joint disorders

what are the three types of cartilage?

• hyaline cartilage

• elastic cartilage

• fibro cartilage

what is the joint capsule?

• fibrous outer joint later

• external to synovium

• highly innervated

what is the joint synovium?

• inner joint lining

• immature tissue

  • metabolically active

  • rich with blood supply

• synovial cells

  • collagen

what is the synovium fluid function?

• lubricates articular cartilage and provides nourishment through diffusion

  • made from ultra filtrate of blood plasma

    • regulated by synovium

      • healthy knee contains 2 mL of synovial fluid

  • consists of hyalauronic acid, lubricin, proteinase, collagenases, prostaglandins

• secreted by synovial cells

• nearly perfect lubricant

is cartilage innervated?

nope, no nerves!

what is the innervation of synovium?

very few nerves

What is capsule/ligaments inneravation?

many nerves: pain, proprioception, pressure

bone is highly inneravated

swelling increases the capsule pain

can hyaline cartilage be repaired?

it cannot be repaired

fills in with fibrocartilage: good at compression, not shear

what are the inflammatory arthritis?

• rheumatoid arthritis

• juvenile arthritis

• psoriatic arthritis

• ankylosing spondylitis

• crystalline

  • gout and pseudogout

what is non-inflammatory arthritis?

• osteoarthritis

• neuropathic

where does RA begin?

• cellular proliferation

• lymphocytes

• protein

What is synovial fluid comp for RA?

• more fluid (water)

• more protein/cells (cloudy appearance)

• less hyaluronic acid: less viscosity (poor lubrication)

does RA affect both sides?

yes! autoimmune affects both sides equally

what is involved with RA?

• symmetric joint involvement

• periarticular osteopenia

• pannus formation (synovium proliferation)

• joint loss and bone erosion (pannus/peripheral invasion)

clinical features of RA?

• epidemiology

  • F>M (3:1)

  • age 35-45 (peak age)

what are the clinical features of hands?

• MCP/PIP swelling

• swan neck deformity

• boutonniere deformity

• joint subluxation

• ulnar drift

what are the RA clinical features for the wrist?

• caput ulnae (ulnar prominence)

• extensory tenosynovitis

• skin nodules

what are RA clinical features for the feet?

• bunion deformities

• lesser toe deformities

• hindfoot valgus

what is the biomodal peak onset of Juvenile rheumatoid arthritis (JIA)?

• age 1-3

• OR

• age 8-12

what os the variable pattern for JIA?

• monoarticular (one)

• pauciarticular (<5)

• polyarticular (many, rare)

what are the clinical features of JIA?

• systemic illness

  • fever, rash

  • liver/spleen/lymph node enlargement

• occular inflammation

  • can lead to blindness

  • referral to ophthalmology

what is the testing and treatment for JIA?

• lab testing

  • RF, anti CCP, ANA

  • frequently negative

• treatment:

  • meds are the primary treatment

    • surgery

    • address inflammation and deformity

• physical therapy to minimize joint stresses

what are the outcomes of JIA?

• growth disturbances (limb length discrepancies)

• joint deformity

• 50% result in disability

what is psoriatic arthritis?

• 30% of individuals with psoriasis

• 20% develop severe joint involvement

• M=F

• age 30-50 at onset

• spine, SIJ, DIP joint

• skin plaques

what are happens to the finger joints with psoriatic arthritis?

articular erosions (pencil in cup)

what is ankylosing spondylitis?

• progressive inflammatory process affecting the spine (SPINE FUSION)

• genetic HLA B27

• male predominance

• can have

  • acetabular protusion

  • SIJ fusion

  • spine fusion (bamboo spine)

what is the clinical presentation of ankylosing spondylitis?

limited spine flexibility

• flexion/extension

• rotation

what is the treatment for ankylosing spondylitis?

medication!

• indocin and sulfasalazine

what happens with acute trauma to ankylosing spondylitis?

traumatic injury

• pain —> fracture

Xrays

• look at soft tissue shadow

• no flexion/extension xrays

Treatment

• immobilize

• referral to ER/MD

what is crystalline gout?

PAINFUL

• uric acid metabolism disorder

• middle ages males

• familial

• diet high in purines, fatty acids

• M:F ration is 6:1

what are clinical features of gout?

• 1st MTP joint

hands feet wrists, bursae

LOOKS RED, SWOLLEN, EXTREME PAIN

RAPID ONSET
CAN LOOK LIKE INFECTION

what are the pathological findings of gout?

• crystals in joint

• tophi around joints/brsua

• pannus eroding joint

what foods to avoid with gout?

those with high purine content

• sardines

• alcohol

• hearts

• herring

• mussels

• smelt

• sweet breads

• yeast

whaht is non inflammatory arthritis neurpathic?

• very destructive form of arthritis

• long standing neuropathy

  • diabetes

• SC compression

  • spinal deformitity

  • SC lesion

• congenital neurpathy

• tertiary syphilis

what is charcot?

from neuropathic arthropathy

• limited pain/proprioception

• repetitive joint trauma, deformity, instability

• looks like joint infection

what is the treatment for neuropathic arthropathy?

first: identify and treat the underlying cause of neuropathy

then:

• brace, case

• deformity correction (foot/ankle)

• arthrodesis

• constrained joint replacement (rare/almost never)

what is degenerative arthritis?

• articular cartilage wear and tear

• secondary inflammation of synovium

• synovial fluid production

  • more fluid (water)

  • few cells (clear, straw colored)

  • less HA/low viscosity (bad lubrication

what is osteoarthritis?

leading cause of disability world wide

• prevalence 33.6% > 65

• 27 million US adults with clinical OA, projected to be 67 million in 2030

• 30% of adults >45 of 2032, hald of them with knee OA

• lifetime risk of developing knee OA is 45%

what are characteristics of osteoarthritis?

NOT JUST CARTILAGE DEGENERATION

• abnormal joint loading

• genetic influences

• cartilage degen

• metalloproteinases

how to diagnose osteoarthritis?

history and clinical exam

• can be difficult to distinguish at times

• joint deformity

• limited motion

standing x-rays

MRI if xrays are inconclusive

what are signs of osteoarthritis on x-ray?

• sclerosis

• loss of joint space

• subchondral cysts

• osteophytes

what are non-surgical treatments for OA?

• weight loss

• activity modification

• ADs

• bracing/splinting

• joints mobs

• water therapy

• strengthening

• analgesic meds/ NSAIDs

• psychological/emotional counseling

injections for arthritis?

• corticosteroid injections

  • decrease inflammation

  • reliable response

  • may have adverse effect on cartilage

  • LIMIT NUMBER OF INJECTIONS FOR NORMAL JOINT WITH HEALTHY CARTILAGE

what are viscosupplement injections?

• preferred for young, active patients (<50)

• particularly if minimal radiographic findings

• exclude/treat meniscus tear

• variable response

• hella expensive

what are surgical options for OA?

“joint preserving”

• athroscopy

• osteotomy

• synovectomy

“arthroplasty”

• partial

• total

• resection

Arthrodesis (fusion)

what is an arthroscopy?

minimally invasive procedure performed with a lighted camera called an arthroscope

• synovectomy

• meniscus repair

• partial menisetomy

• ligament reconstruction

what are ostochondral lesions?

• focal or ostochondral lesions

  • 63% of 30,000 arthroscopies performed

• Osteochondral lesions result in decreased activity/lifestyle modifcation and are linked to early OA

what is a cartilage debridement?

the drill into bone to get fibro cartilage to place into articular cartilage

microfracture (“stem cells”)

what is cartilage restoration?

• autologous cartilage implantation

• osteochondral transfer (OATS)

• major osteochondral structural graft

what is an osteotomy?

purpose is to cut and realign bones and joints, it is a joint sparing surgery

• prox tibia

• distal femur

• pelvis/prox femur

• distal tibia

• calcaneus

what are indications for an osteotomy?

• young or active patient

• relatively preserved joint space

• GOOD ROM

what are complications of osteotomys?

• nonunion/malunion

• recurrence

80% 10 year success rate

can be converted to arthroplasty later

what os arhthrodesis?

• fusion

• goal: pain relief, global function

• trade off

  • loss of motion

  • limb shortening

  • transfer of stress to other joints

what are indications for arthrodesis?

• spinal fusion is the preferred treatment

• hand/wrist

  • laborer

• knee

  • failed TKA

  • injection/failed extensor mech.

• Hip

  • young patient, single joint

what is an arthroplasty?

joint replacement

• reliable procedure to improve pain

  • potential to improve ROM

• durability 15-20 years expected

  • 5-10% will be revised in < 5 years

what are common arthroplastys?

• hip, knee, shoulder are very common

• elbow, ankle are infrequent

• spine is infrequent

• small joints are rare

what are the indications for arthroplasty?

• primary

  • pain relief

• secondary

  • correct deformity

  • improve ROM

  • improve function

what are contraindications for arthroplasty?

• stiffness without pain

• xray findings only

• high functional status

• active infection

• neuropathic joint

• limited life expectancy

• morbid obesity

what is a total joint arthroplasty?

replaces both sides of the joint

what is a fixation?

either cemented or cementless

what is the bearing surface?

metal, ceramic or polyethylene

what is a hemiarthroplasty?

replaces one side of a joint

• more common in shoulder and hip

• becoming less common

what is a unicompartmental arthroplasty (knee)?

• replaces one compartment of joint

• preserves ACL/knee function

what are early complications of joint arthroplasty?

• hyaluronic acid

• PE, MI, DVT/PE, CVA, CHF

• surgical 3-5%

  • infection, dislocation, anesthesia, neurovascular injury

what are late complications of a joint arthroplasty?

• aseptic loosening

• inflammatory reaction to wear particles

• polyethylene > metal

• resorption of bone at interface wtih component or cement

• increased risk with time (younger patient)

• dislocation

  • component malposition

  • females/AVN/fem neck fx

• infection

  • delayed vs hematogenous

    • skin ulcers

    • GU/oral/GI

    • pulmonary

what are precautions for a posterolateral (workhorse) THA?

• flexion beyond 90 degrees

• adduction, IR

what are precautions for an antero lateral THA?

none, may need to protect active hip abd

what are precations for a direct anterior THA?

maybe none vs extension, ER, adduction