ortho 05 common rheumatic dx rx


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ortho 05 common rheumatic dx rx

  1. 1. Common Rheumatological disorders in Orthopaedics Department of Orthopaedic Surgery Faculty of Medicine Siriraj Hospital Mahidol University
  2. 2. Contents <ul><li>Osteoarthritis </li></ul><ul><li>Gouty Arthritis </li></ul><ul><li>CPPD </li></ul><ul><li>Rheumatoid Arthritis </li></ul>
  3. 3. Prevalence of rheumatic disease in rural Thailand (Nakornayok Province) N=2455, age > 15 yrs J Rheumatol 1998; 25: 1382-7 Diagnosis Prevalence % OA Myofascial pain syndrome Low back pain Arthralgia Epicondylitis Gout RA Seronegative Tendinitis Myalgia MCTD Unclassified CTD 11.3 6.3 4.0 3.2 1.4 0.16 0.12 0.12 0.09 0.09 0.04 0.04
  4. 4. Osteoarthritis
  5. 5. <ul><li>Heterogeneity of osteoarthritis </li></ul><ul><li>Monoarthritis </li></ul><ul><li>Pauciarticular arthritis </li></ul><ul><li>*affecting large weight-bearing joints </li></ul><ul><li>Polyarthritis </li></ul><ul><li>*affecting numerous sites including IP joints of fingers </li></ul>
  6. 6. Classification of Osteoarthritis I. Primary (idiopathic)    A. Localized (principal site)      1 . Hip (superolateral, superomedial, medial, inferoposterior)      2. Knee (medial, lateral, patellofemoral)     3. Spinal apophyseal      4. Hand (interphalangeal, base of thumb)      5. Foot (first metatarsophalangeal joint, midfoot, hindfoot)     6. Other (shoulder, elbow, wrist, ankle)    B. Generalized      1. Hands (Heberden's nodes)      2. Hands, knees and spinal apophyseal (generalized OA)
  7. 7. Classification of Osteoarthritis II. Secondary    A. Dysplastic      1. Chondrodysplasias      2. Epiphyseal dysplasias      3. Congenital joint displacement      4. Developmental disorders (Perthes' disease, epiphysiolysis)     B. Post-traumatic      1. Acute      2. Repetitive      3. Postoperative     C. Structural failure      1. Osteonecrosis     2. Osteochondritis
  8. 8. Classification of Osteoarthritis II. Secondary       D. Post-inflammatory      1. Infection      2. Inflammatory arthropathies E. Endocrine and metabolic      1. Acromegaly      2. Ochronosis      3. Hemochromatosis      4. Crystal deposition disorders    F. Connective tissue      1. Hypermobility syndromes      2. Mucopolysaccharidoses  
  9. 9. <ul><li>CLINICAL FEATURES </li></ul><ul><li>General Presentation </li></ul><ul><li>middle or later years, overweight </li></ul><ul><li>History </li></ul><ul><li>1) Pain : localized or refer pain </li></ul><ul><li> - according to amount of exertion </li></ul><ul><li>- exacerbated by movement & weight bearing </li></ul><ul><li> - relieved by rest (except in advanced stages) </li></ul>
  10. 10. CLINICAL FEATURES 2) Stiffness Initially, intermittent < 30 minutes 3) Swelling and deformity Superficial joints (knee or IP joints) * Bowlegs or knock knees
  11. 11. CLINICAL FEATURES 4) Loss of function Specific to the site involved * Poor grip : osteoarthritis of hands *Difficult grooming : osteoarthritis of the shoulders *Restricted walking distance, limp, fatigue : osteoarthritis of the hips and knees
  12. 12. <ul><li>CLINICAL FEATURES </li></ul><ul><li>Examination </li></ul><ul><li>1) Disturbance of gait </li></ul><ul><li> *often noticed first osteoarthritis of the hip or knee *real or apparent shortening of one of lower limbs </li></ul><ul><li>2) Swelling and deformity </li></ul><ul><li>3) Muscle wasting </li></ul><ul><li>4) Tenderness </li></ul><ul><li>5) Synovial thickening </li></ul><ul><li>6) intra-articular fluid, marginal osteophytes </li></ul>
  13. 13. Heberden’s & Bouchard’s node
  14. 14. OA HIP
  15. 15. OA knee Bowel leg
  16. 16. Imaging Plain radiographs most useful form of imaging, not most sensitive Cardinal features - asymmetric narrowing of the joint space - sclerosis of subchondral bone under area of cartilage loss - cysts close to the subchondral bone plate - osteophytes at joint margins, and bone remodeling -intraarticular loose bodies , deformity, subluxation
  17. 17. Laboratory Investigations **No reliable diagnostic test Synovial fluid Nonspecific : non- inflammation *increased volume, decreased viscosity *mild pleocytosis, and slight increase in protein
  18. 18. General principles of OA treatment <ul><li>Relieving symptoms </li></ul><ul><li>Maintaining and/or improving functions </li></ul><ul><li>L imit physical disability </li></ul><ul><li>Avoiding drug toxicity </li></ul>
  19. 19. OA treatment <ul><li>Non pharmacologic therapy </li></ul><ul><li>Pharmacologic therapy </li></ul><ul><li>Surgery </li></ul>
  20. 20. OA treatment <ul><li>Non pharmacologic therapy </li></ul><ul><ul><li>P atient education </li></ul></ul><ul><ul><li>Physical therapy </li></ul></ul><ul><ul><li>Occupational therapy </li></ul></ul><ul><ul><li>Weight reduction </li></ul></ul>
  21. 21. OA treatment <ul><li>Pharmacologic therapy </li></ul><ul><ul><li>- Systemic </li></ul></ul><ul><ul><ul><li>Analgesi c agent </li></ul></ul></ul><ul><ul><ul><ul><li>non - narcotic analgesic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>narcotic analgesi c </li></ul></ul></ul></ul><ul><ul><ul><li>Anti-inflammatory </li></ul></ul></ul><ul><ul><ul><ul><li>NSAIDS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Specific COX 2 inhibitor </li></ul></ul></ul></ul>
  22. 22. OA treatment <ul><ul><li>- Local </li></ul></ul><ul><ul><ul><ul><li>Intraartricular </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>:-C orticosteroid injection </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>:- Viscosupplementation - hyaluronan injection </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Topical therap y </li></ul></ul></ul></ul><ul><ul><ul><ul><li>:- Capsaici n </li></ul></ul></ul></ul><ul><ul><ul><ul><li>:- Tropical NSAIDs </li></ul></ul></ul></ul>
  23. 23. Alternative and experimental therapy <ul><li>Glucosamine sulfate </li></ul><ul><li>C hondroitin sulfate </li></ul><ul><li>Diacerein </li></ul><ul><li>Miscellaneous </li></ul>
  24. 24. OA treatment <ul><li>Surgery </li></ul><ul><li>Arthroscopic debridement </li></ul><ul><li>Osteotomy </li></ul><ul><li>Unicompartment/Total joint replacement </li></ul>
  25. 25. OA treatment guideline Tramadol opioid Rheumato/ortho consultation Tramadol or COX-2 inhibotor Tramadol or opioid NSAIDS +/- anagesics Diagnosis of OA nonpharmacologic +/- acetaminophen +/- topical agent symptoms not improve NAIDS contraindication GI risk kidney risk No risk
  26. 26. <ul><li>Rheumato / Orthopedic consultation </li></ul>Symptoms not improve Add intraarticular steroid injection Hyaluronate injection disease modifying anti-osteoarthritic drug Surgery
  27. 27. GOUT
  28. 28. Hyperuricemia Serum urate conc. > 7 mg/dL ( 7 men , 6 women ) Strong correlate *** BSA : BW, Ht ** Age * Sex Prevalence : 2.3 - 17.6 % of the populations Annual incidence rate of gout 4.9 % for levels > 9 mg/dl 0.5 % for levels 7 - 8.9 mg/dl 0.1 % for levels < 7 mg/dl GOUT
  29. 29. Incidence 0.20 - 0.35 per 1000 Prevalence 1.60 - 13.6 per 1000 Increase incidence with * Age * Sex * Serum urate level Gout - Epidemiology Prevalence 0.7-1.4 % in men 0.5-0.6% in women Prevalence in age > 65 4.4-5.2 % in men 1.8-2.0 % in women But onset of gout after age > 60 men and women is almost equal, and onset after 80,women seem predominate GOUT
  30. 30. Four stages: 1) Asymptomatic hyperuricemia 2) Acute gouty arthritis 3) Intercritical (or interval) gout 4) Chronic tophaceous gout Spectrum of Gout GOUT
  31. 31. <ul><li>M ost : asymptomatic throughout their lifetime </li></ul><ul><li>Risk of acute gout increases with </li></ul><ul><li>* serum urate concentration </li></ul><ul><li>R isk of nephrolithiasis increases with </li></ul><ul><li>* serum urate level </li></ul><ul><li>* daily urinary uric acid excretion </li></ul><ul><li>> 20 years of sustained hyperuricemia - Gout </li></ul>Asymptomatic Hyperuricemia GOUT
  32. 32. Acute Gouty arthritis <ul><li>The onset first attack : 40-60 yrs </li></ul><ul><li>Site : great toe, ankles, knees </li></ul><ul><li>: wrists, fingers, and elbows </li></ul><ul><li>: prepatellar or olecranon bursa </li></ul><ul><li>: Heberden’s nodes </li></ul><ul><li>Symptom </li></ul><ul><li>: explosive suddenness, at night </li></ul><ul><li>: joint becomes hot, dusky red, swollen, tender </li></ul><ul><li>: systemic signs of inflammation </li></ul>GOUT
  33. 33. Acute Gouty arthritis GOUT
  34. 34. Definitive diagnosis : aspiration of the joint : intracellular needle-shaped crystals : negative birefringence with compensated polarized light microscopy Acute Gouty arthritis GOUT
  35. 35. Acute Gouty arthritis GOUT
  36. 36. Acute Gouty arthritis Strongly negative birefringent crystal GOUT
  37. 37. Acute Gouty arthritis <ul><li>S ubside several hours to weeks </li></ul><ul><li>B ecomes asymptomatic (intercritical period) </li></ul><ul><li>Provocative factors </li></ul><ul><li>Drugs : anti-hyperuricemic therapy </li></ul><ul><li>: drug-induced hyperuricemia </li></ul><ul><li>Infections </li></ul><ul><li>Trauma, surgery, hemorrhage </li></ul><ul><li>Alcohol ingestion </li></ul><ul><li>Dietary excess </li></ul>GOUT
  38. 38. Acute Gouty arthritis GOUT
  39. 39. Intercritical Gout Second attack within 6 mo - 2 yrs Diagnosis : difficult or inconclusive GOUT
  40. 40. Characters * chronic polyarticular gout * without pain-free intercritical periods * average of 11.6 years * severe crippling disease Chronic tophaceous gout GOUT
  41. 41. Chronic tophaceous gout GOUT
  42. 42. Chronic tophaceous gout
  43. 43. Therapeutic aims * To terminate the acute attack * To prevent recurrences        * To prevent or reverse complications ( deposition of MSU or UA crystals )    * To prevent or reverse associated features ( obesity, hyper TG & HT ) TREATMENT OF GOUT GOUT
  44. 44. Acute Gouty Arthritis <ul><li>Colchicine, NSAID, Corticosteroid </li></ul><ul><li>Patient cannot take medications by mouth </li></ul><ul><li>IV colchicine </li></ul><ul><li>IV glucocorticoids </li></ul><ul><li>IM corticotropin (ACTH) </li></ul>**** avoid adjust antihyperuricemic drugs **** ****** during an acute attack ******* GOUT
  45. 45. Prophylaxis against acute attacks of gout <ul><ul><li>Colchicine 0.6 mg once or twice a day </li></ul></ul>***Continued until the serum urate value maintained well within the normal range, no tophi and no acute attacks for 3 to 6 months*** GOUT
  46. 46. Control of Hyperuricemia in MSU Deposit <ul><ul><li>Indication: Gout attack > 3 times in 1 year </li></ul></ul><ul><ul><li>In general, the aim of anti- hyperuricemic therapy </li></ul></ul><ul><ul><li>Reduce the serum urate < 5.0- 6.0 mg/dl </li></ul></ul><ul><ul><li>by allopurinol or a uricosuric agent </li></ul></ul><ul><ul><li>1.Uricosuric agent </li></ul></ul><ul><ul><ul><li>Probenecid, Sulfinpyrazone, Benzbromarone </li></ul></ul></ul><ul><ul><ul><li>* age < 60 years </li></ul></ul></ul><ul><ul><ul><li>* normal renal function </li></ul></ul></ul><ul><ul><ul><li>(creatinine clearance greater than 80 ml/minute) </li></ul></ul></ul><ul><ul><ul><li>* UA excretion < 700 mg/24 hours on a general diet </li></ul></ul></ul><ul><ul><ul><li>* no history of renal calculi </li></ul></ul></ul>GOUT
  47. 47. <ul><li>Indications </li></ul><ul><ul><li>Gout attack > 3 times in 1 year or positive tophi </li></ul></ul><ul><ul><li>Uric acid nephropathy </li></ul></ul><ul><ul><li>Nephrolithiasis </li></ul></ul><ul><ul><li>Prophylaxis before cytolytic therapy </li></ul></ul><ul><ul><li>Gout with </li></ul></ul><ul><ul><ul><li>1.Intolerance or reduced efficacy of uricosuric agents 2.Renal insufficiency (GFR <60 ml/min) </li></ul></ul></ul><ul><ul><ul><li>3.Allergy to uricosuric agent </li></ul></ul></ul>2.Allopurinol GOUT
  48. 48. CPPD Calcium pyrophosphate dihydrate deposition disease
  49. 49. CPPD <ul><li>Calcium pyrophosphate dihydrate that deposit in cartilage </li></ul><ul><li>If crystal released into a joint  acute painful arthritis (Pseudogout) </li></ul><ul><li>Can appear as chondrocalcinosis in X-ray </li></ul><ul><li>but other crystals can seen as chondrocalcinosis (calcium hydroxyapatite, calcium oxalate) </li></ul>
  50. 50. Prevalence <ul><li>Common in elderly </li></ul><ul><li>Most studies used radiologic or anatomically defined articular calcification as a marker </li></ul><ul><li>Prevalence 8% (age 63-93) </li></ul><ul><li>15% in age 65-74, 36% in age 75-84 </li></ul><ul><li>22% in excised cadaver menisci </li></ul>
  51. 51. Clinical feature <ul><li>M:F = 1.5:1 </li></ul><ul><li>Mean age at time of diagnosis = 72 years </li></ul><ul><li>Feature </li></ul><ul><li>Pseudogout </li></ul><ul><li>Pseudo-RA </li></ul><ul><li>Pseudo-OA </li></ul>
  52. 52. Pseudogout <ul><li>Found 25% </li></ul><ul><li>Acute or subacute arthritis(last 1-28 days) </li></ul><ul><li>Involve one or few joints </li></ul><ul><li>Most common in knee joint </li></ul><ul><li>May severe as gout, longer time to peak intensity </li></ul><ul><li>Less painful and disabling </li></ul><ul><li>20% hyperuricemia, 5% MSU deposit </li></ul>
  53. 53. Pseudo-RA <ul><li>Found 5-10 % </li></ul><ul><li>Subacute attacks (4 weeks-several months) </li></ul><ul><li>Non-specific symptoms (morning stiffness, fatigue) </li></ul><ul><li>Large joint common: knee, elbow, ankle </li></ul><ul><li>But also small joints of hands and feet </li></ul><ul><li>Synovial thickening, localized pitting edema, limit joint motion, flexion contracture,  ESR </li></ul><ul><li>Positive RF 10%, 3% RA have calcified cartilage </li></ul>
  54. 54. Pseudo-RA <ul><li>Differentiate from RA  </li></ul><ul><li>1. difference severity of multiple joints </li></ul><ul><li>2. asymmetrical involvement </li></ul><ul><li>3. osteophyte positive </li></ul><ul><li>4. positive chondrocalcinosis </li></ul><ul><li>5. no periarticular osteoporosis </li></ul><ul><li>6. no bony erosion </li></ul><ul><li>But CPPD with RA co-exist 1% </li></ul>
  55. 55. Pseudo-OA <ul><li>Found 34-50 % </li></ul><ul><li>Women predominate </li></ul><ul><li>Most common :knee > wrist >hip, shoulder, elbow, ankle, and spine </li></ul><ul><li>Chronic joint pain </li></ul><ul><li>Generally symmetric, with further advanced on one side, flexion contracture </li></ul><ul><li>50% episodic attacks, some time severe as gout </li></ul><ul><li>Concomitant Heberden’s and Bouchard’s nodes </li></ul>
  56. 56. Pseudo-OA <ul><li>Differentiate from primary OA  </li></ul><ul><li>1. severe degenerative change </li></ul><ul><li>2. atypical joints: MCP, wrist, elbow, shoulder </li></ul><ul><li>3. unilateral or bilateral genu valgus changes </li></ul><ul><li>4. isolated patellofemoral OA. </li></ul><ul><li>5. Flexion contractures </li></ul><ul><li>6. more likely to symmetric than primary OA </li></ul><ul><li>7. Radiographs: Chondrocalcinosis and exuberant osteophyte formation </li></ul>
  57. 57. Asymptomatic <ul><li>May be the most common clinical presentation </li></ul><ul><li>Incidental finding from radiograph </li></ul>
  58. 58. A , Acute pseudogout. B , Pseudo-osteoarthritis. C , Pseudo-rheumatoid arthritis with boutonniere deformity. D , Pseudo-rheumatoid arthritis showing ulnar deviation, interosseous muscle atrophy, and metacarpophalangeal and wrist joint involvement. The patients in A , C , and D are siblings.
  59. 59. Radiographic features <ul><li>knee menisci and articular cartilage </li></ul><ul><li>triangular ligaments of the radiocarpal joint </li></ul><ul><li>fibrocartilage of the symphysis pubis </li></ul>
  60. 62. Synovial fluid findings <ul><li>usually cloudy, WBC 2,000-80,000/mm 3 , 80% PMN with intracellular and extracellular crystals </li></ul><ul><li>resolving arthritis, the WBC usually <2,000 /mm 3 , MNC>PMN </li></ul><ul><li>rhomboid or rod-shaped, weakly birefringent crystals with positive elongation </li></ul><ul><li>cannot exclude other causes of acute or chronic inflammation such as infection, rheumatoid arthritis </li></ul>
  61. 63. Treatment <ul><li>Proven Benefits </li></ul><ul><li>NSAIDs or COX-2 inhibitors </li></ul><ul><li>Intra- articular steroid </li></ul><ul><li>Systemic steroids </li></ul><ul><li>ACTH </li></ul><ul><li>Prophylactic low-dose colchicine </li></ul><ul><li>Possible Benefits </li></ul><ul><li>Hydroxychloroquine </li></ul><ul><li>Oral magnesium (for pts. With hypomagnesemia) </li></ul><ul><li>Others </li></ul><ul><li>Aspiration, removal CPPD crystal </li></ul><ul><li>Resting the affected joints </li></ul>
  62. 64. Rheumatoid Arthritis
  63. 65. Rheumatoid arthritis
  64. 66. Rheumatoid arthritis
  65. 67. Treatment Guideline