1、非感染性关节病,骨关节炎 OA 股骨头坏死 FHN,北京大学第一医院骨科,Osteoarthritis OA,Department of Orthopaedics First Hospital, Peking university,Introduction,骨关节炎(OA)是一种慢性退行性(degenerative)关节病，主要病变是关节软骨(articular cartilage)的退行性变和继发性骨质增生(hypertrophy) 是老年人致残的最主要的因素,分类,原发性骨关节炎(Primary OA) 原因不明的多关节退变 继发性骨关节炎(Secondary OA) 继发于关节的创伤、畸
2、形、感染或其它疾病,Primary OA,病因学,年龄 性别、种族 遗传 雌激素 骨密度 饮食 肥胖,职业 运动 结晶体沉积性关节病变： 代谢异常使软骨变性： 其他使软骨磨损的原因：感染、血友病,继发性骨关节炎的常见原因,畸形，力线异常 创伤：关节内骨折、脱位 先天性关节发育异常 骨骺疾病，儿童期关节结构变化 韧带不稳 骨坏死,Secondary to genu valgus Secondary to tibial condylar fracture,Secondary hip OA,原发性和继发性骨关节炎的临床特点比较,Pathogenesis,Collagen and proteoglyc
3、an degradation Flaking and fibrillation of the articular cartilage surface Variations in the cellularity and vascularity of subchondral bone leads to sclerosis Cystic degeneration of the bone Osteophytes formation at the edges Narrowing of the joint space Change of Synovial membrane, Capsular & musc
4、le Deformity of joint,Imaging :Plain Radiographs,Joint space narrowing Osteophytes Bony cysts Subchondral sclerosis,Arthroscopy,Outerbridge grade articular softening articular fissuring 1.3cm exposed subchondral bone,Relationship between Chondral Degeneration and X-ray Imaging,MRI/CT,Changes in surf
5、ace morphology and full thickness cartilage defects can be seen, Fibrillation cannot yet be evaluated. MRI is not essential for osteoarthritis diagnosis.,Degeneration of Cartilage,Clinical Features,Patients are usually over the age of 50 Complain of pain and stiffness in the affected joint(s), which
6、 is exacerbated with activity and relieved by rest. Early morning stiffness, is typically less than 30 minutes. Joint tenderness Crepitus on movement Swelling,Radiography Findings & Symptoms,There are no positive correlation between the symptoms and degeneration degree on X ray. Knee pain severity w
7、as a more important determinant of functional impairment than radiographic severity of osteoarthritis. The presence of osteophytes had a very strong association with knee pain. The absence or presence of joint space narrowing was not associated with knee pain.,Learning Points,Osteoarthritis is a com
8、mon disease with high morbidity. The aetiology is multifactorial. Plain radiographs are the current most common way of assessing progression of osteoarthritis.,Common locations,Knee Hip Hand First carpometacarpal joints First metatarsophalangeal joints,Diagnostic Criteria of Knee OA,Knee Pain with o
9、steophytes on X-Ray and One of the following Crepitus on knee range of motion Age 50 years or older Morning stiffness of short duration (30 minutes),Differential Diagnosis,Rheumatoid arthritis，RA Gouty arthritis Pigmented villonodular synovitis，PVNS Reaction arthritis,Treatment,The aims of managemen
10、t of patients with OA Patient education. Pain control. Improve function. Alter the disease process.,Management Interventions,Education Exercise Weight loss Physiotherapy Appliances Drugs Surgery,Drug Therapies,Non-steroidal anti-inflammatory drugs (NSAIDS) Intra-articular corticosteroids Hyaluronic
11、acid derivatives Glucosamine sulphate Chondroitin sulphates,NSAIDs,Adverse effects of NSAIDs,GI adverse events Bleeding/Ulcer/Perforation Cardiovascular events Risk factors Age65 Comorbid medical conditions Oral glucocorticoids History of peptic ulcer disease History of upper gastrointestinal bleedi
12、ng Anticoagulant,Surgery,Arthroscopic debridement and lavage Osteotomy: High tibial osteotomy，HTO Knee joint replacement,Arthroscopic debridement,limited synovectomy excision of osteophytes removal of loose bodies Chondroplasty removal of damaged menisci drilling of exposed bony lesions,Indication,M
13、ild to moderate OA of the knee Conservative treatment has been exhausted.,High Tibial Osteotomy，HTO,Indication Degenerative arthritis is confined to medial compartment with a corresponding varus deformity Young than 55 years of age Varus deformity is 15 or less Flexion contracture 90 ,HTO,HTO,Knee J
14、oint Replacement,Total knee arthroplasty (TKA) Uni-compartmental knee arthroplasty (UKA),UKA,Indication Patients with primarily unicompartmental osteoarthritis of the knee. Contraindication Absent ACL Opposite compartment and patellofemoral joint show significant degenration (Eburnated bone),UKA,Tot
15、al Knee Arthroplasty (TKA),Indications Wearing in tri-compartment Age65 or 60,Non weight loading Weight loading,Severe OA with Instability,Learning Points in Management of OA,Importance of patient education. Early involvement to help with exercise advice, weight loss where appropriate, or walking ai
16、ds. NSAIDs should be used with caution, especially in at-risk patients. Intra- articular corticosteroids injection tends to work better in those with joint effusions. Glucosamine and chondroitin sulphates are safe treatments. Hyaluronic acid derivatives should be reserved for use in severe disease or if surgery is not possible. Joint replacement is the final solution for many patients.,谢谢,
