monoarticular pain 3. osteoarthritis · monoarticular pain 3. osteoarthritis miss joanna richards...
TRANSCRIPT
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Monoarticular Pain 3. Osteoarthritis
Miss Joanna Richards MBChB BSc MRCS Trauma & Orthopaedic Registrar
Birmingham Orthopaedic Training Programme
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• Lecture 1: Introduction • Lecture 2: Septic Arthritis
• Lecture 3: Osteoarthritis: • Case
– History – Examination – Investigations – Differential diagnosis
• Condition overview • Management • Complications • Risk Factors • Pathophysiology • Comparison with normal joint on ageing
• Lecture 4: Crystal Arthropathies
Module Overview
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Case • PC
– 60 year old lady presents with right knee pain
• HPC
– Occurring most days in the past few months; much worse today
– Gradual onset; worse in the morning with associated stiffness
– Over anterior aspect of knee; worse when going up and down stairs
– Buckling sensation in the right knee
• PMHx
– Nil of note
• SHx
– Landscape gardener
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Examination
• General inspection: – Steady by slow gait; favouring left side
– Increased BMI
• Focused examination: – Look
• Minimal swelling
– Feel • Small effusion with diffuse crepitus; medial joint line
tenderness
– Move • Limited flexion (90)
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Investigations
• Bloods
– FBC, U&Es, CRP, ESR, urate levels
– Blood cultures
• Joint aspiration
– Send for MC&S, urgent gram stain and crystals
• Imaging
– X-ray
– USS
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Osteoarthritis
• Degenerative synovial joint disorder – Failure to maintain homeostatic balance of cartilage
matrix synthesis and degradation
– Progressive loss of articular cartilage
• Commonly affects knees
• Presents with joint pain and stiffness – Typically worse with activity
• Slightly more common in females
• Can be primary or secondary
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Presentation
• History – Symptoms – Standard history of pain such as SOCRATES
• Remember duration of symptoms
– Impact on life- work, activity of daily living
• Examination – Signs – Limb alignment
• Altered mechanical axis
– Remember to examine joint above and below joint in question • Pain can be referred
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Signs and Symptoms
• Symptoms – Pain worsens with activity and results in limitations – Chronic onset – Stiffness on resting; eases gradually on movement
• Signs – Initially none – Swelling with activity – Deformity due to osteophytes – Crepitus – Reduced range of motion – New use of walking aid
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Diagnosis
• Can be made clinically without investigations if a person1
– If 45 years old or over
– Has activity related joint pain
– Has morning joint- stiffness lasting less than 30 minutes
1) Osteoarthritis: care and management in adults; NICE Clinical Guideline (February 2014)
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Imaging
• Radiographs – Need weight bearing films
• Cannot see joint space narrowing on non weight bearing films
– 2 views • Anteroposterior (AP) and lateral of joint
• Findings – Joint space narrowing – Subchondral sclerosis (thickening) – Osteophyte – Bone cysts
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Preserved joint space
Joint space narrowing
Osteophyte
Subchondral sclerosis
Bone cyst
Image from http://www.mattdriscollmd.com/knee-arthritis-matthew-driscoll-sports-medicine.html (accessed March 2018)
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Describe the Radiographs
Patient ID: 12345678 DoB 12/03/1945 10/09/2017
AP Lateral
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Patient ID: 12345678 DoB 12/03/1945 10/09/2017
AP Lateral
AP and lateral weight-bearing radiographs of the left knee of 73yo Patient 12345678 taken 10/09/2017 showing osteoarthritis indicated by the joint space narrowing (worse on the lateral side), osteophytes associated with the tibia and patella mainly and subchondral sclerosis.
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Management
• Nonoperative (conservative) – Weight loss/ weight management programmes – Physiotherapy/ activity modification programmes – Education – Analgesia
• Paracetamol; NSAIDs
– Joint injections • Steroids, anaesthetic • Can also be useful for diagnosis
• Operative – Arthroscopic debridement – Joint arthroplasty (replacements) or joint fusion – Corrective osteotomies to restore mechanical alignment
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Complications
• Disability
• Immobility
• Chronic pain
• Joint destruction
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Risk Factors • Modifiable
– Articular trauma • Especially with resulting misaligned articular surface
– Occupation and recreational joint stress – Muscle weakness – Large body mass – Increased joint laxity
• Non-modifiable – Gender
• females >males
– Increased age – Genetics – Developmental or acquired deformities
• Hip dysplasia • Slipped upper femoral epiphysis • Legg- Calve- Perthes disease
– See ‘The Limping Child’ talk for more information
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Pathophysiology
• Articular(hyaline) cartilage – Failure of homeostatic balance of cartilage matrix
synthesis and degradation – Increased water content causes proteoglycan
reductions and collagen abnormalities resulting in loss of orientation and organisation
• Synovium and capsule – Becomes inflammed, hypervascular and increasingly
thick as severity increases
• Bone – Subchondral bone remodelling leads to lytic lesions
with sclerotic edges, bone cysts and osteophyte formation
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Comparison of Normal Aging Joint Changes vs Osteoarthritis
Feature Aging Osteoarthritis
Water Content Decreased Increased
Collage Same Disorganised
Proteoglycan content Decreased Decreased
Proteoglycan synthesis Same Increased
Chondrocyte size Increased Same
Chondrocyte number Decreased Same
Modulus of elasticity Increased Decreased
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Summary
• Degenerative disease of synovial joint
• Common chronic disease on advancing age characterised by joint pain on activity and stiffness settling within 30 minutes
• Analgesia, physiotherapy and joint replacement/ fusion surgery
• 4 classic signs on weight bearing radiographs – Joint space narrowing – Subchondral sclerosis – Subchondral cysts – Osteophytes
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References
• BMJ Best Practice (available online at bestpractice.bmj.com; accessed February 2017)
• Oxford Handbook for the Foundation Programme (2nd edition)
• Ritchie Chalmers, C. Parchment Smith, C. MRCS Part A: Essential Revision Notes (book 1) (PasTest 2012)
• www.orthobullets.com
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Thank you!
Presentation available on https://www.bon.ac.uk