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Jovan Octara 2011730143


Dr. Ihsanil Husna, Sp.PD







AssalamualaikumWr. Wb.

Alhamdulillah, Puji syukur penyusun panjatkan kehadiran ALLAH SWT atas

terselesaikannya tugas Laporan Kasus OSTEOARTRITHIS.

Makalah ini disusun dalam rangka untuk dapat lebih mendalami dan memahami
mengenai OSTEOARTRITHIS..Tujuan khususnya adalah sebagai pemenuhan tugas
kepaniteraan Stase Ilmu Penyakit Dalam.

Semoga dengan adanya laporan kasus ini dapat menambah khasanah ilmu pengetahuan
dan berguna bagi penyusun maupun peserta didik lainnya.

Penyusun menyadari bahwa laporan kasus ini masih jauh dari kesempurnaan, oleh karena
itu penyusun sangat membutuhkan saran dan kritik untuk membangun laporan kasus yang lebih
baik di masa yang akan datang.


WassalamualaikumWr. Wb

Jakarta, Februari 2017



A. Patients identity

Name : Mrs. S

Age : 51th years old

Addres : Kp Rawa Selatan No.2 RT 02 RW 05

Education : Senior High school

Marital status : Married

Occupation : Seller

Religion : Moslem

Tribe : Sundanese

Date of admission : 20 Feb 2017

B. Anamnesis

1. Chief complaint :

Patient complained of right knee pain.

Another complaint :

Patient felt difficult to walk.

2. History of present illness

Patients come escorted his family to the Polyclinic Internal Medicine RSIJ Cempaka

Putih on February 20, 2017, 11:45 pm complaining of right knee pain and difficult to

walk. This patients complaint has felt since 5 years ago. Pain felt by the patient as a

pulsating, stiff and needles. The pain did not disappear with compress and massage oil.

Patients pain increasingly when she folded his knees and move his feet but a little

relieved with rest. Initially, patients admitted getting complaints of pain of her right knee

and had difficulty walking when a patient wants to get out of bed and into the bathroom.

When going up, the patient felt his right knee was very painful and difficult to be moved

up so the patient fell to the floor. In fact, patients have long felt pain in right knee during

5 years, but slowly felt more and more become heavy since there is swelling in the right

knee and the peak is one week later before came to the polyclinic in RSIJ Cempaka Putih.

A history of eating and drinking, defecating and urinating all still within normal limits.

Patients also admitted that before she got sick during 5 years, patients still often do

chores such as sweeping and cooking, but since the right knee pain patients can just walk

leisurely around the house.

3. History of past illness

No history of Hypertension
No history of DM
No history of kidney disease
No history of asthma
No history of allergic
4. History of family
No history of hypertension
No history of DM
No history of allergic

5. History of allergy
Patient has no allergy to food, drugs and weather.
6. History of treatment
Patients were not taking any medications.
7. Habits
Smoking habits : Denied
Drinking alcohol : Denied
Doing exercise : Denied

C. Physical Examination
- Generalis status :Mild ill
- Conciusness: composmentis

Vital sign

- blood pressure: 130/90 mmHg

- Heart rate: 88x/minute
- Respiratory rate: 18x/minute
- Temperature : 37.0 C

D. General physical examination

Head : normocephal, deformity (-)
Eyes : anemic conjungtiva (-/-), icteric sclera (-/-), arcus senilis (+/+)
Mouth : the oral mucosa moist
Neck : not palpable mass, suprasternal retracion (-)


Inspection : the movement of the chest symmetrical, intercosta retraction (-)

Palpation :same vocal fremitus in dextra and sinistra

Percussion : sonor

Auscultacion : vesicular breath sounds + / +, ronkhi - / -, wheezing - / -


Inspection : ictus cordis not seen

Palpation : ictus cordis not palpable

Auscultation : Regular 1st& 2nd heart sounds, murmur (-), gallop (-)


Inspection: looked flat

Auscultation: bowel sounds (+)

Palpation: touching pain epigastrik (-) epigastrik retraction (-)

Percussion: timphani (+)


1) Extremity Posterior

The movement of the motor in the normal range, the signs of inflammation (-), edema

(-), erythematous (-), CRT <3 seconds, clubbing finger (-), nail necrosis (-), warm

fingertip (+), deformity (-).


The movement of the motor in the normal range, the signs of inflammation (-), edema

(-), erythematous (-), CRT <3 seconds, clubbing finger (-), nail necrosis (-), warm

fingertip (+), deformity (- ).

2) Extremity inferior

The movement of motor knee joint is limited (+), signs of inflammation of the knee

joint (+), edema of the knee joint (+), deformity of the knee joint (+), crepitus knee

joint (+), pain in motion and press (+), hyperemia ( -), nail necrosis (-), warm

fingertip (+).

The movement of motor knee joint is limited (-), signs of inflammation of the knee

joint (-), edema of the knee joint (-), deformity of the knee joint (-), crepitus knee

joint (-), pain in motion and press the (-), hyperemia ( -), nail necrosis (-), akral warm


Resume :

Ms. S, 51th years old came to hospital with complained of her pain in the right knee since

5 years ago. She also complained that she difficult to walk. Pain felt by the patient as a

pulsating, stiff and needles. In fact, patients have long felt pain in right knee during 5

years, but slowly felt more and more become heavy since there is swelling in the right

knee and the peak is one week later before came to the polyclinic in RSIJ Cempaka Putih.

History of past illness: No history of hypertension and DM treatment Physical

Examination: TD: 130/90 mmHg

Problem List:

Osteoartrithis right genu


1. Osteoartrithis Right Genu

S: Ms. S, 51th years old came to hospital with complained of her pain in the right

knee since 5 years ago. She also complained that she difficult to walk. Pain felt by

the patient as a pulsating, stiff and needles. In fact, patients have long felt pain in

right knee during 5 years, but slowly felt more and more become heavy since

there is swelling in the right knee and the peak is one week later before came to

the polyclinic in RSIJ Cempaka Putih.

- Blood pressure: 130/90 mmHg
- Heart rate: 88x/minute
- Respiratory rate: 18x/minute
- Temperature : 37.0 C
Extremity inferior
The movement of motor knee joint is limited (+), signs of inflammation of

the knee joint (+), edema of the knee joint (+), deformity of the knee joint (+),

crepitus knee joint (+), pain in motion and press (+).

A: Osteoartritis
Artrithis Rhematoid
Spondilitis Ankilosing
Plan :
- Laboratory Examination
- X- Ray of Knee
Therapy :
- Non-Medikamentosa :
1. Fisiotherapy to train joints and to reduce the pain
2. Avoid obesity by decreasing weight
3. Reduce the activity that can increasing the pain on the knee

- Medikamentosa :
1. Analgetics oral : Ibuprofen 400mg
2. Analgetics Topical : Natrium Diclofenac Gel 1%



A. Definition
Osteoarthritis (OA, also known as degenerative arthritis, degenerative joint disease) is a
degenerative joint disease that affects the joints fulcrum weight with pathologic features
in the form of destruction of joint cartilage, where there is a degradation process
interactive joint complex, consisting of the repair of cartilage , bone and synovial
followed by a secondary component inflamation process.

B. Epidemiology

Osteoarthritis is a joint disease that is most commonly found in the world,
including in Indonesia. In fact, since 2001 to 2010 was declared as the decade of bone
and joint diseases throughout world 5 disease , second only to cardiovascular disease as a
cause of physical disability. In England and Wales, about 1.3 to 1.75 million people have
symptoms of OA. In America, one out of seven people suffer OA.3,4
In Australia in 2002, estimated the national costs for OA at 1% of GNP, which reached
Aus $ 2,700 / person / years. In Indonesia alone, the total prevalence of OA as many as
34.3 million people in 2002 and reached 36.5 million people in 2007. An estimated 1 to 2
million elderly people in Indonesia suffer disability due to osteoarthritis. In several
studies show that an increase in the occurrence of obesity and osteoarthritis in weight-
body bearing joints. Of the many that can be affected OA joints, the knee is the joint most
often found attacked by OA. Arthritis Research Campaign Data show that more than 550
thousand people in the UK suffer from severe knee OA and over 80 thousand knee joint
replacement surgery performed in England in 2000 at a cost of 405 million pounds.

C. Patophysiology

The occurrence of OA can not be separated from the many joints in the human
body. A total of 230 joints connecting the 206 bones that allow the friction. To protect the
bones from friction, in the body there is cartilage. However, due to various risk factors
exist, then there is erosion of the cartilage and loss of fluid in the joints. Cartilage itself
serves to a vibration between the bones. Cartilage consists of collagen soft tissue that
serves to strengthen the joints, proteoglycans that create the network of elastic and water
(70% share), which became bearings, lubricants and nutrition giver.
Chondrocyte cells whose job is to form proteoglycans and collagen in cartilage.
Osteoarthritis occurs due to failure chondrocytes synthesize the matrix quality and
maintain the equilibrium between the synthesis and degradation of extracellular matrix,
including collagen type I, III, VI and X overload and short proteoglycan synthesis. This
causes a change in the diameter and orientation of the collagen fibers that change the
biomechanics of cartilage, resulting in joint cartilage loss.

Besides chondrocytes, sinoviosit also play a role in the pathogenesis of OA,

particularly after synovitis, causing pain and discomfort. Sinoviosit inflamed will produce
Matrix metalloproteinases (MMPs) and various cytokines are released into the joint
cavity and damage the cartilage matrix and activate chondrocytes. At the end of
subchondral bone will also come into play, which will be stimulated osteoblast and
generate proteolytic enzymes.

Agrekanase is an enzyme that will break down proteoglycans in the cartilage

matrix called agrekan. There are two types of agrekanase namely agrekanase 1
(ADAMTS-4) and agrekanase 2 (ADAMTS-11). MMPs produced by chondrocytes, then
activated through a cascade involving serine proteinase (plasminogen activator,
plamsinogen, plasmin), free radicals and some membrane type MMPs. This enzymatic

cascade controlled by various inhibitors, including plasminogen activators and inhibitors
TIMPs. Other enzymes that contribute to damaging type II collagen and proteoglycans
are katepsin, who works at low pH, including aspartic proteinase (katepsin D) and
cysteine proteinase (katepsin B, H, K, L and S) that disimpam in lysosomes
chondrocytes. Hyaluronidase is not present in cartilage, but other glycosidase contribute
damaging proteoglikan.

Various cytokines play a role in stimulating chondrocytes produce cartilage

damaging enzymes. Cytokines are pro-inflammatory will attach to receptors on the
surface of chondrocytes and sinoviosit and cause MMP gene transcription so that the
enzyme production increases. The most important cytokine is IL-1, as well as regulatory
cytokines (IL-6, IL-8, LIFI) and cytokine inhibitors (IL-4, IL-10, IL-13 and IFN-). This
cytokine inhibitor together with IL-Ira can inhibit the secretion of MMPs and TIMPs
increase secretion. In addition, IL-4 and IL-13 can also fight the metabolic effects of IL-
1. IL-1 also acts to lower the synthesis of collagen type II and IX and increasing the
synthesis of collagen type I and III, thus producing cartilage matrix is of poor quality.

D. Osteoartrithis Clasification
OA may occur in the primary (idiopathic) or secondary, as listed below:


Local trauma
Hand - acute
- Heberden and Bouchard's nodes - Chronic (occupational, port)
(nodal) Congenital or developmental:
- Erosive arthritis interphalangeal Local disorders:
- Carpal-metacarpal I - Disease Leg-Calve-Perthes
feet: - Congenital Dislocation Koksa
- Haluks valgus - Slipped epiphysis
- Haluks rigidus mechanical factors
- Finger contractures (hammer / - Long legs are not the same
cock-up toes) - Deformities valgus / varus
- talonavikulare - Hypermobility syndrome
Coxae metabolic
- Eccentric (superior) - Okronosis (alkaptonuria)
- Concentric (axial, medial) - Haemochromatosis
- Diffuse (Koksa Senile) - Wilson's disease
vertebrae - Gaucher Disease
- Joint apofiseal endocrine
- Intervertebral joints - acromegaly
- Spondylosis (osteophytes) - hyperparathyroidism
- Ligament (hyperostosis, - Diabetes mellitus
Forestier's disease, diffuse - Obesity
idiopathic - Hypothyroidism
skeletal hyperostosis = DISH) Calcium Deposit Disease
Other places: - Deposits of calcium pyrophosphate
- glenohumeral dihydrate
- akromioklavikular - Hydroxyapatite arthropathy
- tibiotalar Bone and Joint Diseases Other
- sakroiliaka Local:
- temporomandibular - fractures
thorough: -Nekrosis avascular
Covering three or more areas
mentioned above (Kellgren-Moore)

E. Clinical Manifestation
1. Joint pain
Especially when the joint is moved or burden, which will be reduced if the patient

2. Stiffness in the morning (morning stiffness)
Stiffness in the joints are attacked occur after long immobilization (gel phenomenon),

often mentioned rigid appeared on the morning after waking up (morning stiffnes)
3. Barriers motion

Barriers to the movement of these joints is slowly progressive, gain weight slowly in
line with increasing pain in the joints.
4. Krepitation
Rattling flavor (often to be heard) that occur in diseased joints.
5. Change the form of joint
The joints are experiencing osteoarthritis usually experience changes such as changes
in shape and the narrowing of the gap joints
6. Changes in gait
The most disturbing thing is the patient changes in gait, almost all patients with

osteoarthritis of the ankle, knee and hip experience changes in gait (limping).

F. Risk Factor Osteoartrithis Genu

Broadly speaking, there are two divisions, namely knee OA risk factors predisposing

factors and biomechanical factors.

1. Predisposition Factor
a. Demography Factor
1) Age
Of all the risk factors for the onset of osteoarthritis, factors that are the strongest. The

aging process is considered as the cause of increased weakness around the joints,

decreased joint flexibility, calcification of cartilage and reduce the function of

chondrocytes, which all support the occurrence of OA. Framingham study showed

that 27% of people aged 63-70 years had suffered radiographic evidence of knee OA,

which increased to 40% at age 80 years or more..

2) Gender
The prevalence of OA in men before age 50 years higher than for women, but after

more than 50 years of age the prevalence of taller women suffer from OA than men.

This is associated with a significant reduction in the hormone estrogen on women.

3) Ethnicity
The prevalence of OA of the knee in patients in European and American countries are not

different, while some studies have shown that African race - Americans have a risk of

developing knee OA 2 times greater than Caucasians. Asian population also has the risk

of developing knee OA higher than Kaukasia.10,11 One other study concluded that

populations of color more than the skin of developing OA.

b. Genetic Factor
Hereditary factors also play a role in the onset of osteoarthritis. The presence of

mutations in procollagen gene or genes to other structural elements such as the joint

cartilage collagen, proteoglycans play a role in the onset familial tendency in osteoartritis.
c. Lifestyle
1) Smoking
Smoking can damage cells and inhibit cell proliferation of joint


Smoking may increase oxidant stress that affects the loss of cartilage.

Smoking can increase the content of carbon monoxide in the blood,

causing lack of oxygen and the can inhibit bone tissue formation.
2) Vitamin D
People who are not used to consume foods that contain vitamin D had a 3-

fold increased risk of suffering from knee OA.

d. Metabolic Factor
1) Obesity
Excess weight may increase the mechanical stress on the body weight-bearing

joints, and more often lead to osteoarthritis of the knee.

2) Osteoporosis
The relationship between knee OA and osteoporosis support the theory that

abnormal bone mechanical movement will accelerate the destruction of joint

3) Other Diseases

OA knee shown to be associated with diabetes mellitus, hypertension and

hiperurikemi, with patient records were not obese

4) Histerktomi

It is believed to be related to the reduction in estrogen production after

removal of the uterus.

5) Manisektomi

Meniscectomy is an operation conducted in the area of the knee and has been

identified as an important risk factor for knee OA. This is related to the loss of

meniscus tissue.

2. Biomechanical factors

a. Knee Trauma History

Including acute trauma knee cruciate ligament tear in the meniscus and a risk

factor for the onset of knee OA.

b. Anatomical abnormalities

Risk factors for knee OA among other local pathology in the knee joint such

as genu varum, genu valgus, Legg - Calve -Perthes disease and dysplasia


c. Work

Osteoarthritis commonly found in heavy physical labor, particularly the many

uses force knees (farmers, porters, etc.).

d. Physical activity

Heavy physical activity such as standing long (2 hours or more per day),

walking distance (two hours or more every day), heavy lifting (10 kg - 50 kg

for 10 times or more per week), pushing the object weight ( 10 kg - 50 kg for

10 times or more per week), up and down the stairs every day is a risk factor

for knee OA.

e. habit Sports

Sport athlete concussion and burden knee like football, marathon running and

kung fu at increased risk of developing knee OA.

G. Criteria for Diagnosis of Osteoarthritis Knee (Genu)
Criteria for the diagnosis of knee OA using the criteria of the American College of

Rheumatology classification as listed in the following table:

The degree of osteoarthritis of the knee graded into five degrees by Kellgren and

Lawrence, namely:
- Degree 0: no overview of osteoarthritis.
- Degree 1: osteoarthritis doubtful with an overview of normal joints, but

osteophytes are minimal.

- Degree 2: minimal osteoarthritis with osteophytes in the second place, there are

no subchondral sclerosis and cysts, as well as a good joint gap.

- Degree 3: moderate osteoarthritis with moderate osteophytes, deformity end bone

and joint narrow slit.

- Degree 4: severe osteoarthritis with large osteophytes, deformity of the bones, slit

joints disappear, and adanyasklerosis and subchondral cysts.

H. Management of Osteoarthritis
Destination management of patients with osteoarthritis are:
1. Relieves pain
2. Optimizing joint function
3. Reduce dependence on others and improve quality of life
4. Inhibit the progression of the disease
5. Preventing complications
Therapy in patients with osteoarthritis, namely:
1. Modification of lifestyle
2. Education
3. Break regularly aimed at reducing the use of load on the joints
4. Modification of the activity
5. Lose weight
6. Medical rehabilitation / physiotherapy
Static exercises and strengthens the muscles

Physiotherapy, which is useful for reducing pain, strengthen muscles, and

increase the area of joint movement

7. The use of tools.


1. Systemic

a. analgesics

Non narcotics: paracetamol

opioids (codeine, tramadol)

b. Steroidal anti-inflammatory (NSAIDs)



the suppository

c. DMOADs (disease-modifying OA drugs)

Among nutraceutical currently available in Indonesia are the Glucosamine

sulfate and Chondroitine sulfate.

2. Topical

a. Rubefacients cream and capsaicin.

Some preparations have been available in Indonesia with the workings are

generally counter irritant.

b. cream NSAIDs

Some of which can be used are gel piroxicam, and diclofenac sodium.

3. Intra-articular Injection / intra lesion

Basically there are two intra-articular injections indication that symptomatic

treatment with steroids, and viskosuplementasi with hyaluronan to modify

the course of disease. Some intraarticular injection preparations, including:

a. Steroids (triamsinolone hexacetonide and methyl prednisolone)

Only be granted if there are one or two joints with pain and inflammation

that are less responsive to administration of NSAIDs, can not tolerate

NSAIDs or no comorbidity a contraindication to the administration of


The dose for large joints such as the knees of 40-50 mg / injection, while for

the small joints typically used a dose of 10 mg.

b. Hyaluronan: high molecular weight and low molecular weight

Granted consecutive 5 to 6 times at intervals of one week each 2 to 2.5 ml

hyaluronan. Preparations in Indonesia include Hyalgan and Osflex.

4. Surgery

Before it was decided to surgical therapy, should first consider the risks and

benefits. Consideration of operative measures conducted when:

a. Deformity cause interference mobilization
b. Pain that can not be resolved with medical and rehabilitative


There are 2 types of surgical therapy: Realignment osteotomy and

joint replacement.

Various kinds of surgery for osteoarthritis of the knee joint:

a. Partial replacement / unicompartemental

b. High tibial osteotomy: young people

c. Patella and condyle resurfacing
d. Minimally constrained total replacement: the stability of the joints is

done in part by the original ligament and partially by the artificial

e. Cinstrained joint: fixed hinges: used when there is a missing bone

and severe instability.

f. Total knee replacement, if obtained pain, deformity, instability due to

arthritis or osteoarthritis.


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