1. Arthritis Hip and Knee Nigel Brewster 1998

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

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

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

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

6. 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

7. 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

8. Rheumatoid Arthritis early joint changes

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

10. Rheumatoid Arthritis advanced joint changes

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

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

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

14. 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

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

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

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

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

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

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

21. Osteoarthritis X-ray changes

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

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

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

25. Arthritis knee arthroplasty

26. Joint Replacement indications l Disabling pain l Functional limitations

27. Joint Replacement history l pain l function l medical l expectations

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

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

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

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

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

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

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

35. 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

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

37. 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

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