Osteoarthritis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou [2], Irfan Dotani [3]

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. This word is derived from the Greek word “osteo“, meaning “of the bone”, “arthro“, meaning “joint”, and “itis“, meaning inflammation. Inflammation, however, is not a common finding in this regard. OA possesses a great degree of variability in disease onset, progression, and severity. The earliest descriptions of OA were provided by Heberden and Haygarth in the 19th century. In the 1930s and 1940s, Dr. Stecher showed that there were two forms of OA: idiopathic and post-traumatic. 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 Dr. Charnley and Dr. McKee ^{[1] [2] [3]}.

According to the available pieces of evidence, osteoarthritis (OA) has been called by different terminologies: arthrosis deformans, osteoarthrosis-osteoarthritis, degenerative joint disease, Morbus (malum) coxae seniles^[4]. Loss of cartilage associated with bone features (such as osteophytes and subchondral bone sclerosis) is common among all types of OA^[5]. As mentioned before, this illness has been called by many names over the years, but none of them are entirely satisfactory for this condition. Despite the fact that the word “Osteoarthritis” is a misnomer because it implies a definite existence of an inflammatory process, it has been used for many decades in the English language and will probably continue to do so because of its well-known appeal compared to other more accurate terms of degenerative joint disease^[4]. Osteoarthritis is considered a non-inflammatory disease of movable joints characterized by the possible formation of new bone at the articular surface and subchondral bone involvement with the abrasion and deterioration of involved articular cartilages ^[6][7].

The historical view of osteoarthritis from antiquity to the present year has a conventional perspective which can be found among paleopathological findings of skeletal discoveries. With no doubt, osteoarthritis can be called as a disease with the best paleopathology documents. For example, in a 200 million-year-old Dimetrodon Permian reptile recovered in Texas, USA there was an interesting piece of evidence of a compound fracture in its spine which was infected with pus formation. Moreover, the first polyarthritis in history was found on the posterity in the Mesozoic Platecarpus found in Kansas. All joints on the left hallux of this reptile had deformations, potentially caused by osteoarthritis. According to the microscopic evaluations of its bones, there was the common feature of increased vascular spaces with overgrowth of its articular margins which can be found in osteoarthritis pathology. Consequently, osteoarthritis can be called the oldest known disease on earth. On the other hand, osteoarthritis was found in the fossil of a Neanderthal man from La Chapelle-aux-Saints. In another piece of evidence, chronic osteoarthritis found in ancient Egypt with a history of older than 3000 years. Also, severe osteoarthritis of the hip in a Romano-Briton with a “lipped” acetabulum and deformation on the femoral head was also found in this regard. Among ancient Egyptian, Early Eskimo, Iron Age British, and American Indian populations, there is a strong correlation of evidence with the vertebral lipping limited to the lumbar region ^[8] .

Available visual arts in addition to historical pieces of evidence can be an important tool for paleopathological study in this regard. While searching for specific evidence for OA in history, some important data was found. Because painters are known to be good observers, they can transfer what they had seen from their society through their arts to us. From their drawings, they can help us find things that we cannot get from available skeletons. Here, we can find some impressive arts indicative of osteoarthritis during the ancient histories^{[9][10][11][12][13][14]}:

I: In a Greek script from the late 14th century (kept in National Library, Paris), there is a Byzantine physician visiting a patient having a straight rigid spine with his hand stuck in a bent position (suggestive of spinal stenosis). We can conclude that the patient suffered from diffuse idiopathic spinal hyperostosis (DISH; Forestier disease).

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II: In a great art by Jan Van Eyck (St. Bavo Cathedral, Ghent) about the St. John Baptist of the Adoration of the Lamb, we can see a typical Heberden node on his left thumb.

III: Similar to the above-mentioned art, in another painting by different artist (Frans Hals) about the Portrait of Sara Andriesdr Hessix (Lisbon, Portugal), we can see a typical Heberden node on her both hands.

IV: In a painting by George de la Tour ’s about the St. Hieronymus (as penitent), with a little care we can found Hallux valgus on his foot.

V: In another artwork by Diego Velasquez (1632) about the Jester “Don John of Austria”, the gesture of this indicative for genu valgum.

According to the ancient era, osteoarthritis is a common finding in Egyptian mummies and also in ancient skeletons found in England. There are strong pieces of evidence in ancient skeletons with osteoarthritis in their shoulders. Moreover, some degenerative changes in the lumbar spine were found. Historical evidence revealed that arthritis was considered to be clinical presentations of gout and there are some physical signs described by Hippocrates (460–375 BC), in this regard. There is a big question that despite the significant pieces of evidence of osteoarthritis in ancient skeletons, physicians did not recognize osteoarthritis until the 18th century. However, according to the book named, “The Biology of Degenerative Joint Disease”, by Sokoloff in 1969, there are a number of pathological descriptions indicative of osteoarthritis.

In 1793, Sandiford of Leiden described osteoarthrosis of the hip.

In 1802, William Heberden in his book named “Commentaries on the History and Cure of Diseases” has described a disease which had no connection with gout. He also described the small nodes which later we know those nodes with his name.

In 1805, John Haygarth described polyarticular disease influencing the distal interphalangeal and other joints, resembling almost perfectly OA as seen in our present modern society.

In 1824, Bell, similar to Sandifort in 1793, had described osteoarthrosis of the hip.

In 1829, Benjamin C Brodie revealed a non-inflammatory erosion of articular cartilage peculiar to the elderly.

In 1831, Robert Adams distinguished osteoarthritis from polyarticular rheumatoid arthritis considering its localized character (also he even tried to use “partial” rheumatic arthritis name for osteoarthritis). This big step in differentiating OA from rheumatic arthritis had a huge acceptance in many parts of European scientist.

In 1835, J V Cruveilhier and Cruveilhier’s mentor Laennec (inventor of the stethoscope) were used the term “unsure” for defects in the articular cartilage of involved joints.

In 1835, Robert Smith named the degenerative joint disease as: “sui generis” and after that, he came with the description of “malum coxae senilis” related to the osteoarthritis of the hip.

In 1857, Schöman made monographs affirming Adams’ great work (in 1831) and published them were published 1857.

In 1859, Alfred Baring Garrod separated the osteoarthritis and rheumatic arthritis and he was the first one proposed the name rheumatic arthritis.

In 1869, Charcot and Virchow, known as the fathers of cellular pathology, used the term “arthritis deformans” for both osteoarthritis and rheumatic arthritis.

In 1889, John Kent Spender was the first one introduced the term osteoarthritis.

In 1890, AE Garrod was granted the current title of “osteoarthritis“.

In 1895, (Soon after the introduction of X-rays as a great step in medicine by Wilhelm Konrad Röntgen), Joel E. Goldthwait were able to differentiate two main forms of arthritis: a) the “atrophic” type, which was found as polyarticular, in young population, and b) the “hypertrophic” type, non-polyarticular form occurred in fewer joints in young population. Then, hypertrophic arthritis and Atrophic arthritis were considered as osteoarthritis and rheumatic arthritis, respectively.

In 1908, Hoffa and Wollenberg Confirmed the work done by Joel E. Goldthwait.

In 1909, Nichols and Richardson Confirmed the work done by Joel E. Goldthwait.

In 1907, Albutt and Rolleston in a book named Albutt and Rolleston’s System of Medicine describes both osteoarthritis and rheumatic arthritis separately with their own different special pathological specifications.

In 1910, Sir William Osler in his book “The Principles and Practise of Medicine” clearly worked on these two diseases and tried to differentiate them based on the clinical features and pathology.

In 1952, Kellgren and Moore connected the Heberden noduli to osteoarthritis, considering it as a primary generalized OA in order to differentiate it primary generalized OA from secondary OA.

In the 1950s and 1960s, Kellgren and Lawrence introduced a radiographic scoring system in grading OA.

In 1953, Collins described the possible association of age with the prognosis of trauma in pathological evaluations.

In 1970, Dick et al worked on the radionuclide studies evidence of synovial inflammation.

In 1982, Goldenberg et al worked on the histological evidence of synovial inflammation.

In 1989, Hans Valkenburg’s team worked on the descriptive epidemiology of osteoarthritis.

In 1997, Spector et al worked on the biochemical evidence of synovial inflammation.

In 2001, Sokoloff highlighted malum coxae senilis, hip osteoarthritis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou [2].

Since OA can affect any joint in human body. there several different classification system based on the involved joint and its location.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou [2] Robert G. Badgett, M.D. [2] Luke Rusowicz-Orazem, B.S.; , Irfan Dotani [4]

Osteoarthritis (OA) is a result of a variety of disorders that lead to structural and functional failure in involved joints. Osteoarthritis, traditionally, has been considered as a disease specifically related to articular cartilage. Presently, it’s been proven that OA influencing the whole joint system consisted of capsule, and synovium, subchondral bone, cartilage, menisci, ligaments, and periarticular muscle^[1][2].

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou [2], Irfan Dotani [3]

OA must be differentiated from other diseases that cause joint impairment and other related signs and symptoms such as Rheumatoid arthritis, Gout, Joint tuberculosis.

Diseases which can have similar symptoms are ^[1][2][3][4]:

• Rheumatoid arthritis
• Gout
• Joint tuberculosis

Diagnoses of arthritis are largely clinical, but laboratory tests such as ANA, erythrocyte sedimentation rate, C-reactive protein can help differentiate osteoarthritis from an inflammatory cause of arthritis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou [2], Irfan Dotani [3]

OA is one of the most frequent diagnoses and is the leading cause of disability among the adult population in the USA. According to the National Health and Nutrition Examination Survey (NHANES), more than 26 million people in the USA were diagnosed with different forms of OA. The National Health Interview Survey (NHIS) reported that the 46.4 million Americans and 21.6% of Americans adults were diagnosed with arthritis. OA can involve any joint, but knees, hips, hands, are most common sites for this involvement ^{[1] [2]}.

The obtained OA prevalence had significant differences due to the various definitions of OA. Some use only the radiographic criteria for OA while others prefer the clinical criteria in their study protocols. A combination of radiographic and clinical criteria would be the best method for OA prevalence, but unfortunately, the combination of these two criteria would be more costly than using each criterion alone. The available data about the incidence and prevalence of osteoarthritis are different. For example, OA mostly assessed by radiography which there should be a marked damage to be detectable in radiography. Near 6% of adults with the age of 30 years suffer from repeated knee pain and in their radiographic evaluation reveal osteoarthritis. As previously mentioned in risk factors for OA are age, sex, nutritional deficiencies, occupational involvements, trauma, genetic, and race. It was predicted that more than 26 million people in the USA have OA. The OA in hand, hip, and knee have positive correlations with age and as mentioned before OA is more common women than men, particularly after the age of 50 ( due to the menopause and hormonal changes)^[3][4][5].

The incidence rate of OA reported by the Fallon Community Health Plan in Massachusetts (U.S.A) was the frequency of knee OA, hand OA, and hip OA were  240/100 000 person-years, 100/100 000 person-years, and 88/100 000 person-years, respectively (Figure1).

The prevalence of hand OA is in the range of 27% 80%. 75% of women with the age of 60 – 70 years had distal interphalangeal (DIP) OA.  The US National Health and Nutrition Examination Survey (NHANES III) reported the prevalence of hand OA in 8% of the population. In a cohort study, the prevalence of symptomatic OA was twice as high in women than men (26.2%vs 13.2%, respective). Meanwhile, another study, conducted in Iran, reported the prevalence of hand OA among patients with the age of 40-50 years and >70 years 2.2%, and 22.5%, respectively ^[6][7].

Knee OA is less common than hand OA, although, knee OA occurs commonly in women (female-to-male ratio: 1.5:1-4:1). Epidemiology of knee OA in the USA is similar to European population. In a study by Framingham, the frequencies of Knee OA among patients with the age of 25-34 years and older than 75 years are 1% and 50%, respectively. Similar to Hand OA, the symptomatic knee OA in men and women older than 20 years old nearly doubles and triples, respectively (Figure 2). In contrast to a similar study conducted in China, the bilateral knee OA was reported to be around twice higher than Framingham Study in the USA. Accordingly, the prevalence of knee OA in Iranian rural area was 19.3%.

Comparing to the OA in hand or knee, the Hip OA has less common occurrence. The prevalence of hip OA in women older than 65 years old in the USA was reported between 1.0% to 6.2%. The prevalence of hip OA in the African and Asian population was 2.8 and 1.4 Percents, respectively^[8][9][10].

In a study performed by the Fallon Community Health Plan a well-known health maintenance organization in north-east of United States of America, the incidence rate of hip OA, hand OA, and knee OA were 88 per 100 000 person-years, 100 per 100 000 person-years, and 240 per 100 000 person-years, respectively. In another study, the incidence rate of knee OA and hip OA conducted in Rochester, Minnesota were reported 163.8 per 100 000 person-years and 47.3 per 100 000 person-years, respectively^[11][12].

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou [2].

Osteoarthritis is a multifactorial disease and the interactions between systemic and local factors play important role in development and prognosis of OA.

Knee, hip, and hand osteoarthritis are higher in women than men. It has also been reported that the frequency of osteoarthritis in women and men are 68% and 58% respectively. And it has been reported that women have a greater level of pain and disability.

There are significant differences in the prevalence and the joint involvement patterns of OA between different racial and ethnic groups. The African American women had similar OA of Hip similar to white women. Its been reported that the knee OA in the USA is more common in Blacks than whites. Prevalence of hip OA in among whites in Africa and the Caribbean was higher than blacks. In another study, comparing the prevalence of knee OA between Chinese and whites in the USA, despite the higher rate of obesity among whites, knee OA was higher among Chinese women. The frequencies of hand OA and hip OA in Chinese population is 50% and 10% of the normal population. It can be concluded that the lower risk of hip and hand OA can be due to the genetic factors while the higher prevalence of knee OA can be linked to their squatting and other daily and occupational physical activities, which causes excessive pressure on their knee.

Age plays an important role in the development of osteoarthritis. The correlation between age and the occurrence of OA is complex. Higher age through oxidative damage, thinning of cartilage, muscle weakening, reduces the basic cellular mechanisms that maintain tissue homeostasis which leads to an insufficient response to stress or joint injury, demolition of joint tissue destruction. Higher age leads to decrease in the tensile property of cartilage in articular cartilage in the accumulation of glycation consequently it can cause mechanical failure

It’s been showed that genetic factors play important roles in development and even the prognosis of osteoarthritis. genetic factors are leads to osteoarthritis in nearly 70% of cases. Moreover, specific genes such as chromosomes 2, 3, 4, 6, 7, 11, 16, the X. It’s been reported that there is a strong correlation between the chromosome 2q13–32 and particular types of OA. For example, chromosomes 4, 6, 7, and 16 (susceptible locus: 4q35, 6p12.3–q13, 7q34-7q36.3, 7p15-7p21, 7q22, and 16p12.3-p12.1, respectively) are linked for hip and hand OA. The previously mentioned locus of chromosome 4 and 7 are also linked to knee OA.

The osteoarthritis of knee, hip, and hand significantly increases around the time of menopause. Because of this, it’s been hypothesized that hormonal factors might be involved in the occurrence of OA. Up to this time, there is no report regarding the confirmation regarding the possible correlation between sex hormones and hand, knee, or hip OA in women. Osteocalcin, as a marker of bone turnover, decreases in women after their menopause which consequently women after menopause are more susceptible to knee arthritis.

Dietary related agents have an important roll in OA. Lower vitamin D, vitamin C, and selenium intakes have been associated with an increased risk of progression of knee OA in the older population. Also, using unrefined carbohydrates and junk foods in daily diet increase the chance of chronic diseases. Meanwhile, chondrocytes is an important and powerful origin of reactive oxygen species (ROC). Chondrocytes can damage cartilage collagen and synovial fluid hyaluronate. Meanwhile, micronutrients antioxidants, by providing defense against tissue injuries, are helpful to protect against osteoarthritis.

Smoking is proven to be correlated with an increased risk of cartilage loss and knee pain in OA.

Doing repetitive and excessive joint loading which is common in specific heavy physical activities such as long-distance runners, karate, kung fu, and gymnastic could increase the risk of knee injury and developing OA in involved joints.

The traumatic injuries are known to have a strong association with the development of OA. Acute injuries such as bone fractures and dislocations, meniscal tearing and cruciate tearing, direct damage to local tissues, normal biomechanics disruption, increase the risk of OA development. Articular cartilage bears pressures from daily physical activities. Joints injuries and trauma the cartilage can influence their flexibility, eliminate cellular system and consequently decrease the subchondral loading capability.

Higher body mass index (BMI) is a well-known predictor for risk factors of OA. It’s been reported that the correlation between obesity and knee OA is greater than with hip OA. Also, OA is associated with the metabolic syndrome, cardiovascular risk factors such as hypertension and hypercholesterolemia. Although the association between diabetes and OA is contradictory, it has been hypothesized that higher glucose concentrations product ROS and glycation leading to the cartilage degeneration and degradation. Since high BMI and obesity are considered as the major risk factor for OA, it’s been found that weight loss improves patient outcomes.

A meta-analysis of weight reduction and knee osteoarthritis concluded that weight loss of 5 percent from baseline was sufficient to reduce disability. Additionally, pain and disability were reduced if patients lost more than 6 kg (13.2 lb). Aerobic exercise is important for weight loss but can be challenging in persons with osteoarthritis of weight-bearing joints. Swimming, elliptical training, cycling, and upper body exercise may help in such cases.

Occupation facing heavy loads and having stress activities such as workers whose jobs require repeated pincer grip and prolonged squatting and kneeling are consequently associated hand OA and knee OA, respectively ^[1].

The mechanical alignment of the knee plays an important roll in distributing the pressure through the articular surfaces. In a normal knee, 60-70% of the pressure is transferred through the medial compartment. Any structural problems like valgus or varus influences pressure distribution in joint and this misalignment play an important role in the development and progression of OA.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou[2], Irfan Dotani [3]

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

Accurate data about the prevalence of OA can be useful for the health care system to have appropriate plans for management of OA patients. Nowadays, the OA screening in general population depends on the self-reported symptoms recorded during the clinical evaluation. An approved screening algorithm OA with sufficient sensitivities and specificities is necessary for OA management. Due to the lack of a reliable screening test for OA, the assessments of the prevalence of OA in a general population is difficult. Meanwhile, some scientist have worked on the screening questionnaires for identifying the knee or hip OA. Using only a questionnaire to identify OA cases without the physical examinations and radiographs would be non-verifiable^[1][2][2].

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammadmain Rezazadehsaatlou[2], Irfan Dotani [3].

The orthopedic surgeons are frequently asked by their patients regarding the final outcome and the prognosis of their diseased joint/joints caused by OA.

Information about the natural history of OA is very important for upcoming determinations and planning for patients management. A small number of studies are available studied the role of the radiographic findings, joint congruence, or even the daily life activity on the OA progression ^{[1][2][3][4][5]} :

Its been reported that the patients with unilateral idiopathic hip OA are most likely to develop OA in the contralateral hip. In a 10 years expectancy, the frequencies of OA development and undergoing the total hip total hip replacement (THR) among the contralateral hips considered as normal are 35-45% and 5-20%, respectively. Therefore, due to the importance of this topic and lack of confidential information in this regard, a long-term longitudinal study is needed in order to answer this big question that how often and how long does takes for symptomatic joint injury and the requirement of surgical involvement in this regard. Meanwhile, the incidence and prevalence rates of THR in hip OA were 2.5% and 17%, respectively.

Based on the radiological evaluation of knee OA, the incidence rate of knee OA was 2-4% annually and this incidence rate was higher among women. Though most importantly, its been reported that the incidence rate of OA in radiography evaluations was twice higher than symptomatic OA which highlights the role of radiography in this regard. In a cohort study, the OA progression in a 3-year evaluation reported to be 15.5%.

The hand as the most common and important peripheral site of osteoarthritis (OA), because the hand involvement in OA could affect patients life through disability. Meanwhile, the base of the thumb, and distal interphalangeal joints (DIPs), proximal interphalangeal joints (PIPs) of fingers are the most common site for hand OA. The prevalence of hand OA among men and women older than 65 years is 64-78% and 71 to 99%, respectively.

OA is a leading cause of morbidity having significant effects on patients life and the health care system and even it could cause heavy economic burden. According to the American Academy of Orthopedic Surgeons report movement limitation are found in 80% of adults diagnosed with osteoarthritis. Meanwhile, 25% of these patients facing difficulties in their of daily living activities. 11% of them need personal care assistance and 14% required help with their routine needs.

Unfortunately, despite high prevalence and influence of OA on human life, there are only a limited studies working on the complications caused by OA. Possible complications of osteoarthritis include^[6][7][8][9]:

• Gout.

Gout is known as an inflammatory form of arthritis caused by high amount of urate leading to sodium urate crystals formation around the involved joints. Gout may affect the cartilage system and trigger the crystal formation, especially in cases with higher serum levels of urate. In the foot, osteoarthritis in the big toe is a common site for involvement it could be considered as a common site of the occurrence of gout.

• Chondrocalcinosis.

Osteoarthritis can also lead to calcium pyrophosphate crystals formation in diseased cartilage. This is process named calcification or chondrocalcinosis. Chondrocalcinosis can be developed in any joint, with/without the existence of osteoarthritis. In a patient with osteoarthritis, chondrocalcinosis is common in the knee.

• Long-term (chronic) pain.
• Rapid and the complete breakdown of cartilage resulting in loose tissue material in the joint (chondrolysis).
• Joint deformities (hard or bony nodules that form where two bones come together, often giving the joint a knobby or knotted appearance)
• Bone death (osteonecrosis).
• Stress fractures (hairline crack in the bone that develops gradually in response to repeated injury or stress).
• Muscle weakness (often occurs when a joint becomes too painful to use, especially with knee osteoarthritis).
• Bleeding within the joint.
• Infection in the joint.
• Deterioration or rupture of the tendons and ligaments around the joint, leading to loss of stability.
• Pinched nerve (in osteoarthritis of the spine).
• Depression.
• Anxiety.
• Sleep disruption.
• Weight gain.
• Difficulty performing daily activities and Reduced productivity.
• Loss of independent living.
• Impaired balance.
• Increased risk of falling.

• Most osteoarthritis cases do stabilize^[10].
• Some osteoarthritis cases progress^[11].
• A small number of osteoarthritis patients improve spontaneously^[11].

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