Day3-04Common Orthopaedic problems_กิตติพงษ์_blind

KNEE PAIN
KNEE PAIN: OSTEOARTHRITIS VS. ???
¢  Osteoarthritis
of the knee
—  degenerative joint disease characterised
by progressive softening and
destruction of articular cartilage
associated with new bone formation and
capsular fibrosis
—  The
commonest joint disease
—  50%
of patients are older than 60 years
¢  Not
purely “degenerative” because it is
accompanied by a healing process in the form of
reactive new bone formation
CLASSIFICATION
¢  Primary:
no obvious cause
¢  Secondary: predisposing factors
— 
— 
— 
— 
— 
— 
— 
Trauma
Congenital predisposition : Blout
Infection
Metabolic: gout, Paget, hemochromatosis
Endocrine: acromegaly, hyperparathyroidism
Occupation
Obesity
ETIOLOGY
¢  Mechanical
derangement
¢  Unbalance reponse in wear vs. repair
¢  Failure of chondrocytes to repair damaged
cartilage
¢  Mechanical consideration
— 
Abnormal loads on normal joint
¢ 
— 
Articular cartilage can withstand loads up to 25 Mpa
without damage
Normal load on abnormal joint
¢ 
Instability or altered congruence concentrates shear and
compression forces on specific regions of cartilage
PATHOGENESIS
¢  Theory
— 
— 
— 
— 
— 
— 
— 
1
Fatigue of collagen meshwork
Increase hydration of articular cartilage and loss of
proteoglycans from matrix into the synovial fluid
Cartilage softens, chondrocytes die and release
proteolytic enzymes causing further damage
Cartilage deformation
Cartilage becomes less capable of taking load
Bone becomes more dense in response to loading
Osteophytes form to increase
PATHOGENESIS
¢  Theory
— 
— 
— 
— 
— 
2
Microfractures following repetitive loading
Healing develops an uneven surface
Stress
Articular loss in areas of maximum stress
Underlying bone hardened
PATHOLOGY
¢  Cartilage
damage
¢  Osteophytes
¢  Subconchondral sclerosis
¢  Subconchondral cysts
¢  Capsular thickening and fibrosis
¢  Mild synovitis
¢  Loose bodies
MOLECULAR PATHOLOGY
—  Cytokines
balance in proteolytic/
synthesis of cartilage
—  Enzymes
involve in proteolytic digestion
of cartilage such as interleukin -1 and
tumor necrosis factor-B
—  Tissue
growth factor-B and insulin
growth factor-1 helps in cartilage
systhesis
HISTORY AND PHYSICAL
¢  Elderly
with knee pain
¢  Start up pain
¢  Insidious
¢  Morning stiffness
¢  Loss of function
¢  Loss of motion
¢  Bony enlargement of joints
¢  Crepitus on motion
¢  Pain with motion
¢  Malalignment and/or joint deformity
FILM STANDING KNEE AP, LAT
¢  Kellgren
and Lawrence grades of knee
¢  Grade 0: no osteophytes, normal joint space
¢  Grade 1: doubtful narrowing, possible osteophytic
lipping
¢  Grade 2: minimal but definite osteophytes, joint
space narrowing
¢  Grade 3: definite and moderate osteophytes,
definite narrowing of joints space, some sclerosis
and possible deformity of bone contour
¢  Grade 4: large osteophytes, marked narrowing of
joint space, severe sclerosis and definite
deformity of bone contour
MEDICATION
¢  Analgesics:
paracetamol, NSAIDS, opiods
¢  Disease modifying osteoarthritis drug (DMOAD)
— 
— 
— 
Recognition of chondroprotective drugs that reduce
cartilage breakdown and stimulate matrix repair
But not all sturctural improvement relieves illness
Two additonal terms
¢  Structure
modifying OA drugs (SMOAD)
¢  Symptomatic slow-acting drugs for osteoarthritis:
(SYSADOA)
glucosamine sulfate, chondroitin sulfate, diacerein,
hyaluronic acid
GLUCOSAMINE SULFATE
(VIATRIL-S, GLUCOSA,FLEXA)
¢  Naturally
occurring chemical in body use in
building tendons, ligaments, cartilage and
synovial fluid
— 
Component of glycoaminoglycans in matrix of
cartilage and synovial fluid
¢  Shellfish
(chitin)
¢  Different forms: glucosamine sulfate,
glucosamine hydrochloride, N-acetyl-glucosamine
¢  Scientific research on glucosamine sulfate
STUDIES AND RESEARCHES
¢  Long
term effects of glucosamine sulphate on
osteoarthritis progression: a randomised,
placebo-controlled clinical trial
¢  Jean Yves Reginster et al
¢  The Lancet, Volume 357, issue 9252, pages
251-256 January 2001
¢  Randomised, double-blind placebo controlled trial
212 patients with OA knee to take 1500mg oral
glucosamine sulfate for 3 years
¢  Weightbearing,
AP radiographs each knee in full
extension at enrolment, 1 year and 3 years
¢  Mean joint-space width of medial compartment of
tibiofemoral joint assessed by digital image
analysis
¢  Minimal joint-space width was measured by
visual inspection with a magnifying lens
¢  106 patients on placebo showed progressive-joint
space narrowing (mean joint space loss 0.31mm)
¢  106 patients on glucosamine shows no
significant joint-space loss (mean joint space loss
0.06mm)
STUDIES AND RESEACHES
¢  NIH
study of glucosamine/chondroitin arthritis
intervention trial (GAIT) à disappointing results
— 
— 
— 
— 
— 
— 
Short term (6 months) study
5 treatment groups: glucosamine alone, condroitin
sulfate alone, glucosamine and chondrotin sulfate
combo, celecoxib, placebo
Pain relief in positive control (celecoxib vs placebo)
Not significant in other groups vs placebo
Subset study: moderate to severe pain shows
significant pain relief in combo vs placebo
Mild pain may not achieve significant pain relief
GLUCOSAMINE SULFATE
¢  Side
— 
— 
— 
— 
— 
— 
— 
effects
Nausea
Heartburn
Diarrhea
Constipation
Drowsiness
Skin reactions (shellfish allergy)
Headache
GLUCOSAMINE SULFATE
¢  Interact
with DM medication: acarbose,
acetohexaminde, cholorpropamide, glipizide,
metformin
¢  Secretion of insulin by inhibiting glucokinase.
¢  OK in HbA1c < 6.5%
¢  Aware when patient needs tight DM control
¢  Close monitor of blood sugar
ADVICE FOR PATIENTS BUYING THEIR OWN
GLUCOSAMINE SULFATE
¢  Many
over-the-counter supplements
¢  Avoid glucosamine sulfate *NaCl (or KCl), NAG
(N-Acetylglucosamine)
¢  Marketed with combinations (with chondroitin
sulfate) (artroforte)
¢  Not much evidence for combo effects
GLUCOSAMINE SULFATE
Price at local pharmacy
Viartril S sachet
Glucosa sachet
Flexa sachet
DIACEREIN
¢  “The
efficacy and safety of diacerein in the
treatment of painful osteoarthritis of the knee”
Karel Pavelka et al.
Arthritis & Rheumatism vol.56, no 12, December 2007
Randomized, multicenter,double-blind, placebocontrolled study
168 painful OA knee followed up for 6 months with
mostly KL grade 2/3
DIACEREIN
¢  Improve
in pain
¢  NSAID-sparing side effects
¢  Side effects: GI
— 
Loose stool, diarrhea, freqent bowel movements
DIACEREIN
¢  Cochrane
— 
— 
— 
— 
— 
— 
library survey
Seven studies of moderate to high quality
2000 people
100 mg diacerein vs placebo vs NSAIDS
2 months and 3 years
Pain improvement
No slowing of OA knee progression
OARSI
OSTEOARTHRITIS RESEARCH SOCIETY
INTERNATIONAL
¢  2008:
recommendations for management of hip
and knee arthritis
¢  16 experts from USA, UK, France, Netherlands,
Sweden, Canada
¢  Review 1945 – 2006
¢  25 recommendations
— 
— 
— 
12 non-pharmacological therapy
8 pharmacological therapy
5 surgical treatments
NON-PHARMACOLOGICAL MODALITIES
¢  Walking
aids
¢  Weight loss
¢  Exercise
¢  Thermal modalities
¢  Physical therapy, TENS for short term pain
control
¢  Acupuncture for symptomatic relief
PHARMACOLOGICAL MODALITIES
¢  Acetaminophen
up to 4g/day
¢  NSAIDS use at lowest effective dose and avoid
long term use
¢  Topical NSAIDS
¢  IA injections with corticosteroids
— 
Caution too-frequent use (not more than 4/year!)
¢  IA
injections hyaluronate
¢  Glucosamine/chondrotin sulphate/diacerein
— 
Discontinue in 6 months if no response
¢  Opiods
¢  OARSI
part III 2010: Avocado soybean unsponifiables, vitamin E
¢  www.oarsi.org
AMERICAN ACADEMY OF ORTHOPAEDIC
SURGEONS OA KNEE GUIDELINE (NONARTHROPLASTY) 2008
¢  22
recommedations
¢  Unable to recommend for or against use
acupuncture
¢  Not prescribe glucosamine and/or chondroitin
sulfate with symptomatic OA knee
¢  Recommend acetaminophen and NSAIDS
¢  GI risk (age >=60, Hx GI disease, concurrent
corticosteroids and anticoagulants) to add gastroprotective agent or Cox 2 inhibitors
¢ 
28 JUNE 2554
DIAGNOSIS + AGE > 56
¢  American
rheumatology association
¢  3 symptoms: persistent knee pain, limited
morning stiffness, reduced function
¢  3 signs: crepitus, restricted movement, bony
enlargement
¢  SYSADOA
— 
— 
prescription requires
Xray AP,Lateral standing
Kellgren Lawrence (KL) grading
NON-PHARMACOLOGICAL TREATMENT FOR
3 MONTHS
¢  Weight
¢  Exercise
¢  Walking
aid
¢  Rheumatologist
¢  PMR
¢  Orthopedic
surgeon
¢  SYSADOA
— 
— 
— 
— 
— 
KL grade 2 or more
6 weeks
Cannot supplement with NSAIDS for more than 2
weeks
Evaluate by 3 months
Total 6 months of SYSADOA medication and 3 month
break
58 YEARS FEMALE
XRAYS DON’T WEEP BUT PATIENTS DO.
KNEE PAIN DDX
¢  ***Bursitis
¢  ***Tendonitis
¢  Traumatic
knee pain: meniscus
PES ANSERINE BURSITIS
WORK RELATED PROBLEMS
ELBOW PAIN
¢  Lateral
epicondylitis (tennis elbow)
¢  Medial epicondylitis (golfer elbow)
LATERAL EPICONDYLITIS (TENNIS ELBOW)
¢  Anatomy:
¢  Humerus,
radius, ulna
¢  Bony bumps at bottom of humerus called
epicondyle
¢  Extensor tendons attach to lateral epicondyle
¢  Extensor Carpi Radialis Brevis (ECRB)
CAUSE
¢  Overuse
— 
— 
— 
Damage to specific forearm muscle
ECRB helps stabilize wrist when elbow is straight
Weak ECRB à Microscopic tears where it attaches
to the lateral epicondyle à pain
¢  Activities
— 
— 
Repetitive and vigorous use of forearm muscle
Painters, plumbers, carpenters, auto workers, cooks,
butchers
¢  Age
¢  Unknown
etiology
SYMPTOMS
¢  Pain
on outer part of elbow
¢  Weak grip strength
¢  Worsen with forearm activity
SIGNS
¢  Pain
over lateral epicondyle on palpation
PAIN ON PASSIVE FLEXION OF WRIST
(STRETCHING EXTENSORS)
PRONATE FOREARM AGAINST RESISTANCENO PAIN
Forearm supination against resistance causes pain!
PAIN WORSEN ON RESISTED EXTENSION OF
WRIST WITH ELBOW EXTENDED
MEDIAL EPICONDYLITIS (GOLFER’S
ELBOW)
¢  Pain
at medial side of elbow
¢  Injury to wrist flexors
¢  Increases with wrist flexion
¢  Increases with resisting wrist pronation
INVESTIGATION
¢  X-rays:
exclude arthritis of elbow
¢  EMG: rule out radial nerve compression
TREATMENT
¢  Nonsurgical
— 
— 
— 
— 
— 
— 
Rest
NSAIDS
Physical therapy
Brace
Steroid injections
Extracorporeal shock wave therapy
¢  Surgical
— 
— 
Open
Arthroscopic
TENNIS ELBOW SUPPORT
INJECTION WITH LIDOCAINE AND STEROID
STRECHING AND STRENGTHENING
PROGRAM
WRIST/HAND:
¢  Dequervain
tenosynovitis
¢  Carpal tunnel syndrome
¢  Trigger finger
STENOSING TENOSYNOVITIS
(DE QUERVAIN’S TENOSYNOVITIS)
¢  Tenosynovitis
wrist
— 
— 
of first dorsal compartment of the
Abductor pollicis longus
Extensor pollicis brevis
PRESENTATION
¢  Pain
at the dorsolateral aspect of wrist/ with
thumb motion/ with radial or ulnar deviation of
wrist
¢  Mother with young infants
¢  Finkelstein test: flexion of thumb and ulnar
deviation of wrist
FILM WRIST AP,LAT
¢  DDx:
— 
— 
Osteoarthritis at thumb carpometacarpal (CMC) joint
Fracture Scaphoid
TREATMENT
¢  Medical
— 
— 
— 
— 
— 
rest
Splint with thumb brace
NSAIDs
Physical therapy
Injection with steroid:
¢ 
Make sure the injection is placed in the sheath and not
subcutaneously which can lead to fat and dermal atrophy.
EPL tendon!
EPB tendon!
Anatomical
snuff box!
APL tendon!
Extensor
retinaculum!
STEROID INJECTION: 1 ML OF
1%LIDOCAINE + 1 ML CORTISONE
SURGICAL RELEASE OF 1
ST
DORSAL
COMPARTMENT TO RELIEVE ENTRAPMENT
CARPAL TUNNEL SYNDROME
¢  Compressive
neuropathy of the median nerve
¢  Anatomy:
— 
— 
— 
Three sides of carpal bones
Covered by transverse carpal ligament
Inside median nerve and flexor tendons
¢  Most
common peripheral compressive neuropathy
HISTORY AND PHYSICAL
¢  Pins
and needles paresthesia
¢  Pain
¢  Median
nerve distribution
PARAESTHESIA WITH HYPERFLEXION OF
WRIST FOR 60 SECONDS: PHALEN SIGN
PARAESTHESIA WITH TAPPING THE VOLAR
WRIST OVER THE MEDIAN NERVE: TINEL SIGN
WEAKNESS/ATROPHY OF THENAR
MUSCLE
INVESTIGATION
¢  EMG
TREATMENT
¢  Rest
wrist
¢  Splint with wrist brace
¢  NSAIDs
¢  Corticosteroid injection: use with caution
INDICATION FOR SURGICAL RELEASE OF
TRANSVERSE CARPAL LIGAMENT
¢  Fail
conservation treatment
¢  Thenar muscle weakness/ atrophy
¢  UNTREATED
à thenar atrophy, chronic hand
weakness and numbness along median nerve
distribution
TRIGGER FINGER
(STENOSING TENOSYNOVITIS)
¢  Flexor
tendon irritated as it slides through
tendon sheath tunnel.
GREEN’S STAGES
¢  Grade
I (pretriggering) – pain, history of catching
that is not demonstrable on clinical examination;
tenderness over A1 pulley
¢  Grade II (active) – demonstrable catching,but with
the ability to actively extend the digit maintained
¢  Grade III (passive) – demonstrable locking in which
passive extension is required (IIIA) or unable to
actively flex (IIIB)
¢  Grade IV (contracture) – demonstrable catching
with a fixed flexion contracture of the PIP joint
GRADE II
TREATMENT
¢  Medication
¢  Stretching
flexor tendon
INJECTION TRIAMCINOLONE + LIDOCAINE
SURGICAL RELEASE AFTER FAILURE OF
CONSERVATIVE TREATMENT
THANK YOU!