joint diseases (McCarrel) Flashcards
1
Q
Major classes of joint disease
A
- Developmental orthopedic dz
- Traumatic/degenerative arthritis
- Septic arthritis
- Immune mediated polyarthritis
2
Q
End result of untreated joint dz
A
fuundamentally the same
3
Q
Horses don’t get what kind of arthritis
A
rheumatoid arthritis
4
Q
Developmental orthopedic dzs
A
- Osteochondrosis
- Osteochondritis dessicans
- Subchondral bone cysts
- can be traumatic in origin
- Delayed ossification
- part of angular limb deformity complex of DODs
5
Q
Traumatic/Degenerative osteoarthritis
A
- Chronic degeneration of joint tissues
- irreversible changes to the joint
- loss of function
- pain
6
Q
Tissuse changes in OA
A
- Synovitis
- primary or secondary
- primary is reversible
- primary or secondary
- Capsulitis
- may be reversible
- fibrosis => decreased ROM
- irreversible
- Ligamentous or meniscal injury
- joint instability
- Primary cartilage injury
- abnormal forces, normal cartilage
- intra-articular fracture
- normal forces on abdnormal cartilage
- wear and tear
- abnormal forces, normal cartilage
7
Q
Diagnosis of OA
A
- physical exam
- local anesthesia
- radiographs
- +/- ultrasound
- arthroscopy - gold standard
- nuclear scintigraphy
- computed tomograph
- magnetic resonance imaging
- synovial fluid analysis
8
Q
PE
CS
A
- Pain
- capsule, synovium, tendons, ligaments, periosteum, subchondral bone
- Synovial effusion
- Decreased ROM
- pain
- synovial effusion
- joint capsule fibrosis
- local inflammation (variable)
9
Q
DX OA
Local anesthesia
A
- Perineural
- Intra articular
10
Q
DX OA
Rads
A
- Rads
- enthtesiophytes
- osteophytes
- joint space narrowing
- subchondral bone sclerosis and/or lysis
- osteochondral fragments
11
Q
TX OA
Goals
A
- Multifocal approach
- Goals
- remove inciting cause
- slow progression of degeneration
- alleviate clinical signs
- restore function
- improve quality of life
- No cure for OA
12
Q
TX OA
considerations
A
- age
- size
- intended use
- temperament
- economics
13
Q
TX OA
A
- symptom modifying or disease modifying
- rest
- SX
- biology
- mechanics
- med therapy
- drugs
- biological therapies
- complimentary therapies
14
Q
Surgery for OA
Arthroscopy
A
- Arthroscopy - biology
- remove inciting cause
- fragment removal
- reduce articular fracture (mechanics)
- remove inflammatory mediators
- synovectomy?
- debridement
- repair stimulating techniques
- microfracture
- remove inciting cause
15
Q
Surgery for OA
cartilage repair
A
- Graft procedures
- osteochondral autograft or allograft
- mosac arthroplasty
- Chondrocyte transplantation (auto/allo)
- synthetic absorbably graft materials
- MSC graft
- PDS pins
- osteochondral autograft or allograft
16
Q
SX for OA
arthrodesis
facilitated ankylosis
A
- Arthrodesis
- mechanics
- surgical joint stabilization and fusion
- high motion joints - salvage
- low motion joints - althletic potential
- mechanics
- Ankylosis
- biology => mechanics
- procedures to hasten joint fusion
- surgical
- chemical
- laser
- low motion joints only
- procedures to hasten joint fusion
- biology => mechanics
17
Q
OA medical therapy
NSAIDS
A
- NSAIDS
- phenylbutazone
- flunixin meglumine
- firocoxib
- carprofen
- deracoxib
- etodolac
- meloxicam
18
Q
OA medical therapy
Corticosteroids
A
- intra articular use most common
- methylprednisolone acetate - low motion
- triamcinolone acetonide - high motion
- betamethasone
- isoflupredone
19
Q
Slow acting disease modifiers
examples
A
- hyaluronan
- Polysulphated glycosaminoglycan
- Pentosan polysulphate
20
Q
Hyaluronan
A
- hyaluronic acid, sodium hyaluronate
- IV and IA
- Lubrication
- Anti-inflammatory
- may upregulate endogenous production
- May have chondroprotective functions
21
Q
Polysulphated glycosaminoglycan
A
- Adequan
- IM and IA
- Increased risk of infection if used IA
- Stimulates endogenous hyaluronan synthesis
- Condroprotective effects
22
Q
Pentosan polysulphate
A
- Cartrophen
- IM
- Early OA only
- decreased fibrillation
23
Q
Biological therapy for OA
A
- IRAP or ACS
- PRP
- Stem cells
- MSC vs ASC
- IA injection or graft
- Gene therapy - experimental
- anabolic genes
- inhibitors of catabolic genes
24
Q
Complimentary therapies
A
- Physical therapy, swimming
- Hydrotherapy, ice, heat
- Massage
- Extracorporeal shock wave therapy
- Acupuncture
- Soft laser therapy
- Galvanic or faradic electrical stimulation
- Therapeutic ultrasound
- Counterirritants - blistering
25
Q
Neutraceuticals
A
- Don’t require FDA approval for safety and efficacy
- May include
- glucosamine
- Chondroitin sulfate
- ASU
- MSM
- Fatty acids
- Collagen
- Herbs
- Anti-oxidants
- Questionable quality
26
Q
Septic arthritis
A
- Traumatic
- Iatrogenic
- Hematogenous
*always an emergency
27
Q
Septic arthritis
Foals
A
- S-type
- synovial membrane and fluid
- E-type
- subchondral bone of epiphysis => extends into joint
- P-type
- physis
- may extend into joing
28
Q
DX septic arthritis
A
- CS
- Radiographs
- Synovial fluid
- clinical pathology
- culture
- ultrasound (joint, primary source)
- advanced imaging
29
Q
Septic arthritis
CS
A
- Lameness
- heat and swelling
- synovial effusion
- foals
- febrile
- primary septicemia
- physeal infection painful on palp
- +/- depression, inappetance
30
Q
Septic arthritis
Rads
Chronic changes
A
- Rads
- rule out fracture
- bone involvement
- chronic changes
- joint space narrowing
- subchondral bone lysis
- caution foals
- periosteal proliferation
31
Q
Synovial fluid culture
A
- Aerobic, anaerobic
- consider fungal if traumatic
- negative culture doesn’t rule out infection
- collect sample prior to antibiotics
- still attempt if antibiotics have been started
- enrichment broth
- PCR
32
Q
Synovial fluid culture
Cattle
Adult horse
Foal
A
- Cattle
- A pyogenes, strep, salmonella, E. coli, mycoplasma
- Adult horse
- staph aureus (iatrogenic)
- enteric gram negatives (trauma)
- Foal
- enterobacteriacea, strep, rhodococcus equi, actinobacillus equuli
33
Q
Clin path of synovial fluid
Septic arthritis
A
- Appearance
- Color: anything other than straw colored is abnormal
- Clarity: anything besides clear is abnormal
- Viscosity: sticky is normal
- WBC
- > 30,000 with > 90% neutrophils
- degenerate neutrophils
- rarely see bacteria
- caution with very acute and very chronic cases
- > 30,000 with > 90% neutrophils
- TP > 2g/dl
- +/- synovial fluid lactate: > 4.9 mmol/L
- often no bacteria even in septic arthritis
34
Q
Septic arthritis
TX
A
- Multimodal
- broad spectrum systemic antimicrobials
- synoval lavage
- intra-articular antimicrobials
- regional antibiotic perfusion
- bandage
- analgesia
- +/- arthrotomy
*initiate therapy immediately, do not wait for culture results
35
Q
Synovial lavage
A
- Large volume BES
- DMSO
- General anesthesia vs standing
- Technique
- Arthoscopic
- chronic infection
- Bone involvement
- Traumatic injury - foreign material
- Large guage needle lavage
- often sufficient in acute cases
- switch to arthroscope if large amount of fibrin
- Arthoscopic
36
Q
Intra-artiular antibiotics
A
- Delivery
- intermittent: concentration dependent
- continuous: time dependent
- Results in highest antimicrobial conc in synovium
37
Q
Regional Antibiotic perfusion
A
- Intravenous regional perfusion
- most common
- Intraosseous regional perfusion
- when vein is not accessible
- complications
- Place tourniquet for 30 minutes
- wide tourniquet, minimal movement
- Achieve very high concentrations locally
- less expensive
- avoid complications of systemic administration
38
Q
Analgesia
A
- NSAIDS
- Opiates
- Continuous rate infusion
- Lidocaine
- Detomidine
- Butorphanol
- Ketamine
- Epidural catheter (hind limb)
- morphine and detomidine
- Bandage
39
Q
Arthrotomy
A
- Rarely indicated
- Only very severe chronic cases that have not resolved using other methods
40
Q
When to stop treatment
A
- Return of WBC count to normal is not an accurate guid
- Significant improvement in effusion and lameness
-
never stop antimicrobials until
- lameness and effusion resolved
- substantially improved after removing
- drastically decreasing analgesic therapy
41
Q
Immune mediated polyarthritis
A
- Primarily small animal
- Numerous causes
- idiopathic most common
- CS
- effusion of multiple joints
- pain
- lameness/stiffness
- may have other signs assoc with primary dz
42
Q
DX immune mediated polyarthritis
A
- Three criteria
- inflammatory process affecting synovium of two or more joints
- no identifiable infectious component
- responsive to immunosupressive therapy
- Synovial fluid
- protein > 2.5 g/dl
- NCC > 3000 cells/ul
-
non-degenerate neutrophils predominate
- not in all cases
-
non-degenerate neutrophils predominate
- Radiography
- erosive vs nonerosive
- Tests to rule in/out primary disease process
43
Q
Treatment Immune Mediated polyarthritis
A
- Treat underlying disease
- Immunosuppressants
- Immunomodulating drugs
*No cookbook treatment plan
