Ortho - Arthritis

Arthritis: An Orthopedic Perspective Jose Ramon C.Pascual,MD Fellow Philippine Orthopedic Association Department of Orthopedics De La Salle College of Medicine

To

review normal joint structure and function To identify the different types of arthritides To learn how to formulate a management plan

Objectives

Contents

Joint

with cavity is called a synovial joint Made up of several types of tissue that may be involved in disease processes

Normal Joint

Bone Cartilage Synovium Synovial

Fluid Ligaments/tendons and entheses

Normal Joint

Bone

Normal Joint

Cartilage

◦ Articular cartilage is primarily hyaline ◦ Avascular and aneural ◦ Loadbearing areas that are damaged rarely rethicken and heal

Normal Joint

Synovium

◦ Modified fibroblasts in the intima produce hyaluronic acid which passes into the synovial fluid ◦ Macrophages in the intima are rich in the receptor FcgRIIIa which mediates cytokine release in response to small immune complexes

Normal Joint

Synovial

Fluid

◦ Syn ovium (like an egg) ◦ Viscosity is due to the presence of hyaluronan ◦ Hyaluronan helps maintain a thin layer of lubricin at the surface of the articular cartilage

Normal Joint

Ligaments/tendons

entheses

and

◦ Entheses are the points at which the ligaments, aponeuroses and tendons are attached to the bone ◦ Entheses are a main target in a group of inflammatory disorders associated with the HLAB27 Class I allotype - the seronegative spondarthropathies

Normal Joint

Etiology

◦ Disease process of synovial joint characterized by focal areas of hyaline cartilage loss with increased activity of marginal and subchondral bone

Degenerative Joint Disease

Pathophysiology

Degenerative Joint Disease

Clinical

Manifestations

◦ Pain ◦ Malfunction ◦ Deformity Elderly,Repetitive Trauma or Major Trauma to Joint

Degenerative Joint Disease

Laboratory Plain

Findings

Xray

◦ APL: Loss of joint line space, sclerosis, bone cysts

Degenerative Joint Disease

Laboratory

Findings

◦ Weight bearing views of entire lower extremity : varus / valgus malalignment

Degenerative Joint Disease

Etiology

◦ Chronic, systemic, autoimmune disorder characterized by progressive damage to the synovial joints with cartilage and bone loss

Inflammatory Joint Disease Rheumatoid Arthritis

Pathophysiology

Inflammatory Joint Disease Rheumatoid Arthritis

Pathophysiology

Inflammatory Joint Disease Rheumatoid Arthritis

Clinical

Manifestations

Inflammatory Joint Disease Rheumatoid Arthritis

Clinical

Manifestations

Inflammatory Joint Disease Rheumatoid Arthritis

Clinical

Manifestations

Inflammatory Joint Disease Rheumatoid Arthritis

Laboratory

Findings

◦ Blood Rheumatoid Factor ◦ 50% to 68% of patients may have negative RF test (seronegative) in the first 6 months ◦ Only 85% of RA patients may seroconvert ◦ RF may also be seen in Sjorgen’s syndrome, SLE, sarcoidosis, cirrhosis and other liver problems

Inflammatory Joint Disease Rheumatoid Arthritis

Laboratory

Findings

◦ Blood Anti-cyclic citrullinated peptide test ◦ Higher specificity (95%) than RF (85%) ◦ Better marker of progression than RF

Inflammatory Joint Disease Rheumatoid Arthritis

Laboratory

Findings

◦ Xrays Juxarticular osteopenia Erosions

Inflammatory Joint Disease Rheumatoid Arthritis

Etiology

◦ Peripheral arthritis that results from uric acid crystal deposition in one or more joints ◦ Primary gout ◦ Secondary gout

Crystal Related Arthropathies Gout

Pathophysiology

Crystal Related Arthropathies Gout

Clinical

Manifestation

Crystal Related Arthropathies Gout

Laboratory

Findings

◦ Blood Uric acid levels ◦ Hyperuricemia (>7mg/dL) ◦ Hyperuricemia predisposes to clinical gout but is not the same as clinical gout ◦ Normal uric acid levels in the face of clinical signs of acute gouty arthritis does not not preclude gout

Crystal Related Arthropathies Gout

Laboratory

Findings

◦ Synovial Fluid Synovial Fluid Analysis Disease Normal

WBC's < 200

Traumatic

< 5,000 (w/ RBC's)

Toxic Synovitis/ Gout

5,000- 15,000

Polymorphs < 25 % < 25 % < 25 %

Acute Rheumatic F.

10,000- 15,000

50 %

JRA.

15,000- 80,000

75 %

Septic Arthritis

80,000-200,000

> 75 %

Crystal Related Arthropathies Gout

Laboratory

Findings

◦ Polarized Light Microscopy Picture 3

Crystal Related Arthropathies Gout

Laboratory

Findings

◦ Xray Soft tissue swelling Punched out lesions Tophi Joint space narrowing

Crystal Related Arthropathies Gout

Management Nonoperative

Nonpharmacologic

Management Nonoperative

Nonpharmacologic

◦ Dietary Modification for Gout Food Group

Allowed

Restricted

Vegetable

All except those restricted

Asparagus, cauliflower, mushroom, spinach

Rice or Substitute

Rice, cereals

Oatmeal, whole wheat, whole grain cereals

Meat or Substitute

Milk, cheese, meat in allowed amounts only

Mussels, meat extracts, brain, internal organs, lentils, legumes, sardines, tahong, tunsoy, tamban,

Beverages

Milk, tea, coffee

Alcoholic beverages

Miscellaneous

Gelatin, fruits

Gravies (sarsa), meat extracts, patis, yeast, nuts

Management Nonoperative

mackerel, anchovies, bagoong

Viscosupplementation

Management Nonoperative

Debridement/

Synovectomy

Indications 2.Early inflammatory arthritis without significant joint destruction 3.Early degenerative joint disease (i.e. degenerative meniscal tears with minimal cartilage damage) Contraindications 6.Infectious arthritis 7.Extensive destruction of joint surface

Management Operative

Corrective

Osteotomy

Indications 2.Noninflammatory arthritis 3.Arthritis or prearthritic conditions in young individuals Contraindications 6.Inflammatory arthritis 7.Infectious arthritis 8.Extensive destruction of joint surface

Management Operative

Corrective

Osteotomy

Management Operative

Arthrodesis

Indications 2.Arthritic joints in young patients who plan to engage in heavy physical activity 3.Failed/ infected arthroplasties Contraindications 6.Contralateral fused joint

Management Operative

Arthroplasty Indications 2.Noninflammatory and inflammatory arthritis with severe joint destruction 3.Conversion of ankylosed joint Contraindications 6.Post septic arthritis 7.Young patients (relative contraindication)

Management Operative

Arthroplasty

Management Operative

Picture 2

o study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. ir William Osler

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Osteoarthritis http://www.emedicine.com/radio/topic492.htm Rheumatoid Arthritis http://www.emedicine.com/pmr/TOPIC124.HTM Gout http://www.emedicine.com/Radio/topic313.htm Joint Replacement Arthroplasty http://www.emedicine.com/orthoped/topic347.htm http://www.emedicine.com/radio/topic830.htm Arthroscopy http://www.wheelessonline.com/ortho/arthroscopy_of_the_knee Arthrodesis http://www.wheelessonline.com/ortho/hip_arthrodesis http://www.wheelessonline.com/ortho/ankle_arthrodesis http://www.wheelessonline.com/ortho/knee_arthrodesis http://www.wheelessonline.com/ortho/wrist_arthrodesis Osteotomy http://www.medscape.com/viewarticle/421043 http://www.wheelessonline.com/ortho/high_tibial_osteotomy

References