Arthritic conditions Flashcards
Define pseudogout?
- A metabolic disease resulting from desposition of CALCIUM PYROPHOSPHATE DIHDRATE (CPPD) crystals within the joint space
- Characterised by recurrent monoarticular arthritis
What is the epidemiology of pseudogout?
- Commonly affects the elderly
- rarely affects the young
Name associated conditions?
- Haemochromatosis
- Hyperparathyroidism
- SLE
- Gout
- RA
- Wilson’s disease
- Haemophilia
- Long term haemodialysis
- Chondrocalcinosis present in 7%
How is it different form gout?
- Affects older patient >60 yrs
- Affects more proximal joints
- weakly Positive befringement crystals
Describe the symptoms and signs?
Symptoms
- Acute onset joint tenderness
- warm , erythermatous joint
- Commonly on knee and wrist joint
Signs
- Erythermatous, monoarticular arthritis
- Joint tenderness to palpation
- May observe superficial mineral deposits under skin at affected joints
What is seen on xrays?
- Chondrocalcinosis- calcification of fibroartilage structures
- TFCC in wrist
- Mensicus in knee
How is pseudogout dx?
- Weakly POSTIVE BIFEFRINGENT RHOMBOID shaped crystals
What is the tx of acute gout?
- Acute
- NSAIDS
- Splints for comfort
- Chronic
- Non operative
- Intra-articular yttrium-90 injection
-
cochicine- 0.6mg PO for recurrent cases
- prophylatic cochicine can help to prevent recurrence
Complications of pseudogout?
- Can result in permanent damage to joints and renal disease
NB PSEUDO GOUT “P” for
- postive birefringent rhombpid crystals
- calcium Pyrophosphate dihydrate
What is the epidemiology of ankle arthritis?
Describe the pathophysiology of ankle arthritis?
- Less common than OA of knee/hip
-
Post traumatic arthritis
- Greater than 2/3 ankle arthritis
- Primary OA- Less than 10%
- RA
- Osteonecrosis
- Septic arthritis
- Gout
What is the pathoanatomy of ankle arthritis?
- Nonanatomic fracture healing alters the joint reaction forces of the ankle and changes the load bearing mechanics of the ankle joint
- Loss of cartilage on the talus and tibial plafound-> joint space naarowing, sunchondral sclerosis and Eburnation
Decribe the anatomy of the ankle joint?
- Ginglymus joint- HINGE
- Talar dome is biconcave with a central sulcus
- Dorsiflexion 20o
- Plantarflexion 50o
What are the signs and symptoms of ankle arthritis?
Symptoms
- Pain on weight bearing
- Reduction in motion
Signs
- Joint effusion
- reduced ROM cf contralateral side
- Angular deformity if hx of trauma
What investigations are useful?
Radiographs
- AP standing, lateral standing, oblique
- Loss of joint space, subchondrial sclerosis, Eburnation, possible angular deformity
What is the tx for ankle arthritis?
- Nonoperative
- activity modification, bracing to immobilise ankle,NSAIDS
- single rocker can improve things
- Surgery
-
Debridement with anterior tibial/dortsal talectomy
- Mild disease/ pai onpush off
- Distraction arthroplasty
-
Supramalleolar osteotomy
- medial focused ankle pain
-
Arthrodesis
- eldery less active patient
-
Arthroplasty
- Post-traumatic/ inflammatory arthritis/ eldery pt
- Pt selection is key
What are the Ci for ankle arthroplasty
- Uncorrectable deformity
- Severe osteporosis
- talus ostenecrosis
- Charot joint
- ankle instablity
- obesity
- Young labourer
- Increased reisk of failure and revision
What are the outcomes and complcations of ankle arthrodesis?
- Outcome- relief in pain and return to ADL
- Complications
- by 10 yrs - 50% subtalar arthritis
-
Non union
- RF= Smoking
- Adjacent joint fusion
- Hx of failed arthrodesis
- Avascular necrosis
What are the outomes and complications of ankle arthroplasty?
- Recent 5-10 yr fu showed 90% good- excellent results
- Long term studies results still pending
- complications
- syndesmosis nonunion
- Wound infection
- Deep infection
- Osteolysis
How wpud you tx metatarsal prominence-> ulcers?
Double Rocker
What is the consx tx of toe tip ulceration?
Severe angled rocker
What consx tx is available for fixed angle dorsiflexion deformities?
Negative heel rocker
Define midfoot arthritis?
Arthritis in
- Naviculocuneiform
- Intercuneiform
- Metatarsal cuneiform
What is the aetiology of midfoot arthritis?
- Idiopathic- primary osteoarthritis
- Posttraumatic
- Inflammatory
What is the pathology of midfoot arthritis?
- Large forces seen by joints that have limited motion
- Soft tissues that support joints abnormally high forces over time
- Results in midfoot collapse
What are the symptoms and signs of midfoot arthritis?
Symptoms
- Midfoot pain adn in arch with push off
Signs
- Longitudinal arch collapse- Meary’s angle normally =O- but in this negative with collapse
- Midfoot collapse- Looks like PTTI
- Forefoot abduction
- Hindfoot valgus
- Equinnus contracture of achilles tendon
- Halux valgus
- palpation of arch/midfoot-> pain
What do you see on xrays of midfoot arthritis?
- Lateral- loss of co-linerity between talus and 1st MT= Meary’s line
- Apex of deformity is at level of midfoot
- may shows collapse of LONGITUDINAL ARCH
- AP
- Arthritic signs in midfoot
- Abduction of forefoot
What is the ddx of this
- Post tibial tendon insufficiency
- Midfoot arthritis
- Post traumatic LIs- Franc injury
- Lateral ankle instability
What is the TX of midfoot arthritis?
- Non operative
- NSAIDS, Activity modification, orthotic/bracing
- first line tx
- steriods injections under radiographic guidance
- orthotics
- cushioned heel
- longitudinal arch supports
- stiff sole with rocker bottom
- Operative
-
MIDFOOT ARTHRODESIS +/- TAL +/- HINDFOOT REALIGNMENT
- failure of non op tx
- Outcomes= midfoot joints are non essential joints
- arthrodesis results in close to normal foot function
- Achilles tendon lengthening/ hindfoot relaignment
- may need to be done concomitantly
-
MIDFOOT ARTHRODESIS +/- TAL +/- HINDFOOT REALIGNMENT
Decribe the technique of midfoot arhrodesis?
- Realignment arthrodesis
- Fusion of 1st RAY via the TARSO-METATARSAL joint
- Fusion of the 2/3rd rays via the NAVICULOCUNEIFORM/INTERCUNEIFROM joint
-
Don’t fuse 4/5 TMT joints
- lateral ray facilitates foot accomdation during stance
- Interpositional arthroplasties of 4/5 Tarsometatarsal joints
- for select cases
- will maintain length of lateral column
- can assist with gait accomodation
- can use screws. staples and plates for midfoot fusions
What is the cause of tibiotalar impingment?
- Osteophyte impingment in anterior tibiotalar joint
- Excessive anterolateral soft tissues or posterior soft tissue or osseous abnormalities
What is the epidemiology of tibiotalar impingment?
- Common in athletes who play on turf or on grass including
- Rugby
- football
- dancers
What is the mechanism of tibiotalar impingment?
- Repetitive overuse injuries
- Trauma
- Degenerative sequlae
What are the symptoms and signs of tibiotalar impingment?
- Symptoms
- Pain in anterior ankle
- Signs
- Pain with forced dorsiflexion
- limited dorsiflexion
- Soft tissue swelling and effusion may be evident
- subtalar joint is pain free
What imaging is useful in tibiotalar impingment?
- xrays
- Ap, lateral standing and oblique
- spurs seen anterior disatl tibia or dorsal aspect of talus
- CT
- delinates extent of bony osteophytes
- MRI
- Shows spurring and fluid in joint
What is the tx of talotibial impingement?
- Non operative
- Therapy, lifestyle modficiations, NSAIDS
- first line tx
- Operative
- Arthroscopic excision
What are the complications of ankle arthroscopy?
- Superifical peroneal nerve injury to anterolateral portal creation
- Saphenous vein injury during anteromedial portal creation
- Dorsal neurovascular bundle during tibiotalar spur removal
