Ankylosing spondylitisRheumatoid arthritis

Osteoarthritis

Anish MohanDr. Mahesh

ANKYLOSING SPONDYLITIS

Inflammatory disorder

Primarily affects the axial skeleton

Peripheral joints and extra-articular structures may also be involved

Idiopathic

Rheumatoid factor absent

HLA-B27 present in > 90% cases

Disease usually begins in the second or third decade.

M:F= 3:1

PATHOGENESIS Immune mediated.

In some cases, the disease occurs in these predisposed people after exposure to bowel or urinary tract infections.

? Autoimmunity to the cartilage proteoglycan aggrecan.

PATHOLOGY The site of ligamentous attachment to bone, is

thought to be the primary site of pathology

Associated with prominent edema of the adjacent bone marrow and is often characterized by erosive lesions that eventually undergo ossification.

Sacroiliitis is usually one of the earliest manifestations.

The early lesions consist of subchondral granulation tissue, infiltrates of lymphocytes and macrophages in ligamentous and periosteal zones, and subchondral bone marrow edema.

Synovitis follows and may progress to pannus formation with islands of new bone formation.

The eroded joint margins are gradually replaced by fibrocartilage regeneration and then by ossification.

Ultimately, the joint may be totally obliterated.

8

The outer annular fibers are eroded and eventually replaced by bone → bony syndesmophytes, which then grows by continued enchondral ossification, ultimately bridging the adjacent vertebral bodies = “bamboo spine”.

PRESENTATION Variable

From intermittent episodes of back pain that occur throughout life to a severe chronic disease.

Attacks the spine, peripheral joints and other body organs, resulting in severe joint and back stiffness, loss of motion and deformity as life progresses.

EXTRASKELETAL MANIFESTATION Most common is acute anterior uveitis- typically unilateral, causing pain,

photophobia, and increased lacrimation. Cataracts and secondary glaucoma are also seen. Inflammation in the colon or ileum. Aortic insufficiency. Third-degree heart block. Subclinical pulmonary lesions. Slowly progressive upper pulmonary lobe fibrosis. Retroperitoneal fibrosis. Prostatitis.

LAB. TESTS HLA B27: present in ≈ 90% of patients.

ESR and CRP – often elevated.

Mild anemia.

Elevated serum IgA levels.

ALP & CPK raised.

TREATMENT1. Regular physical therapy 2. NSAIDS Indomethacin (up to maximum of 50 mg PO tid)

COX-2 inhibitors3. Sulfasalazine, in doses of 2 to 3 g/d- Effective for axial and peripheral arthritis4. Methotrexate, in doses of 10 to 25 mg/wk- primarily for peripheral arthritis 5. Local Corticosteroids injection- for persistent synovitis and enthesopathy 6. Medications to avoid-

Long term Systemic Corticosteroids, gold and Penicillamine 7. Anti-TNF-α therapy - heralded a revolution in the management of AS. Infliximab (chimeric human/mouse anti-TNF-α monoclonal antibody) Etanercept (soluble p75 TNF-α receptor–IgG fusion protein) have shown rapid, profound, and sustained reductions in all clinical and

laboratory measures of disease activity. 8. Pamidronate, thalidomide, α-emitting isotope 224Ra9. Most common indication for surgery - severe hip joint arthritis, total hip

arthroplasty.

Anaesthetic considerations A thorough pre-operative assessment is essential to evaluate the severity of

the disease, in particular airway involvement and the extra-articular manifestations of the disease.

Peri-operative neurological deficits should be documented.

The range of movement of all joints should be assessed to plan optimal positioning of the patient.

The extent of pre-operative investigations depends on the severity of the disease and these include echocardiography, lung function tests, imaging of the cervical spine and arterial blood gas analysis.

In view of the potential for conduction defects, a pre-operative ECG is mandatory.

An echocardiogram is required to assess the severity of valvular disease associated with AS.

There is no clear consensus regarding the management of anti-TNF-α blockers in the peri-operative period.

Airway management Difficult intubation is associated with AS involving the cervical spine and can

be compounded further when the temporomandibular joint is involved. Neck movements in extension and flexion should be assessed.

There is significant risk of neurological injury with any excessive neck extension in patients with chronic cervical kyphosis.

Neck extension can cause vertebra basilar insufficiency as a result of bony encroachment on the vertebral artery.

Injuries to the cervical spine and spinal cord such as dislocation of C6 vertebra and quadriparesis after an emergency intubation have been reported

Fixed cervical flexion deformities limit access to the trachea and tracheostomy may be impossible.

Neck supports should be used during anaesthesia and forcible movements of the neck in the presence of neuromuscular blockade avoided.

Awake fibreoptic intubation is the safest option, especially in those patients where it is not possible to visualise the larynx on indirect laryngoscopy or those with severe chin on chest deformity

Retrograde intubation may also be considered.

Regional or local anaesthesia Spinal and epidural anaesthesia is technically difficult and may

result in an increased risk of complications.

The placement of epidural anaesthesia is technically difficult and is associated with an increased risk of an epidural haematoma.

The epidural space is narrow in AS patients and local anaesthetic solutions should be administered slowly in small doses to avoid total spinal anaesthesia.

Postoperative management Precautions regarding patient positioning and neck movement

at emergence from anaesthesia.

Physiotherapy, breathing exercises and early mobilisation should be instituted because patients are at increased risk of respiratory complications.

The effects of fluid shifts and the effects of medications on peri-operative fluid balance should be monitored.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease ofunknown etiology.

Anesthetic risks in osteoarticular disorders involve, besides mechanical deformations from the disease, the cardiovascular, respiratory, renal, and digestive systems.

PRE-ANESTHETIC ASSESSMENT Rheumatoid arthritis is characterized by destruction of synovial

joints, affecting mainly the small joints including the temporomandibular joint and spine joints.

Proliferation and hypertrophy of synovial cells form a layer that destroys articular cartilage, and cause ankylosis of the articular space with fibrosis and calcification

The presence of deformities may affect patient positioning during surgery, hindering access for regional anesthesia or venous cannulation.

The difficulty in positioning the patient on the operating table can result in regions of the body without adequate support, requiring additional support during anesthesia.

Head and neck involvement in rheumatoid arthritis can result in difficult airways due to the complexity of executing the necessary maneuvers for tracheal intubation.

Evaluate the extension of cervical spine, temporomandibular joint, and cricoarytenoid joint involvement before anesthesia

CERVICAL SPINE Anterior axial subluxation can be diagnosed by X-ray

of the cervical spine.

Limit movements of cervical spine extension and flexion during anesthesia, which might result in difficult, if not impossible, conventional direct laryngoscopy

TEMPOROMADIBULAR JOINT Temporomandibular dysfunction is frequently associated with

cervical fixation, and it shows unilateral or bilateral arthritis, producing limitations in mouth opening.

On upper and lower articular surfaces, fibrosis leading to ankylosis may be seen.

These changes are more common in juvenile rheumatoid arthritis (JRA), frequently associated with hypoplastic mandible.

CRICOARYTENOID DYSFUNCTION Laryngeal involvement can be seen in more than 75% of rheumatoid arthritis

patients. Symptoms are rarely evident, but fixation of the cricoarytenoid joint can

present itself as a foreign body sensation in the oropharynx, dysphagia, dyspnea, hoarseness, stridor, and airways obstruction

Laryngoscopy can reveal a reduction in the movement of cricoarytenoid joint and vocal cords during inspiration.

Postoperative vigilance is necessary with adequate monitors and material to detect possible signs of airways obstruction after removal of oro tracheal tube.

SYSTEMIC DISEASES OF INTEREST TOANESTHESIOLOGISTS

Cardiovascular disease has been the greatest cause of RApatients mortality

Pulmonary manifestations of RA are more common in male, Pleural exudate is usually small and frequently asymptomatic

Restrictive disorders cause secondary limitation of chest wall movements

Subclinical renal dysfunction is commonly seen in rheumatoid arthritis patients.

Treatment Rheumatoid arthritis treatment can be divided into two groups:

Drugs that improve symptoms steroidal and non-steroidal anti-inflammatory agents

Drugs that modify the disease mechanism. antimalarial sulfasalazine penicillin azathioprine methotrexate cyclosporine A

Normal cortical response during surgery can be simulated by intravenous administration of hydrocortisone 100 mg at the time of anesthetic induction

Preoperative assessment Patients with RA may require orthopaedic surgery as part of their treatment

or they may present for other types of surgery unrelated to RA. A thorough preoperative assessment is crucial to assess the extent and

severity of the disease including history and physical examination. In particular, the anaesthetist must assess the range of neck flexion and

extension, TMJ mobility and mouth opening. The range of movement of other joints should be noted so as to optimize

patient position during and after surgery. Preoperative neurological deficits should be documented. Preoperative investigations will depend upon the nature and degree of organ

involvement.

Intraoperative management Vascular access

Vasculitis, thin and fragile skin can render establishment of i.v. access difficult.

Central venous catheters may be difficult to insert because of limited neck movement.

The radial artery may be inaccessible because of flexion deformities of the wrist joint.

Regional or local anaesthesia It may be possible to perform surgery under regional or even local nerve

blockade. In general terms, regional or local anaesthesia should be used wherever

acceptable and possible. Regional or local anaesthesia have the advantages of avoiding both neck and

airway manipulation and also the systemic effects of drugs used for general anaesthesia.

Local anaesthetic nerve blocks can be technically challenging because of loss of anatomical landmarks from contractures and flexion deformities.

Spinal and epidural anaesthesia may be technically difficult or impossible especially in cases where the lumbar and thoracic spines are involved in the disease process.

Managing the airway It may be difficult to insert an LMA if the angle between the oral and

pharyngeal axes at the back of the tongue is less than 90°; a reinforced LMA may be preferable in such circumstances.

If tracheal intubation is indicated, this must be achieved without causing

further injury to a potentially unstable cervical spine.

Manipulation of the neck from the neutral position can lead to neurological deterioration, tetraplegia and even sudden death and thus should be avoided.

The recommended ‘sniffing’ position for laryngoscopy, whereby the head is hyperextended on a flexed neck can result in exacerbation of the anterior atlanto-axial subluxation with resultant neurological injury

Meticulous care should be taken during conventional laryngoscopy and neck manipulation in all patients with RA, even without overt cervical spine instability.

An intubating LMA (ILMA) may be used to achieve blind endotracheal intubation with minimal cervical spine movement.

The poor success rate without the use of fibreoptics and the great amount of force that may be exerted on the posterior wall of the pharynx at C2–C3 make the ILMA less attractive as a primary method of intubation.

Awake fibre optic intubation and positioning of the C-spine is highly recommended.

A surgical tracheostomy performed under local

anaesthesia is another method of securing the airway of patients with cricoarytenoid involvement.

Potential difficulties with this method include the presence of an extreme fixed flexion deformity with little or no access to the trachea, tracheal deviation and patient distress.

Other important factors Positioning of the patient should be meticulous and all pressure areas padded

to avoid pressure sores.

Methylcellulose eye drops should be applied as up to 15% of patients with RA suffer from kerato-conjunctivitis sicca and are at risk of corneal ulceration.

Full aseptic technique for establishing i.v. access, epidural/spinal blocks, arterial and CVP-line and urinary catheter is mandatory as these patients may be at increased risk of infections from immunosuppressive drug treatment.

Long-term steroid therapy causes adrenal suppression and patients taking an equivalent dose greater than prednisolone 10 mg daily require steroid cover.

Blood glucose concentrations should be monitored

closely and controlled with insulin if necessary.

Patients taking steroids and NSAIDs are at risk of developing gastro-intestinal tract bleeding and should receive gastric acid prophylaxis.

PHARMACOLOGY

Pharmacology modified as the result of changes in plasma protein concentration or renal dysfunction in rheumatoid arthritis patients.

Reduction in serum protein levels and increased in alpha-1-glycoprotein (AAG) may change the free fraction of drugs.

Net results of the effects depend on the original protein binding of drugs

Binding can be exaggerated in the presence of hypoalbuminemia.

Drugs with high AAG affinity (verapamil, metoclopramide, propranolol) may have a decreased free fraction and, as a result, a reduction in its therapeutic effects.

This can be an advantage when considering local anesthetics

Dose and frequency of drug administration should be carefully titrated to avoid toxic effects.

In the postoperative period the objective is to provide effectiveanalgesia, minimize the risk of respiratory failure, and abbreviate the immobilization period.

Rheumatoid arthritis patients are more sensitive to drugs, andare more predispose to develop respiratory depression.

If considered appropriate, analgesia with opioids should be

carefullytitrated.

The association of obstructive apnea with temporomandibular joint destruction, mandibular hypoplasia, and other type of non-complicated rheumatoid arthritis may increase the susceptibility of patients to the effects of opioid-induced respiratory depression.

Continuous peripheral nerve or lumbar plexus block for the lower limb surgeries are also used as an alternative to continuous analgesia.

A restrictive disorder predisposes patients to hypoventilation, atelectasis, pulmonary infection, and hypoxemia, especially when the diaphragm is fixed due to pain, obesity, or bandages.

Immunosuppressive agents can lead more susceptible patients to develop pulmonary infections.

Fixation of the spine can leave the patient bedridden, making thoracic physiotherapy more difficult.

Osteoarthritis

Definition Osteoarthritis, sometimes called degenerative joint disease or

osteoarthrosis, is the most common form of arthritis. Osteoarthritis occurs when cartilage in the joints wears down over time.

Osteoarthritis can affect any joint in the body, though it most commonly affects joints in hands, hips, knees and spine. Osteoarthritis typically affects just one joint, though in some cases, such as with finger arthritis, several joints can be affected.

Osteoarthritis gradually worsens with time, and no cure exists. But osteoarthritis treatments can relieve pain and help you to remain active. Taking steps to actively manage osteoarthritis may help patient gain control over his osteoarthritis pain.

Risk Factors

Older age. Osteoarthritis typically occurs in older adults. People under 40 rarely experience osteoarthritis.

Sex. Women are more likely to develop osteoarthritis.

Bone deformities. Some people are born with malformed joints or defective cartilage, which can

increase the risk of osteoarthritis.

Joint injuries. Injuries, such as those that occur when playing sports or from an accident, may

increase the risk of osteoarthritis.

Obesity. Carrying more body weight places more stress on weight-bearing joints, such as

knees. But obesity has also been linked to an increased risk of osteoarthritis in the hands,

as well.

Other diseases that affect the bones and joints. Bone and joint diseases that increase the risk of osteoarthritis include gout,

rheumatoid arthritis, Paget's disease of bone and septic arthritis.

OSTEOARTHRITIS-SYMPTOMS

PAIN- Presenting symptom, starts insidiously, relieved by rest, later continuous

STIFFNESS- after inactivity

SWELLING- intermittent or continuous

LOSS OF FUNCTION- limp, stairs difficult, walking distance reduced

DEFORMITY- capsular fracture

Osteoarthritis symptoms most commonly affect the hands, hips, knees and spine.

Unless one has been injured or placed unusual stress on a joint, it's uncommon for osteoarthritis symptoms to affect jaw, shoulder, elbows, wrists or ankles

DIAGNOSIS•X-RAY •Narrowing of joint space,• subchondral sclerosis, • articular cysts,• osteophytes

JOINTS INVOLVED IN OSTEOARTHRITIS

KneesHipsNeck & backBig toesHandsElbowShoulder

ANAESTHETIC PROBLEMS THAT MAY ARISE IN OA

REDUCED JOINT MOVEMENT

AIRWAY MANAGEMENT

DIFFICULTY IN SPINAL OR EPIDURAL

DIFFICULTY IN POSITIONING

CONCURRENT ANALGESIC THERAPY

TREATMENT OF OSTEOARTHRITIS EARLY TREATMENT PHYSIOTHERAPY, LOAD REDUCTION, ANALGESICS LATE TREATMENT USUALLY OPERATIVE INDICATIONS

Progressive increase in painSevere restriction of activitiesMarked deformityLoss of movementJoint destruction

SURGICAL OPTIONS Joint Debridement, Cartilage graft, realignment osteotomy, arthrodesis and

total hip replacement

Surgery for osteoarthritis Surgery is generally reserved for severe osteoarthritis that isn't relieved by

other treatments. Surgical treatments include:

Joint replacement. In joint replacement surgery (arthroplasty), surgeon removes damaged joint

surfaces and replaces them with plastic and metal devices called prostheses. Joint replacement surgery carries a small risk of infection and bleeding. Artificial joints can wear or come loose, and may need to eventually be replaced.

Debridement

Useful in cases with a locking sensation from a torn cartilage or loose debris Debridement is typically done arthroscopically,

Realigning bones

Surgery to realign bones may relieve pain. These types of procedures are typically used when joint replacement

surgery isn't an option. During a procedure called an osteotomy, the surgeon cuts across the bone

either above or below the knee to realign the leg.

Fusing bones

Surgeons can permanently fuse bones in a joint (arthrodesis) to increase stability and reduce pain.

The fused joint, such as an ankle, can then bear weight without pain, but has no flexibility.

Anaesthetic technique Regional anaesthesia is probably the technique of choice

because it: Reduces blood loss Decreases bleeding at the operative site, improves cement

bonding and decreases surgical time Decreases the incidence of DVT and pulmonary embolus in hip

and knee arthroplasty.

Sedation is often desirable because of the duration of the operation, intraoperative noise and patient request.

Intermittent midazolam, titrated in 1 mg increments, may be used

A target-controlled infusion of propofol, 0.5–2 µg/ml, which gives smoother, more titratable sedation.

Oxygen should be administered throughout the operative period.

As sedation deepens, airway obstruction or snoring may occur. This is seldom a problem in the lateral position, but some supine

patients may require a nasopharyngeal airway.

General Anaesthesia: If general anesthesia is indicated, bleeding may

be reduced by modest hypotension in carefully selected patients, using volatile agents.

Unless there is a risk of aspiration, spontaneous ventilation with a laryngeal mask airway is usually appropriate

Intraoperative problems Patient position:

In the lateral position, there is a risk of excessive lateral neck flexion and pressure on the dependent limbs.

Hypothermia:

Orthopedic theatres are often colder than other theatres, with a higher velocity airflow leading to more rapid patient cooling.

Hypothermia may cause poor wound healing

Blood loss

Average blood loss in total hip replacement ranges from 300 to 1500 ml and may double in the first 24 hours postoperatively.

During knee replacement surgery with an intraoperative tourniquet, most blood loss occurs in the recovery area.

Careful fluid balance is essential because compensation for hypovolemia is poor in the elderly.

Cement reactions: Prostheses may be cemented in place.

Drop in blood pressure and oxygen saturation at time of cementing

Thought to be caused by a directly toxic effect of the methyl methacrylate monomer component of the cement

But now known to be caused by a shower of micro emboli of blood, fat or platelets forced into the circulation by high intramedullary pressure during cement packing and prosthesis insertion.

Subsequent embolization to the lungs produces a raised pulmonary vascular resistance and reduction in left ventricular return, resulting in hypotension.

The micro emboli are toxic to the lung parenchyma causing hemorrhage, alveolar collapse and hypoxia.

This may be severe enough to cause cardiovascular collapse, cardiac arrest and death.

Reactions are more common and more severe in bilateral joint replacements and also in under-resuscitated patients; therefore it is vital to ensure that the patient is not hypovolemic before cementing.

Fractional inspired oxygen concentration may have to be increased.

Cement reactions tend to be less common in knee replacement.

Thromboembolism Thromboembolism is common after joint replacement.

DVTs are more common following knee replacements than hip replacements.

Following knee replacement, most DVTs are distal calf thromboses with a low risk of pulmonary embolus.

In hip replacement surgery, extremes of movement at the hip and kinking of

vessels lead to endothelial damage and blood stagnation.

These thromboses tend to be of proximal veins with a higher risk of pulmonary embolus..

The use of a regional technique, low-molecular-weight heparin, graduated compression stockings or pneumatic compression boots decreases the risk of DVT.

Intraoperative low dose intravenous heparin reduces the incidence of DVT without increased bleeding but is not commonly used.

A combination of the above techniques provides the best protection and the anaesthetist should ensure that the local thromboprophylaxis protocol has been followed

Tourniquet In some patients with cardiac disease the increase in systemic vascular

resistance when the tourniquet is inflated has precipitated left ventricular failure.

More of a problem occurs on releasing the tourniquet, when the acidic

byproducts of metabolism are washed out of the limb causing hypotension secondary to vasodilatation and the effects of acidosis on cardiac contractility.

In knee replacement surgery, as the duration of the operation increases, tourniquet pain can become a problem.

Additional analgesia or epidural top-up may be required

Postoperative management Analgesia

Epidural analgesia is excellent, particularly in reducing quadriceps muscle spasm following knee replacements.

There is an increased risk of urinary retention and the resulting catheterization may cause a bacteremia, increasing the risk of prosthesis infection.

Intramuscular opiates may also be considered. NSAIDs should be used with caution especially in the elderly owing to the

increased risk of renal impairment.

Fluid balance: Stringent fluid balance monitoring is mandatory because

blood loss may double in the first 24 hours. Nausea may reduce the patient’s oral intake.

Oxygen: Perioperative ischemia is common and generally silent. Oxygen should be given for the first 72 hours postoperatively

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