Osteoarthritis and Rheumatoid Arthritis

Presented By Siti Nur Rifhan Kamaruddin

Osteoarthritis : Definition

• A chronic joint disorder in which there a progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins and capsular fibrosis.

CAUSES

• The most obvious feature of OA: it increases with age. – shows that it takes many years to develop.

• OA results from disparity between stress applied to articular cartilage and the ability of the cartilage to withstand cartilage

• Due to combination of 2 processes: - Genetic defect in Type II collagen - Increased mechanical stress in the articular

surface (from excessive impact load or reduced articular contact area)

RISK FACTORS • Older Age - Osteoarthritis typically occurs in older adults. People under 40 rarely

experience osteoarthritis. • Sex - Women are more likely to develop osteoarthritis, though it isn't clear why. • 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.

CLINICAL FEATURES• Pt usually presents after middle age• Symptoms may confined to 1 or 2 large joints or

involves multiple joints. • Pain starts insidiously, increases slowly over

months or years• It is aggravated by exertion and relieved by rest. • Stiffness is worst after period of rest• Unlike Inflammatory Joint Disease ( i.e RA),

Osteoarthritis is not assoc. with systemic manifestations.

Features of Advanced Disease

Swelling Deformity Tenderness Crepitus on movement Muscle wasting

CLINICAL VARIANT OF OA1) Monoarticular & Pauciarticular OA• Classically, presents with pain and dysfunction

in 1 or 2 large weight-bearing joints. • There may be obvious underlying

abnormalities : Acetabular dysplasia, Old Perthes Disease/Slipped Epiphysis, long standing joint deformity, previous fracture.

• In many cases the abnormality is subtle

CLINICAL VARIANT OF OA2) Polyarticular (generalized) OA• Most common form of OA. • Typically, Pt is middle aged woman presents with

pain, swelling, and stiffness of distal finger joints. • The changes are obvious in the hands - Interphalangeal joints become swollen & tender . - Heberden’s Nodes. Knobbly appearance of distal IP joints d/t osteophytes & soft tissues swelling over the years. - Bouchard’s Nodes. Proximal IP Joints

CLINICAL VARIANT OF OA3) OA in Unusual Sites • OA is uncommon in shoulder, elbow, wrist and

ankle. • If any of this joints is affected one should

suspect a previous abnormality (congenital or traumatic) or an associated generalized disease such as crystal antropathy.

TESTS AND DIAGNOSISHistory & Clinical examination· X-rays. X-ray images of the affected joint may reveal a narrowing space within a joint, which indicates that the cartilage is breaking down and bone spurs around a joint. · Blood tests. To rule out other causes of joint pain, such as rheumatoid arthritis. · Joint fluid analysis. To determine if pain is caused by gout or an infection. · Arthroscopy. In some cases ,arthroscopy to see inside the joint in order to determine the cause of pain.

X-RAY CHANGES IN OSTEOARTHRITIS

(Left) In this x-ray of a normal hip, the space between the ball and socket indicates healthy cartilage. (Right) This x-ray of an arthritic hip shows severe loss of joint space and bone spurs.

Bilateral Hip Osteoarthritis – Pelvis radiograph reveals severe bilateral hip osteoarthritis characterized by joint spaced narrowing, cystic changes and severe osseous productive changes and remodeling of the femoral head and acetabulum.

CT-Arthrography shows superior and anterior joint space narrowing (blue circle) with denuded chondral surface (yellow arrow), subchondral cysts and sclerosis. No

femoroacetabular impingement or associated labral tear. Normal mineralization.

(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrows). (Right) This x-ray of an arthritic knee shows severe loss of joint space.

TREATMENTEARLY TREATMENT Aim : Relieve Pain, Increases Movement, Reduce Load.• Pain Relief - Analgesics and NSAIDs • Joint Mobility - Physiotherapy • Load Reduction - Walking stick - Soft-soled shoes - Avoid prolonged, stressful activity - Reduce Weight

TREATMENTINTERMEDIATE TREATMENT Indication: If sx increases despite conservative treatment. This will usually be a “holding” procedure, esp. in younger patients who are not yet ready for joint replacement. • Joint debridement (Knee) - Removal of interfering osteophytes, cartilage tags & loose bodies • Realignment Osteotomy (Hip & Knee) - Provide vascular decompression of subchondral bone redistribution of load forces to less damaged parts.

TREATMENTLATE TREATMENT Joint Replacement • Procedure of Choice for - Patient with severe symptoms - Marked loss of function - Significant restriction of daily activities• Total joint replacement by modern techniques promises improvement lasting for 15 years or longer.

RHEUMATOID ARTHRITIS (RA)

DEFINITION

Rheumatoid Arthritis (RA) is a chronic inflammatory disorder that may affect many tissues and organs, but mainly attacks the joints producing an inflammatory synovitis.

ETIOLOGY• The cause is unknown • It is believed that a foreign antigen sets off a a chain of events culminating in a chronic inflammatory disorder in which immunological reactions are prominent. • Production of auto antibodies (IgM & IgG) that attacks body own’s antibodies • This abnormal immune response may be genetically pre-determined – RA patients assoc with increased frequency of HLA-DR4

PATHOLOGY• STAGE 1: Pre-clinical -Before RA becomes clinically apparent, immune pathology already beginning – Raised ESR, C-reactive protein & Rheumatoid Factor.• STAGE 2 : Synovitis - Synovial membrane inflamed & thickened. Joints & tendon are still intact. • STAGE 3 : Destruction - Persistent inflammation causes joint & tendon destruction - Articular cartilage eroded d/t proteolytic enzymes - Bone eroded by granulation tissue & osteoclastic resorption• STAGE 4 : Deformity - d/t articular destruction,capsule stretching, tendonrupture

CLINICAL FEATURES EARLY STAGE• Swelling, Stiffness, Increased Warmth, Tenderness of proximal finger joints and the wrists• X-ray shows soft tissue swelling and periarticular osteoporosis

DISEASE PROGRESSION• Joint movement becomes restricted • Isolated tendon ruptures at the wrists• Subcutaneous nodule felt Olecranon process – Pathognomonic of RA

Swelling at proximal finger joints and wrists.

LATER STAGES• Joint deformity becomes apparent• Acute pain of synovitis is replaced by more constant ache of joint destruction• “Rheumatoid Deformities”: - Ulnar deviation of fingers - Radial displacement of wrists - Valgus Knees - Clawed Toes• Function is increasingly disturbed. Pt need help

dressing, eating.

EXTRA- ARTICULAR SURFACES(Apparent in pt with severe disease) • Muscle wasting• Lymphadenopathy• Skin atrophy/ulceration• Scleritis• Vasculitis • Peripheral sensory neuropathy

X-RAY CHANGES IN RA

• In Early Stages, X-rays show only the features of synovitis : soft tissue swelling and periarticular osteoporosis

• Later Stages are marked by appearance of marginal body erosions and narrowing of the articular space esp. in proximal joints of hands and feet

• In Advanced Disease, articular destruction and joint deformity are obvious.

TESTS

• X Rays– X rays of hands and feet are generally performed

in people with RA.• Magnetic Resonance Imaging (MRI)• Ultrasounds

• Blood Tests– Rheumatoid Factor (RF)• RF is a specific antibody in the blood.• A negative RF does not rule out RA. The arthritis is then

called seronegative, most common during the first year of illness and converting to seropositive status over time.

– Anti-citrullinated Protein Antibodies (ACPAs)• Like RF, this testing is only positive in a proportion of all

RA cases. • Unlike RF, this test is rarely found positive if RA is NOT

present, giving it a specificity of about 95%.

• At least FOUR criteria MUST be met for classification of RA.– Morning stiffness of more than 1 hour most mornings

for at least 6 weeks.– Arthritis and soft-tissue swelling of more than 3 of 14

joints, present for at least 6 weeks.– Arthritis of the hand joints, present for at least 6 weeks.– Symmetric arthritis, present for at least 6 weeks.– Subcutaneous nodules in specific places.– Rheumatoid Factor at a level above the 95th percentile.– Radiological changes suggestive of joint erosion.

DIAGNOSIS

PROGNOSIS• Disability– Daily living activities are impaired.– After 5 years of disease, approximately 33% of

sufferers can no longer work.– After 10 years of disease, approximately 50% of

sufferers have substantial functional disability.

• Some people have mild or short-term symptoms, but in most cases, the disease is progressive for life.

• The life shortening effect of RA varies. Most sources cite a lifespan reduction of 5 to 10 years

COMPLICATIONS• Infections - Pt with RA, even more so with steroid tx are susceptible to infection. Sudden deterioration or increased pain -> alert for septic arthritis• Tendon Rupture - Seen most often at wrist• Joint Rupture - Occasionally, joint lining ruptures and synovial contents spill into soft tissues. • Secondary Osteoarthritis

TREATMENTThere is NO cure for RA Medical ManagementAim: Control Inflammation as rapidly as possible• Corticosteroids - Rapid action, oral 30mg Prednisolone followed with IM 120mg Methyprednisolone. Tapered dose• DMARDs - 10-25mg /week Methotrexate • NSAIDs - To control pain & stiffness• Biological Therapies (TNF inhibitors: Infliximab)

Physiotherapy and Occupational Therapy

• To maintain muscle tone and joint mobility• Measures: - Balanced programme of exercise - Advice on coping with daily living activities - Preventive splinting - Orthotic devices

Surgical ManagementIndication: Indicated at any stage of disease. Ifconservative measures alone are not effective.Early stage (Soft tissues procedures): • Synovectomy• Tendon repair/replacement• Joint StabilizationLate Stage Indications for Reconstructive Surgery:Severe joint destruction, fixed deformity and loss ofFunction• Antrodesis• Osteotomy• Arthroplasty

• Apley and Solomon’s Concise System of Orthopedics and Trauma 4th Edition. CRC Press

REFERENCES

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