ARTHRITIS- Current Medical and Surgical Management

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1 ARTHRITIS- Current Medical and Surgical Management Dr Jacqueline Andrews Consultant Rheumatologist Mr George Whitwell and Mr Campbell Maceachern Consultant Orthopaedic Surgeons Leeds Teaching Hospitals NHS Trust May 9 th 2016

2 What is Arthritis? arth - joint itis inflammation Arthritis inflammation of the joint(s). Types of arthritis- more than 100! Non-inflammatory - mainly managed in Primary Care and by Orthopaedic Surgeons Inflammatory - mainly managed by Rheumatologists Infectious - uncommon Haemorrhagic - very uncommon

3 INFLAMMATORY ARTHRITIS Rheumatoid Arthritis (RA) Juvenile Idiopathic Arthritis Spondyloarthropathies (SpA) Crystal deposition disease (JIA) Ankylosing Spondylitis Psoriatic Arthritis Enteropathic Arthritis- IBD Reactive Arthritis Gout CPPD disease (Pseudogout)

4 RHEUMATOID ARTHRITIS 1% of population Females > Males Most common during child-bearing years Tiredness, weight loss, Pain and swelling of joints Early morning stiffness

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7 3. Reconstruct surgery increasingly uncommon RA - TREATMENT 1. Stop the Inflammation- prevent damage: Traditional disease modifying agents Methotrexate, Sulphasalazine, Hydroxycholorquine, Leflunomide Biologics- target individual molecules involved in inflammation pathways Anti tumour necrosis factor (TNF) drugs: adalimumab, certolizumab, etanercept, infliximab. Other biologics target different proteins: abatacept, rituximab, tocilizumab 2. Rehabilitation and prevent co-morbidities: Occupational therapy, Physiotherapy, Podiatry, Psychology Annual review- cardiovascular risk, bone health, immunisation check etc

8 SPONDYLOARTHROPATHIES (SpA) 1. Ankylosing Spondylitis 2. Psoriatic 3. Enteropathic (IBD) 4. Reactive Arthritis

9 Diagnostic Testing Share common features: Joint, back and eye inflammation, rashes, digestive disorders Associated with the HLA B27 gene no diagnostic laboratory testing But some typical X-Ray appearances eg pencil in cup appearance

10 Ankylosing Spondylitis (AS) Causes inflammation and eventually fusion of the spine and the spinal joints. Involvement of peripheral joints and eye also common. Causes pain, stiffness and decreased spinal mobility Incidence ranges from 0.1 to 1 percent of population Men are affected 3 X more than women Commonly develops age 15 to 40

11 Management of AS Education NSAIDs Exercise Physiotherapy Rehabilitation Spinal disease TNF blockers Peripheral disease Sulfasalazine Local corticosteroids A n a l g e s i c s S u r g e r y Zochling J, et al. Ann Rheum Dis.

12 Psoriatic Arthritis Likely in up to 25-34% of patients with psoriasis Incidence in population around 1% Males =Females Peak age of onset between years enthesitis tenosynovitis dactylitis (inflammation at site of tendon insertion) (inflammation of tendon and its enveloping sheath) ( sausage digit ) Treatment: - Methotrexate very effective for skin and joints - Biologics increasingly used in severe disease - New oral treatment - Apremilast

13 GOUT CRYSTAL DEPOSITION DISEASES Disorder of purine metabolism Leads to deposits of urate crystals in joint and surrounding tissues tophi 2 Types: Primary (95%): inherited disorder with overproduction or under excretion of urate Secondary (5%): due to underlying medical condition (blood or kidney disorder) 20 times more common in men than women Foot, ankles, hands, wrists and elbows most commonly affected

14 GOUT- treatment Acute Attacks:- treat quickly! Indomethacin and other anti-inflammatories (NSAIDS) Colchicine Steroids- tablets, injections Chronic disorder: Adjust diet (low purine) Drugs- Allopurinol, Colchicine

15 PSEUDOGOUT- aka CPPD disease Caused by inflammation due to deposits of calcium pyrophosphate dihydrate (CPPD) crystal- mimics gout More common in later life and if suffer from Osteoarthritis Most often affects the knee and the wrists X-rays show calcium deposits in cartilage and surrounding tissues Treatment- similar to gout

16 Rheumatology at Leeds Teaching Hospitals NHS Trust EULAR (European Rheumatology Society) Centre of Excellence in Rheumatology since 2005 Chapel Allerton Hospital facilities Ward C2-20 bed ward shared with Dermatology Day Care Unit C5-5,00 patient visits per year-new extended hours Outpatient Suite - 35,000 patient visits per year Others - Physiotherapy (hydrotherapy), Occupational Therapy Podiatry, Research Facilities St James s University Hospital: Inpatient beds Outpatient Clinics Wharfedale Hospital: Outpatient Clinics 24 hour 7 day on-call medical service

17 Rheumatology Research at Leeds The Leeds Musculoskeletal Biomedical Research Unit (LMBRU) is an NIHR funded centre of excellence for musculoskeletal research, established in 2008 A partnership collaboration between the Leeds Teaching Hospital Trust and the University of Leeds which has led to: developing and trialling new treatments (especially Biologic agents) for Inflammatory Arthritis blood tests to aid the early diagnosis of Rheumatoid Arthritis new imaging methods to diagnose arthritic conditions earlier and more accurately Research it s important- how you can get involved! LMBRU Patient and Public Involvement Group Established 2009 > 120 active members emma.rice@nihr.ac.uk THANK YOU

18 Hip and Knee Osteoarthritis Mr Campbell Maceachern Mr George Whitwell Consultant Orthopaedic Surgeons Chapel Allerton hospital Leeds

19 Chapel Allerton Orthopaedic Centre Opened 12 Years ago 9 joint replacement surgeons 4 Specialist Orthopaedic Theatres 1400 hip and knee joint replacements per year Dedicated outpatient suite with pre-assessment clinics Dedicated multidisciplinary teams

20 NON - INFLAMMATORY ARTHRITIS OSTEOARTHRITIS Osteoarthritis, is also known as osteoarthrosis or degenerative joint disease Progressive disorder of the joints caused by gradual loss of cartilage resulting in pain and reduced function.

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22 Types of Osteoarthritis Primary / Idiopathic (most common) Secondary Trauma Infection, Rheumatoid, Gout Vascular Neuropathy Haemophilia Metabolic

23 What Causes Primary Osteoarthritis Ageing? Undeniably related Why do some 90 year olds not have it? Overuse Related to job manual labourers Obesity (Secondary due to recurrent microtrauma) Genetic Increasing evidence of genetic component Tends to run in families

24 Symptoms of Osteoarthritis Pain Worse on movement and at end of day Stiffness Stiff after rest, but improves with movement A grating or grinding sensation Swelling The swelling may be hard (bone spurs) or soft (extra fluid) Reduced Function Feeling of instability Reduced range of movement Less Strength

25 How Common is it? Very common 8.5 million people in UK symptomatic True incidence far higher (>80% in over 70s) Women > Men Increasing with ageing population

26 Diagnosis Osteoarthritis History Xrays Magnetic Resonance Imaging Rapidly evolving technology Mr Whitwell Early treatment Hip Replacements

27 Conservative Treatment Physiotherapy and exercise regimes Increase muscle strength and tone Increase joint movement Improve stability Postural advice Improve general fitness

28 Conservative treatment Weight loss - - Activity modification May 9 th 2016

29 Medical treatment

30 Medical Treatment Injections Steroids Hyaluronic acid?

31 May 9 th 2016 Arthroscopy

32 May 9 th 2016 Arthroscopy

33 Knee Arthroscopy

34 Microfracture Debridement Chondroplasty

35 First performed 1960 s Hip replacements 60,000 performed annually in UK Over 90% last patients lifetime Operation of the century All UK operations are now entered on NJR

36 Hip replacements Spinal anesthetic Average hospital stay 3.5 days Patients walking around day of surgery Complication rates < 1%

37 May 9 th 2016 Hip Replacements

38 May 9 th 2016 Hip replacement

39 May 9 th 2016 Hip Replacements

40 Hip Replacements

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42 Surgical Treatment of Knee Arthritis When non-surgical and minimally invasive techniques fail to relieve symptoms Consider Joint Replacement Partial Knee Replacement Total Knee Replacement Pain is severe Function and quality of life is significantly impaired

43 Consider previous Xray demonstrating Arthritis

44 Partial Unicompartmental Knee Replacement

45 Partial Knee Replacement Benefits Feels like native knee Very good function Faster recovery Forgotten Surgery Drawbacks Remainder of knee remains susceptible to arthritis 2.5% of all patients will require revision to full knee replacement 7-10 years later

46 Total Knee Replacement

47 Total Knee Replacement Benefits Very good at reducing pain and improving daily function Pain significantly reduced in 90% of patients Drawbacks Often doesn t feel like native knee Kneeling can be difficult in 50% of patients Mechanical joints can wear out May need a revision procedure

48 Total Knee Replacement - Advancements Templating Import x-rays computer interface Allows accurate measurements Ensure precise fitting implants Custom Patient-Specific Technology Using MRI or CT Very precise custom jigs are 3D printed Used during the operation for precise implant placement Very useful for grossly abnormal anatomy Knee MRI

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