ortho - arthritis
TRANSCRIPT
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