Osteoarthritis overview
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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.
| 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 |
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| 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) |
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| 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 |
Knee
| 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 |
| 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 |
| 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
| 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 |
| 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
| 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
| 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 |
| 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 |
| 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 | – |
| 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 |
| 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) |
| 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
| flattening: common (in one series 27%) |
| osteophytes: common (27%) |
| erosions: 13% |
| sclerosis: less common (9%) |
| subchondral cysts |
Ankle
| 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 |
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.