临床神经病学课件：14-1 骨关节病osteoarthritis

非感染性关节病骨关节炎 OA股骨头坏死 FHNOsteoarthritisOADepartmentofOrthopaedicsFirstHospital,PekinguniversityIntroduction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(articularcartilage)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(PrimaryOA)原因不明的多关节退变继发性骨关节炎(SecondaryOA)继发于关节的创伤、畸形、感染或其它疾病PrimaryOA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SecondarytogenuvalgusSecondarytotibialcondylarfractureSecondaryhipOA原发性和继发性骨关节炎的临床特点比较原发继发年龄35岁以前很少发生可发生于成年后的任何年龄段部位同一时期内多关节发生单关节发生预后发展较慢，转归较好发展快，预后差性别女性比男性多发女性和男性均等发生PathogenesisCollagenandproteoglycandegradationFlakingandfibrillationofthearticularcartilagesurfaceVariationsinthecellularityandvascularityofsubchondralboneleadstosclerosisCysticdegenerationoftheboneOsteophytesformationattheedgesNarrowingofthejointspaceChangeofSynovialmembrane,Capsular&muscleDeformityofjointImaging:PlainRadiographsJointspacenarrowingOsteophytesBonycystsSubchondralsclerosis

ArthroscopyOuterbridgegradeⅠarticularsofteningⅡarticularfissuring<1.3cmⅢarticularfissuring>1.3cmⅣexposedsubchondralboneRelationshipbetweenChondralDegenerationandX-rayImagingMRI/CTChangesinsurfacemorphologyandfullthicknesscartilagedefectscanbeseen,Fibrillationcannotyetbeevaluated.MRIisnotessentialforosteoarthritisdiagnosis.DegenerationofCartilage

ClinicalFeaturesPatientsareusuallyovertheageof50Complainofpainandstiffnessintheaffectedjoint(s),whichisexacerbatedwithactivityandrelievedbyrest.Earlymorningstiffness,istypicallylessthan30minutes.JointtendernessCrepitusonmovementSwellingRadiographyFindings&SymptomsTherearenopositivecorrelationbetweenthesymptomsanddegenerationdegreeonXray.Kneepainseveritywasamoreimportantdeterminantoffunctionalimpairmentthanradiographicseverityofosteoarthritis.Thepresenceofosteophyteshadaverystrongassociationwithkneepain.Theabsenceorpresenceofjointspacenarrowingwasnotassociatedwithkneepain.LearningPointsOsteoarthritisisacommondiseasewithhighmorbidity.Theaetiologyismultifactorial.Plainradiographsarethecurrentmostcommonwayofassessingprogressionofosteoarthritis.CommonlocationsKneeHipHandFirstcarpometacarpaljointsFirstmetatarsophalangealjointsDiagnosticCriteriaofKneeOAKneePainwithosteophytesonX-RayandOneofthefollowing

CrepitusonkneerangeofmotionAge50yearsorolderMorningstiffnessofshortduration(<30minutes)DifferentialDiagnosisRheumatoidarthritis，RAGoutyarthritisPigmentedvillonodularsynovitis，PVNSReactionarthritisTreatmentTheaimsofmanagementofpatientswithOAPatienteducation.Paincontrol.Improvefunction.Alterthediseaseprocess.ManagementInterventionsEducationExerciseWeightlossPhysiotherapyAppliancesDrugsSurgeryDrugTherapiesNon-steroidalanti-inflammatorydrugs(NSAIDS)Intra-articularcorticosteroidsHyaluronicacidderivativesGlucosaminesulphate ChondroitinsulphatesClassificationofsomeNSAIDsSalicylates水杨酸类Aceticacides乙酸类Propionicacides布洛芬酸Naphthyl-alkalone萘基碱类Oxicams昔康类Cox-2specificinhibiterAspirin/Others(nonacetylates)Diclofenac/Indomethacin双氯芬酸/引朵美辛Ibuprofen/Naproxen布洛芬/耐普生Relafen瑞力芬Piroxicam吡罗昔康Celecoxib(celebrex)塞来昔布NSAIDsAdverseeffectsofNSAIDsGIadverseeventsBleeding/Ulcer/PerforationCardiovasculareventsRiskfactorsAge>65ComorbidmedicalconditionsOralglucocorticoidsHistoryofpepticulcerdiseaseHistoryofuppergastrointestinalbleedingAnticoagulantSurgeryArthroscopicdebridementandlavageOsteotomy:Hightibialosteotomy，HTOKneejointreplacementArthroscopicdebridementlimitedsynovectomyexcisionofosteophytesremovalofloosebodiesChondroplastyremovalofdamagedmeniscidrillingofexposedbonylesionsIndicationMildtomoderateOAofthekneeConservativetreatmenthasbeenexhausted.HighTibialOsteotomy，HTOIndicationDegenerativearthritisisconfinedtomedialcompartmentwithacorrespondingvarusdeformityYoungthan55yearsofageVarusdeformityis15°orlessFlexioncontracture<15°Kneeflexion>90°HTOHTOKneeJointReplacementTotalkneearthroplasty(TKA)Uni-compartmentalkneearthroplasty(UKA)UKAIndication

Patientswithprimarilyunicompartmentalosteoarthritisoftheknee.Contraindication

AbsentACLOppositecompartmentandpatellofemoraljointshowsignificantdegenration(Eburnatedbone)UKATotalKneeArthroplasty(TKA)IndicationsWearingintri-compartmentAge>65or60NonweightloadingWeightloadingSevereOAwithInstabilityLearningPointsinManagementofOAImportanceofpatienteducation.Earlyinvolvementtohelpwithexerciseadvice,weightlosswhereappropriate,orwalkingaids.NSAIDsshouldbeusedwithcaution,especiallyinat-riskpatients.Intra-articularcorticosteroidsinjectiontendsto