disorder of synovial jointsortho.md.chula.ac.th/student/sheet/srihatach/djd 2014 part 1.pdf ·...
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นพ. สหธช งามอโฆษ
ภาควชา ออรโธปดกส
คณะแพทยศาสตร จฬาลงกรณมหาวทยาลย
Some illustrations are from the internet and intended for educational purpose only
Synonym
Osteoarthritis (OA)
Hip osteoarthritis
Knee osteoarthritis
Arthrosis (use in ICD coding)
M 16.0 Coxathrosis
M 17.0 Gonarthorsis
Chronic disorder of SYNOVIAL joints
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Mobile
Adequate range of motion (ROM)
Stable
No subluxation/dislocation
Stability from ligaments/ joint
Painless
Complex extracellular matrix 95%
Water: 65-80%
Collagen 10-20%
Type II 90-95%
Type V, VI, IX, X and XI
Proteoglycans 10-15%
Cellular component 5%
Water Deformation of cartilage surface due to stress
Nutrition
Collagen Framework, tensile strength
Proteoglycans Negative-charged hydrophilic molecule
Compressive strength
Chondrocytes Matrix and collagen production
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Avascular
Nutrients from
Diffusion
Synovial fluid
Aneural
Alymphatic
Chains of glycosaminoglycans (GAGs) attached to a linear core protein
Produced by chondrocyte
Disaccharide polymer
Chondroitin sulfate
Keratan sulfate
Dermatan sulfate
Heparan sulfate
Hyaluronic acid
Load distribution
Minimizing loads on subchondral bone
Reduce friction
Smooth joint motion
Resistance to compressive, tensile, and shear forces
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Very poor
High ratio of matrix/ cellular components
Poor ability of cartilage to repair
Low mitotic activity of chondrocytes
Negligible healing of Hyaline cartilage
May form fibrocartilage (scar) instead
Diminished cellularity
Reduced proteoglycan production
Loss of water & elasticity
Decrease strength
Cartilage breakdown
Osteoarthritis
OSTEOARTHRITIS (OA)
Chronic disorder of SYNOVIAL joints Progressive softening and disintegration
of articular cartilage New growth of bone at the joint margins
(osteophytes) Sclerosis from pressure overload in the
subchondral bone Subchondral cyst formation Mild synovitis and capsular fibrosis
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Progressive destruction of the joints leading to joint dysfunction
Stiffness, decrease motion
Painful
Deformity (angulation/shortening)
Loss of joint stability
Ligament injury, subluxation, dislocation
Localized increase in loading stress
Angular deformity,
malunion of intraarticular fracture
Increased stiffness of the cartilage
Decrease amount of proteoglycans
Inflammatory (enzymatic) degradation
Inflammatory joint disease
Restriction of free joint movement
Decrease nutrient from pumping mechanism
Sclerosis in the subchondral bone
Poorer stress distribution than cancellous bone
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OA: Gross Pathology
Articular cartilage Progressive loss
(joint space narrowing)
Subchondral bone Remodeling,
sclerotic change Bone cysts/
osteophytes formation
OA: Gross Pathology
Ligament
Ligament attenuation
Elongation (convex side)
Synovium and capsule
Thickening
Inflammation (synovitis)
Older age
Female sex
Obesity
Repetitive stress and joint overload
Genetic factors
Major trauma
Prior inflammatory joint disease
Metabolic disorder
Proprioceptive defects
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Symptoms
Stiffness
Initial (morning) stiffness
Pain with movement and activity
Improve with rest
Deformity
Angulation, shortening
Abnormal sound
Signs
Joint swelling
Effusion
Enlargement from osteophyte
Deformity
Angulation, shortening
Localized tenderness
Instability
Ligament laxity
Symptoms and signs Joint pain
Restriction of motion
Crepitus with motion
Joint effusions
Deformity
Instability
Radiography Plain X-ray
Radiographic findings
Subchondral bone changes
Osteophyte
Cyst formation
Sclerosis
Narrowed joint spaces
Deformity
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Joint space narrowing
Subchondral sclerosis
Marginal osteophytes
Subchondral cysts
Bone remodelling
Primary OA or Idiopathic
No identifiable etiology
Some relevant risk factors exist
Secondary OA
Underlying causes
Disease, congenital, trauma
Primary OA
Idiopathic
Strong family history
Alterations in structural macromolecules
Mutations in the type II collagen gene
Progressive wear and tear degenerative condition
Common joints
Knee
Spine
Hip
IPJ of hand
IPJ of foot
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Primary OA: knee OA Spine: Spondylosis
Joints of Spine
Synovial joint
Facet joint
Non-synovial joint
Intervertebral disc
OA: Hip OA: Thumb & Fingers
Thumb
1st Metacarpophalangeal joint
Finger
Interphalangeal joint (DIP>PIP)
Heberden's nodes
Bouchard's nodes
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Secondary OA: Etiology
Intra-articular Fx
High intensity impact joint loading
Ligament injury
Joint dysplasia
Aseptic necrosis
Joint infection
Crystal deposition
Ochronosis
Hemochromatosis
Hemophilia
Acromegaly
Paget’s disease
Ehlers-Danlos syndrome
Gaucher’s disease
Stickler’s syndrome
Neuropathic arthropathy
Secondary OA
Secondary OA
Post-traumatic OA Rheumatoid Arthritis
Goal of treatments Decrease pain
Muscle strengthening
Improve or maintain joint function Activity of daily living
Sports activity
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Activity modification Physical therapy Weight loss Low impact exercise
Medications Analgesics NSAIDs SySADOA (Symtomatic Slow-Acting Drugs
For Osteoarthritis)
Arthrodesis (fusion) Reduce pain, no motion
Joint resection Reduce pain, limited motion, no stability
Realignment osteotomy Correct deformity, maintain motion, joint
unloading
Arthroplasty (joint replacement) Correct deformity, improve motion & stability Concerns of longevity
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Knee Realignment Osteotomy
Degenerative change of synovial joint
Cartilage destruction & loss of joint function
Pain & Stiffness
Progressive joint deformity
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Conservative treatment of OA
Activity modification
Conservative treatment of OA
Conservative treatment of OA
SySADOA
Symptomatic Slow Acting Drug for Osteoarthritis Glucosamine
Chondroitin
Diacerein
Hyalulonic acid injection
Conservative treatment of OA
Intra-articular administration of hyaluronic acid
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Surgical treatment of OA
Arthroscopy
Early symptom
Mild pathology –less deformity
Mechanical causes
Surgical treatment of OA
Realignment osteotomy
Normalizes the biomechanical loads on the involved joint
Surgical treatment of OA
Autogenous chondrocyte
transplantation
Isolated, limited size (2- 7 cm2)
chondral defects
Osteochondral autografts
"mosaicplasty”
Autografts of up to 10 mm is
transferred into prepared defects
Surgical treatment of OA
Knee arthroplasty
Unicompartmental knee arthroplasty
Total knee arthroplasty
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ยาลดการอกเสบในกลมสเตยรอยด แบบฉด
มกใชผสมกบยาชาเพอฉดเขาในขอเขา ประสทธภาพด ราคาถก อาจท าใหเกดการตดเชอในขอได ไมควรใชบอย
แบบเมด มผลขางเคยงสง ไมนยมใชในโรคเขาเสอม
อาจพบใน ยาชด ยาหมอ ยาลกกลอน
Loss of joint stability
Localized increase in loading stress
Increased stiffness of the cartilage
Inflammatory (enzymatic) degradation
Restriction of free joint movement
Sclerosis in the subchondral bone
Primary OA: other joints