CASE REPORT

O S T E A RT H R I T I S K N E E
By:
Raja Muhammad Syafiq C 111 1 3 8 4 1
Mohamad Farhan C 111 1 3 8 2 7
Shaliza Hussin C 111 1 3 8 4 3
Zulfatul Ain C 111 1 3 8 6 0
Nur Baeti C 111 1 2 8 4 3

Advising residents:
d r. S t e f a n A . G . P / d r. M a r c e l W i j a y a

Supervisor:
d r. A n d r y U s m a n , P h . D , S p . O T ( K )
Department of Orthopaedic dan Traumatology
Faculty of Medicine Hasanuddin University
Makassar
2018
PATIENT IDENTITY
Name : Mrs. WA
Gender : Female
Age : 87 Years old
Date of Birth : December 31st 1931
Medical Record : 789425
Admitted on : July 28th 2018
HISTORY TAKING

Chief Complaint : Pain on the left knee

• A 87 years old female came with chief complaint pain on the left
knee since 9 months ago before admitted to Wahidin Sudirohusodo
General Hospital. The pain was aggravated by walking or standing
for long time and relieved by resting. She was able to ambulate
without walking aid. There is no morning stiffness. No history of
trauma or fall. No fever. Normal bowel and bladder habit.
HISTORY TAKING

• Medical history:
– There is history of hypertension (consumed Amlodipine 5mg 1 tab daily)
– There is no history of Diabetes Mellitus and Cardiovascular disease
• Past surgical history:
– Operation on the right knee in January 2018 with the similar complaint
• Personal History:
– Non smoker
– Non alcoholic
GENERAL STATUS
• Conscious / Well-nourished
• BMI : 20 kg/m2
• Vital Sign :
Blood pressure : 140/90 mmHg
Pulse : 88 x/menit
Respiratory rate : 20 x/menit
Temperature : 36.70C (axilla)
NRS : 3/10
LOCALIZED STATUS :
REGIO KNEE

Look : Deformity(+), hematoma (-), swelling (-), wound (-), scar (-)
Feel : Tenderness (+), warmness (+)
Move : Active-passive movement of knee joint are restricted due to pain and
reduce range of motion.
NVD : Sensibility good, dorsalis pedis artery and tibialis posterior artery are
palpable, CRT <2 seconds
CLINICAL FINDINGS

Anterior Region Posterior Region

CLINICAL FINDINGS

Medial Left Region Lateral Left Region

RADIOLOGY FINDING
X-ray knee joint AP/lateral

Interpretations:
• There is no fracture, lesser bone density
• Cartilage is hard to evaluate
• There is soft tissue swelling
• There is joint space narrowing
• There are subchondral sclerotic and
osteophyte formation
LABORATORY FINDINGS
DATE : 12.07.2018
Jenis Pemeriksaan Hasil Nilai rujukan Jenis Pemeriksaan Hasil Nilai rujukan

WBC 7,38 x103/uL 4 - 10 x 103/uL LED I 39 mm

L <10 mm
RBC 3,83x106/uL 4 - 6 x 106/uL
LED JAM II 64 mm
HGB 10,5 g/dl 12 - 16 g/dl

HCT 33,6 % 37 - 48 %

MCV 87,7 fl 80 – 97 fl

MCH 27,4 pg 26,5 – 33,5 pg

MCHC 27,4 g/dl 31,5 - 35 g/dl

PLT 247 x 103/uL 150 - 400 x 103/uL

NEUT 4,52 x 103/uL 52.0 - 75,0

LYMPH 1,99 103/uL 20,0 - 40,0

MONO 0,58 103/uL 2,00 - 8,00 x 103/uL

EOS 0,23 103/uL 1,00 - 3,00 x 103/uL

BASO 0.1 x 103/uL 0,00 - 0,10 x 103/uL

ASSESMENT

LEFT KNEE OSTEOARTHRITIS GRADE IV

MANAGEMENT
P H A R M AC L O G Y A N D
N O N P H A R M AC O L O G Y PLANNING

• Activity modification and low-level exercise

• Weight loss, use of a cane • Total Left knee
• NSAIDs and COX-2 inhibitors
• Corticosteroid injections for short-term release Arthroplasty
• Hyaluronic acid injections
• Intravenous Fluid Drips Ringer Lactate 20
tetes menit
• Amlodipin 5 mg / 24 jam/ oral
• Vicillin 1500mg/ 8 jam/ intravena
• Ketorolac 30mg/ 8 jam/ intravena
• Ranitidin 50mg/ 8 jam/ intravena
DISCUSSION
DEFINITION

• Chronic disorder of synovial joints in which there is progressive

softening and disintegration of articular cartilage accompanied by
new growth of cartilage and bone at the joint margins
(osteophyte),cyst formation and sclerosis in the subchondral bone,
mild synovitis and capsular fibrosis.

Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
• Autopsy studies show OA changes in everyone over age of 65 years
• Radiographic surveys shows increment of 1% below the age of 30 years to over
50% In people above the age of 60
• OA of the finger joints is particularly common in elderly women, affecting more
than 70% of those over 70 years
• men and women are equally likely to develop OA, but more joints affected in
women than men
• Female to male ratio for OA of the hip is about 1:1 in northen Europe but near
to 2:1 in southern Europe where there is high incidence of acetabular dysplasia
in girls.

Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
ANATOMY KNEE

Miller M. D, Thompson S. R. Disorder of Knee and Foot, Osteoarthritis : Miller’s Review of Orthopaedics, 7th ed, Elsevier. 2016
Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
 Miller M. D, Thompson S. R. Disorder of Knee and Foot, Osteoarthritis : Miller’s Review of Orthopaedics, 7th ed, Elsevier. 2016
Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
ETIOLOGY

Secondary
Primay
• Idiopathic • Genetic
• Trauma • Anatomical abnormality
• Inflammatory disorders

Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
CLINICAL FINDINGS
Symptoms Signs
Pain Joint swelling

Stiffness Muscle wasting

Swelling Deformity

Deformity Local tenderness

Loss of function Limited movement

Crepitus

Instability

Function in everyday activities must be assessed

Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
CLASSIFICATION
KELLGREN-LAWRENCE GRADING SCALE

Grade 1 (Doubtful)
- Minimal
- Equivocal osteophytes are observed at the medial
joint margin

Hiyashi D., Guermazi A. Imaging for Osteoarthritis, Annals Of Physical And Rehabilitation
Medicine Vol 59 : Elsevier. 2015
• Grade 2 ( Mild)
– Presence of at least one definite marginal osteophyte
– Without evidence of joint space narrowing

Hiyashi D., Guermazi A. Imaging for Osteoarthritis, Annals Of Physical And Rehabilitation
Medicine Vol 59 : Elsevier. 2015
• Grade 3 (Moderate)
– Moderate joint space narrowing
– Marginal osteophyte
– Some sclerosis and possible joint deformity

Hiyashi D., Guermazi A. Imaging for Osteoarthritis, Annals Of Physical And Rehabilitation
Medicine Vol 59 : Elsevier. 2015
• Grade 4 (Severe)
– Bone to bone contact
– Complete obliteration of joint space
– Severe Subchondral Sclerosis
– Definite joint deformity

Hiyashi D., Guermazi A. Imaging for Osteoarthritis, Annals Of Physical And Rehabilitation
Medicine Vol 59 : Elsevier. 2015
STAGE 1
STAGE 2
STAGE 3
STAGE 4
DIAGNOSTIC OSTEOARTHRITIS

History taking Physical examination Radiographs

• Patients complain of dull, • Tenderness to palpation at • Loss of joint space,
achy pain at the involved the joint surface, with loss subchondral sclerosis and
joint, usually worse with of ROM, and pain with cysts, osteophyte
activity passive ROM formation

Miller M. D, Thompson S. R. Disorder of Knee and Foot, Osteoarthritis : Miller’s Review of Orthopaedics, 7th ed, Elsevier. 2016.
DIAGNOSTIC (HISTORY)
• History taking

Age : Patients usually present after middle age

Sex : Men and women are equally likely to develop OA, but more joints are affected in
women than in men
Occupation : There is good evidence of an association between OA and certain
occupations which cause repetitive stress
Body Mass Index : Obesity causes increased joint loading

Complain : Patients complain of dull, achy pain at the involved joint, usually worse with
activity
Joint involvement : One or two of the weightbearing joints (hip or knee), on the
interphalangeal joints (especially in women)
History : A family history is common in patients with polyarticular OA

Miller M. D, Thompson S. R. Disorder of Knee and Foot, Osteoarthritis : Miller’s Review of Orthopaedics, 7th ed, Elsevier. 2016
Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
DIAGNOSTIC (PHYSICAL EXAMINATION)
• Look
– Deformity
– Swelling
– Muscle wasting
• Feel
– Tenderness to palpation at the joint
surface
– Crepitus
• ROM
– with loss of ROM, and pain with passive
ROM
• NVD
Varus deformity of the right knee
– Sensibility good due to osteoarthritis
Miller M. D, Thompson S. R. Disorder of Knee and Foot, Osteoarthritis : Miller’s Review of Orthopaedics, 7th ed, Elsevier. 2016.
Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
DIAGNOSTIC (RADIOGRAPHS)
Radiographs show varying severity of joint
space narrowing and osteophyte formation

- Loss of joint space, subchondral sclerosis

and cysts, osteophyte formation

THE CARDINAL SIGNS OF OSTEOARTHRITIS

Narrowing of
Subchondral Marginal Subchondral
the ‘joint
sclerosis osteophytes cysts
space’

Miller M. D, Thompson S. R. Disorder of Knee and Foot, Osteoarthritis : Miller’s Review of Orthopaedics, 7th ed, Elsevier. 2016.
Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
DIAGNOSTIC (RADIOGRAPHS)

X-ray Radionuclide CT and MRI

scanning

Solomon L, Warwick D, Nayagam S. Osteoarthritis : Apley’s System of Orthopaedics and Fracture. 9th ed, London : Hodder Education. 2010.
DIAGNOSTIC
• Normal radiographs, stiff on examination
Grade 0
• Mild dorsal osteophyte, joint space preserved, mild pain at extremes of ROM
Grade I
Grade II
• Moderate osteophyte formation, joint space narrowing (<50%), moderate pain
with ROM that may be more constant

Grade III
• Severe osteophyte formation, substantial joint space narrowing (>50%),
significant stiffness with pain at extreme ROM but not at midrange

Grade IV
• Same as III but with pain at midrange of passive motion

Miller M. D, Thompson S. R. Disorder of Knee and Foot, Osteoarthritis : Miller’s Review of Orthopaedics, 7th ed, Elsevier. 2016.
 DIFFERENSIAL DIAGNOSIS
Feature OA RA Gout Spondyloarthritis

Onset Gradual Gradual Acute Variable

Inflammation - + + +

Pathology Degeneration Pannus Microtophi Enthesitis

# of joints Poly Poly Mono to poly Oligo or poly

Type of joints Small or large Small Small or large large

Location typically involved
Special articular findings
Bone changes
Hips, knees, spine, 1st CMC
DIP, PIP
Bouchard’s nodes
Heberden’s nodes
Osteophytes
MC, PIP wrists feet, ankles MTP feet, ankles knees Sacroiliac spine large
peripheral
Ulnar dev, swan neck Urate crystals En bloc spine enthesopathy
boutonnière (eg.Achilles)
Osteopenia erosions Erosions Erosions ankylosis

Extra-articular feature SC nodules pulmonary Tophi olec. Bursitis renal Uveitis conjungtivitis aortic
cardiac splenomegaly stones insuff. Psoriasis IBD
Lab data Normal + RF, anti-CCP ↑UA

Sabatin, M. S., 2011, Pocket Medicine, 4th Ed. Lippincott Williams & Walkins, A. Wolters Kluwer
PATHOPHYSIOLOGY
Damage at the
more weight
Osteophytosis
bearing articular
• OA is primarily disease of cartilage cartilage
• The exact initiating factor for
Osteoarthritis is not known
• The equilibrium between anabolism Changes in
Synovitis
Subcondral bone
and catabolism is weighted in favor of
degradation
• The disruption of collagen network 
hyperhydration and reduces stiffness
Thickening of the
of cartilage joint capsule
PATHOPHYSIOLOGY
MECHANISM OF DEGRADATION

Trauma, degenaration of tissues, othe risk factors  activation of macrophages  releases

of inflammatory cytokines

IL-1B, 1L-6, TNF a & VEGF, E-selectin

Combination of these products  promote infllamtory cells requirtment : T cells &

Neutrophils
 CYTOKINES

Cytokines  activate
osteocytes  osteoblast
Cytokines+ T cells will Proteases cause the
(to compensate the
stimulate sinovium to degradation of protein
degradation) by causes
produce Proteases (Cartilage)
subchondral sclerosis 
osteophytes
MEDICAL TREATMENT

Activity Weight loss, use NSAIDs and Corticosteroid Hyaluronic acid

modification of a cane COX-2 injections for injections:
and low-level inhibitors short-term controversial
exercise release and expensive
 SURGICAL TREATMENT
•Refer immediately to orthopedic surgeon on:
• Patients with severe clinical symptoms of OA, persistent or painful symptoms gained weight after
receiving the appropriate standard treatment with recommendations both non-pharmacologically and
pharmacologically (failed conventional therapy).
• Patients who experience progressive complaints and disrupt activity physical everyday.
• Pain complaints interfere with the patient's quality of life.
• Varus or valgus deformity (> 15 to 20 degrees) in knee OA.
• Subluxation of lateral ligament or dislocation.
• Severe mechanical symptoms (walking disorder / giving way, knee locked / locked, unable to squat /
inability to squat): sign the presence of joint structural abnormalities.
• Knee replacement: full knee replacement surgery, medial unicompartmental, patellofemoral and rarely
lateral unicompartmental) in patients with: Painful joints at night are very disturbing, Severe joint
stiffness, Disrupt the daily physical activity.

Textbook of essential orthopaedics. 5th Ed. Chapter 35: Osteoarthritis. The health sciences
publisher.
 SURGICAL TREATMENT
Joint
Osteotomy
replacement

Joint Arthroscopy
debridement Procedure

Ronn Karolin et All. Review article: current surgical treatment of the knee osteoarthritis.Vol 10.
department of Orthology Surgery. Switzerland. 2011
PROGNOSIS

• Depends on the joints involved and severity

• Pharmacology treatment only directed to symptoms relief
• Patient who have urdergoing joint replacement have a good prognosis, with success rate for
knee and hip arthroplasty generally more than 90%
THANK YOU