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SA Orthopaedic surgery > Anatomy and physiology of the synovial joint > Flashcards

Anatomy and physiology of the synovial joint Flashcards

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1
Q

Anatomy of diarthrodial joint (out to in ish)

A

Soft tissue
Bone
Joint capsule - largely fibrous
Articular cartilage
Synovial membrane - usually very thin
Synovial cavity with synovial fluid - important for bathing articular cartilage (avascular)

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2
Q

Articular cartilage

A

Made of chondrocytes and extracellular matrix (largely collagen)

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3
Q

Breakdown of extracellular matrix of cartilage

A

Inflammatory insult
Pro-inflammatory cytokines

Net effect is cartilage destruction and changes to underlying subchondral bone

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4
Q

Synovial fluid

A

Fundamental role in boundary lubrication

Plasma dialysate supplemented with
- hyaluronan from synovial fibroblasts
- lubricin from chondrocytes

Provides glucose, other electrolytes, protein and CO2/O2 for cartilage metabolism

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5
Q

Non-inflammatory joint disease

A

DJD
Trauma
Neoplastic
Osteochondrosis

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6
Q

Inflammatory joint disease

A

Infectious and immunological joint disease

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7
Q

Osteochondral or full thickness defect

A

Right down to the cancellous bone

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8
Q

Chondral or partial thickness defect

A

Down to the subchondral bone

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9
Q

Degenerative joint disease (DJD), osteoarthritis, osteoarthrosis

A

Inherently non-inflammatory disease of synovial joints

CHaracterised by deterioration of articular cartilage and formation of new bone at joint margins

VERY COMMON

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10
Q

Clinical signs of Degenerative joint disease (DJD), osteoarthritis, osteoarthrosis

A

Usually a decreased range of motion
Pain (variable)
Joint swelling (fibrosis or effusive)
Crepitus

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11
Q

Pathology of DJD

A

Cartilaginous abnormalities:
- loss of matrix constituents and chondrocytes
- flaking
- fibrillation

Osteophytes develop at margin between joint capsule and articular cartilage

Synovial membrane changes:
- thickening
- mild inflammation
- joint capsule fibrosis

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12
Q

Radiographic changes indicative of DJD

A

Osteophytes formation
Soft tissue swelling
Joint effusion (often mild)
Subchondral sclerosis
Subchondral bone cysts - v rare in SA

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13
Q

Primary DJD

A

No identifiable cause
Rarely recognised in SAs (maybe aged beagles)

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14
Q

Secondary DJD

A

Secondary to:

  1. congenital problem e.g. dwarfism or achondroplasia
  2. Developmental disease e.g. hip dysplasia, osteochondrosis
  3. Acquired e.g. after articular fractures, luxations, cranial cruciate rupture etc.
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15
Q

Categories of inflammatory joint disease

A

Infectious

Non-infectious
- Immunological - erosive or non-erosive
- non-immnuological - crystal induced or chronic haemathrosis

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16
Q

Causes of infectious (septic) joint disease

A

External trauma and bite wounds

Iatrogenic

Endocarditis or remote infections

Immunodeficiency

Secondary to omphalophlebitis in puppies

Haematogenous spread in large breed dogs with estabilshed DJD

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17
Q

Clinical signs of infectious (septic) joint disease

A

Sudden onset
Pain
Swollen, effusive joint
Distal limb oedema
Lameness
More commonly a signle joint rather than multiple

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18
Q

Diagnosis of infectious (septic) joint disease

A

Radiographs to rule out other disease.
- soft tissue swelling and joint effusion
- later changes: periosteal bone reaction and discrete lucencies

Arthrocentesis
- turbid
- decreased viscosity
- increased volume
- high no. neutrophils, often degenerative

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19
Q

Techniques to increase success of culturing bacteria from joints

A

Incubation of synovial fluid in blood culture media for 24 hours

Submit a sample of synovial membrane for culture

Direct culture of synovial fluid - rarely successful

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20
Q

Treatment of infectious (septic) joint disease

A

Evacuate exudate

Treat with antibiotics - high dose IV

If no response consider lavaging with sterile saline

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21
Q

Prognosis of infectious (septic) joint disease

A

Acute infection: usually good
Chronic cases: much more guarded

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22
Q

Criteria to diagnose rheumatoid arthritis

A
  1. morning stiffness
  2. pain or tenderness on motion of at least one joint
  3. swelling of at least one joint
  4. swelling of one joint within a three month period
  5. symmetrical joint swelling
  6. subcutaneous nodules (not in dog)
  7. destructive radiological changes
  8. serological evidence of rheumatoid factor (IgG, IgM, IgA)
  9. abnomal synovial fluid
  10. characteristic histological changes in the synovial membrane
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23
Q

Definite rheumatoid arthritis- diagnosis

A

Can be diagnosed if 5 criteria are met - including at least the presence of two criteria 7, 8, or 10

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24
Q

Classical rheumatoid arthritis - diagnosis

A

can be diagnosed if 7 criteria are met - including at least the presence of two criteria 7, 8, or 10

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25
Signalment of rheumatoid arthritis
Small breeds, female, middle aged
26
Clinical signs of rheumatoid arthritis
Most commonly affects the carpus and tarsus and distal joints Present with collapse and deformity May be palmigrade or plantigrade Laxity, subluxation, and crepitus May be pyrexic with lymphadenopathy
27
Radiography of rheumatoid arthritis
Subchrondral erosions, soft tissue swelling, subluxations, disuse osteoporosis
28
Laboratory features of rheumatoid arthritis
Rheumatoid factor test: RF is an autoantibody of the IgM (IgG) class against IgG. Not specific Titre greater than 1 in 40 may be significant, but negative result doesn't exclude
29
Treatment of rheumatoid arthritis
Waxes and wanes so in quiescent stages treatment may not be necessary Acute exacerbations can be treated with NSAIDs, steroids, or immunosuppression SUrgical therapy such as cranial crutiate ligament rupture repair or arthrodesis
30
Prognosis of rheumatoid arthritis
Guarded Rarely is a cure obtained May be managed successfully for variable lengths of time
31
Rare erosivejoint conditions
Periosteal porliferative polyarthritis - in young male cats Mycoplasmal polyarthritis - greyhounds, seen in Australia Feltys syndrome - Rheumatoid arthritis, splenomegaly, and neutropenia
32
Idiopathic immune mediated polyarthritis
Most common inflammatory joint disease Non-erosive polyarthritis
33
Pathophysiology of idiopathic mediated polyarthritis
Thought to involve the deposition of immune complexes - or a type III hypersensitivity 4 types: 1. uncomplicated 2. associated with a remote infection e.g. pyometra 3. associated with GIT disease 4. associated with neoplasia e.g. lymphoma in cats
34
Signalment of idiopathic mediated polyarthritis
Often large breeds, spaniels, shelties, young adults
35
Clinical signs of idiopathic mediated polyarthritis
Waxing and waning Lameness, distal joints such as carpus and tarsus most commonly affected, joint effusions, pain on flexion/extension of joints, migratory problem, lethargy, and pyrexia
36
Radiology of idiopathic mediated polyarthritis
Soft tissue swelling, effusion, no erosions, no DJD Image thorax and abdomen to rule out GI disease (type III) and neoplasia
37
Laboratory investigations of idiopathic mediated polyarthritis
Mild anaemia, leucocystosis Negative for ANA and RF Synovial fluid: low viscosity, increased volume, cell count increased neutrophils
38
Treatment of idiopathic mediated polyarthritis
Treat underlying cause e.g. pyometra Immunosuppressive therapy using corticosteroids in a gradually decreasing dosing regime DO NOT taper dose too quickly and continue treatment for several months past remission
39
Prognosis of idiopathic mediated polyarthritis
Type I - in 50% of cases a cure should be obtained, in the other 50% continual therapy may be needed In a few cases medication may be ineffective and euthanasia may be requested
40
Systemic lupus erythematosus
Very rare An inflammatory non-erosive joint disease associated with involvement of other body systems
41
Diagnostic criteria of systemic lupis erythematosus
1. a significant titre of serum anti nuclear antibody (ANA) 2. involvement of more than one body system - e.g. dermatological lesions, AIHA, IMT, IML, glomerulonephritis, NM disease, GIT disease 3. Immunopathological features consistent with clinical involvement should be demonstrable e.g. IMT should be matched by presence of antibodies to platelets
42
Signalment of systemic lupis erythematosus
GSDs, Afghans, Irish setters, OES may be represented Female Any age
43
Clinical signsof systemic lupis erythematosus
Involvement of symmetrical joints, pyrexia, lethargy, inappetant, lymphadenopathy Disease often phasic
44
Labratory findings of systemic lupis erythematosus
Anti nuclear antibody test positive (titre >1:64 - use fluorescent antibody test) Coombs positive if AIHA RF negative Anaemia, leucopenia, thrombocytopaenia, hyperglobulinaemia
45
Treatment of systemic lupis erythematosus
Corticosteroids Cytotoxic drugs
46
Prognosis of systemic lupis erythematosus
Guarded
47
Other very rare inflammatory non-erosive diseases
Canine polyarthritis/polymyositis Canine polyarthritis/meningitis Canine sjorgrens syndrome - KCS, dry mouth (xerostomia) and polyarthritis Polyarteritis nodosa - vasculitis, beagles Plasmacytic lymphocytic gonitis - recognised with cranial cruciate rupture in small breeds Vaccination reaction - calicivirus in cats Drug reactions - potentiated sulphonamides in Dobermanns and Weimaraners Shar-pei fever (familial renal amyloidosis) - sharpei, swollen hocks and pyrexia Heritable polyarthritis in Akitas - young Akitas. Guarded prognosis
48
Management of DJD
Usually multi-modal appraoch needed Surgery critical for end-stage disease Regenerative medicine for the future
49
Most frequently encountered joint disease in general practice
DJD A.K.A oestoarthritis/osteoarthrosis
50
Treatment considerations for DJD
Exercise modulation Weight loss Physical therapy and hydrotherapy Drugs (e.g. NSAIDs, anti-NGF) Surgical options (e.g. osteotomy, arthrodesis, total joint replacement)
51
What causes damage in DJD?
Abnormal wear on normal cartilage Normal wear on abnormal cartilage Age-related 'wear and tear'
52
Exercise for DJD
Eliminate long periods of inactivity Short and frequent periods of gentle controlled exercise
53
Physical therapy for DJD
Massage - stimulates circulation and disperses oedema, relaxes muscles in spasm and prevents or breaks down adhesions Passive range of motion (PROM) exercises - aim to maintain or restore a normal range of motion in affected limbs and may help prevent tendon contractures
54
Hydrotherapy for DJD
Allows joint movement in a non-weight bearing mode - improves joint range of motion, improves muscle strength and general fitness
55
NSAIDs for DJD
Analgesic due to inhibition of prostaglandin synthesis Some studies show that it actually abolishes cartilage synthesis Possible side effects: vomiting, diarrhoea, gastrointestinal ulceration, nephropathy
56
Corticoid steroids for DJD
Potent anti-inflammatort effects Should be reserved for cases that are unresponsive to NSAIDs Repeat injections can cause cartilage degeneration
57
Surgical options for DJD
Correct inciting cause Joint stabilisation Ensure normal joint loading Salvage procedures for chronic arthritis: joint fusion, arthrodesis, joint replacement
58
Chondroprotectants for DJD
Better defined as disease-modifying OA drugs Hyaluronic acid - IV or IA - used in synovitis and early DJD PSGAGs - SC or IM (horse) - Reduces PG degredation and MMP synthesis
59
Regenerative medicine for OA
Platelet rich plasma (PRP) - autologous concentrated platelets - increased PDGF, VEGF, FGF-2, TGF-B - Widely used in management of soft tissue injuries, esp. ligament and tendon
60
Librela and solensia for DJD
Monoclonal antibodies to Nerve Growth Factor (NGF) - implicated in pain in OA Administered by SC injection once monthly Simple, long-lasting, safe Cost reasonable (about £70 pm) Efficacy (in long term) remains unproven

SA Orthopaedic surgery (8 decks)

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