Orthopaedic & Traumatology Department Case Report

Faculty of Medicine Okctober 2017

Hasanuddin University

Right Knee Osteoarthritis

Present By :
Yelly Asta Siusiu Imran C 111 12 893
Sunaia Binti Ismail C 111 12 873
Andi Absharina Binawan C 111 11 894
Rezky Auliah Ikhsan C 111 12 911

Advisors:
dr. Loli Anton
dr. M. Asri Abidin

Supervisor :
dr. M. Andry Usman, Sp.OT, Ph.D
PATIENT’S IDENTITY
 Name : Mr. M
 Gender : Male
 Age : 59 years old
 Occupation : Wood worker/Wooden House
Maker
 Medical Record : 781943
 Date of admission : 26/09/2017
HISTORY TAKING

Chief Complaint
• Pain at the right knee

Anamnesis
• pain complaints on his right knee since last 2 years
• Complaints have been felt since 9 years ago
• Pain is most felt when the patient walks away or is
lifting heavy items
• Perceived pain decrease or disappears when the
patient rest or knee compressed by cold water
HISTORY TAKING cont’

Anamnesis
• The patient can still walk but only walk slowly
because it holds pain in his knee
• This causes the patien to feel worried and
disrupt this daily physical activity
• In addition, patient also often feel stiff on his
knee in the morning especially when waking up,
but the stiffness lasts less than 10 minutes and
over time will disappear by itself
• Patient some times feel warm on his right knee
HISTORY TAKING cont’

Anamnesis
• History of taking analgesic medication is meloxicam
• Work history as a carpenter or wooden house
maker. Pasien often lift heavy loads when working.
• There is no complaint at the other joints
• There is no fever
• There is no history of trauma
• History of the same illness in the family is the
mother
HISTORY TAKING cont’

Anamnesis
• There is history of hypertension, not routinely
taking medication. Denied Diabetes Mellitus
• History of arthroplasty surgery on the left knee on
July 2017
PHYSICAL EXAMINATION

General status
• Obesity (BMI 27,3) / composmentis

Vital status
• BP : 130/70 mmHg
• HR : 74x/i
• RR : 18x/i
• Temp : 36.7 C
• NRS : 0/10 (L) ; 3/10 (R)
LOCALIZED STATUS
Right Knee Region
Look : varus deformity (+), wound (-), swelling (-),
hematoma (-), skin color same as surrounding
Feel : tenderness (+), felt warmer than surrounding,
effusion (-), crepitation (+)
Move : active and passive extension-flexion 0o - 100o

NVD : Sensibility is good, posterior tibial artery & dorsalis

pedis artery pulse is palpable, capillary refill time is
<2 seconds
CLINICAL FINDING

ANTERIOR VIEW LATERAL VIEW

RADIOLOGICAL FINDING on right knee

PRE OP POST OP
INTRAOPERATIVE
 RADIOLOGICAL FINDING
after ARTHROPLASTY in left knee
(21/08/2017)
LABORATORIUM FINDING (19/09/2017)

Blood Test Result Normal Value Unit

WBC 8.80 x 103 4.00-10.0 x 103 /uL

RBC 4.95 x 106 4.00-6.00 x 106 uL
Platelet 329 x 103 150 - 400 x 103 /uL
Hb 13.7 37-48 %
GDS 85 140 mg/dL
Ureum 26 10-50 mg/dL
Creatinin 0.9 <1.3 mg/dL
SGOT 24 <38 U/L
SGPT 19 <41 U/L
RESUME
A men 59 years old, pain complaints on his right knee since last 2 years
Complaints have been felt since 9 years ago. Pain is most felt when the patient walks away or is
lifting heavy items. Perceived pain decrease or disappears when the patient rest or knee
compressed by cold water. In addition, patient also often feel stiff on his knee in the morning
especially when waking up, but the stiffness lasts less than 10 minutes and over time will
disappear by itself. History of taking analgesic medication is meloxicam. Work history as a
carpenter or wooden house maker. Pasien often lift heavy loads when working. History of the same
illness in the family is the mother. There is history of hypertension, not routinely taking
medication. History of arthroplasty surgery on the left knee on Juli 2017

From physical examination, general status was obesity, vital status within normal limit. Localized
status on ringht knee region were found varus deformity, tenderness on palpation, range of
motion was limited. Localized status on right knee region were found normal limit.

From imaging, right knee X-Ray AP/Lat found asymmetrical joint space narrowing with
subluxation, multiple osteophytes, sclerosis, subcondral cyst . left knee X-Ray AP/Lat attached
total knee arthroplasty
DIAGNOSIS

Right Knee Osteoarthritis

Total Left Knee Arthroplasty
MANAGEMENT

Non Operative
Operative
(Farmacologic)
• Meloxicam 7.5 mg/12 • Plan for Total Knee
jam/oral
• Omeprazole 20 m/12 jam/ Replacement
oral
OSTEOARTHRITIS
DEFINITION

definition :
Characterized by loss of the articular cartilage and the formation of new bone in
an attemph at repair.
 ANATOMY OF THE KNEE

Thompson, John C. 2010. Leg and Knee in: Netter's Concise Orthopaedic Anatomy. Second edition. Philadelphia: Saunders Elsevier.
STRUCTURE OF SYNOVIAL JOINT

Thompson, John C. 2010. Leg and Knee in: Netter's Concise Orthopaedic Anatomy. Second edition. Philadelphia: Saunders Elsevier.
PREVALENCE
LITERATURE CASE

Woman : Man , 2 : 1 Man

Prevalence >50% at age >65 years Age 59 years old

More common in some joints ;

Knee joint
fingers, hip, knee, spine

Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.
Knight R. Muscles, Bones and Skin. United Kingdom : Elsevier. 2010
ETIOLOGY


Primary
• = Idiopathic osteoarthritis
• There is no obvious antecedent factor
• The normal aging process in cartilage
• Some individuals on genetic basis
• Continued use and obesity accelerates the local degenerative
process.

Secondary
• Follows a demonstrable abnormality
• Following condition are all capable of initiating the progress :
congenital, infection, injury, metabolic arthritis, extra-articular
deformities
Salter, R. 1999. Textbook of Disorders and Injuries of the Musculoskeletal System.Third edition. USA: Lippincott Williams &
Wilkins.
Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.
 PATHOGENESIS

Disparity between the stress applied to articular

cartilage and the ability of the cartilage to
withstand the stress

Weakening of the articular cartilage

Increased mechanical stress in some part of the

articular cartilage

Solomon L. 2014. Apley and Solomon’s Concise System of Orthopaedics and Trauma. Fourth edition. UK: CRC Press.
 Progressive
PATHOLOGY loss of
articular
cartilage
thickness

Subarticular
cyst
Capsular
formation
fibrosis
and
sclerosis
Cardinal
features

Remodelling
of bone
Synovial
ends and
irritation
osteophyte
formation

Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.
PATHOLOGY
RISK FACTORS

Joint
Trauma
dysplasia

Obesity and
occupation causes
Occupation Obesity increased
joint loading

Family
history

Rasjad, C. 2007. Pengantar Ilmu Bedah Ortopedi. Jakarta: Yarsif Watampone.

Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.
SYMPTOMS

Literature Case
Presents after middle Symptoms present at age
age of 50’s
Pain on his right knee
Pain increase slowly
since last 2 years and
after months or years have been felt since 9
Pain aggelieved by rest years ago
Stiffness worst after Stiffness after wake up
period of rest Pain is most felt when
Movement restricted the patient walks away
SIGN & SYMPTOMS
Literature Case
 Swelling Look : varus deformity
 Local tenderness Feel : tenderness (+)

 Crepitus Move : limited ROM

 Limited movement
 Deformity
 Muscle wasting

Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.
.
IMAGING
Weight-bearing
AP/Lat MRI CT SCAN
• Weight-bearing PA • Not indicated • Preoperative
45-degree bent • Osteonecrosis planning
knee ( X-ray plate suspected • (TKA) planning
is positioned
parallel to tibia)
• Sunrise view
(i.e.,Merchant
view)
• Extension and
flexion lateral

Greenspan-Orthopedic Imaging - A Practical Approach

X-Ray IMAGING

Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.
Schiphof D, et al. 2008. Differences in Descriptions of Kellgren and Lawrence Grades of Knee Osteoarthritis. PubMed: Annals of the rheumatic disease.
  Symptoms present at age of 50’s DIAGNOSIS
 Pain on his right knee since last 2
years and have been felt since 9
HISTORY
years ago
TAKING
 Stiffness after wake up
 Pain is most felt when the patient
walks away

 Look : varus deformity

PHYSICAL RIGHT KNEE
 Feel : tenderness (+)
EXAMINATION  Move : limited ROM OSTEOARTHRITIS

 asymmetrical joint space

narrowing with subluxation
X-RAY  multiple osteophytes
IMAGING  Sclerosis
 subchondral cyst
CLINICAL VARIANTS


Monoarticular and pauciarticular osteoarthritis
• Pain and dysfunction in one or two of the large weight-
bearing joints

Polyarticular (generalized) osteoarthritis

• The most common form of OA
• The distal finger joints, the first carpometacarpal, the big
metatarsophalangeal joints, knees and lumbar facet joints
may be affected

Osteoarthritis in unusual sites

• OA is uncommon in shoulder, elbow, wrist and ankle
• Suspect of previous abnormality (congenital or trauma)

Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.
MANAGEMENT

• Physiotheraphy
Early
Conservative • Load reduction treatment
• Analgetic

Intermediate
• Arthroscopic surgery treatment
Operative • Osteotomy
• Arthroplasty Late treatment

Sinusas K. 2012. Osteoarthritis: Diagnosis and Treatment. Connecticut: American Academy of Family Physicians.
TOTAL KNEE ARTHROPLASTY
• Joint replacement
procedure

• Procedure of choice for

osteeoarthritis especially
for middle age and older
patients

• Indications:
 Severe symptoms
 Marked loss of function
 Significant restriction
of daily activities

Solomon L. 2010. Apley’s System of Orthopaedics and Fractures. Ninth edition. UK: CRC Press.