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ECC > joint diseases (McCarrel) > Flashcards

joint diseases (McCarrel) Flashcards

1
Q

Major classes of joint disease

A
  • Developmental orthopedic dz
  • Traumatic/degenerative arthritis
  • Septic arthritis
  • Immune mediated polyarthritis
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2
Q

End result of untreated joint dz

A

fuundamentally the same

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3
Q

Horses don’t get what kind of arthritis

A

rheumatoid arthritis

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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
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5
Q

Traumatic/Degenerative osteoarthritis

A
  • Chronic degeneration of joint tissues
    • irreversible changes to the joint
    • loss of function
    • pain
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6
Q

Tissuse changes in OA

A
  • Synovitis
    • primary or secondary
      • primary is reversible
  • 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
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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
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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)
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9
Q

DX OA

Local anesthesia

A
  • Perineural
  • Intra articular
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10
Q

DX OA

Rads

A
  • Rads
    • enthtesiophytes
    • osteophytes
    • joint space narrowing
    • subchondral bone sclerosis and/or lysis
    • osteochondral fragments
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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
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12
Q

TX OA

considerations

A
  • age
  • size
  • intended use
  • temperament
  • economics
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13
Q

TX OA

A
  • symptom modifying or disease modifying
  • rest
  • SX
    • biology
    • mechanics
  • med therapy
    • drugs
    • biological therapies
    • complimentary therapies
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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
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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
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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
  • Ankylosis
    • biology => mechanics
      • procedures to hasten joint fusion
        • surgical
        • chemical
        • laser
      • low motion joints only
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17
Q

OA medical therapy

NSAIDS

A
  • NSAIDS
    • phenylbutazone
    • flunixin meglumine
    • firocoxib
    • carprofen
    • deracoxib
    • etodolac
    • meloxicam
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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
  1. hyaluronan
  2. Polysulphated glycosaminoglycan
  3. 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
  • 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
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
  • 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

ECC (18 decks)

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