1. DEGENERATIVE DISORDER
OF BONE AND JOINT
NYOMAN KERTIA
Section of Rheumatology, Internal Medicine Department
Faculty of Medicine GMU / Dr. Sardjito General Hospital

2. LUMBOSACRAL SPONDYLOSIS

3. LUMBOSACRAL SPONDYLOSIS
MAY CAUSE LOCALIZED LOW BACK PAIN
LBP INCREASES ET THE END OF THE DAY AND RADIATES ACROSS THE LOW BACK
NARROWING OF THE SPINAL CANAL  SPINAL STENOSIS & COMPRESSION OF NEURAL ELEMENTS
PAIN WORSENS WITH SPINAL EXTENSION AND IPSILATERAL BENDING
RO: OSTEOPHYTE, FACET JOINT NAROWING, PERIARTICULAR SCLEROSIS

4. SOME SOURCES OF LOW BACK PAIN
Posterior
Longitudinale
Ligament
Discus
Corpus
vertebrae
Procesus
spinosus
Nucleus
Flavum
Ligament
Annulus
Joint
capsul
Nerve
Spinal cordae and
capsule (dura)

5. OSTEOARTHRITIS

6. Prevalence of Radiographic Evidence of OA in the Population10 20 30 40 50 60 70
Knee, man
DIP, man
Knee, women
DIP, women
Prevalence (%)
Age (years)

7. PATHOGENESIS CHANGES IN ARTICULAR CARTILAGE & SUBCHONDRAL BONE
FAILURE OF CHONDROCYTES TO MAINTAIN THE BALANCE BETWEEN DEGRADATION AND SYNTHESIS OF EXTRACELLULAR MATRIX
PROTEINASES AND PROINFLAMMATORY CYTOKINES HAVE AN IMPORTANT ROLE
MECHANICAL STRESS CONTRIBUTES SIGNIFICANTLY TO DISEASE INITIATION & PROGRESSION

8. OSTEOARTHRITIS
The typical stance of a patient with knee OA: elderly female, often overweight, with genu varum deformity. They usually complain of a “mechanical” knee pain, characteristically felt on initial standing from a prolonged sitting position. Unlike patients with RA, those with OA do not have any systemic manifestations.
ACRFP

9. INFLAMMATORY ARTHROPATY

10. The pathologic features readily correlate with the radiographic features of knee OA, i.e. loss of joint space, subchondral cysts, and attempts at repair or regeneration such as sclerosis and osteophytes.

11. NORMAL versus OSTEOARTHRITIS
Normal Joint
OA Joint
Thickness of Capsul
Capsul
Bone Cyst
Cartilage
Subchondral
Sclerosis
Sinovium
OA primarily starts as a cartilage problem, later involving other structures. Once these are affected, the patient starts to develop the pain characteristic of this condition.
Cartilage Fibrillation
Sinovium Hypertrophy
Bone
Osteophyte Formation

13. CLINICAL FEATURES
THE MOST COMMONLY AFFECTED ARE: CERVICAL & LUMBAR SPINE, DIP, KNEE, HIP
STRONGLY AGED RELATED; ADDITIONAL RISK: FEMALE, OBESITY, TRAUMA, FAMILY HISTORY
SIGNS& SYMPTOMS: PAIN, SHORT-LASTING STIFFNESS, CRACKING & CREPITUS, MILD SWELLING, FUNCTIONAL LIMITATION
RADIOGRAPHS IS IMPORTANT IN MAKING THE DIAGNOSIS

14. Drug Therapy Options in Osteoarthritis (Weight loss / exercise)
ACR Guidlines
Drug Therapy Options in Osteoarthritis
Baseline program
(Weight loss / exercise)
Mild or moderate pain Moderate or severe pain
/ inflammation / inflammation
Acetaminophen Steroids COX-2 selective
intra articular Inhibitors NSAIDs
NSAIDs Hyaluronans Traditional NSAIDs
Tramadol intra articular ( plus gastroprotection)
Propoxyphene
Opioids
Surgery

15. DIFFERENTIAL DIAGNOSIS
INFLAMMATORY VS DEGENERATIVE ARTHROPATY
OSTEOARTHRITIS
RHEUMATOID ARTHRITIS

16. RHEUMATOID ARTHRITIS
This shows stage 4 or “burnt-out” RA , with the classical chronic hand deformities including joint subluxation.
ACRFP

17. SOFT TISSUE RHEUMATISM

19. CHEIROARTHROPATHY

20. TENDINITIS

22. BURSITIS

23. ANKYLOSING SPONDYLITIS

24. NON-BACTERIAL INFLAMASI
NORMAL
NON-BACTERIAL INFLAMASI
PURULENT
HEMORAGIK

25. Non-pharmacologic Treatment Options for Pain
Cognitive-Behavioral
Relaxation
Preparatory information
Imagery
Hypnosis
Physical Agents
Application of superficial heat and cold
Massage
Exercise
Immobilization
Electro-analgesia (eg, TENS)
Acupuncture
Carr DB, et al. AHCPR Pub. No

26. Pharmacologic Treatment Options for Pain
Nonopioid analgesics
paracetamol
tramadol
anti-inflammatory agents
Opioid analgesics
Local anesthetics, nerve block
Co-analgesic such B-vitamin, anti-epilepticum (carbamazephin, gabaphentin, pregabalin) &
tricyclic antidepressan
DMOADs (Disease Modifying Osteoarthritis Drugs)
SURGERY

27. Synthesis: Synoviocyte, chondrocyte
Hyaluronic acid
Bone
Cartilage HA
Capsule
Chondrocytes HA • • • • •
Synovial lining •   •  
Osteoclast
Osteoblast
Bone
Synthesis: Synoviocyte, chondrocyte

30. Hyaluronan works on cells that was involved in joint destruction
Inflammatory cells
synoviocytes
Chondrocytes
Decreases cell’s activity
viscoinduction
Improves cells metabolism
Neosynthesis of endogenous HA
JOINT CARTILAGE
Decreased inflammatory
process
Reconstruction on
supervicial level
Matrix synthesis
Improves tissue integration
Pharmacologic activities of HA

31. Standing
wrong
Right
Right
wrong
Sitting
Right
Sleeping
Wrong

32. DIFFERENTIAL DIAGNOSIS OF ARTHRITIS
INFLAMMATION NO/MILD
INFLAMMATION
MONO/ OLYGO POLY
ARTICULAR ARTICULAR DEGENERATIVE
RECURRENCE SYMETRICAL NON-SYMETRICAL
GOUT, CPPD RA, SLE AS, Ps. A, REITER
NON- RECURRENCE
SEPTIC
REMEMBER THE OTHER CLINICAL SIGNS,
SYMPTOMS AND LABORATORY RESULTS