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Osteoarthritis Fk Umy

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  • OSTEOARTHRITISAgus Widiyatmoko

  • *INTRODUCTIONMostly elderlyAgeing process???Repeated micro trauma to the joint??

  • OSTEOARTRITIS

    *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.

  • *INTRODUCTIONMany theories of etiology and pathogenesis

    Start from breakage of cartilage and pathologic condition of the synovium

    Definite treatment ???

  • Epidemiology

    PopulationAge (yrs)Female (%)Male (%)English>357069US Caucasians>404443Alaskan Eskimos>402422Jamaican (rural)35-646254Pima Indians>307456Blackfoot Indians>307461South African Black>355360

  • Indonesia

    Community based

    Urban RuralMalang*10.0 % 13.5%Bandungan** 5.4%* Kalim H, cs 1994, ** Darmawan, 1992

    Hospital based

    RSCM43.8% (total rheumatic patients), 1991-199435.8% (total rheumatic patients), 2000Epidemiology

  • Prevalence of Radiographic Evidence of OA in the PopulationPrevalence (%)Age (years)

  • *ETIOLOGY

    Knowing a normal tissue around the jointChondrocytesCollagenProteoglycanSynovial fluid

  • NORMAL versus OACapsul thicknessKnee OANormal KneeBone cystSubchondral schlerosis

    Cartilage fibrillationSynovium hypertrophyOsteophyte formationCapsulCartilageSynoviumBone

    *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.

  • *CARTILAGEHyaline cartilageFibro cartilage

  • *CARTILAGEFibro cartilage : meniscus

  • 1.psd

    *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.

  • Stresses AbnormalNormal cartilageCartilage abnormalAgingGenetic and metabolic diseaseInflammationAdministration of toxinsImmune responseObesity, Developmental and anatomic abnormalitiesBony remodeling and micro fractureLoss of joint stabilityTraumaTheory A Biomaterial failure collagen networkfractureTheory BCell injuryIncrease of degradative responsesInhibitors reducedProteolytic enzymes increasedDestruction of prteoglycans collagenand other proteinsProteoglycan unravelling

    Cartilage breakdown

    *

  • Degenerative Joint DiseasePathophysiology

    *

  • Degenerative Joint DiseaseClinical ManifestationsPain

    Malfunction

    Deformity

    Elderly,Repetitive Trauma or Major Trauma to Joint

    *

  • Assessment of patients with OANature of painMechanical - related to useInflammatory - stiffness, pain aggravated by restNocturnal - suggest intraosseous hypertensionSudden deterioration - consider sepsis, avascular necrosis, fracture, or crystal synovitis

    Clinical ExaminationPeriarticular or articular source of painGeneralised pain? - consider fibromyalgiaPresence of deformity?Evidence of muscle wasting?Local inflammation or effusion?Generalised or localised OA?

  • WeightPotentially modifiable risk factor

    Joint lockingOrthopaedic referral probably appropriate

    Sleep disturbanceMay be associated with fibromyalgia and depression

    Comorbid disease

    Assessment of patients with Osteoarthritis

  • *CLINICALAltman criteria'sAchlback classificationOuterbridege gradingKellgreen

  • *ALTMANS CRITERIAS CLINICAL and LABORATORY

    Knee pain plus at least 5 of these 9 : 1. Age > 50 years 2. Stiffness < 30 min 3. Crepitus 4. Bony tenderness 5. Bony enlargement 6. No palpable warmth 7. ESR < 40 mm/h 8. RF < 1: 40 ( Rheumatoid Factor ) 9. SF OA ( Synovial Fluid Sign of Osteoarthritis)

  • *ALTMANS CRITERIASClinical and Radiographic

    Knee pain + at least 1 of these 3 : 1. Age > 50 years 2. Stiffness < 30 min 3. Crepitus + osteophytes

  • *ALTMANS CRITERIASClinical

    Knee pain + at least 3 of these 6 : 1. Age > 50 years 2. Stiffness < 30 min 3. Crepitus 4. Bony tenderness 5. Bony enlargement 6. No palpable warmth

  • *KELLGREN LAWRENCE GRADINGGRADE CRITERIA

    0 Normal 1 Doubtful narrowing of joint space, possible osteophytes 2 Definite osteophytes, absent or questionable narrowing of joint space 3 Moderate osteophytes, definitive narrowing, some sclerosis, possible deformity 4 Large osteophytes, marked narrowing, severe sclerosis, definite deformity.

  • *RADIOLOGYSOFT TISSUE : ATROPHY JOINT SPACE : NARROWINGBONE : OSTEOPHYTE, SCLEROSING, BONE CYST, MALALIGNMENT (VARUS, VALGUS)

  • KNEE PAIN*

  • Synovial fluid (SF) criteria for OA are (1) White blood cell
  • *

  • *

  • *

  • *

  • *57/F, OA

  • *64/F, OA

  • *56/M, OA

  • presented at National congress of Indonesian Rheumatology Association. 3rd July 2005. Jogyakarta*69/F, OA

    presented at National congress of Indonesian Rheumatology Association. 3rd July 2005. Jogyakarta

  • *

  • *

    2.psd

  • *

  • *CLINICALAs a wholeHistory.

    AtrophyJoint Contracture Activity daily living

  • ACR 2000 Guidlines-Drug Therapy Options in Osteoarthritis

    Baseline program(Weight loss/exercise)

    Mild/moderate Moderate/severePain pain/inflammation

    AcetaminophenSteroids IA COX-2 specific Inhibitors

    NSAIDs Hyaluronans Traditional NSAIDs Tramadol (plus gastroprotection)Propoxyphene OpioidsSurgery

  • *TREATMENTConservativeOperative.Reduce the symptoms / pain, improve joint function, reduce the progress, and improve quality of life

  • *CONSERVATIVEPharmacogenic :NSAIDCox 2 inhibitor Intra articular injection: hyaluronic acid, analgesic. steroid

  • Things to consider when selecting an NSAID Are they different?goodmodbad

  • Rasio Selektivitas Cox2/Cox1DrugRasio Cox2/Cox1Piroxicam250Acetylsalicylic acid175Indomethacin 60Ibuprofen 15Paracetamol 7.4Sodium salicylate 2.8Carprofen 1Meloxicam 0.8Diclofenac 0.7Naproxen 0.6Nimesulide 0.1ROFECOXIBE 0.02

    Selektif Cox 2 Selektif Cox 1Adapted from Vane, J.R. IC50 Value (mol/L) of NSAIDs on COX-2 or COX-1 activity in intact cells

  • GI Events* Associated With NSAIDsMost Patients AsymptomaticN = 141N = 1,921Armstrong, Blower.Gut. 1987; 28: 527532Singh et al.Arch Intern Med.1996; 156: 15301536

    WithoutsymptomsWithsymptoms

    42%58%

    81%19%*Bleeding, perforation, and gastric outlet obstruction

  • Mortality Associated With TypicalNSAIDs vs Other Causes in USFries et al. Am J Med. 1991; 91: 213222Wilson, Crouch. Science. 1987; 236: 267270Annual risk of death (%)0.250.200.150.100.050.00

    0.400.350.30

  • *

  • Disease Modifying Osteoarthritis Drugs TetrasiklinGlycosaminoglycan polysulfuric acid (GAPS)Glycosaminoglycan peptide complexesPentosan polysulfateGrowth factors and sitokin (TGF-b)Terapi genetikTransplantasi stem cellOsteochondral GraftAnti TNF Alfa (Etanercept)

  • Hyaluronic acid Bone Bone Cartilage

    OsteoclastOsteoblastChondrocytesHAHASynovial liningCapsuleSynthesis: Synoviocyte, chondrocyte

  • Reduction of synovial membrane inflammationin the treatment using hyaluronic acid

    Before treatmentAfter treatment

  • *OPERATIVEArthroscopy : lavage, shaving, drilling.OsteotomyArthroplastyMozaic graftStem cell graft

  • *ARTHROSCOPY

  • *ARTHROSCOPY

  • *ARTHROSCOPY

  • *OSTEOTOMY

  • *MOSAIC-PLASTY

  • *MOSAIC-PLASTY

  • *MOSAIC-PLASTY

  • *MOSAIC-PLASTY

  • *ARTHROPLASTY

  • *ARTHROPLASTY

    6.psd

    7.psd

    8.psd

  • *STEM CELLS

  • *STEM CELLS

  • *STEM CELLS

  • *STEM CELLS

  • benefitriskMeasures the risk and benefit for your patients

  • ALHAMDULILLAHTERIMA KASIH*

    *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.*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.*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.*

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