Osteoarthritis - Case Based Discussion

A case based discussion of Osteoarthritis

1. ORTHOPAEDICS PRESENTATION MOHD AFIQI FIKRI MMMC Malaysia 1

2. NAME AGE ADDRESS OCCUPATION REGISTRATION NUMBER DATE OF ADMISSION DATE OF EXAMINATION PATIENT’S DETAILS 2 CHONG SIU KANG 67 Y/O CHENG MELAKA RETIREE 1117330 2 ND NOVEMBER 2016 4 TH NOVEMBER 2016

3. HISTORY

4. CHIEF COMPLAINT Pain at left knee for 8 years

5. PATIENT’S HISTORY OF PRESENTING ILLNESS Patient was apparently well 8 years ago when he then develop pain on the left knee which is insidious in onset. The pain is pricking in nature, with pain score of 3/10, no radiation, which aggravated by walking and climbing stairs, and relieved by rest . However, the pain increases to the score of 7/10 for the past 2 months. This pain is associated with limited range of movement of the knee. Currently, pain is reduced to 2/10. H e also have similar complaint at her right knee , but it is milder compared to the left knee. Otherwise , he has no morning stiffness, no history of trauma or fall, no fever, no knee swelling, giving way, and locking. 5

6. PATIENT’S HISTORY OF PRESENTING ILLNESS H e is able to ambulate without walking aid and use walking frame if there is pain. There’s no other joint involvement . Intra-articular injection to the left knee was done one time in September 2015, the pain was partially relieved. However, the pain came back after 7 months . H e was currently admitted for left TKR surgery . Upon admission, x-ray of the left knee was taken, analgesic was given. 6

7. PAST MEDICAL HISTORY Hypertension for 8 years T. Amlodipine 10mg OD No Diabetes Mellitus, ischemic heart disease, tuberculosis, bronchial asthma 01. FAMILY HISTORY His father has hypertension. No family history of arthritis, malignancy, diabetes mellitus, ischemic heart disease. 03. PAST SURGICAL HISTORY No significant past surgical history 02. PERSONAL HISTORY Sleep does not disturbed No loss of appetite and loss of weight Normal bowel and bladder habit Non smoker, non alcoholic No known drug or food allergy 04. 7 SOCIOECONOMIC HISTORY m arried and blessed with 5 children Live with his wife and son. Previously work as a hard labor in construction yard for 10 years H e is financially stable . – supported by his son 5 .

8. PATIENT’S PROVISIONAL DIAGNOSIS PRIMARY OSTEOARTHRITIS OF THE LEFT KNEE 67 years old obese patient Pain at left knee for 8 years (long duration) with similar complaint at the right knee work as a hard labor in construction yard for 10 years No history of trauma or fall No fever, inflammation of the knee 8

9. PHYSICAL EXAMINATIONS This includes general and local examination, of which consist of look, feel, move and measure and not forget the special tests. PRIMARY OSTEOARTHRITIS OF THE LEFT KNEE

10. PATIENT’S GENERAL EXAMINATION Patient is lying comfortably in semi-recumbent position, alert and cooperative. She is moderately built and well nourished. BMI : 31.4 (Obese) Vital signs were stable: PR: 70 bpm, regular rhythm, normal volume and character BP: 145/92 mmHg RR: 18 breaths/min Temperature : 37 ºC There is no pallor, no pedal edema . SYSTEMIC EXAMINATION 10 Cardiovascular system, Respiratory system and Abdominal examination were all normal.

11. PATIENT’S LOCAL EXAMINATION STANDING POSITION ANTERIOR Both hip extended and adducted, knee and ankle at neutral position. There is genu varus deformity of the left leg There is muscle wasting at the left thigh and left calf There is apparent shortening of the left lower limb There is no scars, no swelling LATERAL There is no deformity, scars, swelling POSTERIOR There is no swelling on the popliteal fossa, no scars. GAIT Antalgic gait LOOK 11

12. PATIENT’S LOCAL EXAMINATION SUPINE POSITION ANTERIOR Attitude Hips : Both are flexed at 30˚ Knees : Both are flexed at 5º Ankles : Both are at neutral position. There is muscle wasting at the left thigh and left calf There is apparent shortening of the left lower limb There is no deformity of the left leg There is no scars, no swelling LATERAL There is no deformity, scars, swelling LOOK 12

13. PATIENT’S LOCAL EXAMINATION There’s local rise in temperature There’s tenderness over the medial joint line of left knee Crepitus is felt upon moving the left knee joint FEEL 13

14. MOVEMENT KNEE JOINT RIGHT LEFT * Crepitus was felt and heard upon moving the left knee joint Movement Right (active) Right (passive) Extension 0˚ 0˚ Flexion 0˚-110˚ 0˚-110˚ Movement Left (active) Active (passive) Extension 0˚ 0˚ Flexion 0˚-90˚ 0˚-90˚

15. MEASUREMENT Measurement Right (cm) Left (cm) Apparent length 104 102 True length 85 84 Segmental Length Above knee 44 44 Below knee 41 40

16. PATIENT’S NEUROVASCULAR EXAMINATION Peripheral pulse : CRT <2s, distal pulsations felt on both sides (dorsalis pedis artery and posterior tibial artery) 16 PATIENT’S NEUROLOGICAL EXAMINATION Sensory examination is intact on both sides of the lower limb Motor examination : Patient able to dorsiflexion and plantarflexion for left ankle joint.

17. PATIENT’S SPECIAL TESTS Varus stress test : Positive Valgus stress test : Negative Patellar grinding test : Positive Patellar tap: Negative McMurray test: could not elicit due to pain 17

18. PATIENT’S X-RAY 18 02/11/2016 AP VIEW Narrowing of medial joint space Subchondral sclerosis Osteophytes LATERAL VIEW Narrowing of patellar space Subchondral sclerosis

19. INVESTIGATIONS FULL BLOOD COUNT 19 Hb 127 g/L 120.0-150.0 RBC 4.44 10^12/L 3.80-4.80 HCT 38.3 % 36.0-46.0 MCV 86 fL 83-101 MCH 28.7 pg 27.0-32.0 MCHC 33.2 g/ dL 31.5-34.5 RDW-SD 40.3 fL 37.0-46.0 RDW-CV 13.2 % 11.6-14.0 Platelets 236 10^9/L 150-410

20. 20 WBC 8.1 10^9/L 4.0-10.0 Lymphocytes # 2.8 10^3/ uL 1.0-3.0 Neutrophil # 4.2 10^3/ uL 2.0-7.0 Monocytes # 0.8 10^3/ uL 0.2-1.0 Eosinophil # 0.2 10^3/ uL 0.0-0.5 Basophil # 0.1 10^3/ uL 0.0-0.1 Lymphocytes % 34.6 % 20.0-40.0 Neutrophil % 52.3 % 40.0-80.0 Monocytes % 10.4 % 2.0-10.0 Eosinophil % 1.9 % 1.0-6.0 Basophil % 0.8 % <1-2

21. 21 ESR : 45 mm/ hr ( 0-12) CRP : 7.2 mg/l (<5.0)

22. Primary osteoarthritis of left knee with genu varus deformity DIAGNOSIS 22

23. THUS FAR… TREATMENT TREATMENT IN HOSPITAL Analgesics Planned for left total knee replacement 23

24. DISCUSSION osteoarthritis

25. 25 DISCUSSION OSTEOARTRITIS DEFINITION Chronic disorder of synovial joints in which there is progressive softening and disintegration of articular cartilage and bone at the joint margins (osteophytes), cyst formation and subchondral sclerosis, mild synovitis and capsular fibrosis.

26. PRIMARY Occurs in a joint de novo Occurs in old age Mainly in weight bearing joints (knee and hip) More common than secondary OA 26 TYPES OF OSTEOARTHRITIS DISCUSSION SECONDARY There is underlying primary disease of the joint → degeneration of the joint, often many years later May occur at any age after adolescence Commonly at the hip

27. OSTEOARTHRITIS INVESTIGATIONS OA is typically diagnosed on the basis of clinical and radiographic evidence. No specific lab abnormalities are associated with OA. 27 IMAGING X-ray Narrowing of the joint space Subchondral sclerosis Marginal osteophytes Subchondral cyst Bone remodelling RADIONUCLIDE SCANNING Scanning with 99m Tc-HDP shows increased activity during the bone phase in the subchondral regions CT and MRI To elucidate specific problem : bone edema, AVN

28. OSTEOARTHRITIS INVESTIGATIONS OA is typically diagnosed on the basis of clinical and radiographic evidence. No specific lab abnormalities are associated with OA. 28 Serological tests and ESR to rule out rheumatoid arthritis. Serum uric acid to rule out gout. Arthroscopy : if a loose body or frayed meniscus is suspected.

29. OSTEOARTHRITIS TREATMENT PRINCIPLES OF TREATMENT Delay the occurrence Stall progress of the disease and relieve the symptoms To rehabilitate the patient

30. OSTEOARTRITIS TREATMENT The goals of osteoarthritis treatment include alleviation of pain and improvement of functional status. Optimally, pt should receive a combination on non-pharmacologic and pharmacologic treatment. NON-PHARMACOLOGICAL Patient education Thermotherapy Weight loss  Exercise Physical therapy Unloading in certain joints ( eg , knee, hip) 30 PHARMACOLOGICAL Acetaminophen Oral NSAIDs Topical NSAIDs Tramadol Intra articular injections

31. TREATMENT SURGICAL Although osteoarthritis tends to be chronic, the symptoms are rarely progressive and rarely require surgery on the painful spinal joints. 31 Joint debridement Osteotomy Partial Knee Replacement Surgery ( Unicompartmental Knee Arthroplasty) Total Knee Replacement Surgery (Total Knee Arthroplasty )

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33. INDICATIONS relief of significant disabling pain caused by severe arthritis Correction of severe deformity 33 TOTAL KNEE REPLACEMENT SURGERY SURGERY

34. 34 TOTAL KNEE REPLACEMENT SURGERY SURGERY CONTRAINDICATIONS Knee sepsis A remote source of ongoing infection Extensor mechanism dysfunction Severe vascular disease Recurvatum deformity secondary to muscular weakness Presence of a well-functioning knee arthrodesis ABSOLUTE CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS Skin conditions within the field of surgery ( eg , psoriasis) Past history of osteomyelitis around the knee Neuropathic joint Obesity

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36. 36 TOTAL KNEE REPLACEMENT SURGERY SURGERY COMPLICATIONS OF TKR Infection Deep vein thrombosis Common peroneal nerve palsy Fractures Extensor mechanism complications Knee stiffness

37. REFERENCES 37 Apley’s System of Orthopaedics and Fractures 9th edition Maheshwari and Mhaskar Essential Orthopaedics 4th edition Raediopaedia.org Osteoarthritis: care and management. NICE guidelines Published date: February 2014 THANK YOU