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Arthritis

Difference between inflammatory & non inflammatory arthritis

 

Feature Inflammatory arthritis OA (Non inflammatory)
Morning stiffness More than 1 hr Less than 1 hr
Synovial fluid WBC More than 200/ml Less than 200 / ml
Sign of inflammation + -
New bone formation Uncommon Common
X-ray Rarefaction Sclerosis

 

Important Points:
  1. New bone formation characterized by sclerosis and osteophyte formation is characteristic of osteoarthritis, which is a non inflammatory arthritis.
  2. New bone formation may also be seen in inflammatory arthritis with progression of disease. (i.e. in Advance stage)


Table:
Significant HLA Class I and Class II Associations with Disease

 

Disease

Marker

Ankylosing spondylitis, Reiter's syndrome, Acute anterior uveitis

B27

Reactive arthritis, Psoriatic spondylitis

B27

Juvenile arthritis, pauciarticular

DR8, DR5

Rheumatoid arthritis

DR4, DW4

Sjögren's syndrome

DR3

Systemic lupus erythematosus

DR3, DR2

Gluten-sensitive enteropathy (celiac disease)

DQ2

Chronic active hepatitis, Dermatitis herpetiformis

DR3, DR3

Psoriasis vulgaris

Cw6

Pemphigus vulgaris

DR4, DQ1

Bullous pemphigoid variant

DQ7

Type 1 diabetes mellitus

DR4, DQ8, DR3, DR2

Graves' disease, Myasthenia gravis

B8, DR3, B8, DR3

Adrenal insufficiency

DR3

Behcet's disease

B51

Congenital adrenal hyperplasia

B47

Narcolepsy, Goodpasture's syndrome (anti-GBM), Multiple sclerosis

DR2, DR2, DR2


Pattern of joint involvement
 

Osteoarthritis

Rheumatoid arthritis

Psoriatic arthritis

Involved

PIP, DIP & 1st CMC (carpometacarpal) joints

PIP, MCP, wrist

DIP, PIP and any joint

Spared

MCP & wrist

DIP joint

Sparing of any joint

 

Important conditions involving hand joints:

PIP = RA, OA, Psoriases

 

PIP + DIP = OA, Psoriases

 

PIP + DIP + MCP + Wrist = Psoriases

 

PIP + DIP with sparing of MCP and wrist but involvement of thumb base = OA

 

Important Points:
  1. Bouchard’s nodes: Bony enlargement of PIP joint in osteoarthritis
  2. Heberden’s nodes: Bony enlargement of DIP joint in osteoarthritis.
  1. Osteo arthritis - Womack grading.
     
    Stage i there is softening of the cartilage if the surfaces of the knee. This may not show on X-ray.
     
    Stage ii the cartilage starts to wear away and shows as a narrowed joint space.
     
    Stage iii osteophytes are seen. Stage 2 and 3 may merge and be difficult to separate.
     
    Stage iv is the "bone-on-bone" with very narrow joint space, lots of osteophytes, and distortion of the joint
  2. Osteo arthritis - Outerbridge Classification
     
    Grade 0: normal cartilage;
     
    Grade I: cartilage with softening and swelling;
     
    Grade II: a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter;
     
    Grade III: fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm;
     
    Grade IV, exposed subchondral bone
Management
  1. Initial management of
    1. Physical therapy
    2. Bracing, orthoses, ambulatory aids
    3. NSAID, glucosamine, chondroitin, intraarticular injections of steroid or hyaluronic acid, and analgesics.
  2. Arthroscopic débridement is done in active, older adults with mild-to-moderate OA of the knee after conservative treatment has been exhausted.
  3. High tibial osteotomy
     
    It is a well-established procedure for the treatment of unicompartmental OA of the knee.
Synovial fluid (Basic physiology)
  1. Synovial tissue is sterile and composed of vascularized connective tissue that lacks a basement membrane.
  2. Two cells type (type A and type B) are present: Type B produce synovial fluid.
  3. Synovial fluid is made of hyaluronic acid and lubricin, proteinases, and collagenases.
  4. Synovial fluid exhibits non-Newtonian flow characteristics; the viscosity coefficient is not a constant and the fluid is not linearly viscous.
  5. Synovial fluid has thixotropic characteristics; viscosity decreases and the fluid thins over a period of continued stress.
  6. Normal synovial fluid contains hyaluronan (hyaluronic acid).
  7. Hyaluronan is synthesized by the synovial membrane and secreted into the joint cavity to increase the viscosity and elasticity of articular cartilages and lubricate the surfaces between synovium and cartilage.
  8. Synovial fluid contains lubricin secreted by synovial cells. It is chiefly responsible for so-called boundary-layer lubrication, which reduces friction between opposing surfaces of cartilage.
  9. Its functions are :reducing friction by lubricating the joint, absorbing shocks, and supplying oxygen and nutrients to and removing carbon dioxide and metabolic wastes from the chondrocytes within articular cartilage.
  10. It also contains phagocytic cells that remove microbes and the debris that results from normal wear and tear in the joint.
Classification
 
Synovial fluid can be classified into normal, noninflammatory, inflammatory, septic, and hemorrhagic:

 

Classification of synovial fluid in an adult knee joint

Normal

Noninflammatory

Inflammatory

Septic

Hemorrhagic

Volume (ml)

<3.5

>3.5

>3.5

>3.5

>3.5

Viscosity

High

High

Low

Mixed

Low

Clarity

Clear

Clear

Cloudy

Opaque

Mixed

Color

Colorless/straw

Straw/yellow

Yellow

Mixed

Red

WBC/mm3

<200

200-2,000

2,000-75,000

>100,000

Same as blood

Polys (%)

<25

<25

>50

>75

Same as blood

Gram stain

Negative

Negative

Negative

Often positive

Negative


Synovial fluid viscosity
 

Normal viscosity

Normal / Decreased

Decreased Viscosity

1. Normal

2. Traumatic arthritis

3. Degenerative (Osteo) arthritis

4. Pigmented villonodular synovitis

1. SLE

1. Rheumatic fever

2. Rheumatoid arthritis

3. Gout

4. Pyogenic (Septic) arthritis

5. Tubercular arthritis


Synovial membrane contains
 

Synovial cell

Resemble

Prominent organelle

Function

Type A

Macrophage

Mitochondria

Phagocytosis

Type B

Fibroblast

Endoplasmic reticulum

Secrete hyaluronic acid, & proteins complex (mucin) of synovial fluid


Fluid Newtonian
 

Newtonian fluid

Non newtonian

Newtonian Fluid is a fluid whose viscosity is constant in relation to rate of shear changes. Examples are All gases and Simple fluids

Non- Newtonian Fluid is a fluid whose viscosity changes as the rate of shear changes

Thixotropic

Rheopectic

Fluids whose viscosity decreases with increased rates of shear. e.g. Synovial Fluid

Fluids whose viscosity increases with increased rates of shear


Charcot's joint
  1. Neuropathic joint disease (Charcot's joint) is a progressive destructive arthritis associated with loss of pain sensation, proprioception, or both.
  2. Normal muscular reflexes that modulate joint movement are decreased.
  3. Without these protective mechanisms, joints are subjected to repeated trauma, resulting in progressive cartilage and bone damage.
  4. Diabetes mellitus is the most common cause of neuropathic joint disease.
Disorders Associated with Neuropathic Joint Disease
  1. Diabetes mellitus
  2. Tabes dorsalis
  3. Meningomyelocele
  4. Peroneal muscular atrophy
  5. Syringomyelia
  6. Leprosy
  7. Amyloidosis




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