A case based discussion of Osteoarthritis

1. ORTHOPAEDICS
PRESENTATION
M O H D A F I Q I F I K R I
M M M C
M a l a y s i a
1

2. N A M E
A G E
A D D R E S S
O C C U P A T I O N
R E G I S T R A T I O N N U M B E R
D A T E O F A D M I S S I O N
D A T E O F E X A M I N A T I O N
PATIENT’S DETAILS
2
C H O N G S I U K A N G
6 7 Y / O
C H E N G M E L A K A
R E T I R E E
1 1 1 7 3 3 0
2 N D N O V E M B E R 2 0 1 6
4 T H N O V E M B E R 2 0 1 6

3. H I S T O R Y

4. C H I E F C O M P L A I N T
 Pain at left knee for 8 years

5. P A T I E N T ’ S
HISTORY OF PRESENTING
ILLNESS
Patient was apparently well 8 years ago when he then develop pain on the
left knee which is insidious in onset. The pain is pricking in nature,
with pain score of 3/10, no radiation, which aggravated by walking and
climbing stairs, and relieved by rest. However, the pain increases to the
score of 7/10 for the past 2 months. This pain is associated with limited
range of movement of the knee. Currently, pain is reduced to 2/10.
He also have similar complaint at her right knee, but it is milder
compared to the left knee. Otherwise, he has no morning stiffness, no
history of trauma or fall, no fever, no knee swelling, giving way, and
locking. 5

6. P A T I E N T ’ S
HISTORY OF PRESENTING
ILLNESS
He is able to ambulate without walking aid and use walking frame if there is
pain.
There’s no other joint involvement.
Intra-articular injection to the left knee was done one time in September
2015, the pain was partially relieved. However, the pain came back after 7
months.
He was currently admitted for left TKR surgery.
6

7. PAST MEDICAL HISTORY
• Hypertension for 8 years
• T. Amlodipine 10mg OD
• No Diabetes Mellitus, ischemic heart disease, tuberculosis,
bronchial asthma
01.
FAMILY HISTORY
• His father has hypertension.
• No family history of arthritis, malignancy, diabetes mellitus,
ischemic heart disease.
03.
PAST SURGICAL HISTORY
• No significant past surgical history
02.
PERSONAL HISTORY
• Sleep does not disturbed
• No loss of appetite and loss of weight
• Normal bowel and bladder habit
• Non smoker, non alcoholic
• No known drug or food allergy
04.
7
SOCIOECONOMIC HISTORY
• married and blessed with 5 children
• Live with his wife and son.
• Previously work as a hard labor in construction yard for 10
years
• He is financially stable. – supported by his son
05.

8. P A T I E N T ’ S
PROVISIONAL
DIAGNOSIS
PRIMARYOSTEOARTHRITISOF THELEFTKNEE
• 67 years old obese patient
• Pain at left knee for 8 years (long duration) with similar complaint
at the right knee
• work as a hard labor in construction yard for 10 years
• No history of trauma or fall
• No fever, inflammation of the knee
8

9. PHYSICAL EXAMINATIONS
This includes general and local examination, of which consist of look, feel, move and measure and not
forget the special tests.
P R I M A R Y O S T E O A R T H R I T I S O F T H E L E F T K N E E

10. P A T I E N T ’ S
GENERAL EXAMINATION
• Patient is lying comfortably in semi-recumbent position, alert and cooperative. She is
moderately built and well nourished.
• BMI : 31.4 (Obese)
• Vital signs were stable:
I. PR: 70 bpm, regular rhythm, normal volume and character
II. BP: 145/92 mmHg
III. RR: 18 breaths/min
IV. Temperature : 37 ºC
• There is no pallor, no pedal edema.
SYSTEMIC EXAMINATION
10
• Cardiovascular system, Respiratory system and Abdominal examination were all normal.

11. P A T I E N T ’ S
LOCAL EXAMINATION
STANDING POSITION
• ANTERIOR
• Both hip extended and adducted, knee and ankle at neutral position.
• There is genu varus deformity of the left leg
• There is muscle wasting at the left thigh and left calf
• There is apparent shortening of the left lower limb
• There is no scars, no swelling
• LATERAL
• There is no deformity, scars, swelling
• POSTERIOR
• There is no swelling on the popliteal fossa, no scars.
• GAIT
• Antalgic gait
LOOK
11

12. P A T I E N T ’ S
LOCAL EXAMINATION
SUPINE POSITION
• ANTERIOR
• Attitude
 Hips: Both are flexed at 30˚
 Knees: Both are flexed at 5º
 Ankles: Both are at neutral position.
• There is muscle wasting at the left thigh and left calf
• There is apparent shortening of the left lower limb
• There is no deformity of the left leg
• There is no scars, no swelling
• LATERAL
• There is no deformity, scars, swelling
LOOK
12

13. P A T I E N T ’ S
LOCAL EXAMINATION
• There’s local rise in temperature
• There’s tenderness over the medial joint line of left knee
• Crepitus is felt upon moving the left knee joint
FEEL
13

14. MOVEMENT
KNEE JOINT
RIGHT
LEFT
*Crepitus was felt and heard upon moving the left knee joint
Movement Right (active) Right (passive)
Extension 0˚ 0˚
Flexion 0˚-110˚ 0˚-110˚
Movement Left (active) Active (passive)
Extension 0˚ 0˚
Flexion 0˚-90˚ 0˚-90˚

15. MEASUREMENT
Measurement Right (cm) Left (cm)
Apparent length 104 102
True length 85 84
Segmental
Length
Above knee 44 44
Below knee 41 40

16. P A T I E N T ’ S
NEUROVASCULAR EXAMINATION
Peripheral pulse : CRT <2s, distal pulsations felt on both sides (dorsalis pedis
artery and posterior tibial artery)
16
P A T I E N T ’ S
NEUROLOGICAL EXAMINATION
• Sensory examination is intact on both sides of the lower limb
• Motor examination : Patient able to dorsiflexion and plantarflexion for left
ankle joint.

17. P A T I E N T ’ S
SPECIAL TESTS
• Varus stress test : Positive
• Valgus stress test : Negative
• Patellar grinding test : Positive
• Patellar tap: Negative
• McMurray test: could not elicit due to pain
17

18. P A T I E N T ’ S
X-RAY
18
02/11/2016
AP VIEW
• Narrowing of medial joint
space
• Subchondral sclerosis
• Osteophytes
LATERAL VIEW
• Narrowing of patellar space
• Subchondral sclerosis

19. I N V E S T I G A T I O N S
FULL BLOOD COUNT
19
Hb 127 g/L 120.0-150.0
RBC 4.44 10^12/L 3.80-4.80
HCT 38.3 % 36.0-46.0
MCV 86 fL 83-101
MCH 28.7 pg 27.0-32.0
MCHC 33.2 g/dL 31.5-34.5
RDW-SD 40.3 fL 37.0-46.0
RDW-CV 13.2 % 11.6-14.0
Platelets 236 10^9/L 150-410

20. 20
WBC 8.1 10^9/L 4.0-10.0
Lymphocytes # 2.8 10^3/uL 1.0-3.0
Neutrophil # 4.2 10^3/uL 2.0-7.0
Monocytes # 0.8 10^3/uL 0.2-1.0
Eosinophil # 0.2 10^3/uL 0.0-0.5
Basophil # 0.1 10^3/uL 0.0-0.1
Lymphocytes % 34.6 % 20.0-40.0
Neutrophil % 52.3 % 40.0-80.0
Monocytes % 10.4 % 2.0-10.0
Eosinophil % 1.9 % 1.0-6.0
Basophil % 0.8 % <1-2

21. 21
ESR : 45 mm/hr (0-12)
CRP : 7.2 mg/l (<5.0)

22. Primary osteoarthritis of left knee with genu varus
deformity
DIAGNOSIS
22

23. T H U S F A R …
TREATMENT
TREATMENT IN HOSPITAL
• Analgesics
• Planned for left total knee replacement
23

24. DISCUSSION
o s t e o a r t h r i t i s

25. 25
D I S C U S S I O N
OSTEOARTRITIS
DEFINITION
Chronic disorder of synovial joints in which there is
progressive softening and disintegration of articular
cartilage and bone at the joint margins (osteophytes),
cyst formation and subchondral sclerosis, mild synovitis
and capsular fibrosis.

26. PRIMARY
• Occurs in a joint de novo
• Occurs in old age
• Mainly in weight bearing joints (knee and
hip)
• More common than secondary OA
26
TYPES OF OSTEOARTHRITIS
D I S C U S S I O N
SECONDARY
• There is underlying primary disease of the
joint → degeneration of the joint, often
many years later
• May occur at any age after adolescence
• Commonly at the hip

27. O S T E O A R T H R I T I S
INVESTIGATIONS
OA is typically diagnosed on the basis of clinical and radiographic
evidence. No specific lab abnormalities are associated with OA.
27
IMAGING
• X-ray
I. Narrowing of the joint
space
II. Subchondral sclerosis
III.Marginal osteophytes
IV. Subchondral cyst
V. Bone remodelling
RADIONUCLIDE
SCANNING
• Scanning with 99mTc-HDP
shows increased activity
during the bone phase in
the subchondral regions
CT and MRI
• To elucidate specific
problem : bone edema, AVN

28. O S T E O A R T H R I T I S
INVESTIGATIONS
OA is typically diagnosed on the basis of clinical and radiographic
evidence. No specific lab abnormalities are associated with OA.
28
Serological tests and ESR to rule out rheumatoid arthritis.
Serum uric acid to rule out gout.
Arthroscopy : if a loose body or frayed meniscus is suspected.

29. O S T E O A R T H R I T I S
TREATMENT
PRINCIPLES OF TREATMENT
• Delay the occurrence
• Stall progress of the disease and relieve the
symptoms
• To rehabilitate the patient

30. O S T E O A R T R I T I S
TREATMENT
The goals of osteoarthritis treatment include alleviation of
pain and improvement of functional status. Optimally, pt
should receive a combination on non-pharmacologic and
pharmacologic treatment.
NON-PHARMACOLOGICAL
• Patient education
• Thermotherapy
• Weight loss
• Exercise
• Physical therapy
• Unloading in certain joints (eg, knee,
hip)
30
PHARMACOLOGICAL
• Acetaminophen
• Oral NSAIDs
• Topical NSAIDs
• Tramadol
• Intra articular injections

31. T R E A T M E N T
SURGICAL
Although osteoarthritis tends to be chronic, the symptoms are rarely
progressive and rarely require surgery on the painful spinal joints.
31
• Joint debridement
• Osteotomy
• Partial Knee Replacement Surgery
(Unicompartmental Knee Arthroplasty)
• Total Knee Replacement Surgery (Total Knee
Arthroplasty)

32. 32

33. INDICATIONS
• relief of significant disabling
pain caused by severe arthritis
• Correction of severe deformity
33
TOTAL KNEE REPLACEMENT SURGERY
S U R G E R Y

34. 34
TOTAL KNEE REPLACEMENT SURGERY
S U R G E R Y
CONTRAINDICATIONS
• Knee sepsis
• A remote source of ongoing infection
• Extensor mechanism dysfunction
• Severe vascular disease
• Recurvatum deformity secondary to muscular weakness
• Presence of a well-functioning knee arthrodesis
ABSOLUTE CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS
• Skin conditions within the field of surgery (eg, psoriasis)
• Past history of osteomyelitis around the knee
• Neuropathic joint
• Obesity

35. 35

36. 36
TOTAL KNEE REPLACEMENT SURGERY
S U R G E R Y
COMPLICATIONS OF TKR
• Infection
• Deep vein thrombosis
• Common peroneal nerve palsy
• Fractures
• Extensor mechanism complications
• Knee stiffness

37. REFERENCES
37
1) Apley’s System of Orthopaedics and Fractures 9th edition
2) Maheshwari and Mhaskar Essential Orthopaedics 4th edition
3) Raediopaedia.org
4) Osteoarthritis: care and management. NICE guidelines Published
date: February 2014
T H A N K Y O U