Degenerative

Arthropathies
Definition
Are due to degenerative processes
that affect joint and bone tissue
Conditions under this type
Osteoarthritis
Cervical spondylosis
Avascular necrosis
Osteoarthritis
Osteoarthritis
A slowly progressive musculoskeletal
disorder affecting the joints of:
the hands ( those involved with a pinch
grip)
Spine
weight bearing jts ( hip, knee) of LE
The most common articular disorder
Other names
Ostoearthrosis
Degenerative Joint Disease (DJD)
Hypertrophic Arthritis
Degenerative Disc Disease ( DDD, in the
Spine)
Generalized Osteoarthritis ( Kellegrens
Syndrome)
Epidemiology:
Associated with increased age
More common in women than men
Radiographic evidence in > 50-80% of
those 65 y/o.
Estimated 2-3 % of the audit population
has symptomatic OA.
Risk Factors for OA:
Obesity
Heredity ( esp. OA of the DIP jts)
Age
Previous Joint Trauma
Abnormal Joint Mechanics ( Excessive
knee varus or valgus )
Smoking ( may contribute to
degenerative joint dse)
Pathologic Features of OA
EARLY:
Swelling
Loosening of collagen framework structure
restraint
Chondrocytes increase proteoglycan
synthesis but also realease more
degradative enzymes.
Increase Cartilage Water Content
Pathologic Features of OA
LATER
Degredative Enzymes break down
protooglycans faster than it can be
produced by chondrocytes, resulting in
diminished proteoglycan content in the
cartilage.
Articular Cartilage thins and softens ( jt-
space narrowing will be seen eventually)
Fissuring and cracking of cartilage.
Repair attempted but inadequate
Pathologic Features of OA
LATER
Underlying bone is exposed, allowing
synovial fluid to be forced by the
presence of wt into the bone. This shows
up as cyst or geodes on radiograhs
Remodelling and hypertrophy of the
subchondral sclerosis and osteophytes
(spurs) formation
Classification of OA
Idiopathic
Secondary
Classification of OA
Idiopathic
A. Localized OA
B. Generalized OA includes 3 or more areas
(Kellgren-Moore)
Classification of OA
Secondary
A. Trauma
B. Congenital or developmental
C. Metabolic
D. Endocrine
E. Calcium deposition diseases
F. Other bone and joint diseases
G. Neuropathic (Charcot joints)
H. Endemic
I. Miscellaneous
Clinical manifestations
Pain in involved joints
Pain worse activity, better with rest
Morning stiffness ( if present) < 30 mins
Stiffness after a period of immobility
( gelling)
Clinical manifestations
Joint enlargement
Joint Instability
Limitation of joint mobility
Periarticular Mm atrophy
Crepitus
RADIOGRAPHIC FEATURES:
No ankylosis
Alignment may be abnormal
Bone Mineralization
Bony Subchondral sclerosis
Bony Spurs ( Osteophytes )
RADIOGRAPHIC FEATURES:
Bony Spurs ( Osteophytes )
No Calcification in cartilage
Cartilage space narrowing which is non-
uniform (occurs in area of maximal
stress in wt bearing jts.)
Laboratory Findings:
ESR normal
RF Negative
ANA not present
Synovial Fluid
High Viscosity with good string sign
Color is yellow and clear
WBC counts typically < 1000-2000/
mm3
No crystals and negative cultures
Differential Dx of OA and RA
OA RA
non systemic systemic
non-inflammatory assoc. with
cutaneous
and
inflammatory
changes
affects wt. bearing jts small jts.
(-) RF (+) RF but not all
(-) subcutaneous (+) subcutaneous
nodes
Differential Dx of OA and RA
OA RA
Normal ESR inc. ESR;
and Serologic test
Leukocytosis
with
eosinophilia
clear synovial fluid; high synovial fluid is
turbid; viscosity
low viscosity
and few cells
with many
polymorphonuclear
cells
Differential Dx of OA and RA
OA RA
(+) osteophytes (-) osteophytes
DIP affectation terminal jts not

usually
affected ( ex.
DIP)
involve fewer jts involves
many jts
at particular
time
OA is sometimes difficult to
differentiate with RA because
sometimes the two may co exist.
OA maybe stipulated by gouty,
neuropathic or tuberculous jt dse.
MEDICAL MANAGEMENT
General Measures:
reassurance
rest/ modification of activity
Local Treatment:
Splints/ braces
Massage
Exercise
Pharmacologic Mx
Aspirin-drug of choice
NSAIDS
Corticosteroid
SURGERY - last resort
Indications:
Severe pain
Loss of function
Progression of deformity
SURGERY
SOFT TISSUE PROCEDURES
Synovectomy
Soft tissue release
Tendon transfer
SURGERY
BONE AND JOINT PROCEDURES
Arthrodesis
to relieve pain, result to a very stable joint but
sacrifices freedom of motion
Osteotomy
improve jt alignment
Arthoplasty
jt replacement to relieve pain and restore fxn
Cervical
Spondylosis
Cervical spondylosis
the degenerative changes which
occur to the intervertebral disc and
vertebral bodies.
EPIDEMIOLOGY:
Common in advancing age ( esp. in the
cervical spine)
Less than 40 y.o ( asymptomatic), 25%
have DJD, 4% have foraminal stenosis.
More than 70 yo: 70% have
degenerative spine changes.
ETIOLOGY
No specific cause
Factors contributing to degenerative
changes of the spine:
Aging
Trauma
Work activities
Genetics
PATHOPHYSIOLOGY
IV disc loses hydration with age, leading
to cracks and fissures.
Disc subsequently collapses owing to
biomechanical incompetence causing
annulus to bulge outwards
Surrounding ligaments also lose their
elastic properties and develop taction
spurs.
PATHOPHYSIOLOGY
Uncovertebral spurring occurs as a
result of the degenerative process in
which the facet jts. lose cartilage,
becomes sclerotic and develop
osteophytes.
Stenosis due to spur formation, disc
protrusion, ligamentum hypertrophy.
CLINICAL MANIFESTATION
Morning neck pain
Stiffness
Neck fatigue late in the day
Loss of neck ROM
Pain at the extremes of ROM extension
ROM is affected first
Sometimes crystallization
COMPLICATIONS
Neurological deficits
Vertebral artery injury
due to facet osteophyte formation
Myelopathy
if arthritis is combined with disc
degeneration or post disc herniation
Cervical spinal stenosis
DIAGNOSIS:
Plain films- later radiograph
CT scan- ( to R/O fx)
MRI- Most sensitive
MEDICAL MANAGEMENT
Long hot shower for morning stiffness
soft cervical collar
Pharmacologic Mx
NSAIDS
Possess unacceptable medical risk for
complication.
Acetaminophen
Avascular Necrosis
Avascular necrosis
Bone death resulting from blood
supply deprivation in the absence of
pyogenic and tuberculous infection
Osteonecrosis is the term currently
used recognizing the fact that bone
may die because of reasons other
than loss of circulation
Epidemiology
Sites of Predilection:
Femoral head
Carpal bones (Keinbocks disease & Preisers
disease)
Metatarsal head (Freibergs disease)
Tarsal navicular bone (Kohlers disease)
Talus
Segmented fractures
Other locations (less common)
Etiology
Any condition that cuts off blood
supply to the bone:
Trauma
Fractures
Dislocations
Surgery
Excessive stripping of the periosteum
Organ transplantation
Prolonged corticosteriod intake
Radiation exposure
Clinical Manifestations
General:
Local swelling
Tenderness
Thickening over affected bone
Limited ROM
Muscle atrophy
Clinical Manifestations
Specific:
Carpal bone osteonecrosis
LOM of wrist extension
Hip avascular necrosis
Pain in groin & thigh
Tenderness over hip joint
LOM in F-Ab-IR
Antalgic gait
X-ray shows Crescent Sign
Complications
Gout
Traumatic arthritis
Renal transplantation
Sickle cell disease and other
hemoglobinopathies
Caissons disease - decompression
sickness; divers paralysis
Diagnosis
X-ray
Thin radioluscent line beneath joint surface
Crescent Sign in hip avascular necrosis)
Denser area
Fragmentation
Thickening over fragmented area
Diagnosis
Scintigraphy using radioactive
technetium diphosphate
Cold initially
With time & revascularization becomes hot
Prognosis
May progress into osteoarthritis
Kohlers disease good prognosis; little
or no permanent disability
Medical / Surgical Management
Femoral head
Medical Management: (children)
Conservative protection of hip joint in abduction for
prolonged period until reconstitution of femoral head is
complete
Surgical Management: (older patients)
Intramedullary or muscle-pedicle bone grafting
Osteotomy
Interposition or replacement arthroplasty
Arthrodesis
Total hip replacement
For older patients and other patients with activity
restrictions
Medical / Surgical Management
Carpal bones (Keinbocks disease &
Preisers disease)
Medical Management:
Wrist immobilization in short dorsiflexion splint
Surgical Management:
Reserved only if immobilization gives
unsatisfactory healing
Simple excision
Total bone replacement
Arthrodesis
Medical / Surgical Management
Metatarsal head (Freibergs disease)
Medical Management:
Immobilization in a plaster boot or anterior arch
pad
Surgical Management:
Reserved only in late painful cases
Simple excision with use of anterior arch
support post-op
Medical / Surgical Management
Tarsal navicular bone (Kohlers disease)
Medical Management:
Use of longitudinal arch support & restriction of
activity
Immobilization with foot in slight inversion by
plaster cast for 6 8 weeks
If much pain upon weight-bearing
Surgical Management:
Usually not applicable