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Osteoarthritis - Case Based Discussion
This document contains details about a 67-year-old male patient presenting with left knee pain for 8 years. His history, examinations, investigations and x-ray findings are consistent with primary osteoarthritis of the left knee. He is currently admitted for a planned left total knee replacement surgery to relieve his disabling knee pain. Osteoarthritis is a chronic joint condition involving cartilage breakdown and bone changes. Treatment involves non-pharmacological and pharmacological options, with surgery considered for severe cases not relieved by other measures.
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Osteoarthritis - Case Based Discussion
- 1. ORTHOPAEDICS PRESENTATION M O HD A F I Q I F I K R I M M M C M a l a y s i a 1
- 2. N A ME A G E A D D R E S S O C C U P A T I O N R E G I S T R A T I O N N U M B E R D A T E O F A D M I S S I O N D A T E O F E X A M I N A T I O N PATIENT’S DETAILS 2 C H O N G S I U K A N G 6 7 Y / O C H E N G M E L A K A R E T I R E E 1 1 1 7 3 3 0 2 N D N O V E M B E R 2 0 1 6 4 T H N O V E M B E R 2 0 1 6
- 3. H I ST O R Y
- 4. C H IE F C O M P L A I N T Pain at left knee for 8 years
- 5. P A TI E N T ’ 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. He 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. P A TI E N T ’ S HISTORY OF PRESENTING ILLNESS He 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. He was currently admitted for left TKR surgery. 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 • married and blessed with 5 children • Live with his wife and son. • Previously work as a hard labor in construction yard for 10 years • He is financially stable. – supported by his son 05.
- 8. P A TI E N T ’ S PROVISIONAL DIAGNOSIS PRIMARYOSTEOARTHRITISOF THELEFTKNEE • 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 includesgeneral and local examination, of which consist of look, feel, move and measure and not forget the special tests. P R I M A R Y O S T E O A R T H R I T I S O F T H E L E F T K N E E
- 10. P A TI E N T ’ 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: I. PR: 70 bpm, regular rhythm, normal volume and character II. BP: 145/92 mmHg III. RR: 18 breaths/min IV. Temperature : 37 ºC • There is no pallor, no pedal edema. SYSTEMIC EXAMINATION 10 • Cardiovascular system, Respiratory system and Abdominal examination were all normal.
- 11. P A TI E N T ’ 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. P A TI E N T ’ 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. P A TI E N T ’ 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 wasfelt 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. P A TI E N T ’ S NEUROVASCULAR EXAMINATION Peripheral pulse : CRT <2s, distal pulsations felt on both sides (dorsalis pedis artery and posterior tibial artery) 16 P A T I E N T ’ 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. P A TI E N T ’ 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. P A TI E N T ’ 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. I N VE S T I G A T I O N S 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/L4.0-10.0 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 : 45mm/hr (0-12) CRP : 7.2 mg/l (<5.0)
- 22. Primary osteoarthritis ofleft knee with genu varus deformity DIAGNOSIS 22
- 23. T H US F A R … TREATMENT TREATMENT IN HOSPITAL • Analgesics • Planned for left total knee replacement 23
- 24. DISCUSSION o s te o a r t h r i t i s
- 25. 25 D I SC U S S I O N 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 ina joint de novo • Occurs in old age • Mainly in weight bearing joints (knee and hip) • More common than secondary OA 26 TYPES OF OSTEOARTHRITIS D I S C U S S I O N 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. O S TE O A R T H R I T I S 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 I. Narrowing of the joint space II. Subchondral sclerosis III.Marginal osteophytes IV. Subchondral cyst V. Bone remodelling RADIONUCLIDE SCANNING • Scanning with 99mTc-HDP shows increased activity during the bone phase in the subchondral regions CT and MRI • To elucidate specific problem : bone edema, AVN
- 28. O S TE O A R T H R I T I S 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. O S TE O A R T H R I T I S TREATMENT PRINCIPLES OF TREATMENT • Delay the occurrence • Stall progress of the disease and relieve the symptoms • To rehabilitate the patient
- 30. O S TE O A R T R I T I S 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. T R EA T M E N T 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)
- 32.
- 33. INDICATIONS • relief ofsignificant disabling pain caused by severe arthritis • Correction of severe deformity 33 TOTAL KNEE REPLACEMENT SURGERY S U R G E R Y
- 34. 34 TOTAL KNEE REPLACEMENTSURGERY S U R G E R Y 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
- 35.
- 36. 36 TOTAL KNEE REPLACEMENTSURGERY S U R G E R Y COMPLICATIONS OF TKR • Infection • Deep vein thrombosis • Common peroneal nerve palsy • Fractures • Extensor mechanism complications • Knee stiffness
- 37. REFERENCES 37 1) Apley’s Systemof Orthopaedics and Fractures 9th edition 2) Maheshwari and Mhaskar Essential Orthopaedics 4th edition 3) Raediopaedia.org 4) Osteoarthritis: care and management. NICE guidelines Published date: February 2014 T H A N K Y O U
Editor's Notes
- #28 Radio-nuclide : d/t increased vasc and new bone formation CT MRI : eg early detection of osteocartilageneous #, bone edema , avn
- #29 Arthroscopy : may show cartilage damage before xray changes appear
- #31 Patient information 1.3.1 Offer accurate verbal and written information to all people with osteoarthritis to enhance understanding of the condition and its management, and to counter misconceptions, such as that it inevitably progresses and cannot be treated. Ensure that information sharing is an ongoing, integral part of the management plan rather than a single event at time of presentation. Thermotherapy 1.3.4 The use of local heat or cold should be considered as an adjunct to core treatments. Exercise and manual therapy 1.4.1 Advise people with osteoarthritis to exercise as a core treatment (see recommendation 1.2.5), irrespective of age, comorbidity, pain severity or disability. Exercise should include: local muscle strengthening and general aerobic fitness. Oral analgesics 1.5.1 Healthcare professionals should consider offering paracetamol for pain relief in addition to core treatments (see recommendation 1.2.5); regular dosing may be required. Paracetamol and/or topical non-steroidal anti-inflammatory drugs (NSAIDs) should be considered ahead of oral NSAIDs, cyclo-oxygenase 2 (COX-2) inhibitors or opioids. [2008] 1.5.2 If paracetamol or topical NSAIDs are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people. Topical treatments 1.5.3 Consider topical NSAIDs for pain relief in addition to core treatments (see recommendation 1.2.5) for people with knee or hand osteoarthritis. Consider topical NSAIDs and/or paracetamol ahead of oral NSAIDs, COX-2 inhibitors or opioids. [2008] Osteoarthritis: care and management (CG177) © NICE 2014. All rights reserved. Page 16 of 38 1.5.4 Topical capsaicin should be considered as an adjunct to core treatments for knee or hand osteoarthritis.
- #32 Partial TKR only part of damaged is removed. knee is opened, a cap is put on top of damaged part without removing any lig n muscles etc for partially damaged knee Total TKR - goal- to achieve optimal alignment of leg and soft tissue balance between lig around knee