Penyakit Internal Gangguan Metabolit Dan Genetik Osteoarthritis
12. Dr. Karuniawan - Osteoarthritis
-
Upload
lettasamudra -
Category
Documents
-
view
117 -
download
2
Transcript of 12. Dr. Karuniawan - Osteoarthritis
Karuniawan
Definisi Osteoarthritis
Penyakit osteoarthritis adalah Perubahan sel dan matriks sendi
yang ditinjau dari baik segi morfolagi, biokimia , molekuler dan biomekanika yang mengarah kepada melunaknya , fibrilasi dan eburnasi pada tulang subchondaral ; osteofit ; kista subchondral
Osteoartritis (OA) didefinisikan sebagai penyakit yang diakibatkan kejadian biologik dan mekanik
yang menyebabkan gangguan keseimbangan antara proses degradasi dan sintesis dari kondrosit,matriks ekstraseluler tulang rawan sendi dan tulang subkondral,
Penyakit OA bermanifestasi sebagai : perubahan morfologik, biokimia,
molekuler dan biomekanik dari sel dan matriks yang mengakibatkan
perlunakan, fibrilasi, ulserasi, menipisnya tulang rawan sendi
sklerosis dan eburnasi tulang subkondral
osteofit dan kista subkondral
Faktor risiko pada OA dapat dibedakan faktor risiko kejadian awal (incident) faktor risiko progresivitas dan
beratnya OA
faktor risiko yang diduga berperan pada progresivitas OA lutut ialah densitas massa tulang (DMT).
Jaringan yang terlibat Kartilago / tulang rawan sendi Kapsul sendi Ligamentum Otot/ muskulus Membrana synovial Tulang subchondral Jaringan peri- artikular
2 proses berperan terjadi osteoarthritits
1. Inflamasi2. Proses degeneratif
Anatomy of The KneeAnatomy of The Knee
Anatomy of The KneeAnatomy of The Knee
Diagnosis osteoarthritis
usia > 50 th nyeri pagi <30 menit krepitasi tulang lembek tullang membengkak sendi panas tidak teraba Varus deformity (bow legged) gambaran khas radiologi
penurunan the cartilage spaceosteofit robekan meniscus MRI
Usia Wanita Obesitas Trauma (riwayat) Malaliggnment
extremitas bawah Aktifitas High
impact Otot / muskulus
lemah
Osteoarthritis Osteoarthritis sendi lututsendi lutut
I.I. Pandangan umum Pandangan umum EpidemiologEpidemiologii DefiniDefinisisi FactorFactor risiko risiko
II.II. Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
III.III. Differential DiagnosisDifferential Diagnosis
IV.IV. Diagnosis Diagnosis Osteo arthritis sendi lututOsteo arthritis sendi lutut
V.V. Management Management LifestyleLifestyle Medical Medical SurgicalSurgical
Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut ““dokter , lutut saya nyeri dokter , lutut saya nyeri !”!”
Riwayat Riwayat
InflammaInflammasi : si : demam demam , , sendi sendi
meradang / panas meradang / panas
Riwayat Riwayat trauma trauma atau pembedahanatau pembedahan
InstabilitInstabilitasas
Functional lossFunctional loss
Riwayat pengobatan Riwayat pengobatan
Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
Pemeriksaan fiisik Pemeriksaan fiisik
Tanda vital Tanda vital
PalpaPalpasi :nyeri lokal si :nyeri lokal , effusi, , effusi, kkrepitrepitasiasi
ROM: ROM: ukur derajad fleksiukur derajad fleksi
StabilitStabilitas :as :ligaments menisligaments meniskuskus
Alignment: genu varus or valgusAlignment: genu varus or valgus
FunFungsi gsi : gait, duck waddle: gait, duck waddle
Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
Varus Test (LCL)Varus Test (LCL)Valgus Test Valgus Test (MCL)(MCL)
McMurray McMurray ManeuverManeuver
(menisci)(menisci)
Lachman Test Lachman Test (ACL)(ACL)
Duck Waddle Duck Waddle (stability)(stability)
Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
TesTes laboratorium dan –ray laboratorium dan –ray
Darah lengkap Darah lengkap , , LEDLED, RF, RF
ArthrocentesisArthrocentesis
X-rays (3 views)X-rays (3 views) Weight-bearing AP Weight-bearing AP LateralLateral Tangential Patellar (Sunrise)Tangential Patellar (Sunrise)
MRIMRI
Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
I.I. Pandangan umum Pandangan umum EpidemiologEpidemiologii DefiniDefinisisi FactorFactor risiko risiko
II.II. Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
III.III. Differential DiagnosisDifferential Diagnosis
IV.IV. Diagnosis Diagnosis Osteo arthritis sendi lututOsteo arthritis sendi lutut
V.V. Management Management LifestyleLifestyle Medical Medical SurgicalSurgical
Differential Diagnosis Differential Diagnosis nyeri sendi nyeri sendi lututlutut
Nyeri Nyeri MedialMedial OAOA MCLMCL MeniscusMeniscus BursitisBursitis
Nyeri Nyeri DiffuseDiffuse OAOA Infectious arthritisInfectious arthritis Gout, pseudogoutGout, pseudogout RARA
Nyeri Nyeri LateralLateral OAOA LCLLCL MeniscusMeniscus Iliotibial band syndromeIliotibial band syndrome
Nyeri Nyeri AnteriorAnterior OAOA Patellofemoral syndromePatellofemoral syndrome Prepateller bursitisPrepateller bursitis Quadriceps mechanismQuadriceps mechanism
Osteoarthritis of The KneeOsteoarthritis of The Knee
I.I. Pandangan umum Pandangan umum EpidemiologEpidemiologii DefiniDefinisisi FactorFactor risiko risiko
II.II. Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
III.III. Differential DiagnosisDifferential Diagnosis
IV.IV. Diagnosis Diagnosis Osteo arthritis sendi lututOsteo arthritis sendi lutut
V.V. Management Management LifestyleLifestyle Medical Medical SurgicalSurgical
Diagnosis of Knee OADiagnosis of Knee OA
Classic Clinical CriteriaClassic Clinical Criteria established by ACR, 1981established by ACR, 1981 sensitivity 95%, specificity 69%sensitivity 95%, specificity 69%
knee painknee pain plus at least 3 of 6 characteristics: plus at least 3 of 6 characteristics:• > 50 yo> 50 yo• Morning stiffness < 30 minMorning stiffness < 30 min• CrepitusCrepitus• Bony tendernessBony tenderness• Bony enlargementBony enlargement• No palpable warmth No palpable warmth 55
Diagnosis of Knee OADiagnosis of Knee OA
Algoritma Algoritma Clinical symptomsClinical symptoms Synovial fluidSynovial fluid
1.1. WBC<2000/mmWBC<2000/mm33
2.2. Clear colorClear color3.3. High ViscosityHigh Viscosity
X-raysX-rays1.1. OsteophytesOsteophytes2.2. Loss of joint spaceLoss of joint space3.3. Subchondral sclerosisSubchondral sclerosis4.4. Subchondral cystsSubchondral cysts
Confirmed by arthroscopyConfirmed by arthroscopy (gold standard) (gold standard) 66
No OANo OA
Sensitivity 94 %; Specificity 88 %
Diagnosis of Knee OADiagnosis of Knee OA
Osteoarthritis of The KneeOsteoarthritis of The Knee
I.I. Pandangan umum Pandangan umum EpidemiologEpidemiologii DefiniDefinisisi FactorFactor risiko risiko
II.II. Pendekatan klinis pada nyeri lutut Pendekatan klinis pada nyeri lutut
III.III. Differential DiagnosisDifferential Diagnosis
IV.IV. Diagnosis Diagnosis Osteo arthritis sendi lututOsteo arthritis sendi lutut
V.V. Management Management LifestyleLifestyle Medical Medical SurgicalSurgical
Management: LifestyleManagement: Lifestyle Weight lossWeight loss
Nutrition referralNutrition referral Exercise ProgramExercise Program
PT referral PT referral Quadriceps strengthening Quadriceps strengthening ROM exercisesROM exercises Low impact activities e.g. swimming, biking Low impact activities e.g. swimming, biking 77
Ambulatory assist devicesAmbulatory assist devices CaneCane Walker Walker
InsolesInsoles Unloader knee bracesUnloader knee braces
Management: LifestyleManagement: Lifestyle
Varus (bowlegged) vs Valgus (knock-kneed)Varus (bowlegged) vs Valgus (knock-kneed)
G2 Unloader G2 Unloader BraceBrace
Management: MedicalManagement: Medical
Glucosamine/ChondroitinGlucosamine/Chondroitin AcetaminophenAcetaminophen NSAIDsNSAIDs Cox-2 inhibitorsCox-2 inhibitors OpioidsOpioids Intraarticular injectionsIntraarticular injections
GlucocorticoidsGlucocorticoids HyaluronansHyaluronans
Management: MedicalManagement: Medical
Glucosamine/ChondroitinGlucosamine/Chondroitin 1500 mg/1200 mg daily ($40-50/month)1500 mg/1200 mg daily ($40-50/month) Glucosamine: building block for glycosaminoglycansGlucosamine: building block for glycosaminoglycans Chondroitin: glycosaminoglycan in articular cartilageChondroitin: glycosaminoglycan in articular cartilage
Management: MedicalManagement: Medical
AcetaminophenAcetaminophen/ parasetamol / parasetamol IndiIndikkaasi si : mild-moderate pain: mild-moderate pain 1000 mg Q6h PRN1000 mg Q6h PRN Better than placebo but less efficacious than NSAIDs Better than placebo but less efficacious than NSAIDs 99 Caution in advanced hepatic diseaseCaution in advanced hepatic disease
NSAIDsNSAIDs IndiIndikkaasisi: moderate-severe pain, failed acetaminophen: moderate-severe pain, failed acetaminophen GI/renal/hepatic toxicity, fluid retentionGI/renal/hepatic toxicity, fluid retention Risiko gastro intestinal bleeding :Risiko gastro intestinal bleeding : use anti-ulcer agents use anti-ulcer agents
concurrentlyconcurrently highly variable efficacy and toxicityhighly variable efficacy and toxicity
Management: MedicalManagement: Medical
NSAIDsNSAIDs1010
Management: MedicalManagement: Medical
Cox-2 inhibitorsCox-2 inhibitors Indication: mod-severe pain, failed NSAID, risk of GIBIndication: mod-severe pain, failed NSAID, risk of GIB OA pain relief similar to NSAIDsOA pain relief similar to NSAIDs Fewer GI events e.g. symptomatic ulcers, GIBFewer GI events e.g. symptomatic ulcers, GIB Celecoxib 200 mg dailyCelecoxib 200 mg daily GI/renal toxicity, fluid retentionGI/renal toxicity, fluid retention Increased risk of CV events? Increased risk of CV events?
APC Trial: 700 pts each assigned to placebo, 200 BID, 400 BIDAPC Trial: 700 pts each assigned to placebo, 200 BID, 400 BID Increased risk at higher doses Increased risk at higher doses 1111
CLASS Trial: 8,000 pts compared Celecoxib vs IbuprofenCLASS Trial: 8,000 pts compared Celecoxib vs Ibuprofen
Similar risk to Ibuprofen Similar risk to Ibuprofen 1212
Management: Management: obat-obatan obat-obatan
Analgetik opioid Analgetik opioid Indikasi Indikasi : :
Moderate-severe painModerate-severe pain Acute exacerbationsAcute exacerbations NSAIDs/Cox-2 inhibitors failed or contraindicatedNSAIDs/Cox-2 inhibitors failed or contraindicated
Oxycodone synergistic w/ NSAIDs Oxycodone synergistic w/ NSAIDs 1313
Tramadol/acetaminophen vs codeine/acetaminophenTramadol/acetaminophen vs codeine/acetaminophen Similar pain relief Similar pain relief 1414
Avoid long-term useAvoid long-term use Caution in elderlyCaution in elderly
Confusion, sedation, constipationConfusion, sedation, constipation
Management: Management: obat-obatan obat-obatan
Intraarticular InjectionsIntraarticular Injections
GlucocorticoidsGlucocorticoids
Indication: pain persists despite oral analgesicsIndication: pain persists despite oral analgesics
40 mg/mL triamcinolone (kenalog-40)40 mg/mL triamcinolone (kenalog-40)
Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL)Solution: 5 mL (lidocaine 4 mL + kenalog 1 mL)
Limit to Q3months, up to 2 yrsLimit to Q3months, up to 2 yrs
Effective for short-term pain relief < 12 wksEffective for short-term pain relief < 12 wks
Acute flare w/in 48 hrs post-injection Acute flare w/in 48 hrs post-injection 1515
Management: Management: obat-obatan obat-obatan
Intraarticular InjectionsIntraarticular Injections
Hyaluronans (e.g. Synvisc)Hyaluronans (e.g. Synvisc) Indication: pain persists despite other agentsIndication: pain persists despite other agents Synthetic joint fluidSynthetic joint fluid Pain relief similar to steroid injectionsPain relief similar to steroid injections
2 mL injection Qwk x 3, $560-760/series2 mL injection Qwk x 3, $560-760/series
Medicare reimburses 80%, Medi-cal $455.90Medicare reimburses 80%, Medi-cal $455.90 60-70% patients respond, relief up to 6 months60-70% patients respond, relief up to 6 months Patient satisfaction Patient satisfaction 16, 1716, 17
Management: Management: obat-obatan obat-obatan
Intraarticular InjectionsIntraarticular Injections TechniqueTechnique
22 gauge 1.5 inch needle22 gauge 1.5 inch needle Approach accuracy:Approach accuracy:
Lateral mid-patellar 93% Lateral mid-patellar 93% 1818
Patient supinePatient supine Leg straight Leg straight Manipulate patella Manipulate patella Angle needle slightly posteriorly Angle needle slightly posteriorly Inject after drop in resistance or fluid aspiratedInject after drop in resistance or fluid aspirated
Management: AlgorithmManagement: Algorithm
Modifikasi lifestyle Modifikasi lifestyle Acetaminophen Acetaminophen PRNPRN
NSAIDs PRNNSAIDs PRN
Opioids PRNOpioids PRN
CelecoxibCelecoxib
Steroid Steroid InjectionsInjections
Hyaluronan Hyaluronan InjectionsInjections
Rujuk bedah Rujuk bedah orthopaedi orthopaedi
Management: SurgicalManagement: Surgical
Kapan dirujuk ke dokter bedah Kapan dirujuk ke dokter bedah orthopaedi ?orthopaedi ?
Nyeri lutut persisten dg gangguan fungsi Nyeri lutut persisten dg gangguan fungsi tidak kunjung sembuh dengan pengobatan tidak kunjung sembuh dengan pengobatan
non bedah non bedah
Types of ProceduresTypes of Procedures Arthroscopic IrrigationArthroscopic Irrigation Arthroscopic DebridementArthroscopic Debridement High Tibial OsteotomyHigh Tibial Osteotomy Partial Knee ArthroplastyPartial Knee Arthroplasty Total Knee ArthroplastyTotal Knee Arthroplasty
Managemen: Managemen: pembedahan pembedahan
High Tibial OsteotomyHigh Tibial Osteotomy
IndiIndikasikasi:: Unicompartmental arthritisUnicompartmental arthritis Genu varus or valgusGenu varus or valgus
Realign mechanical axisRealign mechanical axis
Age < 60yoAge < 60yo
< 15 degrees deformity< 15 degrees deformity1919
Managemen: Managemen: pembedahan pembedahan
Partial Knee ArthroplastyPartial Knee Arthroplasty
IndiIndikasi kasi ::
Unicompartmental arthritisUnicompartmental arthritis
Ligaments sparedLigaments spared
Increased ROMIncreased ROM
Faster recoveryFaster recovery
Prosthesis 10-yr survival: 84% Prosthesis 10-yr survival: 84% 2020
Managemen: Managemen: pembedahan pembedahan
Total Knee ArthroplastyTotal Knee Arthroplasty IndiIndikasi kasi ::
Diffuse arthritisDiffuse arthritis Severe painSevere pain Functional impairmentFunctional impairment
Pain relief > functional gainPain relief > functional gain ACL sacrificedACL sacrificed PCL also may be sacrificedPCL also may be sacrificed Prosthesis 10-yr survival: 90% Prosthesis 10-yr survival: 90% 2121
Hal-hal penting di klinik Hal-hal penting di klinik
Evaluasi fungsi ug hilang Evaluasi fungsi ug hilang
Pemeriksaan lutut : palpasi Pemeriksaan lutut : palpasi , ROM, duck waddle, ROM, duck waddle
Rujuk ke ahli nutrisi Rujuk ke ahli nutrisi
Exercise program/PT referralExercise program/PT referral
OrthoOrthosis / alat bantu sis / alat bantu
Lateral mid-patellar or superolateral approachLateral mid-patellar or superolateral approach Edukasi pasien thd :Edukasi pasien thd :glucosamine/chondroitin, glucosamine/chondroitin,
Cox-2 inhibitors, injeCox-2 inhibitors, injeksi ksi