12. dr. karuniawan - osteoarthritis

Karuniawan

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 terjadi osteoarthritits

1. Inflamasi2. Proses degeneratif

Anatomy of The KneeAnatomy 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 spaceosteofit robekan meniscus MRI

Usia Wanita Obesitas Trauma (riwayat) Malaliggnment

extremitas bawah Aktifitas High

impact Otot / muskulus

lemah

Osteoarthritis Osteoarthritis sendi lututsendi lutut

I.I. Pandangan umum Pandangan umum EpidemiologEpidemiologii DefiniDefinisisi FactorFactor risiko risiko

II.II. Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut

III.III. Differential DiagnosisDifferential Diagnosis

IV.IV. Diagnosis Diagnosis Osteo arthritis sendi lututOsteo arthritis sendi lutut

V.V. Management Management LifestyleLifestyle Medical Medical SurgicalSurgical

Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut ““dokter , lutut saya nyeri dokter , lutut saya nyeri !”!”

Riwayat Riwayat

InflammaInflammasi : si : demam demam , , sendi sendi

meradang / panas meradang / panas

Riwayat Riwayat trauma trauma atau pembedahanatau pembedahan

InstabilitInstabilitasas

Functional lossFunctional loss

Riwayat pengobatan Riwayat pengobatan

Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut

Pemeriksaan fiisik Pemeriksaan fiisik

Tanda vital Tanda vital

PalpaPalpasi :nyeri lokal si :nyeri lokal , effusi, , effusi, kkrepitrepitasiasi

ROM: ROM: ukur derajad fleksiukur derajad fleksi

StabilitStabilitas :as :ligaments menisligaments meniskuskus

Alignment: genu varus or valgusAlignment: genu varus or valgus

FunFungsi gsi : gait, duck waddle: gait, duck waddle


Varus Test (LCL)Varus Test (LCL)Valgus Test Valgus Test (MCL)(MCL)

McMurray McMurray ManeuverManeuver

(menisci)(menisci)

Lachman Test Lachman Test (ACL)(ACL)

Duck Waddle Duck Waddle (stability)(stability)


TesTes laboratorium dan –ray laboratorium dan –ray

Darah lengkap Darah lengkap , , LEDLED, RF, RF

ArthrocentesisArthrocentesis

X-rays (3 views)X-rays (3 views) Weight-bearing AP Weight-bearing AP LateralLateral Tangential Patellar (Sunrise)Tangential Patellar (Sunrise)

MRIMRI

Differential Diagnosis Differential Diagnosis nyeri sendi nyeri sendi lututlutut

Nyeri Nyeri MedialMedial OAOA MCLMCL MeniscusMeniscus BursitisBursitis

Nyeri Nyeri DiffuseDiffuse OAOA Infectious arthritisInfectious arthritis Gout, pseudogoutGout, pseudogout RARA

Nyeri Nyeri LateralLateral OAOA LCLLCL MeniscusMeniscus Iliotibial band syndromeIliotibial band syndrome

Nyeri Nyeri AnteriorAnterior OAOA Patellofemoral syndromePatellofemoral syndrome Prepateller bursitisPrepateller bursitis Quadriceps mechanismQuadriceps mechanism

Osteoarthritis of The KneeOsteoarthritis of The Knee






Diagnosis of Knee OADiagnosis of Knee OA

Classic Clinical CriteriaClassic Clinical Criteria established by ACR, 1981established by ACR, 1981 sensitivity 95%, specificity 69%sensitivity 95%, specificity 69%

knee painknee pain plus at least 3 of 6 characteristics: plus at least 3 of 6 characteristics:• > 50 yo> 50 yo• Morning stiffness < 30 minMorning stiffness < 30 min• CrepitusCrepitus• Bony tendernessBony tenderness• Bony enlargementBony enlargement• No palpable warmth No palpable warmth 55


Algoritma Algoritma Clinical symptomsClinical symptoms Synovial fluidSynovial fluid

1.1. WBC<2000/mmWBC<2000/mm33

2.2. Clear colorClear color3.3. High ViscosityHigh Viscosity

X-raysX-rays1.1. OsteophytesOsteophytes2.2. Loss of joint spaceLoss of joint space3.3. Subchondral sclerosisSubchondral sclerosis4.4. Subchondral cystsSubchondral cysts

Confirmed by arthroscopyConfirmed by arthroscopy (gold standard) (gold standard) 66

No OANo OA

Sensitivity 94 %; Specificity 88 %

Osteoarthritis of The KneeOsteoarthritis of The Knee






Management: LifestyleManagement: Lifestyle Weight lossWeight loss

Nutrition referralNutrition referral Exercise ProgramExercise Program

PT referral PT referral Quadriceps strengthening Quadriceps strengthening ROM exercisesROM exercises Low impact activities e.g. swimming, biking Low impact activities e.g. swimming, biking 77

Ambulatory assist devicesAmbulatory assist devices CaneCane Walker Walker

InsolesInsoles Unloader knee bracesUnloader knee braces

Management: LifestyleManagement: Lifestyle

Varus (bowlegged) vs Valgus (knock-kneed)Varus (bowlegged) vs Valgus (knock-kneed)

G2 Unloader G2 Unloader BraceBrace

Management: MedicalManagement: Medical

Glucosamine/ChondroitinGlucosamine/Chondroitin AcetaminophenAcetaminophen NSAIDsNSAIDs Cox-2 inhibitorsCox-2 inhibitors OpioidsOpioids Intraarticular injectionsIntraarticular injections

GlucocorticoidsGlucocorticoids HyaluronansHyaluronans


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


AcetaminophenAcetaminophen/ parasetamol / parasetamol IndiIndikkaasi si : mild-moderate pain: mild-moderate pain 1000 mg Q6h PRN1000 mg Q6h PRN Better than placebo but less efficacious than NSAIDs Better than placebo but less efficacious than NSAIDs 99 Caution in advanced hepatic diseaseCaution in advanced hepatic disease

NSAIDsNSAIDs IndiIndikkaasisi: moderate-severe pain, failed acetaminophen: moderate-severe pain, failed acetaminophen GI/renal/hepatic toxicity, fluid retentionGI/renal/hepatic toxicity, fluid retention Risiko gastro intestinal bleeding :Risiko gastro intestinal bleeding : use anti-ulcer agents use anti-ulcer agents

concurrentlyconcurrently highly variable efficacy and toxicityhighly variable efficacy and toxicity


NSAIDsNSAIDs1010


Cox-2 inhibitorsCox-2 inhibitors Indication: mod-severe pain, failed NSAID, risk of GIBIndication: mod-severe pain, failed NSAID, risk of GIB OA pain relief similar to NSAIDsOA pain relief similar to NSAIDs Fewer GI events e.g. symptomatic ulcers, GIBFewer GI events e.g. symptomatic ulcers, GIB Celecoxib 200 mg dailyCelecoxib 200 mg daily GI/renal toxicity, fluid retentionGI/renal toxicity, fluid retention Increased risk of CV events? Increased risk of CV events?

APC Trial: 700 pts each assigned to placebo, 200 BID, 400 BIDAPC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID Increased risk at higher doses Increased risk at higher doses 1111

CLASS Trial: 8,000 pts compared Celecoxib vs IbuprofenCLASS Trial: 8,000 pts compared Celecoxib vs Ibuprofen

Similar risk to Ibuprofen Similar risk to Ibuprofen 1212

Management: Management: obat-obatan obat-obatan

Analgetik opioid Analgetik opioid Indikasi Indikasi : :

Moderate-severe painModerate-severe pain Acute exacerbationsAcute exacerbations NSAIDs/Cox-2 inhibitors failed or contraindicatedNSAIDs/Cox-2 inhibitors failed or contraindicated

Oxycodone synergistic w/ NSAIDs Oxycodone synergistic w/ NSAIDs 1313

Tramadol/acetaminophen vs codeine/acetaminophenTramadol/acetaminophen vs codeine/acetaminophen Similar pain relief Similar pain relief 1414

Avoid long-term useAvoid long-term use Caution in elderlyCaution in elderly

Confusion, sedation, constipationConfusion, sedation, constipation


Intraarticular InjectionsIntraarticular Injections

GlucocorticoidsGlucocorticoids

Indication: pain persists despite oral analgesicsIndication: pain persists despite oral analgesics

40 mg/mL triamcinolone (kenalog-40)40 mg/mL triamcinolone (kenalog-40)

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

Limit to Q3months, up to 2 yrsLimit to Q3months, up to 2 yrs

Effective for short-term pain relief < 12 wksEffective for short-term pain relief < 12 wks

Acute flare w/in 48 hrs post-injection Acute flare w/in 48 hrs post-injection 1515


Intraarticular InjectionsIntraarticular Injections

Hyaluronans (e.g. Synvisc)Hyaluronans (e.g. Synvisc) Indication: pain persists despite other agentsIndication: pain persists despite other agents Synthetic joint fluidSynthetic joint fluid Pain relief similar to steroid injectionsPain relief similar to steroid injections

2 mL injection Qwk x 3, $560-760/series2 mL injection Qwk x 3, $560-760/series

Medicare reimburses 80%, Medi-cal $455.90Medicare reimburses 80%, Medi-cal $455.90 60-70% patients respond, relief up to 6 months60-70% patients respond, relief up to 6 months Patient satisfaction Patient satisfaction 16, 1716, 17


Intraarticular InjectionsIntraarticular Injections TechniqueTechnique

22 gauge 1.5 inch needle22 gauge 1.5 inch needle Approach accuracy:Approach accuracy:

Lateral mid-patellar 93% Lateral mid-patellar 93% 1818

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

Management: AlgorithmManagement: Algorithm

Modifikasi lifestyle Modifikasi lifestyle Acetaminophen Acetaminophen PRNPRN

NSAIDs PRNNSAIDs PRN

Opioids PRNOpioids PRN

CelecoxibCelecoxib

Steroid Steroid InjectionsInjections

Hyaluronan Hyaluronan InjectionsInjections

Rujuk bedah Rujuk bedah orthopaedi orthopaedi

Management: SurgicalManagement: Surgical

Kapan dirujuk ke dokter bedah Kapan dirujuk ke dokter bedah orthopaedi ?orthopaedi ?

Nyeri lutut persisten dg gangguan fungsi Nyeri lutut persisten dg gangguan fungsi tidak kunjung sembuh dengan pengobatan tidak kunjung sembuh dengan pengobatan

non bedah non bedah

Types of ProceduresTypes of Procedures Arthroscopic IrrigationArthroscopic Irrigation Arthroscopic DebridementArthroscopic Debridement High Tibial OsteotomyHigh Tibial Osteotomy Partial Knee ArthroplastyPartial Knee Arthroplasty Total Knee ArthroplastyTotal Knee Arthroplasty

Managemen: Managemen: pembedahan pembedahan

High Tibial OsteotomyHigh Tibial Osteotomy

IndiIndikasikasi:: Unicompartmental arthritisUnicompartmental arthritis Genu varus or valgusGenu varus or valgus

Realign mechanical axisRealign mechanical axis

Age < 60yoAge < 60yo

< 15 degrees deformity< 15 degrees deformity1919


Partial Knee ArthroplastyPartial Knee Arthroplasty

IndiIndikasi kasi ::

Unicompartmental arthritisUnicompartmental arthritis

Ligaments sparedLigaments spared

Increased ROMIncreased ROM

Faster recoveryFaster recovery

Prosthesis 10-yr survival: 84% Prosthesis 10-yr survival: 84% 2020


Total Knee ArthroplastyTotal Knee Arthroplasty IndiIndikasi kasi ::

Diffuse arthritisDiffuse arthritis Severe painSevere pain Functional impairmentFunctional impairment

Pain relief > functional gainPain relief > functional gain ACL sacrificedACL sacrificed PCL also may be sacrificedPCL also may be sacrificed Prosthesis 10-yr survival: 90% Prosthesis 10-yr survival: 90% 2121

Hal-hal penting di klinik Hal-hal penting di klinik

Evaluasi fungsi ug hilang Evaluasi fungsi ug hilang

Pemeriksaan lutut : palpasi Pemeriksaan lutut : palpasi , ROM, duck waddle, ROM, duck waddle

Rujuk ke ahli nutrisi Rujuk ke ahli nutrisi

Exercise program/PT referralExercise program/PT referral

OrthoOrthosis / alat bantu sis / alat bantu

Lateral mid-patellar or superolateral approachLateral mid-patellar or superolateral approach Edukasi pasien thd :Edukasi pasien thd :glucosamine/chondroitin, glucosamine/chondroitin,

Cox-2 inhibitors, injeCox-2 inhibitors, injeksi ksi

12. dr. karuniawan - osteoarthritis

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