osteoarthritis, rheumatoid arthrits and ankylosing sopndylitis

1. ASEPTIC
ARTHRITIS
Dr. sunil pahari, 3rd year resident , Yangtze university , hubei ,
china

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Osteoarthritis (OA)
is a type of joint diseases that results from breakdown
of joint cartilage and underlying bone. The most
common symptoms are joint pain and stiffness. Initially,
symptoms may occur only following exercise, but over
time may become constant.

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GENERAL CONSIDERATION OF OA
 70% of the aseptic
arthritis
 Chronic articular
disease
 Other similar terms
– osteoarthropathia
– senile arthritis
– proliferative arthritis
– hypertrophic arthritis
Involving joints in OA
DIP, PIP, 1st CMC
knee , hip , spine , shoulder
ankle
not involved - wrist and MCP
joint

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 Hips
 Knees
 Hands
 Spine
 Feet
Involved joints

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Normal vs OA Joint
Normal knee Osteoarthritic knee
Capsule
Cartilage
Synovium
Bone
Thickened capsule
Cyst formation
Sclerosis in
subchondral bone
Fibrillated cartilage
Osteophyte formation
Synovial hypertrophy

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 Family history of
disease
 Increasing age
 Being female
Risk factors you cannot change

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 Overuse of the joint
 Major injury
 Overweight
 Muscle weakness
Risk factors you can change

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Clinical Manifestation
Symtoms
– Arthralgia
– Decreased range of motion：stiffness，
abnormal knocking, locked joint (loose body)
– Swelling around the joint
– Deformity and rigidity of the joint

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PE
– Tenderness around the joint
– Limitation of activity; limitation of motion (LOM),
possible locking
– Deformities（varus, valgus）

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X-ray

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Treatment
1、General treatment：control the
risk factors，rest，physical therapy
（painless functional exercises）

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2、Medication：
 Systemic administration：
– NSAIDS (Diclofenac sodium, Celecoxib)
COX-2 inhibitor（decrease the side
effects on GI ）
 Local application：
– Intra-articular injection of Sodium
Hyaluronate (lubricant)

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Surgical procedures
Arthroscopy
Osteotomy
Joint replacement

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21. RHEUMATOID ARTHRITIS

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RHEUMATOID ARTHRITIS
. Rheumatoid arthritis is an autoimmune
disease that causes chronic inflammation of
the joints and other areas of the body.
INVOLVING JOINTS IN RA
common - wrist joint , MCP , PIP
less common – upper cervical , hip ,
TMJ
not involved – lumber ( so no back
pain ), DIP

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(1) Initial synovial inflammation within joints, bursae, and tendon
sheaths, with cellular infiltrate, hyperemia, edema, and increased
synovial fluid.
(2) Synovium becomes hypertrophied to form granulation tissue
(pannus), which spreads over cartilage surface.
RHEUMATOID ARTHRITIS
PATHOLOGIC FEATURE(1)

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(3) pannus directly invades into the bone, resulting in marginal
erosions and cartilage destruction.
(4) Eventually, fibrous and bony ankylosis ensues (abnormal stiffening
and immobility of a joint due to fusion of the bones)
(5) Rheumatoid nodules are firm lumps under the skin. They form
close to joints affected by rheumatoid arthritis.

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RHEUMATOID ARTHRITIS
PATHOLOGIC FEATURE(3)
HAND AND FOOT DEFORMITIES IN RA

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(1) Onset is usually between
20 and 60 age, with the highest
incidence among the 40- to 50-
year-old group.
(2) Under 40, females 3:1; over
40, equal, 1:1.
(3) Signs and symptoms are
variable and may be episodic
or persistent.
(4) Low-grade fever, fatigue,
weight loss, muscle soreness,
and atrophy.
RHEUMATOID ARTHRITIS
CLINICAL FEATURES

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(5) Symmetric peripheral joint pain and
swelling, polyarticular, particularly of the
hands.
(6) Later deformities may ensue-ulna
deviation, boutonniere, swan neck
deformity .
(7) RA factor positive in 70% of cases,
anemia, and elevated ESR.
Swan neck deformity

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(8)Radiologic feature:
General radiologic features in
rheumatoid arthritis
Bilateral symmetry
Periarticular soft tissue swelling
Uniform loss of joint space
Marginal erosions
Juxtaarticular periostitis
Juxtaarticular osteoporosis
Large pseudocysts
Joint deformity
RHEUMATOID ARTHRITIS
CLINICAL FEATURES

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Diagnostic Criteria for Rheumatoid Arthritis
Physical
1.Morning stiffness.
2.Pain on motion or tenderness in at least one joint.
3.Soft tissue swelling or joint effusion in at least one joint.
4.Swelling of at least one other joint (with 3 months).
5.Bilateral,symmetrecal, and simultaneous joint swelling (except DIP
joints).
6.Subcutaneous nodules—bony protuberances (extensor surfaces),
juxtaarticular.
Laborotory
7.Typical X-ray manifestations
8.Positive agglutination test (rheumatoid factor).
9.Poor mucin precipitate from synovial fluid.
10.Synovium---at least three of:
a. Marked hypertrophy
b. Superficial synovial cell proliferation
c. Marked inflammatory cell infiltrate fibrin deposition
d. Foci of cell necrosis
RHEUMATOID ARTHRITIS
DIAGNOSIS

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Classification
Classic >7 criteria (with swelling for >6 weeks)
Definite >5criteria(with continuous joint symptoms >6
weeks)
Probable >3 criteria (with continuous joint symptoms)(4—
6weeks)
Possible At least two stiffness, pain swelling, nodules,
elevated ESR or CRP, or iritis with joint
symptoms for at least 3 weeks.
RHEUMATOID ARTHRITIS
DIAGNOSIS

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Diagnostic standard of American College of Rheumatology,
ACR, 1987
 1.Morning stiffness lasts 1 hour (≥6 weeks)
 2.Three or more joints swelling (≥6 weeks)
 3. Wrist, metacarpophalangeal joint and PIP joint
swelling (≥6 weeks)
 4. Symmetric joint swelling (≥6 weeks)
 5. Subcutaneous nodules
 6. Typical X-ray manifestations (Juxtaarticular
osteoporosis, narrowing of joint space)
 7. Rheumatoid factor (RF) positive
≥4 criteria can establish the diagnosis of RA

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The goal of treatment is to reduce pain, decrease inflammation, and improve a
person's overall functioning
(1) Conservation:
Non steroidal Anti-inflammatory Drugs (NASAIDs)
Disease modifying Anti-Rheumatic Drugs (DMARDs)
such as immune depressant (MTX,methotrexate)
(2) Operation:
Synovectomy;
Joint replacement.
RHEUMATOID ARTHRITIS
TREATMENT

33. ANKYLOSING
SPONDYLITIS

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ANKYLOSING SPONDYLITIS
GENERAL CONSIDERATIONS
A chronic inflammatory
disorder principally
affecting the articulations,
ligaments, and tendons of
the spine and pelvis often
resulting in complete
polyarticular stiffness of
joint .

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(1) In synovial joints the initial change is that of a
nonspecific synovitis similar to rheumatoid arthritis,
except that it is less extensive and of lower
intensity, with subsequent fibroplasias, leading to
resultant ossification.
(2) In cartilage joints the initial subchondral osteitis is
replaced by fibrous tissue that subsequently
ossifies .
ANKYLOSING SPONDYLITIS
PATHOLOGIC FEATURE

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pathologic feature
1) Initially sinovitis occur.
2) Followed later by cartilage destruction and bony erosion.
(3) Initial change occur in the sacroiliac joints, followed by the spines
from the lumbar region upward .
(4) Up to 50% have rhizomelic involvement (hips, shoulders).
(5) Major signs are osteoporosis, erosions with surrounding sclerosis,
and bony ankylosis.
(6) The most commonly involved areas are the sacroiliac joints,
spine, and proximal large joints of the shoulder, hip, and rib cage.

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ANKYLOSING SPONDYLITIS
PATHOLOGIC FEATURE

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ANKYLOSING SPONDYLITIS
PATHOLOGIC FEATURE
back

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(1)Onset is usually between 15 and 35 years
and involves males 10:1.
(2)Initially at the sacroiliac joints bilaterally,
then ascends the spine.
(3)Initially pain and stiffness may be noticed
after a period of rest , and improve with
movement.
(4)Pain and tenderness, especially over bony
protuberances, and increasing stiffness..
ANKYLOSING SPONDYLITIS
CLINIC FEATURES AND DIAGNOSIS

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(6)Heel pain, muscle spasm, and atrophy may be
prominent.
(7)Complications include iritis, valvular
incompetence, aneurysms, conduction blocks,
pulmonary fibrosis, inflammatory bowel
disease (17%), renal failure due to secondary
amyloidosis, carrot stick fractures, Andersson
lesion, and prosthesis ankylosis.
(8)Laboratory findings will show ESR elevation,
depending on disease activity, mild anemia,
positive HLA-B27 (90%; 6% false-positive), and
negative RA latex (seronegative).

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(9)Radiologic finding
Radiologic Changes in the Sarcoiliac joints in Ankylosing
Spondylitis
General
Bilateral, symmetric
Iliac side more extensively involved
Early (“sacroilitis”)
Articular erosions (“rosary bead”)
Diminished joint space
Loss of articular cortex definition (“pseudowidening”)
Patchy reactive sclerosis
Subchondral osteoporosis
Late
Bony ankylosis “bamboo”
Generalized osteoporosis
ANKYLOSING SPONDYLITIS
CLINIC FEATURES AND DIAGNOSIS
See the picture

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(1)Conservation:
NSAIDs’ position, etc.
(2)Operation:
Osteotomy; THR.
ANKYLOSING SPONDYLITIS
TREATMENT

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