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BOALA ARTROZICA
Definitie, clasificare (primara, secundara) Epidemiologie Etiologie: factorii de risc Patogenie Manifestari clinice, radiologice, biologice Artrozele periferice : mana, genunchi, sold Artrozele vertebrale : spondiloza, discartroza, artroza interfatetara, spondiloza hiperostozanta Evolutie si prognostic Principii de tratament
CE ESTE ARTROZA ?
Boala articulara progresiva caracterizata prin durere, redoare articulara si limitarea miscarii. NU ESTE UN PROCES NORMAL DE IMBATRANIRE !
Procesul patologic nu afecteaza numai cartilajul articular ci include osul subcondral, ligamentele, capsula, membrana sinoviala si musculatura periarticulara. periarticulara.
Reprezinta a doua cauza de suferinta cronica dupa bolile cardiovasculare. Prevalenta creste odata cu varsta :
< 0,1% intre 25 - 30ani > 80% dupa varsta de 55 ani (modif RX)
13% 5% 3%
(1,2,3,4)
Factori de risc
Gradul de eviden
Tipul de OA Puternic
Virsta Sexul feminin Activitatea fizica Obezitatea Densitatea osoasa Traumatism anterior Terapie hormonala (protector) Virsta Virsta
Intermediar
Vitamina D Fumatul (protector) Aliniamentul
Sugerat
Forta musculara le nivelul cvadricepsului (protector) Activitati sportive intense
Incidenta Genunchi
Virsta
old
Virsta
FACTORI MECANICI
PATOGENIE
Modificarile degenerative in OA incep la nivelul cartilajului articular si apar prin perturbarea balantei intre sinteza si degradarea cartilajului.
Anabolism Catabolism
Patogenie
Modificarea cartilajului (Procesul de degradare depaseste biosinteza si apar fisuri, eroziuni, ulceratii)
Cartilaj
Osteofit Os
Sinteza Degradare
Semne clinica :
Crepitatii Tumefiere articulara ferma (ingrosarea articulatiei prin hipertrofie osoasa) Puncte dureroase periarticulare Revarsate sinoviale Reducerea mobilitatii
Se coreleaza cu episoadele de activitate induse de traumatisme sau depunerile de cristale (1) Boli concomitente : metastazele, boala Paget, necroza aseptica, infectii, inflamatii
Clasificarea radiografic
Kellgren-Lawrence (1)
Clasificarea Kellgren-Lawrence este cea mai utilizata in studiile epidemiologice(2) Modificarile gr 1 ar putea sa nu fi considerate OA ci asociate varstei (2)
1.Kellgren JH, Lawrence JS. Osteoarthritis and disk degeneration in an urban population. Annals of 1958. 2. Thorstensson CA et al Ann Rheum Dis 2004
1.L Punzi,et al, Ann Rheum Dis, 2005, 64 2. Wolfe F, et al, J Rheumatol, 1997, august; 28 (8): 1486 3. Sturmer T, et al, Ann Rheum Dis 2004,63 4 Spector TD, et al Arthritis & Rheumatism, 1997, aprilie; 40
Importanta problemei
Artroza genunchiului reprezinta principala cauza de durere, disabilitate si costuri in populatia generala, in special la varstnici (1)
Epidemiologie
Prevalenta artrozei de genunchi simptomatice 1111-13% (1,2,3,4) (1,2,3,4)
Artroza de genunchi simptomatica este cea mai frecventa localizare a bolii artrozice periferice (5)
1. 2. 3. 4. 5.
Peat G, McCarney R, Croft P.AnnRheumDis 2001 Bedson J,et al Family Practice 2005 Lau EM, et al, Clinical Orthopaedics & Related Research.1996 Croft P.et al 2007. Mannoni A et al. Ann Rheum Dis 2003
Factorii de risc
Varsta (Grotle M et al,AnnRheumDis 2006) Obezitatea (Mazzuca SA et al, Ann Rheum Dis 2003; Manninen P et al,AnnRheumDis 2004) Densitatea minerala osoasa (Hart et al, AnnRheumDis, 1994; Zhang et al,
JRheumatology, 2000 ; Hart D et al, Arthritis&Rheumatism,2002)
Leziunile anterioare (von Porat A, Roos E, AnnRheumDis, 2004; Boszotta et al, Aktuelle
Traumtol 1994; Neyret P et al, BrJ Rheumatology, 1994)
Factorii genetici (Spector et al, BMJ, 1996; Neame R et al, AnnRheumDis, 2004;
Jones G et al, AnnRheumDis,2004)
Examenul radiologic
Stadializare Kellgren-Lawrence 2 Alhadlaq HA, Y Xia, J B
Moody, J R Matyas. Ann Rheum Dis 2004
Pensarea spatiului articular se coreleaza cu progresia bolii Sugiyama S, M Itokazu, Y Suzuki, K Shimizu. Ann Rheum Dis
2003; Bruyere O et al, AnnRheumDis, 2005
Modificarile osului subcondral se coreleaza cu durerea nocturna si progresia bolii Dieppe P, Arthritis&Rheumatism,
2005
Ultrasonografia
Comparativa cu RMN (efuziune articulara si chist Baker)Conaghan P et al, AnnRheumDis, 2005; DAgostino M, AnnRheumDis, 2006
In artroza de genunchi este standardul de aur in evidentierea inflamatiei sinoviale (sinovita si efuziune) Hill et all,AnnRheumDis, 2007 si evaluarea progresiei Cicuttini,
AnnRhemDis, 2004 ; Ionichenok N et al, AnnRheumDis,2006
Rol diagnostic pentru gonalgie asociata cu blocaj sau instabilitate : distructie meniscala sau ligamentara Jackson, JL, O'Malley, PG,
Kroenke, K. Evaluation of acute knee pain in primary care. Ann Intern Med 2003)
Metode de scorificare
Diagnosticul diferential
Sindromul patelofemural : durere de genunchi anterioara i bilateral ce apare la pacien ii tineri (< 45 ani). Artrit monoarticular determinat de microcristale (gut , pseudogut ), spondilartropatii seronegative, artrit reumatoid Hemartroz (posttraumatic)
Diagnosticul diferential
Afectiunile mecanice locale: ruptura de menisc, dislocare menisc, patelara, modificari de ax Bolile reumatice inflamatorii cronice Afectiunile hematologice: discrazii sanguine (hemartroza) (hemartroza) Bolile endocrine: acromegalie, hipotiroidia Bolile metabolice : boala depozitelor de cristale
Hooper M et al; Arthritis and Allied Conditions, 2004
Modificari radiologice :
Prezenta osteofitelor SENSIBILITATE 91% SPECIFICITATE 86%
Altman R; Asch E; Bloch D; Bole G; Borenstein D; Brandt K; Christy W; Cooke TD; Greenwald R; Hochberg M; et al Arthritis Rheum 1986 Aug;29(8):1039-49
Modificari radiologice :
Prezenta osteofitelor SENSIBILITATE 91% SPECIFICITATE 86%
Altman R; Asch E; Bloch D; Bole G; Borenstein D; Brandt K; Christy W; Cooke TD; Greenwald R; Hochberg M; et al Arthritis Rheum 1986 Aug;29(8):1039-49
Recomandari
Diagnosticul artrozei primare de genunchi simptomatice: simptomatice
Examenul clinic Examenul radiologic
Blocaj/instabilitate
RMN
Importanta problemei:
Artroza de old:
o problema in crestere in societatile vestice; o cauza majora de morbiditate si disfunctionalitate, in special la pacientii virstnici; o conditie musculo-scheletala cu consecinte economice musculomajore.( 1,2)
1. 2.
1. Gabriel SE, Crowson CS, O'Fallon WM. J Rheumatol 1995 2. Hadler NM. Osteoarthritis as a public health problem. Clin Rheum Dis 1985
13% 5% 3%
(1,2,3,4)
1.Lau EM, Symmons DP, Croft P.. Clinical Orthopaedics & Related Research.1996 2.Croft P. The 5% symptomatic OA prevalence. 2007. Ref ID: 2882 3. Peat G, McCarney R, Croft P.AnnRheumDis 2001 4.Bedson J,et al Family Practice 2005
Importanta problemei:
Artroza de old:
o problema in crestere in societatile vestice; o cauza majora de morbiditate si disfunctionalitate, in special la pacientii virstnici; o conditie musculo-scheletala cu consecinte economice musculomajore.( 1,2)
1. 2.
1. Gabriel SE, Crowson CS, O'Fallon WM. J Rheumatol 1995 2. Hadler NM. Osteoarthritis as a public health problem. Clin Rheum Dis 1985
Epidemiologie
Prevalenta artrozei de sold simptomatica la populatia Caucaziana nu s-a schimbat in ultimele patru decade : 3-6% (1) Pentru artroza simptomatica frecventa localizarii la nivelul soldului este de 7,7%(2); Pentru grupul de virsta 45-64 ani artroza de sold este mai frecventa la barbati(3);
1.J Am Acad Orthop Surg, Vol 9, No 5, September/October 2001, 320-327. 2001 the American Academy of Orthopaedic Surgeons Primary Osteoarthritis of the Hip: Etiology and Epidemiology Franklin T. Hoaglund, MD and Lynne S. Steinbach, MD 2.Mannoni A si colab. Epidemiological profile of symptomatic osteoarthritis in older adults: a population based study in 3.Dicomano, Italy. Ann Rheum Dis 2003; 62: 576-578 Silman AJ, Hochberg MC. Epidemiology of the rheumatic diseases. Oxford: Oxford University Press, 1993.
Simptome si semne
Simptome: Durerea - localizata in regiunea inghinala sau pe partea interna a coapsei, adesea iradiata la nivelul genunchiului; Redoare matinala prelungita si durere nocturna (in boala severa); Semne: Postura antalgica; Semnul Trendelenburg; Limitarea miscarilor in articulatia soldului.
1.Moskowitz, RW, Holderbaum, D. Clinical and laboratory findings in osteoarthritis. In: Arthritis and Allied Conditions, Koopman WJ (Ed), Williams & Wilkins, Baltimore 2001. p.2216. 2. Altman, R, Alarcon, D, Appelrouth, D, et al. The American College of Rheumatology criteria for the classification of osteoarthritis of the hip. Arthritis Rheum 1991; 34: 505.
Examinarea soldului
Manevre specifice (1,2): (1,2):
- Rotatie interna si externa limitata - Flexie limitata (< 115) insotite de durere usoara (< 115 severa; - Manevra Patrick pozitiva;
Moder, KG, Hunder, GG. Examination of the joints. In: Textbook of Rheumatology, 5th edition, Kelley, WN, Harris, Ed, Ruddy, S, et al (Eds), WB Saunders, Philadelphia 1997, p.364.
1.
Detecteaza modificarile precoce de la nivelul cartilajului si osului sugestive pentru artroza de sold; Nu este necesara pentru diagnosticul artrozei de sold; Este indicata in cazul durerii cronice de sold de cauza neelucidata.
1.Dougados M, 1.Dougados M, Harris ED, et al., eds. Kelleys textbook of rheumatology,Philadelphia:Elsevier/Saunders, 2005. rheumatology, 2. Steinberg GG et al Bara Orthopaedics in primary care3rd ed. Baltimore: Lippincott Williams &Wilkins, 1999.
Diagnostic diferential
DIAGNOSTIC
ARTROZA DE SOLD
EXAMINARE
REDOARE SI DURERE USOARA/MODERATA LA ROTATIE INTERNA/ EXTERNA/ AMINDOUA DURERE LA PALPAREA TROHANTERULUI HIPOESTEZIA/PARESTEZIA FETEI ANTEROLATERALE A COAPSEI DURERE SEVERA LA ROTATIE INTERNA / EXTERNA DURERE SEVERA LA ROTATIE INTERNA / EXTERNA DUPA TRAUMATISM PULS DIMINUAT LA A.DORSALA A PICIORULUI SI LA A. TIBIALA POSTERIOARA MANEVRA PICIOR INTINS + (LASSEQUE?) DURERE AGRAVATA DE FORTA APLICATA PE FEMUR ?
CONFIRMARE
RADIOGRAFIA DE PELVIS AP
BURSITA TROHANTERICA MERALGIA PARESTEZICA NECROZA AVASCULARA DE SOLD, ARTRITA SEPTICA, ARTRITA ACUTA FRACTURA OCULTA DE SOLD
ANESTEZIE LOCALA
MRI RADIOGRAFIA DE PELVIS AP ASPIRATIE PRIN FLUORORSCOPIE MRI RADIOGRAFIA DE PELVIS AP ECO DOPLLER
INSUFICIENTA VASCULARA
Evaluation of the adult with hip pain Bruce C Anderson, MD- UPTODATE 2007
Boli metabolice :
Boli endocrine :
Koopman WJ (Ed), Arthritis and Allied Conditions, Lippincot, Williams & Wilkins, Philadelphia 2005
Durere spontana localizata in regiunea inghinala la mers, ortostatism prelungit Criterii radiologice :
osteofit femural sau acetabular ngustarea spatiului articular (superior, axial sau medial)
Altman, R, Alarcon, D, Appelrouth, D, et al. The American College of Rheumatology criteria for the classification of osteoarthritis of the hip. Arthritis Rheum 1991; 34: 505.
EVOLUTIE SI PROGNOSTIC
Se stiu putine lucruri despre istoria naturala a osteoartritei soldului; Are probabil cel mai prost prognostic dintre celei trei localizari ale bolii; Un numar semnificativ de pacienti ajung, intr-o perioada de 1-5 ani, sa necesite protezarea soldului; In unele cazuri , osteoartrita de sold se vindeca spontan, cu imbunatarirea atat a modificarilor radiologice, cat si a simptomatologiei.
DRAFT FOR CONSULTATION Osteoarthritis National clinical guideline for the careand management of osteoarthritis in adults
Recomandari
Diagnosticul artrozei primare de sold simptomatice:
Importanta problemei
Una dintre cele mai frecvente afectiuni musculoscheletale ce cauzeaza durere in articulatiile afectate si periarticular, tumefactie, rigiditate, deformare si pierdere gradata a functionalitatii 1,2 Poate aparea relativ devreme in cursul vietii, aparea reducand capacitatea de munca a pacientilor 3
1. 2. 3.
Fife RS. Primer on the Rheumatic Diseases, 11th ed. Atlanta, Georgia: Arthritis Foundation, 1997 Hochberg MC. Primer on the Rheumatic Diseases, 11th edn. Atlanta, Georgia: Arthritis Foundation, 1997 Research in hand osteoarthritis: time for reappraisal and demand for new strategies. An opinion paper
Epidemiologie (2)
Prevalenta artrozei de maini in functie de criteriul radiologic si localizare:
Articulatiile IFD au fost cel mai frecvent afectate (47.3%) Articulatiile CMC1/TS (35.8%), Articulatiile IFP (18.2%), Articulatiile MCF (8.2%)
Epidemiologie (3)
Afectarea poliarticulara interfalangiana este considerata un marker pentru artroza generalizata (1) Cea mai frecventa asociere este intre artroza de maini si artroza de genunchi (2 (15%) (2)
Kellgren J. H. Moore. Generalised osteoarthritis and Heberdennodes. Br. Med. 1952; 1; 181-3 1812. Dicomano, Italy. Ann Rheum Dis 2003; 62: 576-578 Silman AJ, Hochberg MC. Epidemiology of the 576rheumatic diseases. Oxford: Oxford University Press, 1993.
1.
Prognostic si evolutie
Frecvent prognostic bun Cele mai multe cazuri devin asimptomatice dupa cativa ani Pot persista tumefactii dure la nivelul IFD/IFP (noduli Heberden/Bouchard) Implicarea CMC1 posibil prognostic mai prost
DRAFT FOR CONSULTATION Osteoarthritis National clinical guideline for the careand management of osteoarthritis in adults
Factori de risc
1. 2. 3. 4. 5. 6. 7.
1. 2. 3. 4. 5 6
Sunt mai putin cunoscuti decat in cazul genunchiului si soldului Factorii de risc indiscutabili asociati cu artroza mainilor : Varsta (1) Sexul feminin(2) Obezitatea (indexul de masa corporala)(3) Factorii biomecanici (ocupationali)(4) Fumatul (factor protectiv) (5) protectiv) Factorii genetici (agregarea familiala)(6) Hipermobilitatea pt CMC I
Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a osteoarthritis: survey. Dutch population with that in 10 other populations.J L van Saase , L K van Romunde , A Cats , J P populations. Vandenbroucke , H A Valkenburg Cushnagan J, Dieppe P. Study of 500 patients with limb joint osteoarthritis. I. Analysis by age, sex, and distribution of symptomatic joint sites. Ann Rheum Dis 1991;50:813. 1991;50:8 The Rotterdam Study, Annals of the Rheumatic Diseases 2007;66:916-920 S Dahaghin 1 2007;66:916Hand use and patterns of joint involvement in osteoarthritis. A comparison of female dentists and teachers S. Solovieva, T. Vehmas1, H. Riihimki, K. Luoma2 and P. Leino-Arjas Leino(Petersson IF, Jacobsson LTH. Osteoarthritis of the peripheral joints. Best Pract Res Clin Rheumatol 2002;16:74160 2002;16:741 Familial agregation of osteoarthritis-Baltimore Longitudinal Study on Aging-Rosemarie Hirsch, osteoarthritisAgingRobert Hanson
Simptome
Durere (exacerbata de miscare) (1) Redoare vesperala(2) Disfunctionalitate
(1)
1. 2
Hochberg MC, Vignon E, Maheu E. Session 2: clinical aspects. Clinical assessment of hand osteoarthritis. Osteoarthritis Cartilage 2000;8 (Suppl) :S3840. :S38 Rhythmic variations in pain, stiffness, and manual dexterity in hand osteoarthritis N Bellamy 1, R B Sothern 2, J Campbell 3, W W Buchanan
Semne
Tumefactii dure Heberden (IFD) - Bouchard (IFP) Deformari aspect de degete serpuitoare (1) Deformari Semne de inflamatie artroza eroziva Uneori anchiloze artroza eroziva (2)
1 2.
Belhorn LR, Hess EV.. Semin Arthritis Rheum 1993 Verbruggen G , Veys EM. Arthritis Rheum 1996
1. 2. 2 3
1. Kellgren JH, Lawrence JS. Atlas of standard radiographs: the epidemiology of chronic rheumatism.1963. 2 Kallman DA, Wigley FM, Scott WW, Hochberg MC, Tobin JD. New radiographic grading scales for allman osteoarthritis of the hand. Arthritis Rheum 1989;32:1584-1591[Medline]. 1989;32:15843 Greenspan A; 2003; Semin Muskuloskeletal Radiology; Erosive Osteoarthritis; 155-160 155-
1 2 3.
Iagnocco A, Filippuci E, Ossandon A, Ciapetti A, Salaffi F, Basili S, et al. J Rheumatol 2005 Tan AL, Grainger AJ, Tanner SF, Shelley DM, Pease C, Emery P, McGonagle D. Arthritis Rheum 2005 Hutton CW, Higgs ER, Jackson PC, Watt I, Dieppe PA. Ann Rheum Dis 1986
Recomandari
Diagnosticul artrozei primare simptomatice de maini : Examen clinic Investigatii imagistice : examenul radiologic Investigatii biologice (artroza eroziva): VSH, PCR, FR, acid uric
Rol in diagnosticul sinovitei, a leziunilor de menisc si a ligamentelor Metoda reproductibila de evaluare a progresiei bolii. (scorul BLOKS) in studii epidemiologice si trialuri clinice (2)
J Hunter, ARD, 2007, on line