arthritis- current medical and surgical management · arthritis- current medical and surgical...
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ARTHRITIS- Current Medical and Surgical Management
•
Dr Jacqueline Andrews
Consultant Rheumatologist
Mr George Whitwell and Mr Campbell Maceachern
Consultant Orthopaedic Surgeons
Leeds Teaching Hospitals NHS Trust
May 9th 2016
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What is Arthritis?
• arth - joint
• itis – inflammation
• Arthritis – inflammation of the joint(s).
Types of arthritis- more than 100!
• Non-inflammatory - mainly managed in Primary Care and by Orthopaedic Surgeons
• Inflammatory - mainly managed by Rheumatologists
• Infectious - uncommon
• Haemorrhagic - very uncommon
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INFLAMMATORY ARTHRITIS
• Rheumatoid Arthritis (RA)
• Juvenile Idiopathic Arthritis (JIA)
• Spondyloarthropathies (SpA)
• Crystal deposition disease
Ankylosing SpondylitisPsoriatic ArthritisEnteropathic Arthritis- IBDReactive Arthritis
GoutCPPD disease (Pseudogout)
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RHEUMATOID ARTHRITIS
• 1% of population
• Females > Males
• Most common during child-bearing years
• Tiredness, weight loss,
• Pain and swelling of joints
• Early morning stiffness
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5
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1. Stop the Inflammation- prevent damage:
• Traditional disease modifying agents
– Methotrexate, Sulphasalazine, Hydroxycholorquine, Leflunomide
• Biologics- target individual molecules involved in inflammation pathways
– Anti “tumour necrosis factor” (TNF) drugs: adalimumab, certolizumab, etanercept, infliximab.
– Other biologics target different proteins: abatacept, rituximab, tocilizumab
2. Rehabilitation and prevent co-morbidities:
Occupational therapy, Physiotherapy, Podiatry, Psychology
Annual review- cardiovascular risk, bone health, immunisation check etc
3. Reconstruct –surgery increasingly uncommon
RA - TREATMENT
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SPONDYLOARTHROPATHIES (SpA)
1. Ankylosing Spondylitis
2. Psoriatic
3. Enteropathic (IBD)
4. Reactive Arthritis
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Diagnostic Testing
Share common features:
• Joint, back and eye inflammation, rashes, digestive disorders
• Associated with the HLA B27 gene
• no diagnostic laboratory testing
• But some typical X-Ray appearances – eg “pencil in cup” appearance
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Ankylosing Spondylitis (AS)
• Causes inflammation and eventually fusion of the spine and the spinal joints.
• Involvement of peripheral joints and eye also common.
• Causes pain, stiffness and decreased spinal mobility
• Incidence ranges from 0.1 to 1 percent of population
– Men are affected 3 X more than women
– Commonly develops age 15 to 40
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Management of AS
Education
Exercise
Physiotherapy
Rehabilitation
NSAIDs
Peripheral
disease
Spinal
disease
Sulfasalazine
TNF blockers
A
n
a
l
g
e
s
i
c
s
Local corticosteroids
S
u
r
g
e
r
y
Zochling J, et al. Ann Rheum Dis.
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Psoriatic Arthritis
Likely in up to 25-34% of patients with psoriasis
Incidence in population around 1%
Males =Females
Peak age of onset between 30-55 years
“enthesitis” (inflammation at site of tendon insertion)
“tenosynovitis” (inflammation of tendon and its enveloping sheath)
“dactylitis “ (“sausage digit”)
Treatment:
- Methotrexate very effective for skin and joints
- Biologics increasingly used in severe disease
- New oral treatment - Apremilast
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CRYSTAL DEPOSITION DISEASES
GOUT
• Disorder of purine metabolism
• Leads to deposits of urate crystals in joint and surrounding tissues “tophi”
• 2 Types: – Primary (95%): inherited disorder with overproduction or under excretion of
urate
– Secondary (5%): due to underlying medical condition (blood or kidney disorder)
• 20 times more common in men than women
• Foot, ankles, hands, wrists and elbows most commonly affected
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GOUT- treatment
Acute Attacks:- treat quickly!
• Indomethacin and other anti-inflammatories (NSAIDS)
• Colchicine
• Steroids- tablets, injections
Chronic disorder:
• Adjust diet (low purine)
• Drugs- Allopurinol, Colchicine
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PSEUDOGOUT- aka CPPD disease
• Caused by inflammation due to deposits of calcium pyrophosphate dihydrate (CPPD) crystal- mimics gout
• More common in later life and if suffer from Osteoarthritis
• Most often affects the knee and the wrists
• X-rays show calcium deposits in cartilage andsurrounding tissues
• Treatment- similar to gout
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Rheumatology at Leeds Teaching Hospitals NHS Trust
• EULAR (European Rheumatology Society) Centre of Excellence in Rheumatology since 2005
• Chapel Allerton Hospital facilities
– Ward C2 - 20 bed ward shared with Dermatology
– Day Care Unit C5 - 5,00 patient visits per year-new extended hours
– Outpatient Suite - 35,000 patient visits per year
– Others - Physiotherapy (hydrotherapy), Occupational Therapy
Podiatry, Research Facilities
• St James’s University Hospital:
– Inpatient beds
– Outpatient Clinics
• Wharfedale Hospital:
– Outpatient Clinics
• 24 hour 7 day on-call medical service
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Rheumatology Research at Leeds
• The Leeds Musculoskeletal Biomedical Research Unit (LMBRU) is an NIHR funded centre of excellence for musculoskeletal research, established in 2008
• A partnership collaboration between the Leeds Teaching Hospital Trust and the University of Leeds which has led to:
– developing and trialling new treatments (especially Biologic agents) for Inflammatory Arthritis
– blood tests to aid the early diagnosis of Rheumatoid Arthritis
– new imaging methods to diagnose arthritic conditions earlier and more accurately
• Research –it’s important- how you can get involved!
– LMBRU Patient and Public Involvement Group
– Established 2009 > 120 active members
– THANK YOU
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Hip and Knee
Osteoarthritis
Mr Campbell Maceachern
Mr George Whitwell
Consultant Orthopaedic Surgeons
Chapel Allerton hospital Leeds
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Chapel Allerton Orthopaedic Centre
• Opened 12 Years ago
• 9 joint replacement surgeons
• 4 Specialist Orthopaedic Theatres
• 1400 hip and knee joint replacements per year
• Dedicated outpatient suite with pre-assessment clinics
• Dedicated multidisciplinary teams
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NON - INFLAMMATORY ARTHRITIS
OSTEOARTHRITIS
Osteoarthritis, is also known as osteoarthrosis or degenerative joint disease
Progressive disorder of the joints caused by gradual loss of cartilage resulting in pain and
reduced function.
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Types of Osteoarthritis
• Primary / Idiopathic (most common)
• Secondary
– Trauma
– Infection, Rheumatoid, Gout
– Vascular
– Neuropathy
– Haemophilia
– Metabolic
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What Causes Primary Osteoarthritis
• Ageing?– Undeniably related– Why do some 90 year olds not have it?
• Overuse– Related to job – manual labourers– Obesity– (Secondary – due to recurrent microtrauma)
• Genetic– Increasing evidence of genetic component– Tends to run in families
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• Pain – Worse on movement and at end of day
• Stiffness – Stiff after rest, but improves with movement
• A grating or grinding sensation
• Swelling – The swelling may be hard (bone spurs) or soft (extra fluid)
• Reduced Function
– Feeling of instability
– Reduced range of movement
– Less Strength
Symptoms of Osteoarthritis
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• Very common
• 8.5 million people in UK symptomatic
• True incidence far higher (>80% in over 70s)
• Women > Men
• Increasing with ageing population
How Common is it?
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• History
• Xrays
• Magnetic Resonance Imaging
– Rapidly evolving technology
Diagnosis Osteoarthritis
• Mr Whitwell
– Early treatment
– Hip Replacements
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Conservative Treatment
Physiotherapy and exercise regimes
• Increase muscle strength and tone
• Increase joint movement
• Improve stability
• Postural advice
• Improve general fitness
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Conservative treatment
Weight loss -
- Activity modification
May 9th 2016
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Medical treatment
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Medical Treatment
• Injections
– Steroids
– Hyaluronic acid ?
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Arthroscopy
May 9th 2016
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Arthroscopy
May 9th 2016
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Knee Arthroscopy
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Microfracture Debridement Chondroplasty
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Hip replacements
• First performed 1960’s
• 60,000 performed annually in UK
• Over 90% last patients lifetime
• “Operation of the century”
• All UK operations are now entered on NJR
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Hip replacements
• Spinal anesthetic
• Average hospital stay 3.5 days
• Patients walking around day of surgery
• Complication rates < 1%
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Hip Replacements
May 9th 2016
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Hip replacement
May 9th 2016
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Hip Replacements
May 9th 2016
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Hip Replacements
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Surgical Treatment of Knee Arthritis
– When non-surgical and minimally invasive techniques fail to relieve symptoms
– Consider Joint Replacement
• Partial Knee Replacement
• Total Knee Replacement
– Pain is severe
– Function and quality of life is significantly impaired
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Consider previous Xray
demonstrating Arthritis
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Partial Unicompartmental Knee Replacement
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Partial Knee Replacement
• Benefits
• Feels like native knee
• Very good function
• Faster recovery
• “Forgotten Surgery”
• Drawbacks
• Remainder of knee remains susceptible to arthritis
• 2.5% of all patients will require revision to full knee replacement 7-10 years later
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Total Knee Replacement
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Total Knee Replacement
• Benefits
• Very good at reducing pain and improving daily function
• Pain significantly reduced in 90% of patients
• Drawbacks
• Often doesn’t feel like native knee
• Kneeling can be difficult in 50% of patients
• Mechanical joints can wear out
– May need a revision procedure
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Total Knee Replacement - Advancements
• Templating
• Import x-rays computer interface
• Allows accurate measurements
– Ensure precise fitting implants
• Custom Patient-Specific Technology
• Using MRI or CT
• Very precise custom jigs are 3D printed
• Used during the operation for precise implant placement
• Very useful for grossly abnormal anatomy
Knee MRI
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