DEGENERATIF_BEDAH_DASAR osteoarthritis .PPT

degenrative

1. PRABEDAH / RIO / 2006 1
Degenerative
Disorder of
Bone and Joints
Department of Orthopaedic and Traumatology
Medical Faculty Airlangga University /
Dr.Soetomo General Hospital
Surabaya.

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What is degenerative disorder ?
a : progressive deterioration of
physical characters from a level
representing the norm of earlier
generations or forms
b : deterioration of a tissue or an organ
in which its function is diminished
or its structure is impaired
Merriam Webster dictionary

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Painful Knees
Osteoarthritis
Rheumatoid
Trauma
Others

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OA referred to
•Degenerative arthritis
•Osteoarthrosis
•Degenerative joint disease
•Hypertrophic arthritis

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Background
•Osteoarthritis (OA) is a chronic,
degenerative disorder of multifactorial
aetiology, characterised by loss of articular
cartilage and periarticular bone remodelling.
•OA is the most common form of progressive
joint disease

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Background…
•Age is the strongest determinant of OA.
–OA affects 25-30% of persons aged 45-64
years,
–60% of persons older than 65 years, and
–affects more than 80% of persons older than 75
years.

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Pattern of joint
involvement in
osteoarthritis.

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Causes
•Primary OA is idiopathic
•Secondary OA:
–Previous trauma (ie, posttraumatic OA)
–Infection
–Crystal deposition
–Previous rheumatoid arthritis (ie, burnt-out
rheumatoid arthritis)

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The viscious cycle of degenerative arthritis
MECHANICAL
OR
CHEMICAL INJURY
PROTEOGLYCAN
DEPLETION
LOSS OF
ELASTICITY
MECHANICAL
STRESS
FIBRILLATION
ENZYME
RELEASE
ENZYME
RELEASE
SYNOVITIS
CELL DEATH &
PROTEOGLYCAN
DEBRISE

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Cytokines – joint inflammation
IL-1
(from synoviocytes, chondrocytes,
neutrophils, monocytes, etc)
CHONDROCYTES
Stromelysin (L)
Collagenase (L)
Stromelysin (A)
Collagenase (A)
Plasmin (A)
Plasminogen
(from serum &
synovial fluid)
Proteoglycan
Matrix
Protein
Collagen
MATRIX
Inhibitor Activator (L) Latent Enzyme (A) Active Enzyme Activation Inhibition Proteolytic Action
TIMP
PAI-1
TPA

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PATHOGENESIS
Changed chondrocyte
function/release of
destructive enzyme
Mechahnical
stress
Alteration of
proteoglycan
matrix
Alteration of
collagen matrix
Symptomatic OA
Cartilage
destruction
Mineralization
Cartilage changes
Synovial
Inflammation
Genetic
Predisposition
Multiple
aetiological factors

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Diagnosing OA
 History
 Signs & Symptoms
 Radiology
 Laboratory findings

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Symptoms characteristic of
osteoarthritis
Pain
Deep, aching, poorly localized
Early, pain with use; later, pain at rest
Stiffness
Localized to involved joints
Rarely exceeds 15 to 30 minutes’ duration
Related to weather change
Crepitus, crackling
Limitation of joint motion
Giving way of weight-bearing joints

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Signs of osteoarthritis
Tenderness on palpation
May involve widely separated areas of the joint
Pain on passive motion
Crepitus, crunching on joint motion
Joint enlargement---due to
Cartliage and bone proliferative spur formation, or
Synovitis with acute flares or after prolonged disease
Limitation of motion--due to
Joint surface incongruity
Muscle spasm and contracture
Mechanical block (osteophytes, loose bodies)
Deformity, subluxation (seen late)--due to
Cartilage loss
Subchondral bone collapse
Bone cysts
Bony overgrowth
Muscle artophy
Rarely, ankylosis

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Anatomy of Normal Knee

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Tibia Femoral
Angle
Genu Varum
and
Flexion Contracture

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Radiology (Twersky)
1. Narrowing joint space + subchondral bone sclerosis
2. Altered shape of bone ends
3. Cystic formation
4. Osteophyte
5. Periarticular calcification
6. Mal alignment
Mild OA : any 2 of these findings
Moderate OA : any 3 of these findings
Severe OA : any 4 of these findings

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Radiographic changes on OA

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Relationship between radiologic evidence of osteoarthritis
of the knee and clinical manifestations by age group
(Modified from Lawrence et al, 1966)

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Laboratory
Primary OA
No specific findings
ESR ?
C-reactive protein ?
Secondary OA
Specific lab.studies
Synovial fluid

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Main factors in pathogenesis according to osteoarthritis location
Intrinsic factors extrinsic factors
Age SexHeredity Obesity mation trauma DisturbancesAngulation
Inflam- MechanicalDysplasia or
Fingers : Distal + ++ ++
Interphalangeal joints
and nodal generalized
OA
Finger : Proximal + + ++
interphalangeal joints
and non-nodal
generalized OA
First carpometacarpal joint + + +
First metatarsophalangeal (+)
joint
Hip (+) ++
Knee (+) + + + ++
Shoulder (+) + +
Ankle +
Wrist +
From Peyron JG : Semin Arthritis Rheum 8 : 288-306, 1979

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Management of Arthritis
Surgical option usually considered after
failure of conservative management
or
As a primary option in selected patients
Patient’s & Surgeon’s expectation has changed

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Surgical Treatment-The
Options!
Normal cartilage Osteoarthritic cartilage

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•Synovectomy
•Debridement
•Osteotomy
•Total joint replacement
Surgical Management

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Non arthroplasty- Osteotomy
Pre - Op Post - Op

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In normal knee :
mechanical ~ anatomical axis
WB point : medial plateau+2 cm
WB distribution :
70% medial plateau
30% lateral plateau

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•
Correction osteotomy
To correct :
–Mal alignment
–Mal biomechanic
–Mal distribution of load
–Mal stress on cartilage

Realignment by osteotomy

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Pre – Op X-Ray Both Knee
Up Right Weight Bearing Position

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Bilateral Varus Knee ( AP view)

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Bilateral Varus Knee ( Lateral view )

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Post Operative HTO in
Bilateral Knee

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Valgus Knee
Mal Alignment

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Total Knee Replacement

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Intra Operative

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PRE-OP
POST-OP

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Evaluation – 7 years POD
PRE-OP
POST-OP

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18 y.o 65 y.o

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Spondylolisthesis
Spondylos = spina, Olisthenein = to slip
Forward slip of the spine
Mostly occur between L4-L5 or L5-S1

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Degenerative spondylolisthesis
Incidence
- male: female = 1:5
- after age 40
Etiology
disc and facets degeneration
Pain
- local
- claudicatio
- sciatica

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Clinical picture
Symptoms
Pain :
- LBP
- sciatica
Physical exam.
degree of slip and L-S kyphosis
--> physical manifest

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Local palpation
Leg raising -- m.paraspinal spasm
forward flexion – m.hamstring spasm
slip > 50% :
- L-S kyphosis
- trunk shortening
- hyperlordosis Th-L
- body’s center of gravity
To stand erect :
- trunk
- hip & knee

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62 yrs. Man. L4 spondylolisthesis / radiculopathy, LBP
L3/4
L4/5
3
5
3
4
4

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OSTEOARTHRITIS

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Degenerative lumbar
diseases are quite
common pathology in
orthopedic field.

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L5/S1 Hernia at shoulder

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52 yrs. Man. L5 spondylolysis / rt-radiculopathy, LBP
5
4
L5/S
L4/5

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Facet osteoarthritis
•3 times more common in women
•Each degree of increased extension leads to
4% increase in peak pressure
•X-ray changes of OA not easily seen
•Facet joints small unlike the knee

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Spinal stenosis
•Narrowing of the spinal canal causing
mechanical compression of spinal cord or
nerve roots.
•Congenital or degenerative stenosis
•Central or root canal stenosis
•Thickened ligamentum flavum, osteophyte
•Critical spinal canal size

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Causes
•Unknown

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Pathology
Phase
ROM
Pain

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Civilization….. Brought to you by the human thumb
• The thumb has become the power digit
“The thumb presents the last and best proof that the principles of adaptation which
evinces design in creation”
- Sir Charles Bell

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Clinical Features
•1/3 woman over 40 will have x-
ray changes
•Pain , CMC joint stiffness
•Tenderness over CMC joint
•‘ Grind ‘ test positive
•Localized or systemic ( RA ,
gout )

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