ARTHRITIS

Eugene Sherry, MD, MPH, FRACS.

Senior Lecturer,
  Dept. of Orthopaedic Surgery,  
University of Sydney, Australia.

  Osteoarthritis(degenerative joint disease)- is the most

common form of arthritis.

Aetiology - On a cellular level, osteoarthritis may be a result of

a failed attempt of chondrocytes to repair damaged cartilage
as well as increased water content may result from childhood
(SUFE see case 14 , Perthes see POT, CDH, Sepsis,
necrosis) or in adulthood from abnormal bone (Pagets, AVN
Knee replacement
see case 13 ), abnormal cartilage (see POT), abnormal loads
(malunion).

S.U.F.E pot from Case 14

Paget's pot from Case 13

Characteristics - On exam include decreased ROM and

crepitus. The knee is the most common joint affected.
Treatment begins with supportive measures (activity
modification, cane, etc.) and includes NSAIDs and a variety of
surgical procedures ranging from arthroscopy to arthroplasty.

Neuropathic Arthropathy (Charcot Joint)

An extreme form of osteoarthritis caused by a disturbance in

the sensory innervation of a joint. Causes include diabetes
Pagets disease with OA
(foot), tabes dorsalis (lower extremity), syringomyelia (upper
extremity), Hansen’s disease, myelomeningocele.

Acute Rheumatic Fever Group A B-hemolytic strep

infections.

Ochronosis

Charcot forefoot Degenerative arthritis resulting from alkaptonuria, a rare

inborn defect of the homogentisic acid oxidase enzyme
system (tyrosine and phenylalanine catabolism).

(see case 10 for more information.)

Click to see pot from Case 10

Inflammatory Arthritides

Common Characteristics - Include a wide range of

rheumatologic diseases. Rheumatoid arthritis, systemic lupus
erythematosus (SLE), juvenile rheumatoid arthritis (JRA), the
spondyloarthropathies, and crystalline arthropathies.

Rheumatoid Arthritis (RA) - The most common form of

inflammatory arthritis, affects 3% of women and 1% of men.
(See case 16 ).
Click to see pot from Case 16

Etiology - Unclear, but probably related to cell mediated

immune response (T cell) that incites an inflammatory
response initially against soft tissues and later against
cartilage (chondrolysis) and bone (periarticular bone
resorption). Hallmark is synovitis.

Characteristics - Usually an insidious onset of morning

stiffness and polyarthritis. Synovium and soft tissues are first
affected, elevated ESR and a positive RF (IgM). Radiographs
demonstrate periarticular erosions and osteopenia.

Treatment - Control of synovitis and pain, maintenance of joint

function, and prevention of deformities are the goals of
therapy.

Systemic Lupus Erythematosus.

Polymyalgia Rheumatica

Juvenile Rheumatoid Arthritis - Three major types are

recognised.

Spondyolarthropathies - Enthesopathies (occur at ligament

insertion into bone) characterised by positive HLA-B27 (sixth
chromosome, D).

Ankylosing spondylitis - Bilateral sacroilitis - acute anterior

uveitis in a HLA-B27 - positive male is diagnostic of this
disease.

Reiter’s Syndrome - Classic presentation is a young male

with a triad of urethritis, conjunctivitis, and oligoarticular
arthritis.

Psoriatic Arthropathy - Affects about 7% of patients with

psoriasis. Many different HLA loci may be involved.

Enteropathic Arthritis - About 10-20% of Crohn’s disease

and ulcerative colitis patients can develop peripheral joint
arthritis.

Crystal Deposition Disease

Gout - A disorder of nucleic acid metabolism causes

hyperuricemia, which leads to mono-sodium urate crystal
deposition in joints. Recurrent attacks of arthritis, especially in
males 40-60 yo (usually in the lower extremity - especially the
great toe, crystal deposition in tophi (ear helix, eyelid
olecranon, Achilles; usually seen in chronic form), and renal
disease/stones (2% Ca2+ vs. normal 0.2%) are characteristic.

Chondrocalcinosis - Caused by several disorders, including

calcium pyrophosphate deposition disease (CPPD),
ochronosis, hyperparathyroidism, hypothyroidism, and
hemochromatosis, which lead to increased calcium -+
pyrophosphate crystal deposition.

Calcium Hydroxyapatite Crystal Deposition Disease

Infectious Arthritides

Common Characteristics - Aspirates of acute, red, hot,

effusions usually show opaque fluid with >80,000 WBCs (75 +
% PMNs), low glucose (>25 mg/dl less than serum values),
and positive Gram’s stains/cultures.

Pyogenic Arthritis - Occurs from haematogenous spread or

by extension of osteomyelitis. Commonly occurs in children.
Occurs more commonly in adults who are at risk, including IV
drug abusers (esp. SC and sacroiliac joints), sexually active
young adults (gonococcal, especially if seen with skin
papules), diabetics (feet and lower extremities), rheumatoids,
and following trauma (fight bites, open injuries) and surgery
(iatrogenic).

Tuberculous Arthritis - The chronic granulomatous infection

caused by Mycobacterium tuberculosis usually involves joints
by haematogenous spread. Spine and lower extremities are
most often involved, typically in Mexicans and Asians.
Radiographically, both sides of the joint. Diagnosis is helped
with positive PPD, demonstration of acid-fast bacilli and rice
bodies (fibrin globules) in joint fluid, positive cultures (may
take several weeks), and characteristic x-rays (subchondral
osteoporosis, cystic changes, notch-like bony destruction of
the edge of the joint, and joint space.

Fungal Arthritis - More common in neonates, AIDS victims,

and drug users.

Lyme Disease

Haemorrhagic Effusions.

Can be the result of haemophilia, sickle cell disease,

pigmented villonodular synovitis, or other causes discussed
elsewhere.

Haemophilic Arthropathy - X-linked recessive factor VIII

deficiency (haemophilia A -classic or factor IX deficiency;
haemophilia B-Christmas disease) associated with repeated
hemarthrosis from minor trauma leading to synovitis, cartilage
destruction (enzymatic processes).

Sickle Cell Disease