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JOINt DISeaSe & injury

JOINt DISeaSe & injury. Ri Long Jin. Osteoporosis. Osteoporosis Prevalence. Affects 200 million women worldwide 1/3 of women aged 60 to 70 2/3 of women aged 80 or older Approximately 30% of women over the age of 50 have one or more vertebral fractures

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JOINt DISeaSe & injury

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  1. JOINtDISeaSe& injury Ri Long Jin

  2. Osteoporosis

  3. Osteoporosis Prevalence • Affects 200 million women worldwide • 1/3 of women aged 60 to 70 • 2/3 of women aged 80 or older • Approximately 30% of women over the age of 50 have one or more vertebral fractures • Approximately one in five men over the age of 50 will have an osteoporosis-related fracture in their remaining lifetime IOF, 2005 (www.osteofound.org)

  4. Osteoporosis • Loss of bone mass • Increase bone fragility • Increase risk of fractures Osteoporosis, or porous bone, is a devastating disease that robs its victims of bone mass.

  5. Osteoporosis Normal Bone Osteoporotic Bone

  6. Burden of Disease

  7. 1.5 Million Fractures Annually Vertebral Fractures: 700,000+ Wrist Fractures: 200,000+ Hip Fractures: 300,000+ Other Fractures: 300,000+ Source: National Osteoporosis Foundation, 2000

  8. Osteoporosis Normal Spine Osteoporotic Spine Source: National Osteoporosis Foundation, 2000

  9. Osteoclasts Osteoblasts Osteoid Mineralised Bone Bone Osteoid Courtesy of Michael Amling

  10. Excess Resorption - menopause - hyperPTH Insufficient formation - aging Resorption Reversal Bone Loss Bone Loss Formation Quiescence Unbalanced Remodeling: Bone Loss

  11. Bone Mass

  12. Osteoporosis - types • Postmenopausal osteoporosis (type I) • Caused by lack of estrogen • Causes PTH to overstimulate osteoclasts • Excessive loss of trabecular bone • Age-associated osteoporosis (type II) • Bone loss due to increased bone turnover • Malabsorption • Mineral and vitamin deficiency • Secondary osteoporosis (ex, steroid, heparin, hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, etc)

  13. Characterization of the two main types of osteoporosis Age(yr) Sex ratio(F:M) Type of bone loss Rate of bone loss Bone marker Fracture sites Parathyroid function Calcium absorption Metabolism of 25OH-D to 1,25(OH)2D Main causes 51 - 70 6 : 1 Mainly trabecular Accelerated Increased Vertebrae & distal radius Decreased Decreased Secondary decrease Related to menopause > 70 2 : 1 Trabecular & cortical Not accelerated Not increased Vertebrae & hip Increased Markedly decreased Primary decrease Related to aging Type I Type II

  14. Symptoms and Warning Signs I Persistent, unexplained back pain Shorter than you used to be Spinal deformities

  15. Symptoms and Warning Signs II Recurrent fractures Fracture from minimal trauma Experiencing chronic medical problems

  16. Factors contributing to osteoporosis I 1) Genetic or constitutional factors a. white or Asia ethnicity b. maternal history of fractures c. small body frame d. long hip axis length e. premature menopause (<45 years) f. late menarche European Osteoporosis Foundation

  17. Factors contributing to osteoporosis II 2) Lifestyle and nutritional factors a. nulliparity b. prolonged secondary amenorrhea c. smoking d. excessive alcohol intake e. inactivity f. prolonged immobilization g. prolonged parenteral nutrition h. low body weight European Osteoporosis Foundation

  18. “Women married to a smoker have a 91% greater risk of heart disease”

  19. WARNING TOBACCO USE CAN MAKE YOU IMPOTENT Cigarettes may cause sexual impotence due to decreased blood flow to the penis. This can prevent you from having an erection. Health Canada

  20. Factors contributing to osteoporosis III 3) medical disorders a. anorexia nervosa b. malabsorption due to gastrointestinal and hepatobiliary disease c. primary hyperparathyroidism d. thyrotoxicosis e. primary hypogonadism f. prolactinoma g. hypercortisolism (Cushing's disease or syndrome) h. Osteogenesis imperfectai. rheumatoid arthritis j. chronic obstructive pulmonary disease k. post transplantation l. chronic neurological disorders m. chronic renal failure n. mastocytosis o. type I diabetes European Osteoporosis Foundation

  21. Factors contributing to osteoporosis IV 4) Drugs a. chronic corticosteroid therapy b. excessive thyroid therapy c. anticoagulants d. chemotherapy e. gonadotropin releasing hormone agonist or antagonist f. chronic phosphate-binding antacid use g. anticonvulsant European Osteoporosis Foundation

  22. Diagnosis • BMD test • Biochemical markers - Blood - urine

  23. X-ray finding: 1.Mineral loss 30-40% 2. Generalized decreased density of bone 3. Spine –manifested in early stage Loss trabeculae (transverse >longitudinal), thining of cortex, codfish spine; Wedging of vertebra caused by compression Fx > round back or kyphotic deformity 4. Widening of medullary canal – loss of both cortical & trabecular bones 5. Bone densitometries a. Singh’s index b. Photon absorptiometry c. Dual energy X-ray absorptiometry DEXA d. Quantitative computed tomography, QCT

  24. Bone Densitometry

  25. DXA ; Dual Energy X-ray Absorptiometry • low energy and high energy X-ray • lumbar spine A-P & Lat., femoral neck, whole body, ulnar & radius • good precision and accuracy • low dose X-ray (1/50 of chest X-ray) • Most popular

  26. WHO criteria of osteoporosis Normal : T-score > -1.0 Osteopenia : -2.5 < T-score < -1.0 Osteoporosis : T-score < -2.5 Servere osteoporosis : T-score < -2.5 with presence of one or more fractures (established osteoporosis) T-score ; adult peak bone density와 비교한 score

  27. Biochemical markers of bone turnover Bone formation Osteocalcin (bone gla protein) Bone-specific alkaline phosphatase Procollagen type I propeptides C-terminal (PICP) N-terminal (PINP) Bone resorption Pyridinoline & Deoxypyridinoline Type I collagen telopeptide N-terminal C-terminal Hydroxyproline Tartrate resistant acid phosphatase Galactosyl hydroxylysine

  28. Bone Densitometry Anyone with a fragility fracture All women age 65 and older Postmenopausal younger than 65 with risk factors Men over 50 with risk factors

  29. Treatment

  30. Treatment of Osteoporosis 1. Treament for primary factor or disease & regular exercise 2. medication: - Enough dose of calcium + activated Vitamin D (1(OH)D3 or 1.25(OH)2D3) - Estrogen threapy for type I osteoporosis - Synthectic calcitonin 3. Fracture : Avoid longterm bed rest Early ambulation after firm internal fixation

  31. Medication Bisphosphonates Fosamax Actonel Didronel Estrogen Replacement Therapy Medications made from natural hormones SERMs Raloxifene (Evista) Calcitonin Sodium Flouride

  32. Medication-Under Investigation Vitamin D metabolites Parathyroid hormone New bisphosphonates New SERMs

  33. Weight-Bearing Exercise

  34. II. Chronic Arthritis • Inflammation of a joint usually accompanied by pain swelling and changes in structure • Etiology • Degenerative Joint Disease • Osteoarthritis, Rheumatoid • Metabolic disturbances • Gout • Infection • Gonococcus, TB, Pneumonia

  35. Arthritis • 1. Classification: major socio-ecomomic problem I. Rheumatoid Arthritis (RA) II. Degenerative arthritis ․Primary osteoarthritis ․Secondary osteoarthritis III. Others : Hemophilic Arthritis Gouty Arthritis Neuropathic or Charcot Joint Chondrocalcinosis &Pseudogout

  36. Manifestations • Pain • Stiffness • Redness • Swelling • Knee effusions • Crepitus

  37. Rheumatoid Arthritis

  38. Rheumatoid Arthritis • Chronic, Systemic Autoimmune Disease • Inflammation of the connective tissue, • Inflammation of the joint • Prevalence 0.5-1% • 30-50 yrs F>M

  39. Reason • unkonwn • Infectious : hemolytic and nonhemolytic types streptococci • Endocrine: this is suggested by response to adrenocortical steroids. • Autoimmune: frequently exhibit various allergic manifestations. = Eosinophilia is frequent. • Metabolic:

  40. pathogen • Diffuse proliferative synovitis Villous processes hypertrophy -> necrotic &extruded into the joint . • Fibrinoid necrosis around withfibroblasts • ->fibrous tissue • Synovium making->pannus- cover the articular surface withfibrous connective tissue • Vascular granulation tissue ->growing from medullary->distruction articular cartilage

  41. Manifestations of RA • Joint symptoms • Pain, swelling, stiffness (↑in morning) • Deformity and muscle atrophy • Limited ROM • Other Symptoms • Fatigue • Anorexia • Low-grade fever • Inflammatory changes of heart and lungs

  42. Sites affected

  43. 3. Dx of RA: ACR classification criteria for RA • Morning stiffness at least 1 hour • Swelling of 3 or more joint • Swelling of hand joints (P.I.P M.C.P. or Wrist) • Symmetric joint swelling • Erosion or decalcification on radiograph of hand • Rheumatoid nodule • Presence of serum rheumatoid factor 1987 USA RA Association: 4 of more of sever criteria

  44. Diagnosis of RA • History and physical exam • Labs • Rheumatoid factors (RF) • ESR (Erythrocyte Sedimentation Rate) • Synovial fluid exam • X-rays • Symmetric periarticular osteoporosis • Narrowing joint space • Bony trabeculation bridge, obliterate the joint space: ankylosis

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