Karuniawan

OSTEOARTHRITIS

Definisi Osteoarthritis
Penyakit osteoarthritis adalah Perubahan sel dan matriks sendi yang ditinjau dari baik segi morfolagi, biokimia , molekuler dan biomekanika yang mengarah kepada melunaknya , fibrilasi dan eburnasi pada tulang subchondaral ; osteofit ; kista subchondral

 Osteoartritis (OA) didefinisikan sebagai penyakit yang diakibatkan kejadian biologik dan mekanik yang menyebabkan gangguan keseimbangan antara proses degradasi dan sintesis dari kondrosit,matriks ekstraseluler tulang rawan

sendi dan tulang subkondral,

Penyakit OA bermanifestasi sebagai : perubahan morfologik, biokimia, molekuler dan biomekanik dari sel dan matriks yang mengakibatkan perlunakan, fibrilasi, ulserasi, menipisnya tulang rawan sendi sklerosis dan eburnasi tulang subkondral osteofit dan kista subkondral

Faktor risiko pada OA dapat dibedakan faktor risiko kejadian awal (incident) faktor risiko progresivitas dan beratnya OA
faktor risiko yang diduga berperan pada

progresivitas OA lutut ialah densitas massa tulang (DMT).

Jaringan yang terlibat Kartilago / tulang rawan sendi Kapsul sendi Ligamentum Otot/ muskulus Membrana synovial Tulang subchondral Jaringan peri- artikular

2 proses berperan osteoarthritits

terjadi

1. Inflamasi 2. Proses degeneratif

Anatomy of The Knee

Anatomy of The Knee

Diagnosis osteoarthritis

usia > 50 th nyeri pagi <30 menit krepitasi tulang lembek tullang membengkak sendi panas tidak teraba Varus deformity (bow legged) gambaran khas radiologi penurunan the cartilage space osteofit robekan meniscus MRI

 Usia Wanita Obesitas Trauma (riwayat) Malaliggnment extremitas bawah Aktifitas High impact Otot / muskulus lemah

Osteoarthritis sendi lutut

I.

Pandangan umum
Epidemiologi Definisi Factor risiko

Pendekatan klinis pada nyeri lutut III. Differential Diagnosis IV. Diagnosis Osteo arthritis sendi lutut V. Management
II.
Lifestyle Medical Surgical

Pendekatan klinis pada nyeri lutut

dokter , lutut saya nyeri !

Riwayat
Inflammasi : demam , sendi meradang

/ panas
Riwayat trauma atau pembedahan Instabilitas

Functional loss
Riwayat pengobatan

Pendekatan klinis pada nyeri lutut

Pemeriksaan fiisik
Tanda vital
Palpasi :nyeri lokal , effusi, krepitasi ROM: ukur derajad fleksi Stabilitas :ligaments meniskus Alignment: genu varus or valgus Fungsi : gait, duck waddle

Pendekatan klinis pada nyeri lutut

Valgus Test (MCL)

Varus Test (LCL)

Lachman Test (ACL)

McMurray Maneuver (menisci)

Duck Waddle (stability)

Pendekatan klinis pada nyeri lutut

Tes laboratorium dan ray
Darah lengkap , LED, RF Arthrocentesis X-rays (3 views)
Weight-bearing AP Lateral Tangential Patellar (Sunrise)

MRI

Pendekatan klinis pada nyeri lutut

I.

Pandangan umum
Epidemiologi Definisi Factor risiko

II. III. IV. V.

Pendekatan klinis pada nyeri lutut Differential Diagnosis Diagnosis Osteo arthritis sendi lutut Management
Lifestyle Medical Surgical

Differential Diagnosis nyeri sendi lutut

Nyeri Medial
OA MCL Meniscus Bursitis

Nyeri Lateral
OA LCL Meniscus Iliotibial band syndrome

Nyeri Diffuse
OA

Nyeri Anterior
OA

Infectious arthritis
Gout, pseudogout RA

Patellofemoral syndrome
Prepateller bursitis Quadriceps mechanism

Osteoarthritis of The Knee

I.

Pandangan umum
Epidemiologi Definisi Factor risiko

Pendekatan klinis pada nyeri lutut III. Differential Diagnosis IV. Diagnosis Osteo arthritis sendi lutut V. Management
II.
Lifestyle Medical Surgical

Diagnosis of Knee OA
Classic Clinical Criteria
established by ACR, 1981 sensitivity 95%, specificity 69%

knee pain plus at least 3 of 6 characteristics:

> 50 yo Morning stiffness < 30 min Crepitus Bony tenderness Bony enlargement No palpable warmth 5

Diagnosis of Knee OA
Algoritma Clinical symptoms Synovial fluid
1. 2. 3. WBC<2000/mm3 Clear color High Viscosity Osteophytes Loss of joint space Subchondral sclerosis Subchondral cysts
Sensitivity 94 %; Specificity 88 %

No OA

X-rays
1. 2. 3. 4.

Confirmed by arthroscopy (gold standard) 6

Diagnosis of Knee OA

Osteoarthritis of The Knee

I.

Pandangan umum
Epidemiologi Definisi Factor risiko

Pendekatan klinis pada nyeri lutut III. Differential Diagnosis IV. Diagnosis Osteo arthritis sendi lutut V. Management
II.
Lifestyle Medical Surgical

Management: Lifestyle
Weight loss
Nutrition referral

Exercise Program

PT referral Quadriceps strengthening ROM exercises Low impact activities e.g. swimming, biking 7

Ambulatory assist devices

Cane Walker

Insoles Unloader knee braces

Management: Lifestyle
Varus (bowlegged) vs Valgus (knock-kneed)

G2 Unloader Brace

Management: Medical
Glucosamine/Chondroitin
Acetaminophen NSAIDs

Cox-2 inhibitors
Opioids Intraarticular injections
Glucocorticoids Hyaluronans

Management: Medical
Glucosamine/Chondroitin
1500 mg/1200 mg daily ($40-50/month)
Glucosamine: building block for glycosaminoglycans Chondroitin: glycosaminoglycan in articular cartilage

Management: Medical
Acetaminophen/ parasetamol
Indikasi : mild-moderate pain

1000 mg Q6h PRN

Better than placebo but less efficacious than NSAIDs Caution in advanced hepatic disease
9

NSAIDs
Indikasi: moderate-severe pain, failed acetaminophen GI/renal/hepatic toxicity, fluid retention

Risiko gastro intestinal bleeding : use anti-ulcer agents

concurrently highly variable efficacy and toxicity

Management: Medical
NSAIDs
10

Management: Medical

Cox-2 inhibitors

Indication: mod-severe pain, failed NSAID, risk of GIB OA pain relief similar to NSAIDs Fewer GI events e.g. symptomatic ulcers, GIB Celecoxib 200 mg daily GI/renal toxicity, fluid retention Increased risk of CV events?
APC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID

Increased risk at higher doses 11

CLASS Trial: 8,000 pts compared Celecoxib vs Ibuprofen

Similar risk to Ibuprofen 12

Management: obat-obatan
Analgetik opioid
Indikasi :

Moderate-severe pain Acute exacerbations NSAIDs/Cox-2 inhibitors failed or contraindicated Oxycodone synergistic w/ NSAIDs 13 Tramadol/acetaminophen vs codeine/acetaminophen Similar pain relief 14 Avoid long-term use Caution in elderly Confusion, sedation, constipation

Management: obat-obatan
Intraarticular Injections
Glucocorticoids
Indication: pain persists despite oral analgesics 40 mg/mL triamcinolone (kenalog-40)

Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL)

Limit to Q3months, up to 2 yrs Effective for short-term pain relief < 12 wks Acute flare w/in 48 hrs post-injection 15

Management: obat-obatan
Intraarticular Injections
Hyaluronans (e.g. Synvisc)
Indication: pain persists despite other agents Synthetic joint fluid Pain relief similar to steroid injections 2 mL injection Qwk x 3, $560-760/series Medicare reimburses 80%, Medi-cal $455.90 60-70% patients respond, relief up to 6 months Patient satisfaction 16, 17

Management: obat-obatan
Intraarticular Injections Technique
22 gauge 1.5 inch needle Approach accuracy:
Lateral mid-patellar 93% 18

Patient supine
Leg straight Manipulate patella Angle needle slightly posteriorly Inject after drop in resistance or fluid aspirated

Management: Algorithm
Modifikasi lifestyle Acetaminophen PRN

NSAIDs PRN

Celecoxib

Steroid Injections

Opioids PRN

Hyaluronan Injections

Rujuk bedah orthopaedi

Management: Surgical
Kapan dirujuk ke dokter bedah orthopaedi ?
Nyeri lutut persisten dg gangguan fungsi

tidak kunjung sembuh dengan pengobatan non bedah

Types of Procedures

Arthroscopic Irrigation Arthroscopic Debridement High Tibial Osteotomy Partial Knee Arthroplasty Total Knee Arthroplasty

Managemen: pembedahan
High Tibial Osteotomy
Indikasi:
Unicompartmental arthritis Genu varus or valgus

Realign mechanical axis Age < 60yo < 15 degrees deformity19

Managemen: pembedahan
Partial Knee Arthroplasty
Indikasi :
Unicompartmental arthritis

Ligaments spared Increased ROM Faster recovery Prosthesis 10-yr survival: 84% 20

Managemen: pembedahan
Total Knee Arthroplasty
Indikasi :
Diffuse arthritis Severe pain Functional impairment

Pain relief > functional gain ACL sacrificed

PCL also may be sacrificed

Prosthesis 10-yr survival: 90% 21

Hal-hal penting di klinik

Evaluasi fungsi ug hilang

Pemeriksaan lutut : palpasi , ROM, duck waddle

Rujuk ke ahli nutrisi Exercise program/PT referral Orthosis / alat bantu Lateral mid-patellar or superolateral approach Edukasi pasien thd :glucosamine/chondroitin, Cox-2 inhibitors, injeksi