Osteoarthititis and crystal arthropathies

Question 1

What is osteoarthiritis

Answer 1

Progressive, degenerative condition affecting joints due to gradual thinning of cartilage, loss of joint space and formation of bony spurs

Question 2

What is the matrix of the cartilage formed by?

Answer 2

Chondrocytes which are embedded within it

Question 3

What is the pathogenesis

Answer 3

Loss fo matrice, release of cytokines including IL-1,TNF and mixed metalloproteinases as well as prostaglandins by the chondrocytes

Formation of the cartilage surface and attempted repair with osteophyte formation then occurs

Question 4

What are the classic symptoms?

Answer 4

Gradual onset ( moths-years)
Mechanical pain- i.e. pain worse on activity, worse end of the day, received by rest
Crepitus- grinding/cracking on movement
Stiffness (<30 mins),inactivity gelling
Bony swellings and deformities of joints
Can get effusions and soft tissue swelling (synovial thickening)
Can lead to loss of function and morbility

Question 5

What is general varus

Answer 5

A cowboy leg appearance

Question 6

What may be seen in the hands?

Answer 6

DIP,PIP and 1st CMC joints
Bony enlargements may be seen as DIPs (Heberdens nodes ) and PIPs (Bouchards nodes)
Squaring of the thumb

Question 7

What can be seen in the knee?

Answer 7

osteophytes, effusion, crepitus and restrictions of movement
Genu varus and valgus deformities
Bakers cyst

Question 8

What can be seen in the hip?

Answer 8

Restricted movement

the pain felt here may be radiating from the lower back

Question 9

What can occur with osteophytes?

Answer 9

cervical-may impinge on nerve roots

lumbar-osteocytes can cause spinal stenosis if encroach on spinal canal

Question 10

What are risk factors for OA

Answer 10

Age (40+)
Gender- F
Genes (e.g. nodal arthritis)
occupation 0 rep stain, heavy lifting
Previous injury/joint abnormality e.g. hypermobiility
Obesity
Other underlying conditions e.g. rheumatoid arthritis, gout, acromegaly

Question 11

Why are history and examination so important

Answer 11

Exclude primary inflammatory arthiritis

Question 12

What investigations are usually done?

Answer 12

Bloods- inflammatory markers usually normal

X-rays - typical changes inc joint narrowing, subchondral sclerosis, bony cysts and osteophytes

Question 13

What are the primary joints affected in RA and OA

Answer 13

RA- MCP, PIP

OA-DIP, CMC

Question 14

Heberden’s nodes are frequently present in RA T/F

Answer 14

F- they are absent . hebredens nodes are frequently present in OA

Question 15

What are the joint characteristics of RA and OA

Answer 15

RA- sort, warm,tender

OA-Hard, bony

Question 16

RA is worse after resting t/f

Answer 16

T

N.B. is present stiffness will be worse in OA after effort, may be described as evening stiffness

Question 17

Which arthritis has a positive rheumatoid factor, anti CCP antibody and elevated ESR and C reactive protein

Answer 17

RA

Question 18

What is the non-pharmacological management?

Answer 18

Education
Physiotherapy
WT loss
Footwear
Aids

Question 19

What is the pharmacological management?

Answer 19

Analgesia- paracetamol ect
NSAIDs
Pain modulators - amitriptyline ,gabapentin
Intraarticular steroids-only short term relief

Question 20

What could be done in terms of surgery?

Answer 20

Arthroscopic washout, loose body, soft tissue trimming

joint replacement

Question 21

What are the two main conditions of crystal arthopies

Answer 21

Gout

Pseudogout

Question 22

What is Gout?

Answer 22

Inflammatory arthiritis associated with Monosodium urate crystal deposition

most common inflammatory arthritis in men

Question 23

What is Pseudogout?

Answer 23

Calcium pyrophosphate sihydrate/CPPD

Question 24

What is hyperuricaemia?

Answer 24

serum uric acid >7mg/dL

The risk of developing gout is higher the higher the serum uric acid

Question 25

What is diagnosis of gout based on?

Answer 25

Diagnosis of gout is based on identification of crystals or classic radographical findings, not hyperuricemia alone

Question 26

When is the best time to check uric acid

Answer 26

2 weeks after the attack

Question 27

What is acute monoarticular gout

Answer 27

Rapid onset
red-hot joint
severe pain
Duration- up to 2 weeks
Site- 1st MTPJ>ankle>knee>upper limb joints>spine

Question 28

Ddx of gout

Answer 28

Septic arthritis
Trauma
Seronegative arthritis (e.g. psoriatic arthititis, Reiter’s- but need to ask regarding associated symptoms e.g. skin psoriasis, eye symptoms, urethritis

Question 29

Chronic polyarticular gout

Answer 29

Chronic joint inflammation
Usually after having recurrent acute attacks >10 years
often diuretic associated

Question 30

What is the gold standard for dignosing gout

Answer 30

joint aspirate
needle-shaped crystals
Negative birefringerence on polarised light microscopy

Question 31

Management of gout

Answer 31

NSAIDs if no contraindication or colchicine or corticosteroids (oral/IM/IA)

Other analgesia e.g. opiates, paracetamol

Question 32

What lifestyle modifications- can help with gout

Answer 32

Restrict red meat, offal, beans, shellfish
Reduce alcohol
lose weight
Fluids- 2L/day

Question 33

What could be included in prophylaxis of gout attacks?

Answer 33

Urate lowering therapy

• Allopurinol/Febuxostat
• start 2-4 weeks after acute attack
• start low dose and titrate
• aimf or target serum rate <0.30mmol/L

Question 34

What is Pseudogout and how is it diagnosed (also called CPPD)

Answer 34

using a microscope to see small calcium pyrophosphate crystals in joint fluid. They are rhomboid/envelope shaped and there is a weakly positive birefringence

Question 35

What is the treatment of pseudo gout?

Answer 35

NSAIDs
Colchicine
Steroids
Rehydration

Question 36

What is hydroxyapatite?

Answer 36

Hydroxyapatite crystal deposition in and around the joint. Females 50-60
Alizarin stain shows red clumps