HTHSCI 2F03 Lecture Notes - Lecture 6: Autologous Chondrocyte Implantation, Hyaline Cartilage, Soft Tissue Injury

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26 Dec 2020

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Osteoarthritis

Definition

 Degenerative joint disorder in which there is

progressive loss of hyaline cartilage and new bone

formation at the joint surface and its margin.

Aetiology / Risk Factors

 Age (80% > 75yrs)

 Obesity

 Joint abnormality

Classification

 Primary: no underlying cause

 Secondary: obesity, joint abnormality

Symptoms

 Affects: knees, hips, DIPs, PIPs, thumb CMC

 Pain: worse c

¯ movement, background rest/night pain,

worse @ end of day.

 Stiffness: especially after rest, lasts ~30min (e.g. AM)

 Deformity

 ↓ ROM

Signs

 Pouchards (prox), Heberdips (dist.)

 Thumb CMC squaring

 Fixed flexion deformity

History

 Pain severity, night pain

 Walking distance

 Analgesic requirements

 ADLs and social circumstances

 Co-morbidities

 Underlying causes: trauma, infection, congenital

Pathophysiology

 Softening of articular cartilage → fraying and fissuring

of smooth surface → underlying bone exposure.

 Subchondral bone becomes sclerotic c

¯ cysts.

 Proliferation and ossification of cartilage in unstressed

areas → osteophytes.

 Capsular fibrosis → stiff joints.

Differential

 Septic

 Crystal

 Trauma

X-ray Changes

 Loss of joint space

 Osteophytes

 Subchondral cysts

 Subchondral sclerosis

 Deformity

Bloods

 CRP may be mildly elevated

 Ca, PO4 and ALP all normal

MDT: GP, physio, OT, dietician, orthopod

Conservative

Lifestyle: ↓ wt., ↑ exercise

Physio: muscle strengthening

OT: walking aids, supportive footwear, home mods

Medical

Analgesia

Paracetamol

NSAIDs: e.g. arthrotec (diclofenac + misoprostol)

Tramol

Joint injection: local anaesthetic and steroids

Surgical

Arthroscopic Washout

Mainly knees

Trim cartilage

Remove loose bodies.

Realignment Osteotomy

Small area of bone cut out

Useful in younger (<50yrs) pts. c

¯ medial knee OA

High tibial valgus osteotomy redistributes wt. to

lateral part of joint.

Arthroplasty: replacement (or excision)

Arthrodesis: last resort for pain management

Novel Techniques

Microfracture: stem cell release → fibro-cartilage

formation

Autologous chondrocyte implantation

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Back Pain

Mechanical Pain

 Soft tissue injury → dysfunction of whole spine → muscle

spasm → pain.

 May have inciting event: e.g. lifting

 Younger pts. c

¯ no sinister features

 Conservative

 Max 2d bed rest

 Education: keep active, how to lift / stoop

 Physiotherapy

 Psychosocial issues re. chronic pain and disability

 Warmth: e.g. swimming in a warm pool

 Medical

 Analgesia: paracetamol ± NSAIDs ± codeine

 Muscle relaxant: low-dose diazepam (short-term)

Disc Prolapse

 Herniation of nucleus pulposus through annulus fibrosus

Presentation

 L5 and S1 roots most commonly compressed by prolapse

of L4/5 and L5/S1 discs.

 May present as severe pain on sneezing, coughing or

twisting a few days after low back strain

 Lumbago: low back pain

 Sciatica: shooting radicular pain down buttock and thigh

Signs

 Limited spinal flexion and extension

 Free lateral flexion

 Pain on straight-leg raise: Lesague’s Sign

 Lateral herniation → radiculopathy

 Central herniation → corda equina syndrome

L4/5 → L5 Root Compression

 Weak hallux extension ± foot drop

 In foot drop due to L5 radiculopathy, weak

inversion (tib. post.) helps distinguish from

peroneal N. palsy.

 ↓ sensation on inner dorsum of foot

L5/S1 → S1 Root Compression

 Weak foot plantarflexion and eversion

 Loss of ankle-jerk

 Calf pain

 ↓ sensation over sole of foot and back of calf

Ix: MRI (emergency if cauda equina)

 Brief rest, analgesia and mobilisation effective in ≥90%

 Conservative: brief rest, mobilisation/physio

 Medical: analgesia, transforaminal steroid injection

 Surgical: discectomy or laminectomy may be needed in

cauda-equina syndrome, continuing pain or muscle

weakness.

Lumbar Microdiscectomy

 Commonest procedure for disc prolapse

 Microscopic resection of the protruding nucleus pulposus

 Posterior approach c

¯ pt. in prone position.

 May be performed endoscopically

Spondylolisthesis

 Displacement of one lumbar vertebra on another

 Usually forward

 Usually L5 on S1

 May be palpable

Causes

 Congenital malformation

 Spondylosis

 Osteoarthritis

Presentation

 Onset of pain usually in adolescence or early adulthood

 Worse on standing

 ± sciatica, hamstring tightness, abnormal gait

 Plain radiography

 Corset

 Nerve release

 Spinal fusion

Spinal Stenosis

 Developmental predisposition ± facet joint osteoarthritis

→ generalized narrowing of lumbar spinal canal.

Presentation

 Spinal claudication

 Aching or heavy buttock and lower limb pain on

walking

 Rapid onset

 May c/o paraesthesiae/numbness

 Pain eased by leaning forward (e.g. on bike)

 Pain on spine extension

 MRI

 Corsets

 NSAIDs

 Epidural steroid injection

 Canal decompression surgery

Neurosurgical Emergencies

Acute Cord Compression

 Bilateral pain: back and radicular

 LMN signs at compression level

 UMN signs and sensory level below compression

 Sphincter disturbance

Acute Cauda Equina Compression

 Alternating or bilateral radicular pain in the legs

 Saddle anaesthesia

 Loss of anal tone

 Bladder ± bowel incontinence

 Large prolapse: laminectomy / discectomy

 Tumours: radiotherapy and steroids

 Abscesses: decompression

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Osteochondritis

 Idiopathic condition in which bony centres of

children/adolescents become temporarily softened due

to osteonecrosis.

 Pressure → deformation

 Bone hardens in new, deformed position

Radiography

 Initially: ↑ density / sclerosis

 Then: patchy appearance

Scheuermann’s Disease

 Vertebral ring epiphyses

 Auto dom

 Vertebral tenderness and kyphosis

 X-ray: wedge-shaped thoracic vertebra

Kohler’s Disease

 Navicular bone

 Children 3-5yrs

 Pain in mid-tarsal region → limp

Kienbochs Disease

 Lunate bone

 Adults

 Pain over lunate, esp. on active movement

 Impaired grip

Friedberg’s Disease

 2

nd/3rd metatarsal heads

 Around puberty

 Forefoot pain worse c

¯ pressure

Panner’s Disease

 Capitulum of humerus

Perthes’ Disease

 Hip

Traction Apophysitis

Osgood-Shlatter’s

 Tibial tuberosity apophysitis + patellar tendonitis

 Children 10-14yrs, M>F=3:1

 Assoc. c

¯ physical activity

 Symptoms: pain below knee, esp c

¯ quads contraction

 X-ray: tuberosity enlargement ± fragmentation

 Rx: rest, consider POP

Sinding Larsen’s Disease

 Tranction tendinopathy with calcification of proximal

attachment of patellar tendon

 Children 8-10yrs

Sever’s Disease

 Calcaneal apophysitis

 8-13yrs

 Symptoms: pain behind heal + limping

 Rx: physio

Osteochondritis Dissecans

 Piece of bone and overlying cartilage dissects off into

joint space.

 Commonly knee (med. fem. condyle), also elbow, hip

and ankle.

 Young adult / adolescent

 Symptoms: pain, swelling, locking, ↓ ROM

 X-ray: loose bodies, lucent crater

 Mx: arthroscopic removal

Avascular Necrosis

Causes

 # or dislocation

 SCD, thalassaemia

 SLE

 Gaucher’s

 Drugs: steroids, NSAIDs

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Document Summary

Degenerative joint disorder in which there is progressive loss of hyaline cartilage and new bone formation at the joint surface and its margin. Affects: knees, hips, dips, pips, thumb cmc. Pain: worse c movement, background rest/night pain, worse @ end of day. Stiffness: especially after rest, lasts ~30min (e. g. am) Softening of articular cartilage fraying and fissuring of smooth surface underlying bone exposure. Proliferation and ossification of cartilage in unstressed areas osteophytes. Useful in younger (<50yrs) pts. c medial knee oa. High tibial valgus osteotomy redistributes wt. to lateral part of joint. Soft tissue injury dysfunction of whole spine muscle spasm pain. Education: keep active, how to lift / stoop. Psychosocial issues re. chronic pain and disability. Warmth: e. g. swimming in a warm pool. Herniation of nucleus pulposus through annulus fibrosus. L5 and s1 roots most commonly compressed by prolapse of l4/5 and l5/s1 discs.

HTHSCI 2F03 Lecture Notes - Lecture 6: Autologous Chondrocyte Implantation, Hyaline Cartilage, Soft Tissue Injury

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