Selasa, 12 Januari 2015

KNEE OSTEOARTHRITIS
Nama

: Anasti Putri Paramatasari

NIM

: 030.10.028

Pembimbing : dr. Gatot, Sp. OT

Kepaniteraan Klinik Bagian Ilmu Bedah

Sub Departement Orthopedic
Rumah Sakit Umum Bekasi
Periode 5 Januari 14 Maret 2015

TOPIK BAHASAN

BAHASAN
Definisi
Prevalensi
dan Insidensi

Prognosis

Etiologi dan
Klasifikasi

Terapi

Knee
OA

Diagnosis
Banding

Faktor Resiko

Pathogenesis
dan
Pathology

Diagnosis

Pemeriksaan
Penunjang

Manifestasi
Klinis

DEFINISI

I
Degenerative joint disease
Osteoarthrosis
Degenerative arthritis
Senescent arthritis
Hypertrophic arthritis
Ialah gangguan pada satu atau lebih sendi yang
dicetuskan oleh perburukan dari articular cartilage dan
ditandai oleh:

degenerasi kartilago yang progresif,

hipertrofi dan remodelling dari subchondral bone,
dan inflamasi sekunder pada membran synovial.1

1. Salter RB. Textbook of Disorders and Injuries of the Muskuloskeletal System. Degenerative Disoreders of
Joints and Related Tissues. 3rd ed. Philadelaphia, PA: Mosby; 1999; p. 213-23.

PREVALENSI DAN
INSIDENSI

PREVALENSI DAN
INSIDENSI
Data di US selama tahun 2005, OA mengenai 13,9%
individu dewasa berusia lebih dari 25 tahun dan 33,6%
(12,4 juta individu) berusia lebih dari 65 tahun. 2
Insidensi rates dari symptomatic radiographic OA pada
individu dewasa berusia 26 tahun:

Hand OA = 100 per 100,000 individu per tahun

Hip OA
= 88 per 100,000 individu per tahun
Knee OA = 240 per 100,000 individu per tahun.3

Insidensi rates dari OA meningkat sejelan dengan usia,

dan menetap sekitar usia 80 tahun.4
Wanita memiliki rates yang lebih tinggi dibandingkan
pria, terutama pada usia lebih dari 50 tahun.4

2. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in
the United States. Part II. Arthritis Rheum. 2008;58(1):26-35.
3. Oliveria SA, Felson DT, Reed JI, et al. Incidence of symptomatic hand, hip and knee osteoarthritis among patients in
health maintenance organization. Arthritis Rheum. 1995;38(8):134-1141.
4. Buckwalter JA, Saltzman C, Brown T. The impact of osteoarthritis. Clin Orthoped Rei Res. 200:427S:S6-S15.

ETIOLOGI DAN
KLASIFIKASI

ETIOLOGI DAN
KLASIFIKASI
Primary
Kelainan degenerative pada sendi yang mengenai
banyak sendi tanpa diketahui adanya
abnormalitas sebelumnya.1

Secondary
Didahului adanya luka, deformitas atau
penyakit yang dapat mencetuskan initial
cartilage lesion yang berkembang menjadi
progressive secondary degenerative joint disease. 1
1. Salter RB. Textbook of Disorders and Injuries of the Muskuloskeletal System. Degenerative Disoreders of Joints and
Related Tissues. 3rd ed. Philadelaphia, PA: Mosby; 1999; p. 213-23.

ETIOLOGI DAN
KLASIFIKASI (2)

Keadaan yang dapat menginisiasi proses degenerasi yang

progresif pada 2nd type of OA:1

Congenital abnormalities of joints : congenital dislocation of the hip,

clubfeet.
Infections of joints : septic (pyogenic) arthritis, tuberculous arthritis.
Nonspesific inflammatory disorders of joints : rheumatoid arthritis,
ankylosing spondylitis.
Metabolic arthritis : gout, ochronosis.
Repeated hemarthrosis : hemophilia
Injury : (a) Major traumaintra-articular fractures; (b) Minor trauma
occupational stresses.
Acquired incongruity of joint surfaces : avascular necrosis, slipped
epiphysis.
Extra-articular deformities with malaginment of joints : genu valgus,
genu varus.
Joints instability : lax ligaments, subluxation.
Iatrogenic damage to cartilage : continues compression of joint surfaces
during treatment.

1. Salter RB. Textbook of Disorders and Injuries of the Muskuloskeletal System. Degenerative Disoreders of Joints and
Related Tissues. 3rd ed. Philadelaphia, PA: Mosby; 1999; p. 213-23.

FAKTOR RESIKO

FAKTOR
RESIKO5,7-10
Non-modifable

Modifiable

Gender : wanita resiko

Usia: resiko meningkat seiring dengan usia, sekitar
usia 75 tahun.
Ras : Asian resiko
Genetik

Massa tubuh berlebih

Cedera sendi (akibat olahraga, trauma, perkerjaan)
Nyeri lutut
Hand OA
Pekerjaan (mechanical stress: hard labor, heavy lifting,
knee bending, repetitive motion).

5. Jordan JM, Helmick Cg, renner JB, et al. Prevalence of knee symptoms and radiographic and symptomatic knee osteoarthititis in African Ameriicans and Caucasians: The
Jhonston County Osteoarthitis Project. J Rheumatol. 2007;34(1):172-80..
7. Felson DT. Risk Factors of osteoarthritis. Clin Orthoped Rel Res. 2004;427S:S16-S21.
8. Rossignol M, Leclerc A, Allaeret FA, et al. Primary osteoarthritis of hip, knee and hand in relation to occupational exposure. Occup Environ Med. 2005;62:772-777.
9. Cooper C, Snow S, McAlindon TE, et al. Risk factors for the incidence and progression of radiographic knee ostoarthrits. Arthritis Rheum. 2000;43(5):995-1000.
10. Blogojevic M, Jinks C, Jeffrey A, et al. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and metanalysis. Osteoarthritis Cartilage.
2010;18(1):24-33.

PATOGENESIS DAN
PATOLOGI

PATOFISIOLOGI DAN PATOLOGI

Kartilago
Sendi

Otot

Kne
e
Joint
Membrana
Synovial
dan
Kapsula
Fibrosa

Tulang
Subkondral

KARTILAGO SENDI
Loss of proteoglycan of the
matrix

Cartilage is softening and loss

of the normal resillience

Unmasked, more susceptible to

the fricton

Pada area perifer, kartilago

menjadi hipertrofi dan
hyperplasia..

Pada bagian central, yang

banyak terkena friksi,
kartilago terkikis menjadi
tulang subchondral. Hilangnya
kartilago sendi ditandai
dengan penyempitan celah
sendi

Joint surface becomes

yellowish, granular and dull.

Gangguan pergerakan sendi

TULANG
SUBCHONDRAL
Pada central area yang terkena maximum stress dan
friction, tulang menjadi eburnated dan hypertrophies.
Gambaran radiologis : SCLEROTIC

Pada bagian perifer, yang terkena minimal stress,

tulang menjadi atrofi. Gambaran radiologis : LESS
DENSE

Excessive pressure causes microfractures of trabeculae,

juga degenerasi fibrinosa dan mucus pada daerah
sekitar yang dapat menjadi cystic lesions. Gambaran
radiologis: LESI KISTIK

SYNOVIAL MEMBRAN DAN

KAPSULA FIBROSA

Fragment dari kartilago

yang mati berada dalam
cairan synovial

Dianggap benda asing

Terjadi reaksi radang

dan efusi carian sendi,
dengan jumlah mucin
yang lebih banyak
sehingga viskositas
meningkat

Membatasi pergerakan
sendi

Kapsiula fibrosa juga

ikut menebal dan fibrotic

OTOT

Pain

Spasme otot

Contracture

Deformitas
sendi
Gerak sendi
yang terbatas

PATOGENESIS DAN PATOLOGI

PATOGENESIS DAN
PATOLOGI

MANIFESTASI KLINIS

GEJALA

Nyeri

Tumpul

sampai dnegan nyeri yang terasa sangat

berat
Dicetuskan dengan pergerakan sendi (friction effect)
dan berkurang saat istirahat.
Resting pain dapat dirasakan, hal ini berhubungan
dengan hiperemia pada tulang subchondral.

Joint crepitus
Articular gelling

Kekakuan

sendi setelah fase istirahat.

1. Salter RB. Textbook of Disorders and Injuries of the Muskuloskeletal System.

Degenerative Disoreders of Joints and Related Tissues. 3 rd ed. Philadelaphia, PA: Mosby;
1999; p. 213-23.

PEMERIKSAAN
FISIK

Look
Feel
Move

Swelling of the joint, karena ada moderate effusion, dan

sedikit penebalan synovial. Edema akan semakin jelas karena
adanya atrofi dari otot sekitar.
Heberdens nodes pada DIP. Biasanya terdapat pada primary
type, lebih banyak pada wanita.

Teraba kaku.

Gerak aktif dan pasif lebih terbatas. Hal ini dapat diakibatkan
karena adanya kekakuan maupun rasa sakit.
Krepitasi saat sendi digerakkan.

1. Salter RB. Textbook of Disorders and Injuries of the Muskuloskeletal System. Degenerative Disoreders of
Joints and Related Tissues. 3rd ed. Philadelaphia, PA: Mosby; 1999; p. 213-23.

PEMERIKSAAN PENUNJANG

PEMERIKSAAN
PENUNJANG
o

Pemeriksaan Laboratorium

Darah : LED mungkin, namun jarang menunjukkan

adanya penyakit sistemik.
Cairan sendi : mucin

Radiographic

Menunjukkan perubahan pada sendi yang berkorelasi

dengan proses patologis yang terjadi, seperti:
a.
b.
c.
d.

Penyempitan celah sendi.

Subchondral sclerosis dan cyst,
Pembentukan osteophyte,
Joint remodelling dan incongruity.

1. Salter RB. Textbook of Disorders and Injuries of the Muskuloskeletal System. Degenerative Disoreders of
Joints and Related Tissues. 3rd ed. Philadelaphia, PA: Mosby; 1999; p. 213-23.

DIAGNOSIS

DIAGNOSIS11
Clinical and
laboratory

Clinical and
Radiographic

Clinical

Knee pain + at
least 5 of 9
Age>50yo
Stiffness<30m
Crepitus
Bony Tenderness
Bony enlargement
No palpable
warmth
ESR<40mm/hour
RF<1:40
SF OA: clear,
viscous, or
WBC<2,000/mm3

Knee pain + at
least 1 of 3
Age>50yo
Stiffness<30m
Crepitus
Osteophytes

Knee pain + at
least 3 of 6
Age>50yo
Stiffness<30m
Crepitus
Bony Tenderness
Bony enlargement
No palpable
warmth

92% sensitive; 75% specific

91% sensitive; 86% specific

95% sensitive; 69% spesific

11. R. Altman, E. Asch, D. Bloch, G. Bole, D. Borenstein, K. Brandt, et al. The American College of
Rheumatology criteria for the classification and reporting of osteoarthritis of the knee. Arthritis Rheum
1986;29:1039-1049.

GRADE OA12

Kellgren & Lawrence menyusun grade OA berdasarkan

gambaran radiologis menjadi:
Grade

0: Grade 1 : softening and swelling

Grade 2 : fragmentation and fissuring of less than 0.5
inches
Grade 3 : fragmentation and fissuring of greater than
0.5 inches
Grade 4 : erosion down to the subchondral bone

12. Petersson IF, Boegrd T, Saxne T et-al. Radiographic osteoarthritis of the knee classified by the Ahlbck and
Kellgren & Lawrence systems for the tibiofemoral joint in people aged 35-54 years with chronic knee pain. Ann.
Rheum. Dis. 1997;56 (8): 493-6. doi:10.1136/ard.56.8.493.

TATALAKSANA

PRINSIP TERAPI13,14
Non
pharmacologic

Mengurangi
trasa sakit;
Meningkatkan
status
fungsional
Pharmacologic

13. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and
knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. Feb 2008;16(2):137-62.
14. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and
knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence.
Osteoarthritis Cartilage. Sep 2007;15(9):981-1000.

NON-FARMAKOLOGIS14,15
Edukasi pasien
Terapi panas dan dingin
Penurunan berat badan
Olahraga non weight bearing
Terapi yang disesuaikan dengan aktivitas

14. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hip and
knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence.
Osteoarthritis Cartilage. Sep 2007;15(9):981-1000.
15. Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for symptomatic knee osteoarthritis in
women. The Framingham Study. Ann Intern Med. Apr 1 1992;116(7):535-9.

FARMAKOLOGIS
Tujuan dari terapi farmakologis

Untuk
mengurangi
morbiditas

Untuk
mencegah
komplikasi

FARMAKOLOGIS

Agen farmakologis yang digunakan dalam terapi OA

antara lain:
Acetaminophen
Nonsteroidal

anti-inflammatory drugs (NSAIDs), oral and

topical
Intra-articular corticosteroids
Intra-articular sodium hyaluronate
Opioids
Duloxetine
Muscle relaxants
Nutriceuticals (eg, glucosamine/chondroitin sulfate)

FARMAKOLOGIS (2)

Untuk terapi OA lutut, American Collage of Rheumatology

(ACR) merekomendasikan penggunaan salah satu diantara obat
berikut:16:
Acetaminophen
Oral

NSAIDs
Topical NSAIDs
Tramadol
Intra-articular corticosteroid injections

Petunjuk praktek klinis dari American Academy of

Orthopedic Surgeons (AAOS) merekomendasikan
penggunaan farmakologis berikut untuk OA lutut simptomatis 17:
Oral

NSAIDs
Topical NSAIDs
Tramadol

16. Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir AD, Woodard J, et al. Prevalence of knee symptoms and radiographic
and symptomatic knee osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J
Rheumatol. Jan 2007;34(1):172-80.
17. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis (OA) of the Knee. AAOS: American Academy of
Orthopaedic Surgeons. Available at http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp. Accessed July 8, 2013

TINDAKAN OPERATIF

Indication:

relieving pain et cause severe arthritis (e.g. OA grade III-IV)

To correct deformity (e.g. moderate arthritis with moderate
contracture, valgus laxity, valrus laxity).
To

Macam tindakan operative:

removal of meniscal tears and loose bodies;

procedures include:

Arthroscopy:

debridement of loose articular cartilage with a microfracture technique and

cartilaginous implants in areas of eburnated subchondral bone. 18

principle underlying this procedure is to shift weight

from the damaged cartilage on the medial aspect of the knee to the
healthy lateral aspect of the knee.19
Arthroplasty: consists of the surgical removal of joint surface and the
insertion of a metal and plastic prosthesis. 20
Arthrodesis: union of bones on either side of the joint. This
procedure relieves pain but prevents motion and puts more stress on
surrounding joints20.
Osteotomy:

18 Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, et al. A randomized trial of arthroscopic surgery for
osteoarthritis of the knee. N Engl J Med. Sep 11 2008;359(11):1097-107.
19. Pagenstert G, Knupp M, Valderrabano V, Hintermann B. Realignment surgery for valgus ankle osteoarthritis. Oper Orthop Traumatol.
Mar 2009;21(1):77-87.
20. Reichenbach S, Rutjes AW, Nesch E, Trelle S, Jni P. Joint lavage for osteoarthritis of the knee. Cochrane Database Syst Rev. May 12
2010;CD007320.

ARTHROSCOP
Y

Arthroscopic view of a torn meniscus before (top)

and after (bottom) removal of loose meniscal
fragments.

ARTHROPLA
STY

ARTHRODESIS

PROGNOSIS

PROGNOSI
S
The prognosis in patients with osteoarthritis depends on
the joints involved and on the severity of the
condition.21
A systematic review found the following clinical features to
be associated with more rapid progression of knee
osteoarthritis21:

Older

age
Higher BMI
Varus deformity
Multiple involved joints

Patients with osteoarthritis who have undergone joint

replacement have a good prognosis, with success rates
for hip and knee arthroplasty generally exceeding 90%. 21

21. Chapple CM, Nicholson H, Baxter GD, Abbott JH. Patient characteristics that predict progression of knee
osteoarthritis: A systematic review of prognostic studies. Arthritis Care Res (Hoboken). Aug 2011;63(8):1115-25.

TERIMA KASIH

DAFTAR PUSTAKA

DAFTAR
PUSTAKA
1.

Salter RB. Textbook of Disorders and Injuries of the Muskuloskeletal System. Degenerative Disoreders
of Joints and Related Tissues. 3rd ed. Philadelaphia, PA: Mosby; 1999; p. 213-23.

2.

Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other
rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26-35.

3.

Oliveria SA, Felson DT, Reed JI, et al. Incidence of symptomatic hand, hip and knee osteoarthritis
among patients in health maintenance organization. Arthritis Rheum. 1995;38(8):134-1141.

4.

Buckwalter JA, Saltzman C, Brown T. The impact of osteoarthritis. Clin Orthoped Rei Res. 200:427S:S6S15.

5.

Jordan JM, Helmick Cg, renner JB, et al. Prevalence of knee symptoms and radiographic and
symptomatic knee osteoarthititis in African Ameriicans and Caucasians: The Jhonston County
Osteoarthitis Project. J Rheumatol. 2007;34(1):172-80.

6.

Felson DT, Zhang Y. An update on the epidemiology of knee and hip osteoarthritis with view to
prevention. Arthritis Rheum. 1998:41(8):1343-55.

7.

Felson DT. Risk Factors of osteoarthritis. Clin Orthoped Rel Res. 2004;427S:S16-S21.

8.

Rossignol M, Leclerc A, Allaeret FA, et al. Primary osteoarthritis of hip, knee and hand in relation to
occupational exposure. Occup Environ Med. 2005;62:772-777.

9.

Cooper C, Snow S, McAlindon TE, et al. Risk factors for the incidence and progression of radiographic
knee ostoarthrits. Arthritis Rheum. 2000;43(5):995-1000.

10.

Blogojevic M, Jinks C, Jeffrey A, et al. Risk factors for onset of osteoarthritis of the knee in older adults:
a systematic review and metanalysis. Osteoarthritis Cartilage. 2010;18(1):24-33.

11.

R. Altman, E. Asch, D. Bloch, G. Bole, D. Borenstein, K. Brandt, et al. The American College of
Rheumatology criteria for the classification and reporting of osteoarthritis of the knee. Arthritis Rheum
1986;29:1039--1049.

12.

Petersson IF, Boegrd T, Saxne T et-al. Radiographic osteoarthritis of the knee classified by the Ahlbck
and Kellgren & Lawrence systems for the tibiofemoral joint in people aged 35-54 years with chronic
knee pain. Ann. Rheum. Dis. 1997;56 (8): 493-6. doi:10.1136/ard.56.8.493.

DAFTAR PUSTAKA (2)

13.

Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations
for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus
guidelines. Osteoarthritis Cartilage. Feb 2008;16(2):137-62.

14.

Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations
for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment
guidelines and systematic review of current research evidence. Osteoarthritis Cartilage. Sep
2007;15(9):981-1000.

15.

Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for
symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med. Apr 1
1992;116(7):535-9.

16.

Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir AD, Woodard J, et al. Prevalence of knee
symptoms and radiographic and symptomatic knee osteoarthritis in African Americans and
Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol. Jan 2007;34(1):172-80.

17.

American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis (OA) of the Knee. AAOS:
American
Academy
of
Orthopaedic
Surgeons.
Available
at
http://www.aaos.org/research/guidelines/GuidelineOAKnee.asp. Accessed July 8, 2013.

18.

Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, et al. A randomized trial of
arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. Sep 11 2008;359(11):1097-107.

19.

Pagenstert G, Knupp M, Valderrabano V, Hintermann B. Realignment surgery for valgus ankle

osteoarthritis. Oper Orthop Traumatol. Mar 2009;21(1):77-87.

20.

Reichenbach S, Rutjes AW, Nesch E, Trelle S, Jni P. Joint lavage for osteoarthritis of the knee.
Cochrane Database Syst Rev. May 12 2010;CD007320.

21.

Chapple CM, Nicholson H, Baxter GD, Abbott JH. Patient characteristics that predict progression of
knee osteoarthritis: A systematic review of prognostic studies. Arthritis Care Res (Hoboken). Aug
2011;63(8):1115-25.