Osteoarthritis Z. Rozkydal Chrup Synovial joint The end of bones Hyaline cartilage Ligaments Joint capsule Synovial membrane Synovial fluid Hyaline cartilage Chondrocytes Matrix – intercelullar mass: Fibrilar structure - collagen Proteoglycans Proteins of noncollagen nature Hyaluronic acid Water – 70 volume percent Chrup, barva norm Hyaline cartilage Chondrocytes- 2 percent of volume Localised in lacunes of matrix Isogenetic groups 2-8 cells from one mother cell Hyal chrup Chrupavka norm Hyaline cartilage - layers Superficial Middle Deep Zone of calcifying cartilage Bone Chrup, barva norm Collagen Collagen type II (3 alfa-1 chains- 90 %) Chains form fibrils Fibrils form a three dimensional network Paraler to the surface In deep layers in columns Hyal chrup P kolagen 1 Proteoglycans- PG They are high hydrophylic - elasticity !! Large PG - glukosaminoglycans: Chondroitin 6- sulfate Keratansulfate Chondroitin 4- sulfate Small PG: Decorin, biglycan Agrecan – binds on hyaluronic acid Sulfatan glukosaminoglycan Chrup, barva norm Noncollagen proteins Fibronectin, chondronectin Anchorin Cytocins- interleukin-1, interleukin- 6 Enzymes – metaloproteinase (kolagenase, gelatinase) Growth factors Prostaglandins Chrup, barva norm Hyaluronic acid- HA •Hydrophylic, maintains homeostasis •Responsible for lubrication of the joint •Promotes transport of nutritiens into the cartilage •Gives the cartilage elastic resistance •Gives rheologic properties to synovial fluid •HA + proteoglycans + collagen: intercelullar mass • Chrup High volume of water gives resistance in pressure Condrocytes are nourished from synovial fluid Cartilage has no vessels and nerves - low regeneration - The fluid is pushed by movements into the cartilage - Hyaline cartilage Chrup Synovial membrane It contains: Cells A – macrophages Cells B – produce hyaluronic acid Cells C – mixed cells – properties of cells A and B Chrup Network of vessels Chrup Synovial fluid Clear, slight yellowish Viscous The amount of 0,13-3,5 ml In a joint Proteins- only one third of concentration in plasma Chrup Synovial fluid Cytology: 65/mm3 lymfocytes, monocytes, mononucluears Mucin = hyaluronic acid and N-acetylglucosamin - gives viscosity No fibrinogen Diseases of joints •Osteoarthrosis deformans •Rheumatoid arthritis •Psoriatic arthritis •Gout •Ancylosing spondylitis •Septic arthritis • Dieseases of joints •Systemic arthritis (lupus erythematodes) •Haemofilia •Aseptic necrosis •Osteochondritis dissecans •Chondromatosis •Neurogenic arthropathy •Pigmented villonodular synovitis Osteoarthritis •Degenerative, slow and progressive disease • of hyaline cartilage of synovial joint • •All conditions changing the structure and function of hyaline membrane and surrounding tissues lead to osteoarthritis Chrup Osteoarthrosis 15 percent of the population 50 percent of people above 65 years 80 percent of people above 75 years Osteoarthrosis deformans •Primary (after 40 years of age ) • •Secondary – the cause is known • Primary O.A. Begins over 40 y. Small joint in hands Cervical and lumbar spine Hip and knee joints Artroza 2 Hauser 15 Secondary O.A. 1. Mechanical factors (DDH, Perthes disease, aseptic necrosis, slipped femoral epiphysis, condition after fractures) 2. Metabolic disorders (ochronosis, gout, chondrocalcinosis, Gaucher disease) 3. Hormonal disorders (acromegaly, diabetes m.) 4. Haemophilia 5. Inflamated disorders (septic artritis, R.A.) stková 10 DDH- developmental dysplasia of the hip joint Obr. 6 Condition after Perthes disease Obr. 8 O kočovský 1 Idiopatic necrosis of the femoral head CLS - necrosis Jelínek Obr. 7 Olšová 15 Necrosis after femoral neck fracture Obr. 9 Rheumatoid artritis CLS - R CLS- R Obr. 10 Weiterová 1 Ancylosing spondylitis Obr. 12 Septic arthritis Obr. 13 Gaža 15 Risk factors Age over 50 years Obesity Mutation of gene for procollagen II (COL2A1) Autosomal gene for Heberden´s nodes is dominant in female and recessive in male Female are involved twice oft than male - after 55 years – postmenopausal defecit of estrogens - O.A. is more often Mechanical O.A. Výuka schéma artrózy Obr. 14 Paleček ASK Macroscopis changes Cartilage is soft, yellowish, fibrilations Obr. 15 tibie 4 + femur 4 Čechová ASK Ulcers, defects Obr. 16 Obr. 17 Procházka ASK 1 Subchondral bone is sclerotic Obr. 18 Obr. 19 Pribilová 1 Macroscopic changes Subchondral cysts Osteophytes Narrowing of cartilage Hypertrophic synovial membrane Loose bodies Obr. 20 Artroza1 Condrocytes make clusters in 10-20 Irregularities of the surface Fibrilations Fissures, defects of cartilage Collagen network is disturbed Chrup Chrup Biochemical changes Higher amount of water Synthesis of PG is higher Loss of proteoglycans is high Chondroitin 6 sulfate - less Ketaransulfate- less Condroitin 4 sulfate is higher Chrup Clinical symptoms Pain, mild, in weather changes, later is higher Stiffness Effusion, synovitis Limping, difficultis in standing and walking Muscle atrophy, joint contracture Malalignment Kellgren- Lawrence classification I- IV. O I. II. III. IV. 1 Softening and swelling 2 Fragmentation and fissures up to 1,3 cm 3 Fragmentation and fissures above 1,3 cm 4 Erosions up to subchondral bone Chondropathy Chondropathy I. st. S6R00001 Chondromalatia- soft cartilage Chondropathy II. st. S6R00002 Fissures in the cartilage Chondropathy III. st. •Fibrilation- „ crab meet“ Chondropathy IV. st. S6R00002 Defects to subchondral bone Change of life style Low weightbearing Loss of overweight Ortheses, crutches, sticks Physioterapy Physical therapy Conservative treatment Conservative treatment Analgetics nonopioid (paracetamol) Analgetics opioid (tramadol, codein,) Nonsteroidal antiinflammatory drugs (NSAID) Inhibitors of cyclooxygenase 1 COX - 1 inhibitors Ibuprofen indometacin piroxicam naproxen diclofenac tiaprofenic acid NSAID NSAID Inhibitors of cyclooxygenase - 2 COX 2 inhibitors Preferred: meloxicam (Movalis, Recoxa) nimesulid (Aulin, Coxtral, Nimesil) Selective : celecoxib (Aclexa) rofecoxib SYSADOA - Symptomatic, slow acting, antiinflamatory drugs (chondroprotectives) Slowly acting Long lasting efect Stimulation of PG and collagen Inhibition of catabolic enzymes SYSADOA 1.systemic: glucosamin sulfate chondroitin sulfate diacerein ASU piascledine Combined drugs (Alavis) Collagen- GUNA inj. ChondroGrid (hydrolylisated peptids of low molecular weight ≤ 3 kDa SYSADOA local- hyaluronic acid - viscosuplementation Hyalgan Synvisc Synovial Monovisc Hyaline Renehavis Chrup Chrup Local corticosteroids Diprophos Depo-Medrol They influence synovitis Do not stop progression of O.A. Synthetic activity of chondrocytes is lower The amount of chondrocytes and PG is lower Recommended treatment Paracetamol- up to 4 g per day NSAID + inhibitors of proton pump (omeprazol) Chondroprotectives Hyaluronic acid, collagen Local corticosteroids Pain department- in a case surgery is not indicated PRP- platelets rich plasma ACP- autologous conditioned serum- Orthokine Mesenchymal stem cells ? Other options Operative treatment Preventive surgery - correct treatment of intraarticular fractures - correct treatment of ligament injuries - correct treatment of dislocations - correct treatment of menical lesions - treatment of chondromalatia - removal of loose bodies Preventive surgery - Correction of malalignment- osteotomy - Acetabuloplasty, shelf plasty - Replacement of cruciate ligaments - synovectomy, debridement, shaving Operative treatment Operative treatment Resection arthroplasty – op. sec. Keller op. sec. Girdlestone Arthrodesis Total joint replacement K:\kratochvílová 76.jpg Options for localised chondral defects Shaving and drilling - - abraze subch Drilling - Abrasion chondroplasty ER 6 Curretage Shaver ER 7 Perforation of subchondral bone - slight bleeding Steadman, J.R., 1999 Multipotent stem cells into the defecfts The aim- to create fibrocartilago Microfractures ER 7 Microfractures ER 8 ER 10 Hangody, L., 1992 Defects up to 2 - 4 cm2 Osteochondral autograft transfer- OAT Mosaicplasty ER 12a ER 12b ER OAT 1 OAT ER OAT 1 4 years after surgery Scaffolds- HyaloFast, Chondrotissue… Biodegradable Matrix for stem cells from bone marrow after drilling or from serum Hyalografts and chondrografts ER 16 Collagen scaffolds HyaloFast- scaffold Polymer of HA No special fixation Scaffold serves for maintaining of stem cells from bone marrow Supports viable cells Fills the defects of hyaline cartilage C:\Users\Petra Kotalíková\Desktop\surgical_training__overview__01_250x.jpg C:\Users\Petra Kotalíková\Desktop\surgical_training__overview__02_250px0.jpg Differential diagnosis Rheumatoid arthritis Ancylosing spondylitis Psoriatic arthritis Septic arthritis Haemofilic arthropathy Gout Chondrocalcinosis Neurogenic arthropathy Artropatie- Charcot rtg Artropatie Charcot Neurogenic arthropathy Obr. 30 Obr. 31 Neurogenic arthropathy Neur, R.A. •R.A. •Juvenile R.A. • - Still´s disease R Gout Chrup Chrup Chondrocalcinosis • HPT 2 Chrup Synovial chondromatosis Septic arthritis M 000 Boháček