The document discusses several common rheumatological disorders seen in orthopedic departments, including osteoarthritis, gouty arthritis, calcium pyrophosphate deposition disease, and rheumatoid arthritis. It provides details on the prevalence, clinical features, imaging findings, classifications, and treatment approaches for each condition.

1. Common Rheumatological disorders in Orthopaedics Department of Orthopaedic Surgery Faculty of Medicine Siriraj Hospital Mahidol University

2. Contents Osteoarthritis Gouty Arthritis CPPD Rheumatoid Arthritis

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. Osteoarthritis

5. Heterogeneity of osteoarthritis Monoarthritis Pauciarticular arthritis *affecting large weight-bearing joints Polyarthritis *affecting numerous sites including IP joints of fingers

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. 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. 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. CLINICAL FEATURES General Presentation middle or later years, overweight History 1) Pain : localized or refer pain - according to amount of exertion - exacerbated by movement & weight bearing - relieved by rest (except in advanced stages)

10. CLINICAL FEATURES 2) Stiffness Initially, intermittent < 30 minutes 3) Swelling and deformity Superficial joints (knee or IP joints) * Bowlegs or knock knees

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. CLINICAL FEATURES Examination 1) Disturbance of gait *often noticed first osteoarthritis of the hip or knee *real or apparent shortening of one of lower limbs 2) Swelling and deformity 3) Muscle wasting 4) Tenderness 5) Synovial thickening 6) intra-articular fluid, marginal osteophytes

13. Heberden’s & Bouchard’s node

14. OA HIP

15. OA knee Bowel leg

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. Laboratory Investigations **No reliable diagnostic test Synovial fluid Nonspecific : non- inflammation *increased volume, decreased viscosity *mild pleocytosis, and slight increase in protein

18. General principles of OA treatment Relieving symptoms Maintaining and/or improving functions L imit physical disability Avoiding drug toxicity

19. OA treatment Non pharmacologic therapy Pharmacologic therapy Surgery

20. OA treatment Non pharmacologic therapy P atient education Physical therapy Occupational therapy Weight reduction

21. OA treatment Pharmacologic therapy - Systemic Analgesi c agent non - narcotic analgesic narcotic analgesi c Anti-inflammatory NSAIDS Specific COX 2 inhibitor

22. OA treatment - Local Intraartricular :-C orticosteroid injection :- Viscosupplementation - hyaluronan injection Topical therap y :- Capsaici n :- Tropical NSAIDs

23. Alternative and experimental therapy Glucosamine sulfate C hondroitin sulfate Diacerein Miscellaneous

24. OA treatment Surgery Arthroscopic debridement Osteotomy Unicompartment/Total joint replacement

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. Rheumato / Orthopedic consultation Symptoms not improve Add intraarticular steroid injection Hyaluronate injection disease modifying anti-osteoarthritic drug Surgery

27. GOUT

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. 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. Four stages: 1) Asymptomatic hyperuricemia 2) Acute gouty arthritis 3) Intercritical (or interval) gout 4) Chronic tophaceous gout Spectrum of Gout GOUT

31. M ost : asymptomatic throughout their lifetime Risk of acute gout increases with * serum urate concentration R isk of nephrolithiasis increases with * serum urate level * daily urinary uric acid excretion > 20 years of sustained hyperuricemia - Gout Asymptomatic Hyperuricemia GOUT

32. Acute Gouty arthritis The onset first attack : 40-60 yrs Site : great toe, ankles, knees : wrists, fingers, and elbows : prepatellar or olecranon bursa : Heberden’s nodes Symptom : explosive suddenness, at night : joint becomes hot, dusky red, swollen, tender : systemic signs of inflammation GOUT

33. Acute Gouty arthritis GOUT

34. Definitive diagnosis : aspiration of the joint : intracellular needle-shaped crystals : negative birefringence with compensated polarized light microscopy Acute Gouty arthritis GOUT

35. Acute Gouty arthritis GOUT

36. Acute Gouty arthritis Strongly negative birefringent crystal GOUT

37. Acute Gouty arthritis S ubside several hours to weeks B ecomes asymptomatic (intercritical period) Provocative factors Drugs : anti-hyperuricemic therapy : drug-induced hyperuricemia Infections Trauma, surgery, hemorrhage Alcohol ingestion Dietary excess GOUT

38. Acute Gouty arthritis GOUT

39. Intercritical Gout Second attack within 6 mo - 2 yrs Diagnosis : difficult or inconclusive GOUT

40. Characters * chronic polyarticular gout * without pain-free intercritical periods * average of 11.6 years * severe crippling disease Chronic tophaceous gout GOUT

41. Chronic tophaceous gout GOUT

42. Chronic tophaceous gout

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. Acute Gouty Arthritis Colchicine, NSAID, Corticosteroid Patient cannot take medications by mouth IV colchicine IV glucocorticoids IM corticotropin (ACTH) **** avoid adjust antihyperuricemic drugs **** ****** during an acute attack ******* GOUT

45. Prophylaxis against acute attacks of gout Colchicine 0.6 mg once or twice a day ***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. Control of Hyperuricemia in MSU Deposit Indication: Gout attack > 3 times in 1 year In general, the aim of anti- hyperuricemic therapy Reduce the serum urate < 5.0- 6.0 mg/dl by allopurinol or a uricosuric agent 1.Uricosuric agent Probenecid, Sulfinpyrazone, Benzbromarone * age < 60 years * normal renal function (creatinine clearance greater than 80 ml/minute) * UA excretion < 700 mg/24 hours on a general diet * no history of renal calculi GOUT

47. Indications Gout attack > 3 times in 1 year or positive tophi Uric acid nephropathy Nephrolithiasis Prophylaxis before cytolytic therapy Gout with 1.Intolerance or reduced efficacy of uricosuric agents 2.Renal insufficiency (GFR <60 ml/min) 3.Allergy to uricosuric agent 2.Allopurinol GOUT

48. CPPD Calcium pyrophosphate dihydrate deposition disease

49. CPPD Calcium pyrophosphate dihydrate that deposit in cartilage If crystal released into a joint  acute painful arthritis (Pseudogout) Can appear as chondrocalcinosis in X-ray but other crystals can seen as chondrocalcinosis (calcium hydroxyapatite, calcium oxalate)

50. Prevalence Common in elderly Most studies used radiologic or anatomically defined articular calcification as a marker Prevalence 8% (age 63-93) 15% in age 65-74, 36% in age 75-84 22% in excised cadaver menisci

51. Clinical feature M:F = 1.5:1 Mean age at time of diagnosis = 72 years Feature Pseudogout Pseudo-RA Pseudo-OA

52. Pseudogout Found 25% Acute or subacute arthritis(last 1-28 days) Involve one or few joints Most common in knee joint May severe as gout, longer time to peak intensity Less painful and disabling 20% hyperuricemia, 5% MSU deposit

53. Pseudo-RA Found 5-10 % Subacute attacks (4 weeks-several months) Non-specific symptoms (morning stiffness, fatigue) Large joint common: knee, elbow, ankle But also small joints of hands and feet Synovial thickening, localized pitting edema, limit joint motion, flexion contracture,  ESR Positive RF 10%, 3% RA have calcified cartilage

54. Pseudo-RA Differentiate from RA  1. difference severity of multiple joints 2. asymmetrical involvement 3. osteophyte positive 4. positive chondrocalcinosis 5. no periarticular osteoporosis 6. no bony erosion But CPPD with RA co-exist 1%

55. Pseudo-OA Found 34-50 % Women predominate Most common :knee > wrist >hip, shoulder, elbow, ankle, and spine Chronic joint pain Generally symmetric, with further advanced on one side, flexion contracture 50% episodic attacks, some time severe as gout Concomitant Heberden’s and Bouchard’s nodes

56. Pseudo-OA Differentiate from primary OA  1. severe degenerative change 2. atypical joints: MCP, wrist, elbow, shoulder 3. unilateral or bilateral genu valgus changes 4. isolated patellofemoral OA. 5. Flexion contractures 6. more likely to symmetric than primary OA 7. Radiographs: Chondrocalcinosis and exuberant osteophyte formation

57. Asymptomatic May be the most common clinical presentation Incidental finding from radiograph

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. Radiographic features knee menisci and articular cartilage triangular ligaments of the radiocarpal joint fibrocartilage of the symphysis pubis

62. Synovial fluid findings usually cloudy, WBC 2,000-80,000/mm 3 , 80% PMN with intracellular and extracellular crystals resolving arthritis, the WBC usually <2,000 /mm 3 , MNC>PMN rhomboid or rod-shaped, weakly birefringent crystals with positive elongation cannot exclude other causes of acute or chronic inflammation such as infection, rheumatoid arthritis

63. Treatment Proven Benefits NSAIDs or COX-2 inhibitors Intra- articular steroid Systemic steroids ACTH Prophylactic low-dose colchicine Possible Benefits Hydroxychloroquine Oral magnesium (for pts. With hypomagnesemia) Others Aspiration, removal CPPD crystal Resting the affected joints

64. Rheumatoid Arthritis

65. Rheumatoid arthritis

66. Rheumatoid arthritis

67. Treatment Guideline