Arthritis Hip and Knee Nigel Brewster 1998

Aims l Types of arthritis l Symptoms of arthritis l Signs of arthritis l Treatment of arthritis

Types of Arthritis l Rheumatoid arthritis (RA) l Osteoarthritis (OA) l Sero-negative arthritis l Ankylosing spondylitis l Reiter’s disease l Crystal arthropathies

Rheumatoid Arthritis l affects 3% population l female> male (3:1) l 80% RF l 30% ANF l HLA DR4 (chr 6)

Rheumatoid Arthritis Pathology l Synovitis chronic infl, synovial hypertrophy, effusion l Destruction proteolytic enzymes, pannus l Deformity articular destruction, capsular stretching, tendon rupture

Rheumatoid Arthritis extra-articular l nodules l tendon sheath l vasculitis l myopathy and neuropathy l reticulo-endothelial system l visceral - lungs, heart, kidneys, brain, GI

Rheumatoid Arthritis early symptoms l myopathy, tiredness, weight loss, malaise l proximal finger joints l wrists, feet, knees, shoulders l start up pain l tendon crepitus

Rheumatoid Arthritis early joint changes

Rheumatoid Arthritis late symptoms l joint destruction l pain l deformity l instability

Rheumatoid Arthritis advanced joint changes

Rheumatoid Arthritis X-ray findings l joint space narrowing l peri-articular osteopenia l erosions

l stop synovitis l prevent deformity l reconstruct l rehabilitate Rheumatoid Arthritis treatment

Rheumatoid Arthritis prognosis l 10% improve l 60% intermittent, slowly worsening l 20% severe joint erosion, multiple surgery l 10% completely disabled

Osteoarthritis A chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margins (osteophytes) and capsular fibrosis

Osteoarthritis classification l Primary or idiopathic l Secondary - infection - dysplasia - Perthes’ - SUFE - trauma - AVN

Osteoarthritis aetiology l Genetic l metabolic l hormonal l mechanical l ageing

Osteoarthritis mechanism 1 Disparity between:- stress applied to articular cartilage and strength of articular cartilage

Osteoarthritis mechanism 2 Increased stress (F/A) l increased load eg BW or activity l decreased area eg varus knee or dysplastic hip

Osteoarthritis mechanism 3 Weak cartilage l age l stiff eg ochronosis l soft eg inflammation l abnormal bony support eg AVN

Osteoarthritis X-ray changes l joint space narrowing l subchondral sclerosis l osteophytes l cysts

Osteoarthritis X-ray changes

Arthritis symptoms l pain l swelling l stiffness l deformity l instability l loss of function

Arthritis non-surgical treatment l analgesia l disease modifying drugs (RA) l altered activity l walking aids l physiotherapy

Arthritis surgical treatment l arthroscopy l osteotomy l arthrodesis l excision arthroplasty l replacement arthroplasty

Arthritis knee arthroplasty

Joint Replacement indications l Disabling pain l Functional limitations

Joint Replacement history l pain l function l medical l expectations

Joint Replacement history - pain l Site l radiation l limiting activity l disturbing sleep l analgesics

Joint Replacement history - function l Walking distance l walking aids l low chairs l foot care l stairs

Joint Replacement examination l gait l limb alignment l range of movement l stability l peripheral circulation l skin condition

Joint Replacement investigation l X-ray - alignment - deformity - previous fractures and implants - AVN - osteophytes - bone loss l CT, MRI, bone scan - rarely

Joint Replacement ideal l painless joint l full range of movement l stable l permanent

Joint Replacement hip complications l dislocation - 1% l loosening >90% 10y survival l DVT / PE l infection - 1%

Joint Replacement knee complications l limited ROM l patellar instability 3-5% l loosening > 90% 10y survival l DVT / PE l infection - 2%

Ankylosing Spondylitis l 0.2% of population l mainly affects spine and SI joints l male > female l HLA B27 in 90% l synovitis l enthesopathy

Ankylosing Spondylitis hips and knees l flexion deformities l arthritis with large osteophytes l ankylosis

Ankylosing Spondylitis diagnosis Rome criteria A - bilateral SI B - stiff lumbar spine - stiff thoracic spine A+ 1xB - decreased chest or 4xB expansion (<7cm) - >3/12 LBP - iritis

Ankylosing Spondylitis X-ray changes l joint space narrowing l large osteophytes l heterotopic bone l ankylosis