Arthritis

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arthritis, orthopaedic

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Arthritis

  1. 1. Arthritis Hip and Knee Nigel Brewster 1998
  2. 2. Aims <ul><li>Types of arthritis </li></ul><ul><li>Symptoms of arthritis </li></ul><ul><li>Signs of arthritis </li></ul><ul><li>Treatment of arthritis </li></ul>
  3. 3. Types of Arthritis <ul><li>Rheumatoid arthritis (RA) </li></ul><ul><li>Osteoarthritis (OA) </li></ul><ul><li>Sero-negative arthritis </li></ul><ul><li>Ankylosing spondylitis </li></ul><ul><li>Reiter’s disease </li></ul><ul><li>Crystal arthropathies </li></ul>
  4. 4. Rheumatoid Arthritis <ul><li>affects 3% population </li></ul><ul><li>female> male (3:1) </li></ul><ul><li>80% RF </li></ul><ul><li>30% ANF </li></ul><ul><li>HLA DR4 (chr 6) </li></ul>
  5. 5. Rheumatoid Arthritis Pathology <ul><li>Synovitis </li></ul><ul><li>chronic infl, synovial hypertrophy, effusion </li></ul><ul><li>Destruction </li></ul><ul><li>proteolytic enzymes, pannus </li></ul><ul><li>Deformity </li></ul><ul><li>articular destruction, capsular stretching, tendon rupture </li></ul>
  6. 6. Rheumatoid Arthritis extra-articular <ul><li>nodules </li></ul><ul><li>tendon sheath </li></ul><ul><li>vasculitis </li></ul><ul><li>myopathy and neuropathy </li></ul><ul><li>reticulo-endothelial system </li></ul><ul><li>visceral - lungs, heart, kidneys, brain, GI </li></ul>
  7. 7. Rheumatoid Arthritis early symptoms <ul><li>myopathy, tiredness, weight loss, malaise </li></ul><ul><li>proximal finger joints </li></ul><ul><li>wrists, feet, knees, shoulders </li></ul><ul><li>start up pain </li></ul><ul><li>tendon crepitus </li></ul>
  8. 8. Rheumatoid Arthritis early joint changes
  9. 9. Rheumatoid Arthritis late symptoms <ul><li>joint destruction </li></ul><ul><li>pain </li></ul><ul><li>deformity </li></ul><ul><li>instability </li></ul>
  10. 10. Rheumatoid Arthritis advanced joint changes
  11. 11. Rheumatoid Arthritis X-ray findings <ul><li>joint space narrowing </li></ul><ul><li>peri-articular osteopenia </li></ul><ul><li>erosions </li></ul>
  12. 12. <ul><li>stop synovitis </li></ul><ul><li>prevent deformity </li></ul><ul><li>reconstruct </li></ul><ul><li>rehabilitate </li></ul>Rheumatoid Arthritis treatment
  13. 13. Rheumatoid Arthritis prognosis <ul><li>10% improve </li></ul><ul><li>60% intermittent, slowly worsening </li></ul><ul><li>20% severe joint erosion, multiple surgery </li></ul><ul><li>10% completely disabled </li></ul>
  14. 14. Osteoarthritis <ul><li>A chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins (osteophytes) and capsular fibrosis </li></ul>
  15. 15. Osteoarthritis classification <ul><li>Primary or idiopathic </li></ul><ul><li>Secondary - infection </li></ul><ul><ul><ul><ul><ul><li>- dysplasia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- Perthes’ </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- SUFE </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- trauma </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- AVN </li></ul></ul></ul></ul></ul>
  16. 16. Osteoarthritis aetiology <ul><li>Genetic </li></ul><ul><li>metabolic </li></ul><ul><li>hormonal </li></ul><ul><li>mechanical </li></ul><ul><li>ageing </li></ul>
  17. 17. Osteoarthritis mechanism 1 <ul><li>Disparity between:- </li></ul><ul><li>stress applied to articular cartilage </li></ul><ul><li>and </li></ul><ul><li>strength of articular cartilage </li></ul>
  18. 18. Osteoarthritis mechanism 2 <ul><li>Increased stress (F/A) </li></ul><ul><li>increased load eg BW or activity </li></ul><ul><li>decreased area eg varus knee or dysplastic hip </li></ul>
  19. 19. Osteoarthritis mechanism 3 <ul><li>Weak cartilage </li></ul><ul><li>age </li></ul><ul><li>stiff eg ochronosis </li></ul><ul><li>soft eg inflammation </li></ul><ul><li>abnormal bony support eg AVN </li></ul>
  20. 20. Osteoarthritis X-ray changes <ul><li>joint space narrowing </li></ul><ul><li>subchondral sclerosis </li></ul><ul><li>osteophytes </li></ul><ul><li>cysts </li></ul>
  21. 21. Osteoarthritis X-ray changes
  22. 22. Arthritis symptoms <ul><li>pain </li></ul><ul><li>swelling </li></ul><ul><li>stiffness </li></ul><ul><li>deformity </li></ul><ul><li>instability </li></ul><ul><li>loss of function </li></ul>
  23. 23. Arthritis non-surgical treatment <ul><li>analgesia </li></ul><ul><li>disease modifying drugs (RA) </li></ul><ul><li>altered activity </li></ul><ul><li>walking aids </li></ul><ul><li>physiotherapy </li></ul>
  24. 24. Arthritis surgical treatment <ul><li>arthroscopy </li></ul><ul><li>osteotomy </li></ul><ul><li>arthrodesis </li></ul><ul><li>excision arthroplasty </li></ul><ul><li>replacement arthroplasty </li></ul>
  25. 25. Arthritis knee arthroplasty
  26. 26. Joint Replacement indications <ul><li>Disabling pain </li></ul><ul><li>Functional limitations </li></ul>
  27. 27. Joint Replacement history <ul><li>pain </li></ul><ul><li>function </li></ul><ul><li>medical </li></ul><ul><li>expectations </li></ul>
  28. 28. Joint Replacement history - pain <ul><li>Site </li></ul><ul><li>radiation </li></ul><ul><li>limiting activity </li></ul><ul><li>disturbing sleep </li></ul><ul><li>analgesics </li></ul>
  29. 29. Joint Replacement history - function <ul><li>Walking distance </li></ul><ul><li>walking aids </li></ul><ul><li>low chairs </li></ul><ul><li>foot care </li></ul><ul><li>stairs </li></ul>
  30. 30. Joint Replacement examination <ul><li>gait </li></ul><ul><li>limb alignment </li></ul><ul><li>range of movement </li></ul><ul><li>stability </li></ul><ul><li>peripheral circulation </li></ul><ul><li>skin condition </li></ul>
  31. 31. Joint Replacement investigation <ul><li>X-ray - alignment </li></ul><ul><li>- deformity </li></ul><ul><li>- previous fractures and implants </li></ul><ul><li>- AVN </li></ul><ul><li>- osteophytes </li></ul><ul><li>- bone loss </li></ul><ul><li>CT, MRI, bone scan - rarely </li></ul>
  32. 32. Joint Replacement ideal <ul><li>painless joint </li></ul><ul><li>full range of movement </li></ul><ul><li>stable </li></ul><ul><li>permanent </li></ul>
  33. 33. Joint Replacement hip complications <ul><li>dislocation - 1% </li></ul><ul><li>loosening >90% 10y survival </li></ul><ul><li>DVT / PE </li></ul><ul><li>infection - 1% </li></ul>
  34. 34. Joint Replacement knee complications <ul><li>limited ROM </li></ul><ul><li>patellar instability 3-5% </li></ul><ul><li>loosening > 90% 10y survival </li></ul><ul><li>DVT / PE </li></ul><ul><li>infection - 2% </li></ul>
  35. 35. Ankylosing Spondylitis <ul><li>0.2% of population </li></ul><ul><li>mainly affects spine and SI joints </li></ul><ul><li>male > female </li></ul><ul><li>HLA B27 in 90% </li></ul><ul><li>synovitis </li></ul><ul><li>enthesopathy </li></ul>
  36. 36. Ankylosing Spondylitis hips and knees <ul><li>flexion deformities </li></ul><ul><li>arthritis with large osteophytes </li></ul><ul><li>ankylosis </li></ul>
  37. 37. Ankylosing Spondylitis diagnosis <ul><li>Rome criteria </li></ul><ul><li>A - bilateral SI B - stiff lumbar spine </li></ul><ul><li>- stiff thoracic spine </li></ul><ul><li>A+ 1xB - decreased chest </li></ul><ul><li>or 4xB expansion (<7cm) </li></ul><ul><li>- >3/12 LBP </li></ul><ul><li>- iritis </li></ul>
  38. 38. Ankylosing Spondylitis X-ray changes <ul><li>joint space narrowing </li></ul><ul><li>large osteophytes </li></ul><ul><li>heterotopic bone </li></ul><ul><li>ankylosis </li></ul>

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