ortho - arthritis

Arthritis: An Arthritis: An Orthopedic PerspectiveOrthopedic Perspective

Jose Ramon C.Pascual,MD Fellow Philippine Orthopedic Association

Department of OrthopedicsDe La Salle College of Medicine

ObjectivesObjectives

To review normal joint structure and function

To identify the different types of arthritides

To learn how to formulate a management plan

ContentsContents

Normal JointNormal Joint

Joint with cavity is called a synovial jointMade up of several types of tissue that

may be involved in disease processes

Normal JointNormal Joint

BoneCartilageSynoviumSynovial FluidLigaments/tendons and

entheses

Normal JointNormal Joint

Bone

Normal JointNormal Joint

Cartilage◦Articular cartilage is

primarily hyaline◦Avascular and aneural◦Loadbearing areas that are

damaged rarely rethicken and heal

Normal JointNormal 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 JointNormal 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 JointNormal Joint

Ligaments/tendons and entheses◦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 HLA-B27 Class I allotype - the seronegative spondarthropathies

Degenerative Joint DiseaseDegenerative Joint Disease

Etiology◦Disease process of synovial joint characterized

by focal areas of hyaline cartilage loss with increased activity of marginal and subchondral bone

Degenerative Joint DiseaseDegenerative Joint Disease

Pathophysiology

Degenerative Joint DiseaseDegenerative Joint Disease

Clinical Manifestations◦Pain

◦Malfunction

◦Deformity

Elderly,Repetitive Trauma or Major Trauma to Joint

Degenerative Joint DiseaseDegenerative Joint Disease

Laboratory FindingsPlain Xray

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

Degenerative Joint DiseaseDegenerative Joint Disease

Laboratory Findings◦Weight bearing views of entire lower

extremity : varus / valgus malalignment

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Etiology◦Chronic, systemic, autoimmune disorder

characterized by progressive damage to the synovial joints with cartilage and bone loss

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Pathophysiology

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Pathophysiology

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Clinical Manifestations

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Clinical Manifestations

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Clinical Manifestations

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid 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 DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Laboratory Findings◦Blood

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

Inflammatory Joint DiseaseInflammatory Joint DiseaseRheumatoid ArthritisRheumatoid Arthritis

Laboratory Findings◦Xrays

Juxarticular osteopenia Erosions

Crystal Related ArthropathiesCrystal Related ArthropathiesGoutGout

Etiology◦Peripheral arthritis that results from uric acid

crystal deposition in one or more joints◦Primary gout◦Secondary gout

Crystal Related ArthropathiesCrystal Related ArthropathiesGoutGout

Pathophysiology

Crystal Related ArthropathiesCrystal Related ArthropathiesGoutGout

Clinical Manifestation

Crystal Related ArthropathiesCrystal Related ArthropathiesGoutGout

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 ArthropathiesCrystal Related ArthropathiesGoutGout

Laboratory Findings◦Synovial Fluid

Synovial Fluid Analysis

Disease WBC's Polymorphs Normal < 200 < 25 %

Traumatic < 5,000 (w/ RBC's) < 25 %

Toxic Synovitis/ Gout 5,000- 15,000 < 25 %

Acute Rheumatic F. 10,000- 15,000 50 %

JRA. 15,000- 80,000 75 %

Septic Arthritis 80,000-200,000 > 75 %

Crystal Related ArthropathiesCrystal Related ArthropathiesGoutGout

Laboratory Findings◦Polarized Light Microscopy

Crystal Related ArthropathiesCrystal Related ArthropathiesGoutGout

Laboratory Findings◦Xray

Soft tissue swelling Punched out lesions Tophi Joint space narrowing

ManagementManagementNonoperativeNonoperative

ManagementManagementNonoperativeNonoperative

Nonpharmacologic

ManagementManagementNonoperativeNonoperative

Nonpharmacologic◦Dietary Modification for Gout

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

Gelatin, fruitsMiscellaneous

Alcoholic beveragesMilk, tea, coffeeBeverages

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

anchovies, bagoong

Milk, cheese, meat in allowed amounts only

Meat or Substitute

Oatmeal, whole wheat, whole grain cereals

Rice, cerealsRice or Substitute

Asparagus, cauliflower, mushroom, spinach

All except those restricted

Vegetable

RestrictedAllowedFood Group

ManagementManagementNonoperativeNonoperative

Viscosupplementation

ManagementManagementOperativeOperative

Debridement/ SynovectomyIndications1.Early inflammatory arthritis without significant joint destruction2.Early degenerative joint disease (i.e. degenerative meniscal tears with minimal cartilage damage)

Contraindications1.Infectious arthritis2.Extensive destruction of joint surface

ManagementManagementOperativeOperative

Corrective Osteotomy

Indications1.Noninflammatory arthritis2.Arthritis or prearthritic conditions in young individuals

Contraindications1.Inflammatory arthritis2.Infectious arthritis3.Extensive destruction of joint surface

ManagementManagementOperativeOperative

Corrective Osteotomy

ManagementManagementOperativeOperative

Arthrodesis

Indications1.Arthritic joints in young patients who plan to engage in heavy physical activity2.Failed/ infected arthroplasties

Contraindications1.Contralateral fused joint

ManagementManagementOperativeOperative

ArthroplastyIndications1.Noninflammatory and inflammatory arthritis with severe joint destruction2.Conversion of ankylosed joint

Contraindications1.Post septic arthritis2.Young patients (relative contraindication)

ManagementManagementOperativeOperative

Arthroplasty

To 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.

Sir William Osler

ReferencesReferences

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