Symptoms

• A knee with this problem hurts, swells and grinds, crepitus (popping and cracking) can be felt on moving the joint.
• The pain is localized in the front of the knee.
• Activities such as running, jumping stairs, hiking, squats and lunges will exacerbate the condition and increase the swelling.

On  examination

•  The knee may be swollen and have fluid in it.
• The knee may also pop and click when straightening the knee, or descending or ascending stairs.
• Getting up after prolonged sitting typically increases pain

INVESTIGATIONS

• Radiographs (x rays) may be normal or may show some tilt of the patella or narrowing of the joint surface.
• An MRI is also useful.
• But diagnosis is mainly clinical

Treatment of chondromalacia patella

• Decrease exposure to known aggravating activities  including repetitive stair climbing, squatting, running, cycling (especially a stationary bicycle), weight lifting with free weights and even wearing high heels.
• Weight loss (if one pound is lost that decreases the pressure on the patella by 4 lbs
• Medications  like Acetaminophen, Ibuprofen, Naproxen, NSAIDs
• Strengthening exercises that put less pressure on the kneecap are: leg presses and mini squats (0-60 degrees), hamstring curls and hip abductor exercises are useful. Avoid leg extension exercises.
• Surgery-arthroscopy to make the joint surface smooth. This is employed only in resistant cases

PATHOPHYSIOLOGY:

• Its a disorder of Purine metabolism
• The triggering factors are cool temperatures,rapid changes in the uric acid levels, acidosis, extracellular matrix proteins such as proteoglycans, collagens and chondroitin sulphate.

Gout usually affects

Joints.

• Big toe is commonly affected-the metatarsophalangeal joint
• Also affect small joints (finger) and large joints, (knee and hip.)

Bursae.

These are thin, slippery sacs with just a slight amount of fluid in them act as cushions between bones and soft tissues. for example:

• The bony tip of the elbow (olecranon bursa) and the front of the kneecap (prepatellar bursa).

Tendon sheaths.

• The tendons in the hand and feet passes through these tunnels which provide them protection and nutrition.

Kidneys.

• It causes kidney stones finally resulting in kidney scarring /urate nephropathy
• After the first gout attack it may be months or years before another one occurs.
• If no preventive treatment is taken, next attack usually happens within 2 years,.
• Later attacks can become more severe and affect more than one joint at a time.
• As time goes on, gout attacks may also become more frequent.

If uric acid levels remain high over a long period of time, deposits can develop around joints and tendons. This leads to tophi (toothpaste like deposits) that later can cause permanent deformity and pain

CAUSES:

Hyperuricemia is the underlying cause of gout; may be overproduction or underexcretion of uric acid. The risk factors are:

• LIFESTYLE – consumption of alcohol, maet, sea food, fructose sweetened foods. also physical trauma, surgery.
• GENDER AND AGE-men>women. age between 30-45.
• GENETICS-3 genes are commonly associated with gout. SLC2A9, SLC22A12, ABCG2. Rare genetic disorders including familial juvenile hyperuricemic nephropathy, medullary cystic kidney associated with gout.
• MEDICAL CONDITION – Metabolic syndrome (abdominal obesity, hypertension, insulin resistance, abnormal lipid levels), polycythemia, psoriasis, lead poisoning associated with gout.
• MEDICATIONS – Diuretics, niacin, aspirin, immunosuppressive drugs (tacrolimus, ciclosporin) associated with gout.

SYMPTOMS

• It may wake you up at night with intense pain in your big toe
• The joint that is affected is typically red, swollen and hot.

DIAGNOSIS

• Blood Test-high uric acid level (hyperuricemia)
• Plasma urate levels more than 7.0mg/dl in males and 6.0mg/dl in females are diagnostic of gout

2.Synovial Fluid Analysis

• More accurate test for gout. Identification of monosodium urate crystals in synovial fluid.
• Under polarised  light microscopy, Spiked rods of uric acid crystals from synovial fluid.
• The fluid must also be examined relatively quicker after aspiration, as temperature and pH affect the solubility.

3. X-RAY- joint destruction

4.WBC may be > 40,000/mm3, ESR may be elevated.

TREATMENT:

ACUTE PAIN MANAGEMENT

Home remedies.

• Ice- Application of ice to the affected area by wrapping in a cloth for about 20 minute
• Elevate the limb above the level of heart.
• Complete rest to the part when the symptoms are present.
• If it’s a mild attack,  Nonsteroidal anti inflammatory drugs can be given.

Usually used medications:

• NON- STEROIDAL ANTI INFLAMMATORY –agents  such as indomethacin or ibuprofen.Usually improvement is seen within 4 hrs. Its not recommended if there is GI bleeding, renal failure or heart failure.
• COLCHICINE- is also given to reduce inflammation during an acute gout attack. Used as alternative to NSAIDS.
• STEROIDS-corticosteroids for acute gout attacks. It could be injected into the joint. Joint infection should be excluded before injection.

PROPHYLAXIS:

Lifestyle changes. Life style modification to prevent acute attack and future attacks are:

• Daily exercises to maintain body weight at an optimum level.
• Take plenty of water to increase the excretion of uric acid.
• Reduce calorie intake; avoid excess sugar and fat and take complex carbohydrates, increase the intake of vitamin C. (1500mg/day)

Medications. People with high blood uric acid will benefit from medications.

These medicines will keep the uric acid level less than 6 mg/dl. Long term therapy usually is given to those having more than 3 attacks /year, tophi, disabling disease, kidney stones,renal excretion of uric acid crystals

Medicines:

• XANTHINE OXIDASE INHIBITORS: allopurinol and febuxostat block uric acid production. Long term therapy is safe and well tolerated. Can be used in people with renal problems.
• COLCHICINE – used both for prophylaxis and control of acute attack,. It prevents WBC from attacking the gout crystals.
• URICOSURIC AGENTS – Probenecid and sulfinpyrazone are preferred if reduced secretion of uric acid as indicated by 24 hr urine collection shows uric acid level <800 mg. It helps in the excretion of uric acid. Not used if kidney stones present.

Surgical management:

People with destroyed joints due to chronic gout may benefit from surgery,.

Removal of tophi. the uric acid nodules around finger or toe joints, tendons, or bursae  are removed if they are painful or else they may get broken and infected.

Joint fusion: if there is chronic gout and destruction of joint, joint fusion done. It reduces pain and increases mobility.

Joint replacement. Commonly done for knee joint. It will relieve pain and helps in mobility

DIFFERENTIAL  DIAGNOSIS:

• Septic arthritis:considered when signs of infection present such as fever, high WBC count. To confirm gram stain and culture will be done.
• Pseudogout.
• Rheumatoid arthritis.

PROGNOSIS:

Without treatment, an acute attack of gout usually resolves in 5-7 days. 60% will have 2nd attack within one year. Without treatment episodes of acute attack develop into chronic gout with destruction of joint surfaces, joint deformity and painless tophi.

Tophi occur in those who are untreated for 5 yrs often in the helix of the ear, over the olecranon process, or in the achilles tendon. with aggressive treatment they resolve.

Cause

• The articular cartilage that covers the ends of bones in the joints gradually wears away.
• Thus the smooth articular cartilage is now a frayed, rough surface leading to painful joint movements.
• Usually OA develops after many years of use, especially in middle-aged or older.
• Other risk factors- obesity, previous injury to the affected joint, and family history of osteoarthritis.

Anatomy

• A joint is a place where the ends of two or more bones meet.

For example, in knee joint the bones of the lower leg (the tibia and the fibula) and the thigh bone (the femur) constitutes the joint.

• In hip joint the top of the thigh bone (femoral head) meets a concave portion of the pelvis (the acetabulum).
• Articular cartilage is an elastic tissue which covers the ends of the bones that make up the joint and makes painless and smooth movement of healthy joint

Symptoms

• joints affected: any joint in the body, with symptoms ranging from mild to disabling.
• The joint will be painful and inflamed.
• Without cartilage, bones rub directly against each other when the joint moves,causes the pain and inflammation.
• Pain or a dull ache usually develops gradually over time.
• Diurnal variation of pain: worse in the morning and feel better with activity.
• Relation to activities: Vigorous activity – pain may flare up.

For example, in a case of OA-hand: Bone growths on the little finger are typical of osteoarthritis.Joint is Stiff swollen, enlarged or “out of joint.”

A bump over the joint.

• Motion will be limited because bending of joint is difficult, and also if loose fragments of cartilage and other tissue can interfere with the smooth motion of joints.
• The joint may lock or “stick” when used. It may creak, click, snap, or make a grinding noise (crepitus). The joint may become weak and buckle.
• Although osteoarthritis cannot be cured, early identification and treatment can slow progression of the disease, relieve pain and restore function.

Diagnosis

1. Complete medical history
2. Physical examination
3. X-rays
4. Possibly laboratory tests

History

• Any past history of injuries to the joint.
• When did the joint pain began and what the pain feels like.
• Is the pain continuous, or does it come and go? Does it occur in other parts of the body?
• When the pain occurs: Is it worse at night?
• Does it occur with walking, running or at rest?

Physical examination of affected joint:

• It is done to know if there is pain or restricted motion.
• Done keeping the joint in various positions
• Looked for: any cracking or grinding noises (crepitus) that indicate bone-on-bone friction.
• Muscle loss (atrophy)
• Signs that other joints are involved.
• Signs of injury to muscles, tendons, and ligaments.

X-rays

• Helps the doctor to distinguish various forms of arthritis.

It can show

•  The extent of joint deterioration, including narrowing of joint space,
•  Thinning or erosion of bone,
•  Excess fluid in the joint,
•  Any bone spurs or other abnormalities. They can help the doctor to identify stage of the disease

Laboratory tests

To rule out other diseases that cause symptoms similar to osteoarthritis.

Treatment

1. Nonsurgical Treatment
2. Early nonsurgical treatment-reduces the progression of osteoarthritis, increase motion, and improve strength.
3. Treatment programs combine lifestyle modifications, medication, and physical therapy.

Lifestyle Modifications

• Rest or a change in activities to avoid provoking osteoarthritis pain which can include modifications in work or sports activities.
• It may mean switching from high-impact activities (such as aerobics, running, jumping, or competitive sports) to low-impact exercises (such as stretching, walking, swimming, or cycling).
• A weight loss program may be recommended, if needed, particularly if osteoarthritis affects weight-bearing joints (such as the knee, hip, spine, or ankle)

Medications

• Non-steroidal anti-inflammatory drugs (NSAIDS) – reduce inflammation.
• The doctor may recommend strong anti-inflammatory agents called corticosteroids, which are injected directly into the joint.
• This will provide temporary relief of pain and swelling.
• Dietary supplements: glucosamine and chondroitin sulfate may help relieve pain from osteoarthritis
• (should be taken only after consulting the doctor)

Physical Therapy

• A balanced fitness program, physical therapy, and/or occupational therapy
• This will improve joint flexibility, increase range of motion, reduce pain, and strengthen muscle, bone, and cartilage tissues.
• Supportive or assistive devices (such as a brace, splint, elastic bandage, cane, crutches, or walker) may be needed.
• Ice or heat may need to be applied to the affected joint for short periods, several times a day.

2) Surgical Treatment

• Indicated if early treatments do not stop the pain or if they lose their effectiveness.
• This decision depends upon 1)the age and activity level of the patient,
• The condition of the affected joint,
• The extent to which osteoarthritis has progressed.

The options are

1. Arthroscopy
2. Osteotomy
3. joint fusion
4. joint replacement

Arthroscopy

A surgeon uses a pencil-sized, flexible, fiberoptic instrument (arthroscope) to make two or three small incisions
Any bone spurs, cysts, damaged lining, or loose fragments if present in the joint are removed.

Osteotomy

The long bones of the arm or leg are realigned to take pressure off of the joint.

Joint fusion

A surgeon eliminates the joint by fastening together the ends of bone (fusion).
Pins, plates, screws, or rods may hold bones in place while they heal.
The joint’s flexibility is eliminated by this procedure.

Joint replacement

A surgeon removes parts of the bones and creates an artificial joint with metal or plastic components (total joint replacement or arthroplasty).

Dr Hitesh Gopalan U, Orthopaedic Surgeon working at MOSC Medical College, Kolenchery. He is actively involved in treating patients from the following locales; Kolenchery, Tripunithura, Thiruvankulam, Thodupuzha, Kothamangalam, Ernakulam and Idukki

TYPES AND CAUSES OF ARTHRITIS

Osteoarthritis

It is due to wear and tear of joints when the smooth gliding surface covering the end of bones {cartilage} becomes  irregular and destroyed.

• Occur in older people as the ability of the cartilage to heal itself decreases with age.
• Obesity and family history increase the risk of getting arthritis.

Rheumatoid Arthritis: It is an inflammatory disease where patients own body defence mechanism attacks and destroys the cartilage.

• It can affect other organs like eyes, skin, lungs etc .
• Infection or environmental factors makes certain people more susceptible to it.

Post Traumatic Arthritis:

It develops after an injury to the ankle and foot like a fracture, ligament (tough band of tissue which keeps the bones and joints in place) injury, dislocations or severe sprain.

SYMPTOMS

1. Pain or tenderness (pain on touching)
2. Stiffness or reduced motion and difficulty in walking
3. Swelling

DIAGNOSIS:

• Gait analysis is one of the  test performed during physical examination. It will show how the bones in the leg and foot line up with walking, tests the strength of the ankle and feet.
• XRay are most valuable test to diagnose the severity of arthritis it shows changes in the spacing between the bones or in the shape of the bones.
• Weight bearing XRays, Bone scan, CT scan or MRI may also be used in evaluation.

TREATMENT

It depends on the type, location and severity of arthritis.

Treatment can be of many types

NONSURGICAL TREATMENT

• Pain relievers and anti-inflammatory medications (steroids injected into the joints to reduce swelling).
• Physical therapy and exercise
• Shoe inserts (orthotics), such as pads or arch supports like stiff-soled shoe with a rocker bottom
• N ankle-foot orthosis (AFO)
• Weight reduction

SURGICAL TREATMENTS

It is indicated is arthritis is not responding to nonsurgical treatment.

The choice of surgery depends on type of arthritis, the impact of disease on the joint, location of the arthritis.

Surgeries performed for arthritis of the foot and ankle are

1.  Arthroscopic debridement

Cleaning the joint  after  directly inserting a pencil shaped flexible scope   inside the joints and identifying  the problem areas and removing  the area of foreign bony outgrowth (spurs) and    inflamed tissue.

2. Fusion of the joints (Arthrodesis)

Fuses the bones of a joint by using  pins,plates and screws or rods making it one continuous bone.

The complication with arthrodesis is development of arthritis of the joints adjacent to those fused due to increased stresses applied to the adjacent joint.

3. Replacement of the affected joints (Arthroplasty) damaged ankle joint is replaced with an artificial implant

Ankle replacement is advised in patients with Advanced arthritis of the ankle where the  joint surfaces is destroyed

Cause

Seen in genetically susceptible individuals .certain people have genes that make them more prone to the disease. These genes get activated only if there is a ‘trigger’  such as an infection or an environmental factor. Once the body is exposed to these triggers the genes get activated  and  the immune system responds  inappropriately destroying the joint surface instead of protecting it. This leads to joint swelling and pain.

SYMPTOMS

• Multiple joints can get affected
• Swelling, pain, and stiffness in the joint,
• A feeling of warmth around the joint
• Deformities and contractures of the joint
• Fever, loss of appetite
• Weakness due to a low red blood cell count (anemia)
• Nodules, or lumps, particularly around the elbow
• Foot pain, bunions, and hammer toes with long-standing disease

DIAGNOSIS

•  Is always by clinical examination, blood test may reveal  an antibody called rheumatoid factor and by XRAYS.
• The American College of Rheumatology requires at least four of the following seven criteria to confirm the diagnosis:
• Morning stiffness around the joint that lasts at least 1 hour
• Arthritis of three or more joints for at least 6 weeks
• Arthritis of hand joints for at least 6 weeks
• Arthritis on both sides of the body for at least 6 weeks
• Rheumatoid nodules under the skin
• Rheumatoid factor present in blood testing
• Evidence of rheumatoid arthritis on X-rays

TREATMENT

1. Exercises

Exercises can help strengthen the joints without putting stress on the joints.

Splints or corrective footwear may be required

2. Medication

There are two kinds of drugs that are used in treatment. Those that relieve symptoms and those that modify the course of the disease.

Aspirin and  ibuprofen reduce pain and inflammation.

Methotrexate, sulfasalazine  are disease modifying drugs

A newer class of biological agents that target the chemical substances that attack joints is also under research

3.surgery

Joint replacement surgery is an option