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Flashcards in Arthritic conditions Deck (37):
1

Define pseudogout?

  • A metabolic disease resulting from desposition of CALCIUM PYROPHOSPHATE DIHDRATE (CPPD) crystals within the joint space
  • Characterised by recurrent monoarticular arthritis

2

What is the epidemiology of pseudogout?

  • Commonly affects the elderly
  • rarely affects the young

3

Name associated conditions?

  • Haemochromatosis
  • Hyperparathyroidism
  • SLE
  • Gout
  • RA
  • Wilson's disease
  • Haemophilia
  • Long term haemodialysis
  • Chondrocalcinosis present in 7%

4

How is it different form gout?

  • Affects older patient >60 yrs
  • Affects more proximal joints
  • weakly Positive befringement crystals






     

5

Describe the symptoms and signs?

Symptoms

  • Acute onset joint tenderness
  • warm , erythermatous joint
  • Commonly on knee and wrist joint

Signs

  • Erythermatous, monoarticular arthritis
  • Joint tenderness to palpation
  • May observe superficial mineral deposits under skin at affected joints

6

What is seen on xrays?

  • Chondrocalcinosis- calcification of fibroartilage structures
  • TFCC in wrist
  • Mensicus in knee

7

How is pseudogout dx?

  • Weakly POSTIVE BIFEFRINGENT RHOMBOID shaped crystals

8

What is the tx of acute gout?

  • Acute
    • NSAIDS
    • Splints for comfort
  • Chronic
    • Non operative
    • Intra-articular yttrium-90 injection
    • cochicine- 0.6mg PO for recurrent cases
      • prophylatic cochicine can help to prevent recurrence

9

Complications of pseudogout?

  • Can result in permanent damage to joints and renal disease

 

NB PSEUDO GOUT "P" for

  • postive birefringent rhombpid crystals
  • calcium Pyrophosphate dihydrate

10

What is the epidemiology of ankle arthritis?

Describe the pathophysiology of ankle arthritis?

  • Less common than OA of knee/hip

 

  • Post traumatic arthritis
    • Greater than 2/3 ankle arthritis
  • Primary OA- Less than 10% 
  • RA
  • Osteonecrosis
  • Septic arthritis
  • Gout

11

What is the pathoanatomy of ankle arthritis?

  • Nonanatomic fracture healing alters the joint reaction forces of the ankle and changes the load bearing mechanics of the ankle joint
  • Loss of cartilage on the talus and tibial plafound-> joint space naarowing, sunchondral sclerosis and Eburnation

12

Decribe the anatomy of the ankle joint?

  • Ginglymus joint- HINGE
  • Talar dome is biconcave with a central sulcus
  • Dorsiflexion 20o
  • Plantarflexion 50o

13

What are the signs and symptoms of ankle arthritis?

Symptoms

  • Pain on weight bearing
  • Reduction in motion

Signs

  • Joint effusion
  • reduced ROM cf contralateral side
  • Angular deformity if hx of trauma

14

What investigations are useful?

Radiographs

  • AP standing, lateral standing, oblique
  • Loss of joint space, subchondrial sclerosis, Eburnation, possible angular deformity

15

What is the tx for ankle arthritis?

  • Nonoperative
    • activity modification, bracing to immobilise ankle,NSAIDS
    • single rocker can improve things
  • Surgery
  • Debridement with anterior tibial/dortsal talectomy
    • Mild disease/ pai onpush off
  • Distraction arthroplasty
  • Supramalleolar osteotomy
    • ​medial focused ankle pain
  • Arthrodesis
    • eldery less active patient
  • ​Arthroplasty
    • Post-traumatic/ inflammatory arthritis/ eldery pt
    • Pt selection is key

16

What are the Ci for ankle arthroplasty

  • Uncorrectable deformity
  • Severe osteporosis
  • talus ostenecrosis
  • Charot joint
  • ankle instablity
  • obesity
  • Young labourer
  • Increased reisk of failure and revision

17

What are the outcomes and complcations of ankle arthrodesis? 

  • Outcome- relief in pain and return to ADL
  • Complications
    • by 10 yrs - 50% subtalar arthritis
    • Non union
      • RF= Smoking
      • Adjacent joint fusion
      • Hx of failed arthrodesis
      • Avascular necrosis

18

What are the outomes and complications of ankle arthroplasty?

  • Recent 5-10 yr fu showed 90% good- excellent results
  • Long term studies results still pending

 

  • complications
    • syndesmosis nonunion
    • Wound infection
    • Deep infection
    • Osteolysis

19

How wpud you tx metatarsal prominence-> ulcers?

20

Double Rocker

21

What is the consx tx of toe tip ulceration?

Severe angled rocker

22

What consx tx is available for fixed angle dorsiflexion deformities?

Negative heel rocker

23

Define midfoot arthritis?

Arthritis in 

  • Naviculocuneiform
  • Intercuneiform
  • Metatarsal cuneiform

 

 

24

What is the aetiology of midfoot arthritis?

  • Idiopathic- primary osteoarthritis
  • Posttraumatic
  • Inflammatory

25

What is the pathology of midfoot arthritis?

  • Large forces seen by joints that have limited motion
  • Soft tissues that support joints abnormally high forces over time
  • Results in midfoot collapse

26

What are the symptoms and signs of midfoot arthritis?

Symptoms

  • Midfoot pain adn in arch with push off

Signs

  • Longitudinal arch collapse- Meary's angle normally =O- but in this negative with collapse
  • Midfoot collapse- Looks like PTTI
  • Forefoot abduction
  • Hindfoot valgus
  • Equinnus contracture of achilles tendon
  • Halux valgus
  • palpation of arch/midfoot-> pain

27

What do you see on xrays of midfoot arthritis?

  • Lateral- loss of co-linerity between talus and 1st MT= Meary's line
    • Apex of deformity is at level of midfoot
    • may shows collapse of LONGITUDINAL ARCH
  • ​AP
    • Arthritic signs in midfoot
    • Abduction of forefoot

28

What is the ddx of this

  • Post  tibial tendon insufficiency
  • Midfoot arthritis
  • Post traumatic LIs- Franc injury
  • Lateral ankle instability

 

29

What is the TX of midfoot arthritis?

  • Non operative
    • NSAIDS, Activity modification, orthotic/bracing
    • first line tx
    • steriods injections under radiographic guidance
    • orthotics
      • cushioned heel
      • longitudinal arch supports
      • stiff sole with rocker bottom
  • Operative
    • MIDFOOT ARTHRODESIS +/- TAL +/- HINDFOOT REALIGNMENT
      • ​failure of non op tx
      • Outcomes= midfoot joints are non essential joints
      • arthrodesis results in close to normal foot function
      • Achilles tendon lengthening/ hindfoot relaignment
        • may need to be done concomitantly

30

Decribe the technique of midfoot arhrodesis?

  • Realignment arthrodesis
    • Fusion of 1st RAY via the TARSO-METATARSAL joint
    • Fusion of the 2/3rd rays via the NAVICULOCUNEIFORM/INTERCUNEIFROM joint
    • Don't fuse 4/5 TMT joints
      • ​lateral ray facilitates foot accomdation during stance
      • Interpositional arthroplasties of 4/5 Tarsometatarsal joints 
        • for select cases
        • will maintain length of lateral column
        • can assist with gait accomodation
    • can use screws. staples and plates for midfoot fusions

31

What is the cause of tibiotalar impingment?

  • Osteophyte impingment in anterior tibiotalar joint
  • Excessive anterolateral soft tissues or posterior soft tissue or osseous abnormalities

32

What is the epidemiology of tibiotalar impingment?

  • Common in athletes who play on turf or on grass including
    • Rugby
    • football
    • dancers

33

What is the mechanism of tibiotalar impingment?

  • Repetitive overuse injuries
  • Trauma
  • Degenerative sequlae

34

What are the symptoms and signs of tibiotalar impingment?

  • Symptoms
    • Pain in anterior ankle
  • Signs
    • Pain with forced dorsiflexion
    • limited dorsiflexion
    • Soft tissue swelling and effusion may be evident
    • subtalar joint is pain free

35

What imaging is useful in tibiotalar impingment?

  • xrays
    • Ap, lateral standing and oblique
    • spurs seen anterior disatl tibia or dorsal aspect of talus
  • CT
    • delinates extent of bony osteophytes
  • MRI
    • Shows spurring and fluid in joint

36

What is the tx of talotibial impingement?

  • Non operative
    • Therapy, lifestyle modficiations, NSAIDS
    • first line tx
  • Operative
    • Arthroscopic excision

37

What are the complications of ankle arthroscopy?

  • Superifical peroneal nerve injury to anterolateral portal creation
  • Saphenous vein injury during anteromedial portal creation
  • Dorsal neurovascular bundle during tibiotalar spur removal