00:01
Pathogenesis. It's quite complex:
biochemical, biomechanical, cytokine-mediated,
to a certain extent, right?
Because you do have WBCs, but it's
< 2000 in the synovial fluid.
00:15
Now, commonly, the problem is obesity.
00:19
So you take a look at the
patient who's obese.
00:21
Apart from Diabetes Type 2
and so on and so forth,
that the patient has developed,
metabolic syndrome as you know,
the patient now is at risk of definitely
developing osteoarthritis.
00:30
A lot of weight that the patient might…
has to then put on the knees and such.
00:35
That incidence, unfortunately,
osteoarthritis increases with age.
You can't help it, right?
But there are certain things that we can do
to maybe protect ourselves.
00:43
Depends on our, well, genetics.
00:47
Signs and symptoms. Well, important here.
00:50
As I told you,
as you move through osteoarthritis
in your head,
you're going to be comparing this
with rheumatoid arthritis.
00:58
In rheumatoid arthritis…
and that's the first time that I'm giving
you a true comparison now.
01:03
In rheumatoid arthritis, as you know,
it's a autoimmune issue, isn't it?
Autoimmune most likely going to
affect a female, no doubt.
01:11
Autoimmune diseases.
01:14
Here, we have a lot of information.
01:16
In rheumatoid arthritis, for example,
the WBC count in the synovial fluid
can exceed 2,000 cells per microliter.
01:24
They are generally in the range
of 5,000 to 50,000.
01:28
Remember, what should be
normal for synovial fluid?
It's less than 200 cells per microliter.
01:34
Next, the patient says...
01:37
Who's your patient, a lady, young,
maybe 35 or so?
And she tells you,
"Doc, I wake up in the morning and
I'm having a hard time moving."
"How long does it take before you get better?"
"Hmm, maybe about an hour, hour
and a half." That's a long time.
01:51
That's rheumatoid arthritis.
01:53
"And then upon moving,
do your joints feel better or
do they feel worse?"
"Doc, actually, to tell you the
truth, I mean, it just…
When I start moving, it starts…they start
feeling a lot better. So I like to move."
Osteoarthritis doesn't do that.
02:07
Osteoarthritis, OA, worsens with
use. Is that clear?
It's wear and tear. And the more
wear, the more tear.
02:15
Clinically, remind me the joints again?
Reach out your hand,
and you're going to give me your DIP.
02:22
When the DIP has undergone inflammatory
or osteoarthritis,
then it's called Heberden nodes.
02:29
HEB.
02:32
The one that will be proximal,
go in alphabetical order. H will be distal,
B will be your PIP. Those are
called Bouchard,
okay, at your PIP.
02:42
And then which finger did I have you put up?
Not the middle finger, the thumb, yeah.
02:48
The thumb. That's called your carpometacarpal
phalangeal joint.
02:51
That will be affected commonly
in osteoarthritis.
02:55
Frequently, as I told you also, apart
from that, the knees, the spine,
the areas in which you'd expect dependency.
03:01
Now, there's a little bit of an exception.
03:06
Think about the metacarpophalangeal joint.
03:08
What are those?
At times, don't you feel like you just want
to punch me with your knuckles?
Those knuckles are your metacarpophalangeal
joints.
03:17
Notice, that is not affected here.
Commonly, it's not.
03:22
The wrist is not commonly affected
in osteoarthritis.
03:25
But what if you did have a patient
who is an occupation, a welder, what have you,
and deals with the hands as
an occupation for decades.
03:37
Wear and tear.
03:38
And so, therefore,
in that particular instance,
in that occupation, whatever
it may have been,
has come to be known as your Missouri
metacarpophalangeal joint.
03:49
Otherwise, osteoarthritis
normally will not affect those
joints. Keep that in mind.
03:55
And crepitus of affected, so a
little bit of, let's say, noise.
04:00
In osteoarthritis, you'll notice here
that the DIP is affected. What
is that called again, please?
Heberden.
04:07
What is it called if the PIP is affected?
Good. The Bouchard.
04:11
Are your metacarpophalangeal
joint commonly affected?
Yes or no?
No. Good.
04:18
Wrist commonly affected? No.
04:22
Could it be affected? Yes.
04:24
What's your patient doing?
Occupation? Dealing with hands
and wear and tear over a
long period of time.
04:33
And then what about the thumb?
Yes.
04:36
At what joint?
Carpometacarpal joint, CMC.
04:41
Welcome to osteoarthritis.
04:45
On your examination,
on X-ray, what are you going to find?
Well, immediately, you'll notice
the picture on the left
of an X-ray of the knee.
04:56
And you'll notice that the joint
space has indeed narrowed.
05:00
That's what happens with all that
wear and tear taking place.
05:03
In addition, you might find areas
that are a little bit…
You see that? A little bit more
opaqueness taking place?
That area of being more bright white?
The bright white area that
you're seeing there,
the bone is undergoing changes.
05:16
It's sclerotic changes.
05:18
And with that sclerosis, you might even
find what's known as osteophytes,
or bone spurs.
05:24
For example, you ride a horse
with those boots, got the spurs
sticking out of your boots.
05:30
Well, these are the spurs that are
sticking out of a knee…of a bone
called osteophytes.
05:34
That's your fun in osteoarthritis.
05:37
And what about the cartilage
that's undergoing ulceration?
And what do we call cartilage? Chondral,
so subchondral sclerosis,
subchondral type of cyst.
05:47
The joint capsule might become inflamed.
05:50
But be careful, though. Remember,
the synovial fluid.
05:52
Is it…would you call it truly inflammatory
or non-inflammatory?
Good. Non inflammatory. Why?
Because if you did check the synovial fluid
in osteoarthritis, WBC count,
< 2000.
06:06
So, by definition, not truly inflammatory.
Is that understood?
Now, once you have the cartilage
which is being ulcerated,
now it looks as though the bone is smooth.
06:18
A smooth bone is then called eburnation.
06:21
That's what we're seeing here on X-ray.
06:26
On labs, the sedimentation
rate will be normal.
06:30
That's important.
06:32
Rheumatoid factor has nothing to
do with rheumatoid arthritis,
so it's not immune, remember?
So, it's therefore, non-immune.
06:40
The X-ray, I showed you, subchondral sclerosis.
06:43
What does sclerosis mean? Thickening.
06:46
And with that thickening, what
may then happen?
Give formation to osteophytes,
which are known as your bone spurs.
06:53
These osteophytes,
if they're in the PIP, you would
call them Bouchard.
06:58
If they're affecting the DIP you call
them what? Heberden. Good.
07:02
What about management?
NSAIDs, definitely a COX inhibitor.
07:06
Commonly, as I told you, obesity.
07:09
So, conservatively, tell your patient to
exercise, physical therapy and such.
07:15
Worst-case scenario, maybe
the knee is so far gone
that surgery is recommended.
07:20
And there's really no role here
for PO steroids.
07:24
Intraarticular, you could then inject, maybe,
glucocorticoids, though. Keep that in mind.
07:29
Or perhaps, hyaluronic acid. Remember?
The synovial lining,
it's producing synovial fluid
that's made up of
hyaluronic type of fluid, isn't it?