Degenerative and Inflammatory Joint Disease

Question 1

components of articular cartilage

Answer 1

• thin superficial (tangential) zone
• middle (transitional) zone
• deep (radial) zone
• calcified zone

Question 2

resistance to compressive forces

Answer 2

middle -> deep

proteoglycans (CHONDROITIN, keratan sulfate)

Question 3

type of collagen in the ecm of cartilage

Answer 3

type 2

Question 4

hip pain radiates towards __

Answer 4

groin, lateral aspect of thigh, anterior thigh

mostly due to extremes of motion

Question 5

hallmark sign of weakness of hip abductors

Answer 5

trendelenburg sign

• stance phase of gait cycle
• weakness of abductors = dip on contralateral side

Question 6

range of motion of hip

Answer 6

flexion: 0-135 deg
extension: 0-30 deg
abduction: 45-50 deg
adduction: 20-30 deg
ext rot: 0-45 deg
int rot: 0-35 deg

Question 7

range of motion of knee

Answer 7

flexion 0-130 deg
full extension 0 deg
full flexion 100 deg

Question 8

pathophysio of osteoarthritis

Answer 8

• increase in inflammatory markers (il-6 il-1)
• final common pathway = injury to articular cartilage
• most common form of arthritis

Question 9

clinical manifestations of osteoarthritis

Answer 9

• women: hands and knees (distal interphalangeal joints)
• men: hips
• altered balance -> falls
• stiffness (>30 min in morning), swelling and pain, crepitus

Question 10

pathologic findings in osteoarthritis

Answer 10

• fibrillation of cartilage
• increase in water content
• altered proteoglycan content (inc)
• decreased collagen

Question 11

diagnosis of osteoarthritis

Answer 11

• no gold standard

- xray: joint space narrowing, subchondral sclerosis, osteophytes

Question 12

pathophysio of rheumatoid arthritis

Answer 12

• autoimmune, chornic

- unknown cause (genetic, bacterial, mycoplasmal, viral)

Question 13

clinical manifestations of rheumatoid arthritis

Answer 13

polyarthritis

• wrist, metacarpophalangeal, proximal interphalangeal
• elbow
• shoulder
• cervical spine
• hip, knee, ankle
• usually symmetrical/bilateral and migratory

extra-articular involvement

• vasculitis, pericarditis, skin nodules
• pulmonary fibrosis
• penumonitis and scleritis
• felty’s syndrome (arthritis, lymphadenopathy, and splenomegaly)

Question 14

pathologic findings in rheumatoid arthritis

Answer 14

• synovitis

- pannus formation: thickened synovium with activated t and b lymphocytes

Question 15

labs in rheumatoisd arthritis

Answer 15

• high titer of rheumatoid factor
• uniform loss of joint space
• articular erosions
• periaarticular osteoporosis/ osteopenia
• deformities and subluxations

Question 16

joint aspiration of ra vs oa

Answer 16

read

Question 17

general differences between ra and oa

Answer 17

ra: systemic, symmetris, small joints, young
oa: localized, asymmetric, large joints, older

Question 18

pathogenesis of osteonecrosis of the hip

Answer 18

• traumatic or idiopathic
• risk factors: alcohol abuse, gout, caisson disease, renal osteodystrophy, sickle cell anemia, steroids, trauma
• direct cell toxicity, coagulopathic states, fat emboli, vascular interruptions, elevated bone marrow pressure

Question 19

ficat classification of avascular necrosis

Answer 19

• higher stage = more symptomatic
• stage of collapse (stage 3) – crescent sign!

read!!

Question 20

treatment for osteonecrosis depends on __

Answer 20

• symptoms
• collapse of femoral head
• size of the lesion
• degree of involvement of weight bearing surface
• acetabular involvement

Question 21

pharmacologic agents for osteonecrosis

Answer 21

• in early stages
• statins
• anticoagulants and prostacyclin analogs
• inhibiting aggregation of platelets promotes blood flow
• bisphosphonates

Question 22

surgical treatment for osteonecrosis

Answer 22

• in later stages
• head-preserving treatment
• arthroplasty/replacement techniques

Question 23

type of head preserving treatment that is used in patients with >30% involvement of the head

Answer 23

vascularized fibular graft

• preferred for young patients (<50)
• not indicated for early disease

Question 24

what is arthroplasty

Answer 24

• final option
• larger lesions, > 3% of femoral head surface

types:

• resurfacing hemiarthroplasty
• hemiarthroplasty (poorer results)
• resurfacing arthroplasty
• total hip arthroplasty (most popular, modern)

Question 25

conservative methods to treat osteoarthritis

Answer 25

- weight loss - walking aids - limit activities - pain medications (acetaminophen, nsaids) - exercise: strength, rom, agility

Question 26

injections for osteoarthritis

Answer 26

- lidocaine test: diagnostic - corticosteroids: therapeutic - hyaluronic acid: for viscoelasticity

Question 27

surgical options for osteoarthritis

Answer 27

- joint preserving* (younger) - joint salvage procedures: arthrodesis - total joint replacement (hip and knee)

Question 28

what is joint debridement and synovectomy

Answer 28

- to relieve pain by synovium | - to prolong life of hyaline joint surface

Question 29

indications for joint debridement and synovectomy

Answer 29

- chronic synovitis - synovitis limited to membrane - recurrent hemarthroses - imminent destruction of joint by lysosomal enzymes from wbcs in infections - failure of conservative treatment

Question 30

contraindications for joint debridement and synovectomy

Answer 30

- reduced joint range of motion | - significant arthritis/cartilage involvement

Question 31

types of synovectomy

Answer 31

- open synovectomy (infectious) - arthroscopic synovectomy (degenerative arthritis) - radiation synovectomy (rheumatoid arthritis)

Question 32

cartilage transplant techniques

Answer 32

- for athletes with focal cartilage defects | - autologous chrondrocyte transplantation

Question 33

what is osteotomy

Answer 33

- break the bone incompletely so you have a hinge on one side - allows swinging of the bone in a direction to correct defects

Question 34

indications for high tibial osteotomy

Answer 34

- varus knees (for valgus = femoral osteotomy) - unicompartmental arthritis - relatively younger (<50) - pts with good range of motion - no knee instability - normal bmi goal: preserve native knee for as long as possible

Question 35

most common mode of failure of high tibial osteotomy

Answer 35

contralateral compartment disease

Question 36

reasons to consider osteotomy of the hip

Answer 36

- there is normal viable cartilage that may be moved to weight-bearing area where there was thinned cartilage - biomechanical load on the joints that cause pain are reduced

Question 37

what are femoral osteotomies

Answer 37

- performed in the intertrochanteric region | - "derorotation" procedures

Question 38

what is joint salvage

Answer 38

- creation of a bony fusion across a joint | - for younger or cannot get replacements

Question 39

what is the girdlestone procedure

Answer 39

- resection of the femoral head without replacement | - last option after failed replacement

Question 40

indications for girdlestone procedure

Answer 40

- severe infection - limited function - unreconstructable bone defects - poor medical condition - failed arthroplasty

Question 41

what is joint replacement

Answer 41

- last option - to relieve pain - uses prosthetic devices

Question 42

indications for total hip replacement

Answer 42

- debilitating pain - failure of conservative treatment - medically fit - no infection

Question 43

the force generated within a joint in response to the forces acting on it

Answer 43

joint reaction force

Question 44

indications for total knee replacement

Answer 44

- pain affecting activities of daily life - failure of conservative management - no infection - medically fit for surgery

Question 45

goals of total knee replacement

Answer 45

- neutral mechanical alignment - restore the joint line - normal q-angle - well balanced knee

Question 46

complications of arthroplasties

Answer 46

- infection - neurovascular injuries - revision (loosening and wear, osteolysis) - medical (dvt, pe, stroke) - dislocations - peri-prosthetic fractures