Degenerative arthritis,

Osteoporosis and Spondylitis

Degenerative arthritis
(Degenerative joint disease/Osteoarthritis)
Activity :Brainstorming
• What is degenerative arthritis?
 Definition
• Degenerative Arthritis is the degenerative disease
of synovial joint characterized by focal loss of
articular hyaline cartilage with proliferation of
new bone(bone spurs) and remodeling joint
contour(old bone digested by osteoclasts,
absorbed then osteoblasts formulate new bone
tissue).
OR
• It is the most common type of arthritis
characterized by progressive deterioration (wear
and tear) of hyaline cartilage on a joint over a
lifetime.
• There is an imbalance in cartilage breakdown
and cartilage synthesis
• It is most often found in the hands, knees, hips
 Epidemiology
• Weight bearing joints are most
affected eg knee &hip
• Age greater than 65 years,80% have
radiographically feature , 25-30%
have symptoms
• More common in women(joints less
stable(more lax) and Postmenopausal
women, in particular, have an increased
risk of developing arthritis and this has
been linked to the decrease in estrogen
during this time).
• Familial tendency
Risk factors
Constitutional/physiological factors Mechanical factors
• Hereditary • Trauma
• Gender • Joint shape
• Hormonal • Occupation
• Obesity • Ageing
• Increase mineral density
• Ageing
Aetiology
• Primary /Idiopathic
oWhen no obvious predisposing factors for degenerative
arthritis
• Secondary
oDegenerative joint change occur in response of recognized
local or systemic factors
Cause of secondary degenerative arthritis
• Endocrine-Acromegaly(the pituitary gland produces too much growth hormone esp. in adults)
• Inflammation-Rheumatoid Arthritis, Gout
• Metabolic-Wilson disease( inherited disorder that causes too much copper to accumulate in
the organs)

• Traumatic-Intra articular fracture

• Neuropathies-Syriongomyelia( fluid-filled cyst (syrinx) forms within the spinal cord. The syrinx
can get big enough to damage the spinal cord and compress and injure the nerve fibers that carry information to and
from the brain to the body),DM(hyperglycemia promotes deposition of advanced glycation end-products (AGEs)
and affects cartilage health ALSO causes peripheral neuropathy, which can contribute to muscle weakness, joint
instability, and consequent OA of weight-bearing joints.)

• Miscellaneous-Paget disease(disrupts the normal cycle of bone renewal, causing bones to become
weakened and possibly deformed. )
Pathogenesis
• Progressive destruction and loss of
articular cartilage with periarticular
bone response lead to exposure of
subchondral bone which become
sclerotic(stiff), with increase blood
vascularity and cyst formation.
 Pathogenesis
Inflammaging is: the
state of low-grade,
sterile chronic
inflammation that
develops with age
Activity :Brainstorming

• Mention five (5) clinical feature of degenerative arthritis

Clinical feature
• Bony swelling around joint
• Tenderness most superior aspect and less commonly medial
aspect of joint
• Pain maximally deep in groin area
• Antalgic gait/limping
• Weakness and wasting of muscle (Quadriceps and Gluteal)
due to disuse caused by pain
• Knee Pain and restricted internal flexion
Clinical feature cont…
Before the age 45 years
• Single or multiple joint involvement
• Preferentially targeting proximally InterPhangeal Joint(IPJ)
• Subchondral erosion on x ray
• Ankylosis of InterPhangeal Joint
Differential Diagnosis
• Rheumatoid Arthritis
• Gout
Investigations
Laboratory studies
• Full Blood Picture-Normal
• Estimated Sedimentation Rate-normal
• C Reactive Protein-Normal
• Rheumatoid factor-Negative
• Synovial Fluid Analysis-Viscous with low turbidity
Investigation cont…
Imaging
• Plain X ray
• Narrowing joint space
• Subchondral sclerosis
Treatment

Pharmacotherapy
• Paracetamol oral 1gm 6-8hourly
Non pharmacotherapy • Non Steroid Anti-inflammatory
• Provision of Education Drug like Ibuprofen
• Lose weight • Hyaluronic injection-injection
• Exercise each daily for 3-5 week to rubricate joints
for easier mvt
Treatment cont…
Indicated when there is failure
of conservative
• Osteotomy
• Joint replacement
• Total joint replacement
Key points
• Septic arthritis is the inflammation of a synovial membrane
with purulent effusion into joint capsule due to infection.
• Degenerative arthritis is the degenerative disease of synovial
joint characterized by focal loss of articular hyaline cartilage
with proliferation of new bone and remodeling joint contour.
• Both, Septic arthritis and degenerative arthritis can be
managed conservatively or surgically
Evaluation
• Mention three (3) clinical presentation of a patient with septic
arthritis
• Mention four (4) complications of septic arthritis.
• Mention four investigation you can order to the patient
degenerative arthritis
Reference
• Russell R.C.G., Norman S.W. & Bulstrode C.J.K. (2008).
Bailey and Love’s Short Practice of Surgery (25 th edition.).
London: Hodder Arnold
• Update 2011-2019
Osteoporosis
Learning objectives
By the end of this session, student are expected to be able to:
• Define Osteoporosis
• Describe aetiopathology of Osteoporosis
• Describe the management of Osteoporosis
Activity:Brainstorming
• What is Osteoporosis?
 Definition
• Osteoporosis is a common metabolic bone disease
characterized by;
o Reduced bone mass
o Micro architectural deterioration of bone tissue
o An increased risk of fragility fracture
Epidemiology
• One in three women over 50 years suffer from osteoporosis
• One in five men over 50 years suffer from osteoporosis
• 15% - 30% men and 30%-50 women suffer fractures related
to osteoporosis in their life time.
Causes Primary Osteoporosis
Post menopausal osteoporosis
• Caused by a lack of estrogens, which helps to regulate the
incorporation of calcium into bone in women.
• Lack of estrogen increased bone resorption.

Age related Osteoporosis

• Usually affects people over age of 70 years.
• Results from age-related calcium deficiency.
• There is decreased bone formation.
• Patients usually present with fractures of the hip and the vertebrae.
Causes of secondary osteoporosis
• Endocrine or metabolic causes; Acromegaly, Athletic amenorrhea,
Diabetes Melitus, Hemochromatosis, Hyperadrenocoticism.
• Collagen/genetic disorder; Ehlers-Danlose syndrome(Connective tissue
disorder with loose, unstable joints that dislocate easily. stretchy skin), Osteogenisis
imperfecta(fragile bones that break easily.), glycogen storage disease,
Homocystinuria(homocysteine cause Increased reactive oxygen species (ROS)
which induces osteoblast apoptosis thereby decreasing osteoblastgenesis), Gaucher’s disease,

• Medications; Proton pump inhibitors, systemic glucocorticoid

therapy, prolonged use of heparin, aromatase inhibitor(impairing
estrogen )production hence weaken bone, Phenytoin.
Causes of secondary osteoporosis
• Nutritional; Alcoholism, Eating disorder, Gastric bypass
surgery, high caffein intake
• Malignancy/hematological disorders; Multiple myeloma( A
cancer of plasma-immune cells), Leukemia, lymphoma, sickle cell
disease, Thalassemia
• Miscellaneous medical conditions; Chronic liver disease,
chronic renal failure, Chronic obstructive lung disease,
Rheumatoid arthritis, Tobacco use, multiple sclerosis( immune
system eats away at the protective covering of nerves impairing nervous
communication/signals0)
Clinical features
• The most common clinical presentation of osteoporosis is
with fractures of various types.
• Vertebral fractures present with acute back pain which
can be localized to the affected site or can radiate to the
anterior chest wall or abdomen.
• Other common sites of fracture include hip and wrist
• Many patients with vertebral fractures present insidiously
with height loss or kyphosis and chronic back pain.
• In addition to pain and height loss, patients with multiple
vertebral fractures may experience abdominal discomfort
and distension due to compression of abdominal organs
by severe kyphosis.
• Loss of height over time, with an accompanying stooped
posture
Activity :Brainstorming
• Mention five (5) clinical feature of Osteoporosis
Differential Diagnosis

• Hyperparathyroidism
• Paget's Disease
• Osteomalacia(bone softening” in adults that is usually due to prolonged deficiency of
vitamin D.)

• Osteogenesis Imperfecta
• Multiple Myeloma
• Secondary tumours
Investigation
• Complete blood Count(has decreased circulating erythrocytes and lymphocytes due do
dysfunction of bone marrow)

• Low serum Creatinine, blood urea nitrogen, total calcium, phosphate,

albumin and alkaline phosphatase levels.
• Low Serum 25- hydroxyvitamin D levels.
• PTH and TSH levels.-may affect balance of bone minerals like
calcium
• Total and free testosterone levels (for men)-if low can cause
significant low bone density
• Estradiol, FSH, LH and prolactin levels in young amenorrheic women
Investigation for secondary osteoporosis…..
Imaging
• Standard radiographs have poor sensitivity for the detection
and monitoring of osteoporosis, since large amounts of bone
mineral (up to 30%) must be lost or gained from the skeleton
before it can be reliably detected on plain radiographs.
• The principal application of radiographic examination in the
assessment of patients with osteoporosis is in the diagnosis of
fractures
Treatment
• Counseled on risk factor reduction including the importance of
calcium, vitamin D, and exercise as part of any treatment program
for osteoporosis.
• Prior to initiating treatment, patients should be evaluated for
secondary causes of osteoporosis and have BMD measurements
by central DXA, ie Dual energy X-ray Absorptiometry when
available, and vertebral imaging studies when appropriate.when
available, and vertebral imaging studies when appropriate.
• Biochemical marker levels should be obtained if monitoring of
treatment is planned
Guideline for Treatment of osteoporosis
• Calcium intake of 1200mg/day
• Vitamin D intake of 400 to 800 IU/day for high-risk patients
• Regular weight bearing, muscle strengthening exercise
• Avoid smoking: moderate alcohol consumption
• Treat all vertebral and hip fracture cases
Prevention

• Physical activity-weight bearing and muscle strengthening

exercises and exercise should be life long.Exercise improves
bone strength by 30% to 50%.
• Cessation of smoking, alcohol, high caffeine intake.
• Adequate sun exposure.
SPONDYLOSIS
Learning objectives
By the end of this session, student are expected to be able to:
• Define Spondylitis
• Describe aetiopathology of Spondylitis
• Describe the management of Spondylitis
Activity: Brainstorming
• What is Spondylitis?
Definition

• Spondylosis(Spinal Osteoarthritis)-Is the degenerative

disorder in which the is wear and tear that occur on the joint
and bone of the spine as people get older.
• Spondylosis affect cervical (neck),thoracic (midback),or
lumbar( low back)
• Cause loss of normal spinal shape and function.
Area affected

• CERVICAL (NECK)-Complexity anatomy and large

movement in the neck make the area of the body susceptible to
degenerative change. Neck pain from spondylosis is common.
Pain spread into shoulder

• THORACIC(MIDBACK)-Less commonly affected due its

reduced movement. Spondylosis in this region can round to the
appearance called kyphosis

• LUMBAR(LOW BACK)-Often affect lumbar spine over age

of 40 year.Pain and morning stiffness are common complain.
Causes

• Aging-When getting older disc dehydrate, become thinner

and become harder.
• Repetitive Strain Injury (RSI)-Caused due life style without
ergonomic care while working infront of computers, driving
• Genetics-Family history of neck pain
• Smoking –Linked with increased neck pain.
• Occupation-Job with lots of neck motion and over head work
• Mental Health Issue-Depression/Anxiety
• Injuries/Trauma-Job injury
Pathophysiology
• Cervical Spondylosis-Degenerative of intervertebral disk .As
we are aging fragment ,lose water, content collapse
• Start in the nucleus pulpose (inner part of the Intervertebral
Disk( IVD) the water content decrease and will bucking
inward, the annulus fibrosis the outer part IVD will become
thinner and bulge outward.
• When the IVD become thinner it will increase mechanical
stress at cartilaginous end plate at the vertebral body lip.
Pathophysiology cont…
• Cartilage cover and protect joint wear away resulting rubbing
on the bone.
• Lost cartilage the body respond by growing new bone in your
facet to help support the vertebrae.
• Overtime this bone overgrowth called spurs may narrow the
space for the nerve to pass through (stenosis)
• Hypertrophy of uncinated process occur often encroaching on
the ventrolateral portion of the interverbral foramina. It can
pinch or compress those nerve.
Pathophysiology cont…
• Dynamics factors-normal flexion and extension of the cord
may aggravate spinal cord damage initiate by static
compression of cord.
• During flexion spinal cord lengthen resulting in it being
stretched over ventral osteophytic bar.
• During extension ligamentum flavum may buckle into the
cord ,pinching cord between the ligament and anterior
osteophytic
Activity :Brainstorming

• Mention five (5)clinical feature of spondylosis

Clinical features

• Pain from cervical spondylosis

• Neck pain and stiffness
• Numbness and weakness in arm ,hand and finger
• Muscle spasm in the neck and shoulder
• Headache
• Grinding and popping sound/feeling in the neck with
movement
Investigations
• X-ray; aging changes ,loss of disk height or bone
• Magnetic Resonance Imaging (MRI)-Create better image of
soft tissue such as muscles,disk,nerve and spinal cord.
• Computed Tomography (Scan CT Scan)-Specilized X ray for
evaluation of bone and spinal cord.
Treatment
Non- Surgical treatment
• SOFT COLLARS (Neck immobilization)-Limit
neck motion and muscle of the neck to rest.
• ENVIRONMENTAL CHANGES-Proper lifting
technique, wear soft collar to restrict unwanted
movement.
• CERVICAL MECHANICAL TRACTION-
Effective than static traction .Initially weight of
4.5kg eventually increase to 5.5kg indicated for
cervical radiculopathy.
o Contraindicated in patient with myelopathy,
Rheumatoid Arthritis with Atlantoaxial subluxation.
Treatment cont…
Physiotherapy
• HEAT THERAPY-Using heat ,the physical therapist seek to get
more blood to the target because of its oxygen and nutrients
• COLD THERAPY-Decrease inflammation ,muscle spasm and
pain cold pack is placed on target area or even ice message.
• ELECTRICAL STIMULATION-Transcutaneous Electrical
Nerve Stimulation (TENS)-Reduce muscle spasms
• DEEP TISSUE MASSAGE-Target spasm and chronic muscle
tension
Treatment cont…
Medical treatment;
Goal of pharmacotherapy decrease pain and inflammation
• ACETAMINOPHEN-Mild pain, relieved with this drug
• NON STEROID ANTI INFLAMMATORY DRUGS
(NSAID)-Prescribed with Acetaminophen drug like
ibuprofen and naproxen
• MUSCLE RELAXANTS-Cyclobenzaprine,carisoprodol used
in case painful muscle spasm
Treatment cont…
Surgical treatment
• Surgery reserved for patient who have severe pain that hasn't
been relieved by other treatment
o Some patient will be not fit surgical intervention due
widespread nature of Arthritis, other medical condition
• LAMINECTOMY(surgery in which a surgeon removes part or all of the vertebral bone
(lamina) to decrease pressure on the spinal cord or the nerve roots)
Key points
• Osteoporosis is a common metabolic bone disease
characterized by reduced bone mass, micro architectural
deterioration of bone tissue, and an increased risk of fragility
fracture
• Age related osteoporosis result from age related calcium
deficiency
• SpondylosisIs the degenerative disorder in which the is wear
and tear that occur on the joint and bone of the spine people
get older.
• Spondylosis is caused by many cause like aging, repetitive
strain injury, genetics, smoking, Injuries
Evaluation
• Mention three (3) causes of secondary of osteoporosis and
two (2) example each
• Mention three (3) causes of Spondylosis
• Mention four (4) investigation for Spondylosis
Reference
• Somen Das (2008) concise textbook of Surgery (5 th edition).
Kolkata-Dr Somen Das.
• K.Rajgopal Shenoy, Anitha shenoy (2016) Manipal Manual
of surgery (4th edition). CBS New Delhi.
• Russell R.C.G., Norman S.W. & Bulstrode C.J.K. (2004).
Bailey and Love’s Short Practice of Surgery (25 th edition.).
London: Hodder Arnold.
• WWW.Upadate c2011-2019