Case : Osteoarthritis

Patient identity: Age: elderyprimer, young adultpost traumatic, Sex: Female>male, Job: OA
Knee: repetitive stress, knee bending activity.
Scenario:
I. Chief complaint :
- pain at the knee (medial/lateral site), locking, deformity
II. Anamnesis:
-since when? Onset, progressivity, quality, radiating, site. start insidiously and
increase slowly and over months or years. Aggravated by exercation and relieve by rest
and NSAIDS. In the late stage have persistent in bed and night.
-felt crepitation?
- associated complain? (locking, stiffness (after period inactivity), swelling, deformity
giving way, morning stiffness < 30)
- treatment? Medical (joint injection, arthroscopy, debridement)/alternative? Result?
- hystory of traumamechanism and condition after trauma
- history of joint infection? Redness, swelling, heat, pain, sinus.
- systemic illness DM, cought
- family history? Woman with mother has same illness
- Activity daily living? (limp, difficulty down stairs, restricted of walking distance)
- expectation?
- Meniscus tear: Pain always locking, loose body: pain with/without locking
III. Physical Examination:
-General Status : BMI (BW (kg)/BH (m)2 ): Obesity, conscious
Very severely underweight
< 15
Severely underweight
15-16
Underweight
16-18,5
NORMAL
18,5-25
Overweight
25-30
Obesity gr I
30-35
Obesity gr II
35-40
Obesity gr III
> 40
- Posture:
Stand: varus deformity, swelling, muscle atropy, wound, skin color, varicosis, ect.
Walking: Antalgic gait
Special test: thessally testmeniscus tear (if needed)

-Local status:
Knee joint :
Look : varus/valgus deformity, swelling, muscle atrophy, sign of inflammation
(+/-), wound, scar,
Feel : skin temperature, tenderness(+) at joint line and patelofemoral joint.
ROM: active/passive extension/flexion angle. Limited ROM, Fell crepitation.
NVD examination
Special test: a. circumferential muscle atrophy size,
b. Swelling: 1. cross fluctuation,
2. patellar tap,
3. bulge test,
4. juxta patellar hollow test,
5. transilumination.
c. Instability: 1. Lacman test
2. anterior/posterior drawer test,
3. valgus/varus test,
4. pivot test.
d. Meniscus tear:1. Mc Murray test,
2. appley gridding test.
IV. Working diagnosis : Varus/valgus deformity due to Osteoartritis at R/L knee
V. Pemeriksaan penunjang:
- X-rayAP/lat Knee joint bilateral, standing and skyline view:
Observing/notice:
a. Soft tissue
b. Joint space
c. Subchondral sclerosis
d. Osteophytes
e. Subchondral cyst
f. Loose body

g. mechanical axis line: center of femoral head to the center of the ankle joint
h. joint line.
i. line perpendicular to mechanical axis
Cardinal sign OA:
1. Narrowing of joint space
2. subcondral sclerosis
3. marginal ostheophite
4. subchondral cyst
5. bone remodeling
-

CT and MRI: 1. Early detection of an osteocartilagineus fracture.

2. bone edema and avascular necrosis.
- Laboratory
a. Routine lab exam comorbid
b. Synovial fluid analysis
VI. Diagnosis: Varus/valgus deformity due to Osteoartritis at R/L knee.

VII. Management:
1. Non operative Management
a. Non medicamentous
Education/ change lifestyle/ reduce bodyweight
Strengthening exercise/ orthotics/ physical occupational therapy
b. Medicamentous
Analgesics (acetaminophen)/ NSAID/ DMOAD/

viscosupplement IA/ steroid IA (acute phase)

2. Operative
a. HTO/Distal Femoral osteotomy
Indications:
o young, active patient (<50 years) in whom an arthroplasty would fail due to
excessive wear
o healthy patient with good vascular status
o non-obese patients
o pain and disability interfering with daily life
o only one knee compartment is affected
o compliant patient that will be able to follow postop protocol
Specific contraindications:

narrow lateral compartment cartilage space with stress radiographs

loss of lateral meniscus

lateral tibial subluxation >1cm

medial compartment bone loss >2-3mm

varus deformity >10 degrees

Flexion deformity > 15 degrees

Range of Motion < 90 degrees

b. Unicompartment arthroplasty
c. Total Knee arthroplasty
d. Arthroscopic Debridement/lavage

#gebe