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Arthritis: An Orthopedic

Perspective
Jose Ramon C.Pascual,MD
Fellow Philippine Orthopedic Association
Department of Orthopedics
De La Salle College of Medicine
To review normal joint structure and
function
To identify the different types of
arthritides
To learn how to formulate a management
plan

Objectives
Contents
Joint
with cavity is called a synovial joint
Made up of several types of tissue that
may be involved in disease processes

Normal Joint
Bone
Cartilage
Synovium
Synovial Fluid
Ligaments/tendons and
entheses

Normal Joint
Bone

Normal Joint
Cartilage
◦ Articular cartilage is
primarily hyaline
◦ Avascular and aneural
◦ Loadbearing areas that are
damaged rarely rethicken
and heal

Normal Joint
Synovium
◦ Modified fibroblasts in the
intima produce hyaluronic
acid which passes into the
synovial fluid
◦ Macrophages in the intima
are rich in the receptor
FcgRIIIa which mediates
cytokine release in
response to small immune
complexes

Normal Joint
Synovial Fluid
◦ Syn ovium (like an egg)
◦ Viscosity is due to the
presence of hyaluronan
◦ Hyaluronan helps maintain
a thin layer of lubricin at
the surface of the articular
cartilage

Normal Joint
Ligaments/tendons and
entheses
◦ Entheses are the points at
which the ligaments,
aponeuroses and tendons
are attached to the bone
◦ Entheses are a main
target in a group of
inflammatory disorders
associated with the HLA-
B27 Class I allotype - the
seronegative
spondarthropathies

Normal Joint
Etiology
◦ Disease process of synovial joint characterized
by focal areas of hyaline cartilage loss with
increased activity of marginal and subchondral
bone

Degenerative Joint Disease


Pathophysiology

Degenerative Joint Disease


Clinical Manifestations
◦ Pain

◦ Malfunction

◦ Deformity

Elderly,Repetitive Trauma or Major


Trauma to Joint

Degenerative Joint Disease


Laboratory Findings
Plain Xray
◦ APL: Loss of joint line space, sclerosis, bone
cysts

Degenerative Joint Disease


Laboratory Findings
◦ Weight bearing views of entire lower extremity
: varus / valgus malalignment

Degenerative Joint Disease


Etiology
◦ Chronic, systemic, autoimmune disorder
characterized by progressive damage to the
synovial joints with cartilage and bone loss

Inflammatory Joint Disease


Rheumatoid Arthritis
Pathophysiology

Inflammatory Joint Disease


Rheumatoid Arthritis
Pathophysiology

Inflammatory Joint Disease


Rheumatoid Arthritis
Clinical Manifestations

Inflammatory Joint Disease


Rheumatoid Arthritis
Clinical Manifestations

Inflammatory Joint Disease


Rheumatoid Arthritis
Clinical Manifestations

Inflammatory Joint Disease


Rheumatoid Arthritis
Laboratory Findings
◦ Blood
Rheumatoid Factor
◦ 50% to 68% of patients may have negative RF test
(seronegative) in the first 6 months
◦ Only 85% of RA patients may seroconvert
◦ RF may also be seen in Sjorgen’s syndrome, SLE,
sarcoidosis, cirrhosis and other liver problems

Inflammatory Joint Disease


Rheumatoid Arthritis
Laboratory Findings
◦ Blood
Anti-cyclic citrullinated peptide test
◦ Higher specificity (95%) than RF (85%)
◦ Better marker of progression than RF

Inflammatory Joint Disease


Rheumatoid Arthritis
Laboratory Findings
◦ Xrays
Juxarticular osteopenia
Erosions

Inflammatory Joint Disease


Rheumatoid Arthritis
Etiology
◦ Peripheral arthritis that results from uric acid
crystal deposition in one or more joints
◦ Primary gout
◦ Secondary gout

Crystal Related Arthropathies


Gout
Pathophysiology

Crystal Related Arthropathies


Gout
Clinical Manifestation

Crystal Related Arthropathies


Gout
Laboratory Findings
◦ Blood
Uric acid levels
◦ Hyperuricemia (>7mg/dL)
◦ Hyperuricemia predisposes to clinical gout but is not the
same as clinical gout
◦ Normal uric acid levels in the face of clinical signs of
acute gouty arthritis does not not preclude gout

Crystal Related Arthropathies


Gout
Laboratory Findings
◦ Synovial Fluid
Synovial Fluid Analysis
Disease WBC's Polymorphs
Normal < 200 < 25 %

Traumatic < 5,000 (w/ RBC's) < 25 %

Toxic Synovitis/ Gout 5,000- 15,000 < 25 %

Acute Rheumatic F. 10,000- 15,000 50 %

JRA. 15,000- 80,000 75 %

Septic Arthritis 80,000-200,000 > 75 %

Crystal Related Arthropathies


Gout
Laboratory Findings
◦ Polarized Light Microscopy
Picture 3

Crystal Related Arthropathies


Gout
Laboratory Findings
◦ Xray
Soft tissue swelling
Punched out lesions
Tophi
Joint space narrowing

Crystal Related Arthropathies


Gout
Management
Nonoperative
Nonpharmacologic

Management
Nonoperative
Nonpharmacologic
◦ Dietary Modification for Gout
Food Group Allowed Restricted
Vegetable All except those Asparagus,
restricted cauliflower,
mushroom, spinach
Rice or Substitute Rice, cereals Oatmeal, whole wheat,
whole grain cereals

Meat or Substitute Milk, cheese, meat in Mussels, meat extracts,


brain, internal organs,
allowed amounts lentils, legumes, sardines,
only tahong, tunsoy, tamban,
mackerel, anchovies,
bagoong

Beverages Milk, tea, coffee Alcoholic beverages

Miscellaneous Gelatin, fruits Gravies (sarsa),


meat extracts, patis,
yeast, nuts

Management
Nonoperative
Viscosupplementation

Management
Nonoperative
Debridement/ Synovectomy
Indications
2.Early inflammatory
arthritis without significant
joint destruction
3.Early degenerative joint
disease (i.e. degenerative
meniscal tears with minimal
cartilage damage)

Contraindications
6.Infectious arthritis
7.Extensive destruction of
joint surface

Management
Operative
Corrective Osteotomy
Indications
2.Noninflammatory
arthritis
3.Arthritis or prearthritic
conditions in young
individuals

Contraindications
6.Inflammatory arthritis
7.Infectious arthritis
8.Extensive destruction
of joint surface

Management
Operative
Corrective Osteotomy

Management
Operative
Arthrodesis

Indications
2.Arthritic joints in young patients who plan to
engage in heavy physical activity
3.Failed/ infected arthroplasties

Contraindications
6.Contralateral fused joint

Management
Operative
Arthroplasty
Indications
2.Noninflammatory and
inflammatory arthritis with
severe joint destruction
3.Conversion of ankylosed
joint

Contraindications
6.Post septic arthritis
7.Young patients (relative
contraindication)

Management
Operative
Arthroplasty

Management
Operative
Picture 2

o study the phenomenon of disease without books is to sail


an uncharted sea, while to study books without patients is
not to go to sea at all.

ir William Osler
 Osteoarthritis http://www.emedicine.com/radio/topic492.htm
 Rheumatoid Arthritis
http://www.emedicine.com/pmr/TOPIC124.HTM
 Gout http://www.emedicine.com/Radio/topic313.htm
 Joint Replacement Arthroplasty
http://www.emedicine.com/orthoped/topic347.htm
http://www.emedicine.com/radio/topic830.htm
 Arthroscopy
http://www.wheelessonline.com/ortho/arthroscopy_of_the_knee
 Arthrodesis
http://www.wheelessonline.com/ortho/hip_arthrodesis
http://www.wheelessonline.com/ortho/ankle_arthrodesis
http://www.wheelessonline.com/ortho/knee_arthrodesis
http://www.wheelessonline.com/ortho/wrist_arthrodesis
 Osteotomy http://www.medscape.com/viewarticle/421043
http://www.wheelessonline.com/ortho/high_tibial_osteotomy

References