Osteoarthritis and Rheumatoid Arthritis Orthopedic

1. Osteoarthritis and
Rheumatoid Arthritis
Presented By Siti Nur Rifhan Kamaruddin

2. 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.

3. 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)

5. 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.

6. 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.

7. Features of Advanced Disease
 Swelling
 Deformity
 Tenderness
 Crepitus on movement
 Muscle wasting

8. CLINICAL VARIANT OF OA
1) 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

9. CLINICAL VARIANT OF OA
2) 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

11. CLINICAL VARIANT OF OA
3) 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.

12. TESTS AND DIAGNOSIS
History & 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.

13. X-RAY CHANGES IN
OSTEOARTHRITIS

14. (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.

15. 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.

16. 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.

17. (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.

18. TREATMENT
EARLY 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

19. TREATMENT
INTERMEDIATE 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.

20. TREATMENT
LATE 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.

21. RHEUMATOID ARTHRITIS
(RA)

22. 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.

23. 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

24. 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

26. 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

27. Swelling at proximal finger joints and wrists.

28. 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.

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

32. 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.

34. TESTS
• X Rays
– X rays of hands and feet are generally performed
in people with RA.
• Magnetic Resonance Imaging (MRI)
• Ultrasounds

35. • 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%.

36. • 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

37. 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

38. 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

39. TREATMENT
There is NO cure for RA
Medical Management
Aim: 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)

40. 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

41. Surgical Management
Indication: Indicated at any stage of disease. If
conservative measures alone are not effective.
Early stage (Soft tissues procedures):
• Synovectomy
• Tendon repair/replacement
• Joint Stabilization
Late Stage
Indications for Reconstructive Surgery:
Severe joint destruction, fixed deformity and loss of
Function
• Antrodesis
• Osteotomy
• Arthroplasty

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

43. THANK YOU..