Case report :

OSTEOARTHRITIS
MUTIARA RIAHNA SITEPU
030.12.179

PEMBIMBING
dr. T. Nurrobi, Sp.OT(K)Hand

KEPANITERAAN KLINIK ILMU BEDAH FAKULTAS KEDOKTERAN UNIVERSITAS

TRISAKTI
RUMAH SAKIT TNI AL Dr. MINTOHARDJO PERIODE 19 FEBRUARI 2018 – 28 APRIL
2018
 Introduction
Osteoarthritis (OA) is a painful chronic
joint disease that can induce some
changes to the joints, such as articular
cartilage loss, synovial inflammation,
subchondral bone, meniscal damage,
muscle weakness, ligamentous laxity, and
osteophyte development.

When this disease afects the knees (i.e.

gonarthrosis or OA of the knee), the most
commonly afected joint compartments are
the medial tibiofemoral and the Osteoarthritis (OA), the most
patellofemoral. common musculoskeletal
condition, is a long-term chronic
disease involving the thinning of
Knee OA can cause significant disability and cartilage in joints which results in
impaired quality of life, and its development can bones rubbing together, creating
have an impact on patient’s capacity to stiffness, pain, and impaired
undertake daily activities, including their ability movement
to work.
 Case report
NAME Mrs K
GENDER Woman
AGE 59 years old
ADDRESS Karet Pasar Baru Barat II
RELIGION Moslem
WORK -
EDUCATION Middle school
MARITAL STATUS Married
DATE OF ENTRY 25th February 2018
MEDICAL RECORD NUMBER 193334
BMI BB/TB2 = 75/1602 = 29,2
 Anamnesis

Main Pain on both

knees since 10
complaint years ago

Difficult to walk
Additional for a long time
and to take the
complaint stairs
 History of disease

Patient complained of pain on both knees since 10 years ago. Pain is felt
especially when walking and when take the stairs. The patient also
complained that her legs couldn’t be bent and sometimes there’s was a
crackling sound.
Patient went to the Community Health Centre (puskesmas) and got
mefenamic acid but later her legs got swollen after taking the medicine.
The patient then given neurodex but her legs are swollen again
About 3 years ago the patient went to a General Practitioner and was
given methylprednisolone. Then she feel better after taking the drug and
then the patient continuously consume metilprednisolon every morning
because she will feel pain if not take it, without control to the doctor. 1
week ago the patient felt both her knees getting more and more pain and
finally referred to RSAL. After being examined the patient is planned for
surgery on her left knee first because it is more severe
 Past health history
Diabetes Mellitus (+) Heart disease (+)
Have been treated since Have been treated since
5 years ago with february 2018 with
Metformin & Glimepiride Bisoprolol

Hypertension (-)
 Physical examination
General condition

Conscious stage Compos mentis

Nutritional stage Good

BMI= 29,2 (overweight)
(BW/BH= 75kg/160 cm)

Vital sign

Blood tension 130/80

Pulse rate 88x/m

Respiration rate 20x/m

Temperature 36,7°C
 General status

Skin
• Colour : yellowish, not pale, cyanosis (-),Icteric (-), rash (-)
• Lesion : no lession such as macule, papule, pustule or other secondary lession like
keloid and scar on other parts of the body
• Turgor : good
• Temperature : warm

Eye
• Shape : normal, symethrical, xopthalmos (-), enopthalmos (-)
• Palpebrae : normal, ptosis (-), lagofthalmos (-), oedema (-), bleeding (-), blepharitis (-),
xanthelasma (-)
• Movement : good, strabismus (-), nistagmus (-)
• Sclera : icteric (-)
• Pupil : round, isochoric, diameter 3mm, direct light reflex (+) ODS, indirect light
reflex (+) ODS
Ear
• Shape : normotia
• Ear canal : good
• Cerument : found in ADS

Nose
• Shape : normal, no deformity
• Septum : in medial, symetrical
• Nasal Mucose : hyperemia (-), nasal concha eutrophy
• Nasal cavity : bleeding (-)

Mouth and throat

• Lips : normal, pale (-), cyanosis (-)
• Teeth : average hygiene
• Buccal mucose: hyperemia (-)
• Tongue : normoglosia, typhoid tounge (-)
• Tonsils : T1/T1, hyperemia (-)
• Pharynx : hyperemia (-), symetrical pharynx arch, uvule in the middle
Cervical
• Venous congestive : (-), JVP 5+2cm H2O
• Thyroid gland : no enlargement, symetrical
• Trachea : medial

Lymphatic vessels
• Cervical : no enlargement
• Axilla : no enlargement
• Inguinal : no enlargement
Thorax (Lungs)
• Inspection : symetrical movement, no retraction, thoracoabdominal type,
• Palpation : symetrical movement, vocal fremitus balance in hemithorax
• Percussion : sonor in both hemithorax, lung liver border ICS VI linea
midclavicularis dextra, lung stomach border in ICS VIII linea axillaris anterior
• Auscultation : SNV +/+, Rhonki (-), Wheezing (-)

Thorax (Heart)
• Inspection : no thrill, no ictus cordis
• Palpation : ictus cordis on ICS V, linea midclavicularis sinistra
• Percussion : right heart: ICS III-V linea sternalis dextra, left heart: ICS V, 1 cm
lateral linea midclavicularis sinistra, upper heart: ICS II linea sternalis sinistra
• Auscultation : HS I,II regular, murmur (-), gallop (-)
Abdomen
• Inspection : symetrical, no widening vein
• Palpation : tenderness (-)
• Percussion : tympanic in 4 quadrants
• Auscultation : bowel sound: (+), bruit (-)

Extremities
• Upper : No deformity, warm akral +/+ , oedema -/-, CRT < 2", clubbing finger (-)
• Lower : warm akral +/+, oedema +/+, tenderness +/+, pain +/+
Localize status (genu sinistra)
• Look : Edema (+)
• Feel : Tenderness (+), skin temp: warm
• Move : Pain on RoM, Limitation on RoM
Laboratory findings
 Radiology
Genu dextra and sinistra AP/Lateral
 Resume
Patient complained of pain in both knees
since 10 years ago. Pain is felt especially
when walking and when take the stairs. The
patient also complained that her legs
couldn’t be bent and sometimes there was
a crackling sound. From physical diagnosis
found Edema (+) on the right and the left
knee, tenderness (+), skin temperature:
warm, pain on RoM, and limitation on RoM
 Diagnosis

• Osteoarthritis genu
Diagnosis dextra and sinistra

• Rheumatoid arthritis
Differential
• Gout arthritis
diagnosis
 Treatment

Medication
Surgery • Na Diclofenac
2x500g
Arthroscopy
• - Omeprazole 2x1
debridement • - Ceftriaxon 2x2g
 Prognosis

Ad
Ad vitam :
sanationam
ad bonam
: dubia

Ad functionam :
dubia ad bonam
 Follow up post operation
Date Subject and objective Treatment

28/February/ S: pain on left knees (+), IVFD RL 20 dpm

2018 GC / Consciousness : Fair Na diclofenac 3x500mg
/ composmentis Ceftriaxon 2x2gr
VS : Omeprazole 2x1
BP : 140/90 mmHg
RR : 20 x/ min
Pulse : 82 x/ min
T : 36.70C
VAS : 5
Literature review
Anatomy
 Definition

Osteoarthritis (OA) is a painful chronic joint

disease that can induce some changes to the
joints, such as articular cartilage loss, synovial
inflammation, subchondral bone, meniscal
damage, muscle weakness, ligamentous laxity,
and osteophyte development.
 Epidemiology
80% of those
Worldwide estimates with OA will
are that 9.6% of men have limitations
It accounts for 50% of in movement
and 18.0% of women
the entire
over the age of 60
musculoskeletal
years have
disease burden 25% cannot
symptomatic perform their
osteoarthritis major activities
of daily life.

UN : the proportion of
As the elderly
people over the age of
population increases
60 will triple over the
around the world,
next 40 years, meaning
there is a consequent
this demographic will
rise in the prevalence
account for more than
of non-communicable
20% of the world’s
and chronic diseases
population by 2050.
Risk factor
 Classification
Primary Secondary

• As a person ages, the water • Tends to show up earlier in

content of their cartilage life, often due to a specific
decreases, thus weakening cause such as an injury, a
it and making it less job that requires kneeling
resilient and more or squatting for extended
susceptible to degradation. amounts of time, diabetes,
There are strong indications or obesity. But though the
that genetic inheritance is a aetiology is different than
factor, as up to 60% of all that of primary OA, the
OA cases are thought to resulting symptoms and
result from genetic factor pathology are the same
 Pathophysiology
Normally, cartilage undergoes a remodeling process, stimulated by
joint movement or use

In OA, this process is altered by a combination of mechanical,

cellular, and biochemical processes

Resulting in abnormal reparation of cartilage and an increase in

cartilage degradation.

OA is primarily characterized by progressive cartilage loss,

accompanied by an increased thickness of the subchondral plate,
osteophytes (new bone at joint margins) and subchondral bone
cysts

With disease progression, vascular invasion and further

calcification of nearby articular cartilage may occur, leading to
decreased thickness of articular cartilage and, over time, bone
remodeling and enhanced cartilage deterioration
OA develops due to an imbalance between destruction and synthesis of the articular
cartilage. So the pathology of the disease shows both destruction and attempted
repair the joint

Predisposing factor

Actives chondrocytes’s Thickening of the

multiplication articular cartilage

Produces increased of immature Deterioration of the

proteoglycans and collagen cartilage’s physiology

• Cartilage’s smooth surface becomes rough

Progression of OA or eroded with cracks
• Narrowing of joint spaces
• Formation of osteophytes
• Mild synovitis
Kellgren and Lawrence radiographic scale
for Osteoarthritis
 Symptopms
exacerbated by joint
PAIN use and relieved by
rest

usually
lasts for
less than
30
MORNING joint locking or
minutes STIFFNESS joint instability

These symptoms result in loss of function, with patients limiting

their activities of daily living because of pain and stiffness.
 Diagnosis

Anamnesis
Physical examination
Joint pain, worsen by
Pain on range of motion
activity, relieved by
and limitation of range of
analgetic, morning stiffness
motion
(<30mnt), joint locking

Radiographic
joint-space narrowing,
subchondral sclerosis,
osteophytic growths, and
cysts
Radiograph on the knee AP/LAT

Joint space narrowing, osteophyte formation

 2016 ACR revised Criteria for early
diagnosis of knee OA

•In the presence of 3 points out of 10 with at least 1 point from Domain II
along with all entry criteria, the diagnosis of knee OA can be established
•Exclusion criteria are including:
1) Moderate to significant knee synovitis
2) Hot or red knee
3) History and/or physical examination findings compatible with the internal
derangement of knee
•Knee pain that is initiated or increased with knee activity/exercise and finished or
decreased with Knee resting
•Clear fluid with normal viscosity accompanied by WBC count less than 2000/mm3
with less than 25% PMN
•It must be ignored in the presence of osteophyte in knee X-Ray
Practical Guideline approaching toward the
diagnosis of knee OA
 Treatment

Non-
Pharmacologic
pharmacologic

Complementary
Surgical
and alternative
 Non-pharmacologic

Medical rehabilitation
Excercise Weight loss / physiotherapy Use of tools
• muscle strengthening • Obesity is considered • Reducing pain, • Assistive devices such
and range-of-motion a major risk factor for strengthening as walking canes,
exercises osteoarthritis muscles, and increase braces, and
• The American College • Pain and disability the area of joint appropriate footwear
of Rheumatology were reduced if movement may provide
(ACR) recommends patients lost more significant
both land-based and than 6 kg improvement in a
aquatic-based patient’s ability to
programs perform activities of
daily living(ADLs)
 Pharmacologic
• Acetaminophen
Analgetic • Opioids

• Ibuprofen, naproxen, diclofenac

NSAID • Cyclooxygenase-2 inhibitors, such as celecoxib (Celebrex)

Intra-articular injections • Provides short-term relief lasting four to eight weeks

of corticosteroids

Intra-articular hyaluronic • The treatment effect often lasted for up to four months
acid injections and led to improvements in pain and function
(viscosupplementation)
 Complementary and alternative

glucosamine chondroitin

acupunture
 Surgical
• Arthroscopy is a minimally invasive procedure. Arthroscopic
techniques include lavage and debridement of the knee (e.g.,
Arthroscopic shaving of rough cartilage or smoothening of the degenerated
Lavage and meniscus). Used for removal of meniscal tears and debridement
of loose articular cartilage
Debridement • Arthroscopy for OA should relieve symptoms by removing the
debris and inflammatory cytokines that cause synovitis

Cartilage • Only indicated for focal cartilage defects, which can been seen as
Repair a precursor of OA. If the defect is to extended cartilage, repair is
no longer indicated
Techniques.

• Penetration of the subchondral lamina has been shown to

Bone Marrow promote cartilage repair tissue; indeed, pluripotent stem cells
arising from the subchondral bone marrow may promote
Stimulating chondrogenesis in the defect area. This technique enhances
Techniques. chondral resurfacing and takes advantage of the healing potential
of the body
 • Osteotomies around the knee are an accepted method for the
treatment of unicompartmental OA with associated varus or
valgus deformity
Osteotomies • Osteotomies around the knee alter the weightbearing axis of the
lower extremity. The aim is to unload the damaged
around the compartment and to transfer the weight load from the affected
areas by slightly overcorrecting into a valgus or varus axis to
Knee. reduce pain, slow the degenerative process, and delay joint
replacement
• Osteotomies around the knee are an effective procedure in
young and active patients with early OA of one compartment
with associated varus or valgus axis. Appropriate patient
selection, good preoperative planning, accurate surgical
technique, and correct postoperative management can minimize
the complication rate and lead to satisfactory outcome

Unloading osteotomy: exemplary a valgisation

open- wedge high tibial osteotomy in
unicompartmental OA of the medial knee
compartment. The corrected position is
stabilized by a plate with angular locked screws.
 • UKA is indicated in cases where OA involves only one of the
three compartments of the knee
• The commonest UKA replaces the contact surfaces of the
Unicompartmental medial tibiofemoral compartment with two metallic prosthetic
devices and inserts a polyethylene inlay between them
Knee Arthroplasty • For successful medial UKA, the initial conditions must provide
(UKA) a well-preserved lateral compartment with respect to
meniscus and cartilage. The implant is unrestrained in the
sagittal plane, so the stability of the prosthesis depends on
intact cruciate ligaments

Treatment of an isolated medial

compartment OA by
unicompartmental arthroplasty.
 • In advanced knee OA, with more than one
compartment involved and failure of conservative
treatments, TKA has been shown to be a highly
effective treatment that results in substantial
improvement in patient functioning and health-related
quality of life

• Until now it has been the first-line procedure for end-

stage knee OA.
Total Knee
• The option of total knee arthroplasty is typically
Arthroplasty discussed with patients at the point in their lives when
knee pain from arthritis is significantly interfering with
(TKA). activities of daily living. Informed consent requires a
full discussion of the risks and benefits of surgery to
ensure that patient expectations are realistic.
Generally, between 80% and 85% of patients are
satisfied with their knee arthroplasty

• The most significant complication is deep infection,

which complicates between 1% and 2% of operations
and may require further and repeated major joint
surgery
Treatment of advanced knee OA by
total knee arthroplasty
(example without patella resurfacing).
Recommended stepped-care approach for
the treatment of osteoarthritis
 Complication
Osteoarthritis with Baker’s cysts (popliteal
crystals cysts)

occurs when chalky deposits of can form when extra

calcium crystals form in the synovial fuid is produced
cartilage (called calcification or
chondrocalcinosis) and it becomes trapped in
a pouch (hernia) sticking
out of the joint lining

can cause sudden pain and Sometimes a cyst can cause

noticeable swelling of the joint
aching or tenderness when
exercise

Sometimes the crystals can shake loose from the

cartilage, causing a sudden attack of very painful swelling
called acute calcium pyrophosphate crystal arthritis
(acute CPP crystal arthritis), sometimes previously called
‘pseudogout’
 Preventions
Weight
control
Occupational
injury
prevention
Sports injury
prevention
Misalignment PRIMA
RY
Secondary
Early diagnosis which allows for
effective and
appropriate interventions that will
minimize the health consequences of
the disease

self- home help home help rehabilitation surgical

TERTIARY management programs programs services treatments
 COCLUSION

Osteoarthritis is a common degenerative disorder of the articular

cartilage associated with hypertrophic bone changes. Risk factors include
genetics, female sex, past trauma, advancing age, and obesity. The
diagnosis is based on a history of joint pain worsened by movement,
which can lead to disability in activities of daily living. Plain radiography
may help in the diagnosis, but laboratory testing usually does not.
Pharmacologic treatment should begin with acetaminophen and step up
to nonsteroidal anti-inflammatory drugs. Exercise is a useful adjunct to
treatment and has been shown to reduce pain and disability. Total joint
replacement of the knee is recommended for patients with chronic pain
and disability despite maximal medical therapy
THANKY
OU