5] And, in the 1950s the links between Heberden’s nodes and large joint OA were revealed by Kellgren and Moore. In this regard, the first x-ray grading system for OA was developed by Jonas Kellgren and John Lawrence in the 1950s. Surgical management of OA was developed in the 1960s by Drs. Charnley and McKee

Classification

Osteoarthritis is radiographically classified depending on degree of joint involvement. The Kellgren-Lawrence is a common method to classify the severity of OA in knee using five different grades. This classification was proposed by Kellgren et al. in 1957 and then it was accepted by WHO in 1961. 

Classification for Subsets of Osteoarthritis

I: Idiopathic
	A: Localized
		1: Hands: Heberden’s and Bouchard’s nodes (nodal), erosive interphalangeai arthritis (nonnodal), scaphometacarpal joint, scaphotrapezial
		2. Feet: hallux valgus. hallux rigidus, contracted toes (hammer/cockup toes), talonavicular
		3. Knee	a. Medial compartment b. Lateral compartment c. Patellofemoral compartment (chondromalacia)
		4. Hip	a. Eccentric (superior) b. Concentric (axial, medial) c. Diffuse (coxae senilis)
		5. Spine (particularly cervical and lumbar)	a. Apophyseal b. Intervertebral (disc) c. Spondylosis (osteophytes) d. Ligamentous (hyperostosis [Forestier’s disease or DISH])
		6. Other single sites: shoulder, temporomandibular, sacroiliac, ankle, wrist, acromioclavicular
	B. Generalized: includes 3 or more areas listed above (Kellgren-Moore)	1. Small (peripheral) and spine 2. Large (central) and spine 3. Mixed (peripheral and central) and spine
II. Secondary
	A. Posttraumatic
	B. Congenital or Developmental Diseases	1. Localized	a. Hip diseases: Legg-Calve-Perthes, congenital hip dislocation, slipped capital femoral epiphysis, shallow acetabulum b. Mechanical and local factors: obesity (7). unequal lower extremity length, extreme valgus/varus deformity, hypermobility syndromes, scoliosis
		2. Generalized	a. Bone dysplasias: epiphyseal dysplasia, spondyloapophyseal dysplasia b. Metabolic diseases: hemachromatosis, ochronosis, Gaucher’s disease, hemoglobinopathy, Ehlers-Danlos
	c. Calcium Deposition Disease	1. Calcium pyrophosphate deposition disease 2. Apatite atthropathy 3. Destructive arthropathy (shoulder, knee)
	D. Other Bone and Joint Disorders: avascular necrosis, rheumatoid arthritis, gouty arthritis, septic arthritis, Paget’s disease, osteopetrosis, osteochondritis
	E. Other Diseases	1. Endocrine diseases: diabetes mellitus, acromegaly, hypothyroidism, hyperparathyroidism 2. Neuropathic arthropathy (Charcot joints) 3. Miscellaneous: frostbite, Kashin-Beck disease, Caisson’s disease

Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) is used to evaluate the pain, stiffness, and physical function among patients with hip or/and knee osteoarthritis (OA) and it is consists of 24 different items divided into 3 subtypes:

• Pain consisted of 5 items: staying in bed, sitting or lying, and standing. during walking, and using stairs,
• Stiffness consisted of 2 items: after waking up in morning and later in the day.
• Physical Function consisted of 17 items: using stairs, sitting, rising from sitting, standing, bending, walking, getting in and/or getting out of a car, during shopping, heavy household duties, light household duties, putting on/taking off socks, lying in bed, rising from bed, getting in and/or getting out of bath, getting on/off toilet.

Knee

International Knee Documentation Committee (IKDC Questionnaire)

Grade	Description
A	No  joint space narrowing (JSN)
B	>4 mm joint space; small osteophytes, slight sclerosis, or femoral condyle flattening
C	2-4 mm joint space
C	<2 mm joint space

Merchant system: a 45° "skyline" view for the Patellofemoral join

Grade	Description
1 (mild)	Patellofemoral joint space > 3mm
2 (moderate)	Joint space < 3 mm but no bony contact
3 (severe)	Bony surfaces in contact over less than one quarter of the joint surface
4 (very severe)	Bony contact throughout the entire joint surface

Ahlbäck classification of osteoarthritis of the knee joint

Grade	Description
0	Normal
1	Joint space narrowing is <3 mm of the joint space or <50% of the other compartment (with or without subchondral sclerosis)
2	Obliteration of joint space
3	Bone defect/loss <5 mm
4	Bone defect and/or loss 5-10 mm

Hip

Kellgren-Lawrence system

Grade	Description
0	No  joint space narrowing (JSN) or reactive changes
1	Doubtful JSN, possible osteophytic lipping
2	Definite osteophytes, possible JSN
3	Moderate osteophytes, definite JSN, some sclerosis, possible bone-end deformity
4	Large osteophytes, marked JSN, severe sclerosis, definite bone ends deformity

Tönnis classification

Grade	Description
0	No osteoarthritis signs
1 (Mild)	Increased sclerosis, slight narrowing of the joint space, no or slight loss of head sphericity or lipping at the joint margins
2 (Moderate)	Small cysts, moderate narrowing of the joint space, moderate loss of head sphericity
3 (Severe)	Large cysts, severe narrowing or obliteration of the joint space, severe deformity of the head

Shoulder

Samilson-Prieto classification

Grade	Description
1	Inferior humeral or glenoid exostosis, or both, measuring less than 3 mm in height.
2	Inferior humeral or glenoid exostosis, or both, between 3 and 7 mm in height, with slight glenohumeral joint irregularity.
3	Inferior humeral or glenoid exostosis, or both, more than 7 mm in height, with narrowing of the glenohumeral joint and sclerosis

Vertebral column

Kellgren grading of cervical disc degeneration

I	Minimal anterior osteophytosis
II	Definite anterior osteophytosis with possible narrowing of the disc space and some sclerosis of vertebral plates
III	Moderate narrowing of the disc space with definite sclerosis of vertebral plates and osteophytosis
IV	Severe narrowing of the disc space with sclerosis of vertebral plates and multiple large osteophytes

Kellgren grading of cervical facet joint degeneration

Grade	Description
1	Doubtful osteophytes on margins of the articular facets of apophyseal joints
2	Definite osteophytes and subchondral sclerosis in apophyseal joints
3	Moderate osteophytes, subchondral sclerosis and some irregularity of articular facets
4	Many large osteophytes and severe sclerosis and irregularity of the apophyseal joints

Lane grading of lumbar disc degeneration

	Joint space narrowing	Osteophytes anterior and posterior	Sclerosis
0	None	None	None
1	Definite (mild) narrowing	Small	Present
2	Moderate	Moderate	–
3	Severe (complete loss of joint space)	Large	–

Thompson macroscopic grading of lumbar disc degeneration on sagittal sections using MRI

Grade	Nucleus	Anulus	Endplate	Vertebral body
I	Bulging gel	Discrete fibrous laminae	Hyaline, uniform thickness	Rounded margins
II	Peripheral white fibrous tissue	Mucinous material between laminae	Irregular thickness	Pointed margins
III	Consolidated fibrous tissue	Extensive mucinous infiltration; loss of annular-nuclear demarcation	Focal defects in cartilage	Small chondrophytes or osteophytes at margins
IV	Horizontal clefts parallel to endplate	Focal disruptions	Fibrocartilage extending from subchondral bone; irregularity and focal sclerosis in subchondral bone	Osteophytes smaller than 2 mm
V	Clefts extended through nucleus and annulus		Diffuse sclerosis	Osteophytes greater than 2 mm

Pathria grading of lumbar facet joint degeneration

Grade	Description
0	Normal
1	Joint space narrowing (mild degenerative disease)
2	Narrowing plus sclerosis or hypertrophy (moderate degenerative disease)
3	Severe osteoarthrosis with narrowing, sclerosis, and osteophytes (severe degenerative disease)

Weishaupt Grading of lumbar facet joint degeneration using CT and MRI

Grade	Description
0	Normal facet joint space (2–4 mm width)
1	Narrowing of the facet joint space (<2 mm) and/or small osteophytes and/or mild hypertrophy of the articular process
2	Narrowing of the facet joint space and/or moderate osteophytes and/or moderate hypertrophy of the articular process and/or mild subarticular bone erosions
3	Narrowing of the facet joint space and/or large osteophytes and/or severe hypertrophy of the articular process and/or severe subarticular bone erosions and/or subchondral cysts

Temporomandibular joint

Radiographic features Changes are usually more evident on the condylar side of the TMJ joint

flattening: common (in one series 27%)

osteophytes: common (27%)

erosions: 13%

sclerosis: less common (9%)

subchondral cysts

Ankle 

 Takakura Classification

Stage I	Early sclerosis and osteophyte formation, no joint space narrowing
Stage II	Narrowing of medial joint space (no subchondral bone contact)
Stage IIIA	Obliteration of joint space at the medial malleolus, with subchondral bone contact
Stage IIIB	Obliteration of joint space over roof of talar dome, with subchondral bone contact
Stage IV	Obliteration of joint space with complete bone contact

Giannini Classification

Stage 0	Normal joint or subchondral sclerosis
Stage I	Presence of osteophytes without joint-space narrowing
Stage II	Joint-space narrowing with or without osteophytes
Stage III	Subtotal or total disappearance or deformation of joint space

Cheng Classification

Stage 0	No reduction of the joint space Normal alignment
Stage I	Slight reduction of the joint space Slight formation of deposits at the joint margins Normal alignment
Stage II	More pronounced change than mentioned above Subchondral osseous sclerotic configuration Mild malalignment
Stage III	Joint space reduced to about half the height of the uninjured side Rather pronounced formation of deposits Obvious varus or valgus alignment
Stage IV	Joint space has completely or practically disappeared

Canadian Orthopedic Foot and Ankle Society (COFAS) classification

Stage I	Isolated ankle arthritis
Stage II	Ankle arthritis with intra-articular varus or valgus deformity or a tight heel cord, or both
Stage III	Ankle arthritis with hindfoot deformity, tibial malunion, midfoot abductus or adductus, supinated midfoot, plantarflexed first ray, etc
Stage IV	Types 1–3 plus subtalar, calcaneocuboid, or talonavicular arthritis

Pathophysiology

Causes

Differentiating Osteoarthritis overview from Other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Routine screening for osteoarthritis is not indicated unless the patient is symptomatic.

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

Diagnosis

Diagnostic Criteria

History and Symptoms

Physical Examination

Laboratory Findings

Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Prevention

References