The Review of Osteoarthritis, Summaries of Medicine

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OSTEOARTHRITIS

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A. Definition Osteoarthritis according to the American College of Rheumatology is a heterogeneous group of conditions that lead to joint signs and symptoms.Osteoarthritis (OA) is the most common form of arthritis and one of the leading causes of disability. The knee is the largest synovial joint in humans, consisting of bony structures (distal femur, proximal tibia, and patella), cartilage (meniscus and hyaline cartilage), ligaments and synovial membrane. The latter is responsible for the production of synovial fluid, which provides lubrication and nutrition to the avascular cartilage. Unfortunately, given the high usage and stress of this joint, it is a frequent site for painful conditions including OA. 7 It is also recognized that cartilage tissue is not the only tissue involved. Due to its lack of blood vessels and innervation, cartilage by itself is incapable of producing inflammation or pain at least in the early stages of the disease. Therefore, The main source of pain comes from changes in the noncartilaginous components of the joint, such as the joint capsule, synovium, subchondral bone, ligaments, and periarticular muscles. As the disease progresses, these structures are affected and changes including bone remodeling, osteophyte formation, periarticular muscle wasting, ligament laxity, and synovial effusion may become evident.This disorder is a degenerative process in the joints that affects the knee joint. B. Knee Anatomy

1. Knee Joint Bones The knee joint is formed by several bones, namely: a. Femur The femur is the longest tubular bone. The framework at the base of which is connected to the acetabulum forms a joint head called the head of the femur. Above and below the columna femoris there are spurs called the trochanter major and trochanter minor, at the ends forming the knee joint, there are two protrusions called the condylus medianus and condylus lateralis. Between these two condyles there is an indentation where the kneecap bone (patella) is located which is called the condylar fossa.

The quadriceps femoris muscle is one of the skeletal muscles found on the front of the human thigh. This muscle has the dominant function of extension at the knee. The quadriceps femoris muscle consists of four muscles, namely: Figure 2. Quadriceps Femoris Muscle i. Rectus Femoris muscle It is located most superficially on the ventalis surface between the other quadriceps muscles, namely the NPRStus lateralis and medialis muscles. It originates at the anterior inferior iliac spine (caput rectum) and at the ilium in the cranialis acetabulum (caput obliquum) and holds the insertion of the tibial tuberosity by means of the patellar ligament. This muscle is classified into muscle type 1. ii. NPRStus Lateralis muscle This muscle type is a type II muscle that is on the lateral side which holds attachments to the ventrolateral surface of the major trochanter and the lateral labium, linea aspera femoris. iii. Medial NPRS muscle Attached to the labium medial linea aspera (lower two-thirds) and includes type II muscles.

iv. NPRStus intermedius muscle Attachment to the ventro-lateral surface of the corpus femoris is also a type II muscle. b. Knee Flexor Muscles (Hamstrings) Hamstrings is a hamstring muscle that functions as a knee flexor and hip extensor. In general, the hamstring is a type II muscle fiber muscle. The hamstring is divided into three muscles namely: Figure 3. Hamstring muscles 3 i. Biceps Femoris Muscle Has two heads. Caput longum and breve, longum head originates on the medial part of the tuber ichiadicum and semitendinosus muscle while the breve head originates on the lateral labium linea aspera femoris, inserts this muscle on the capitulum of the fibula. ii. Semitendinosus muscle This muscle originates on the medial part of the tuber ichiadicum and inserts on the medial surface of the proximal end of the tibia. iii.Semimembranosus muscle Attached to the lateral pars of the ichiadicum tube descends towards the medial side of the posterior femoral region and inserts on the posterior surface of the medial condylus of the tibia.

femoral condyle which functions to prevent the tibia from sliding anteriorly towards the femur, resists external rotation of the tibia during knee flexion, prevents knee hyperextension and helps when rolling and gliding the knee joint. b. Posterior cruciate ligament The posterior cruciate ligament is a shorter ligament than the anterior cruciate ligament. This fan-shaped ligament extends from the posterior aspect of the tibia to the upper anterior portion of the tibial intercondyloid fossa and is attached to the outer anterior aspect of the medial condyle of the femur. This ligament functions to control the slide of the tibia backward against the femur, preventing hyperextension of the knee and maintaining stability of the knee joint. c. Medial collateral ligament The medial collateral ligament is the broad, flat ligament and its membranous band lies on the medial side of the knee joint. This ligament lies more posteriorly on the medial surface of the tibiofemoral joint where it attaches above the medial epicondyle of the femur below the adductor tubercle and downwards to the medial condyle of the tibia and to the medial meniscus. This ligament is often injured and its function is to maintain extension and prevent outward movement d. Lateral collateral ligaments The lateral collateral ligaments are strong and attach above the epicondyle of the femur and below the outer surface of the head of the fibula. The function of this ligament is to control extension and prevent medial movement. In knee flexion this ligament protects the lateral side of the knee

4. Joint Capsule The bones that form joints are connected to one another by a sheath called the capsule articularis as a sheath that surrounds the joint surfaces and tightly wraps the joint space between the bones. The outer layer of the

articular capsule (lamina fibrosa) is one of the important structures that binds the bones forming joints. The fibrous lamina can withstand great strain. The inner layer of the articular capsule (lamina synovial) is formed by the synovial membrane which secretes synovial fluid (synovia) into the joint space. The articular ends of the bone become enlarged and have a thin but dense outer layer of bone (compacta), within which there is a network of spongiosa bone. This knee joint capsule includes fibrous tissue which is vascular so that if an injury is difficult the healing process a. Articular cartilage /cartilage Most adult joints are of the hyaline cartilage type and are the vascular, alymphatic, and aneural tissues that cover the joint surfaces of the long bones. Attached to the subchondral bone. The function of cartilage is to cushion the bony covering in synovial joints, which allows:3,

• Withstanding pressure on the joint surface.
• Transmits and distributes increased loads.
• Maintains contact with minimal frictional resistance. b. Exchange Bursa is a bag filled with fluid that functions to prevent direct friction, maybe muscle to muscle, muscle to bone and muscle to skin. There are several bursae found in the knee joint, including: (1) popliteus bursa (2) suprapatellaris bursa (3) infrapatellar bursa (4) prepatellar subcutaneous bursa (5) subpatellaris bursa. 5. Meniscus The meniscus is a soft tissue, the meniscus in the knee joint is the lateral meniscus. The functions of the meniscus are (1) spreading the load (2) shock absorbers (3) facilitating rotational movements (4) reducing movement and stabilizers. Each pressure will be absorbed by the meniscus and passed on to a joint.

D. Etiology Until now, the exact cause of knee OA is not known, but there are several risk factors associated with knee osteoarthritis.

1. Age The most important risk factor for OA is age, usually from young adults to the elderly, but often over 50 years of age. With increasing age there will be a decrease in cartilage volume, proteoglycan content, cartilage vascularization, and cartilage perfusion. These changes can cause characteristic changes that can be found on radiology, including thinning of the joint space, and the appearance of ostheocytes. The prevalence and severity of OA will increase with age, but OA does not only occur as a result of increasing age, but can also occur due to changes in joint cartilage.
2. Gender The prevalence of OA is higher in women compared to men, 3.2% : 3%. This is associated with changes in postmenopausal women's hormones
3. Hereditary Factor Mutations in the procollagen gene or other structural genes for joint cartilage elements such as collagen and proteoglycans play a role in the emergence of a familial tendency in OA.^8
4. Obesity Obesity is a modifiable risk factor for OA. Obesity increases the mechanical stress on the joints on which the body rests. This is closely related to OA in the knees and in the lowest part of the hip. A study evaluating the association between body mass index (BMI) over 14 years and knee pain at 15 years in 594 women found that a high BMI at 1 year and a significant increase in BMI over 15 years were predictors of knee pain overall. bilateral at year 15.
5. traumatized

Hip joint injury will cause reticular changes in the joint so that it has an impact on the incidence of OA disease. In addition, heavy work will determine the severity of OA experienced

6. Physical Activity Heavy physical activity/weight bearing such as standing for a long time (2 hours or more per day), walking long distances (2 hours or more per day), lifting heavy objects (10 kg – 50 kg for 10 or more times per week), pushing heavy objects (10 kg – 50 kg for 10 or more times per week), going up and down stairs every day are risk factors for knee OA. E. Clinical Signs and Symptoms Symptoms that are commonly complained of by patients include: 1,8,
7. Joint pain : This complaint is the main complaint that often brings patients to the doctor. Pain usually increases with movement or certain activities and slightly relieved by rest. Certain movements sometimes cause more intense pain than other movements.
8. Barriers to joint movement : this disorder usually gets worse slowly in line with increasing pain.
9. Stiff in the morning : in some patients, joint pain or stiffness may occur after immobility, such as sitting in a chair or car for a long time or even after waking up (for < 30 minutes).
10. Crepitation : a grinding (sometimes audible) feeling in the affected joint.
11. Joint enlargement (deformity) : the patient may indicate that one of his joints (often seen in the knee or hand) is slowly enlarging.
12. Gait change : almost all patients with OA ankle, heel, knee or hip develop a limp and is a symptom that bothers the patient.
13. Other muscle pain of the musculoskeletal system.
14. Fatigue. F. Diagnosis The diagnosis of OA is established by history taking, physical examination of the affected joint, checking for swelling and measuring the limits of joint

Figure 6. Local examination of the knee joint 8 (a) Fluctuation test to see if there is fluid in the knee; (b) Palpation of the lateral line of the joint in a patient with knee OA. Figure 7. Knee Joint ROM 8 Flexion and extension. (^) Internal and external rotation cannot be performed during extension. In 90° of knee flexion with the lower leg hanging freely, the knee exhibits a ROM from 10◦ in internal rotation to 25◦ in external rotation. Provocation tests that can be done to check the knee joint: a. McMurray test This test is an examination to reveal meniscal lesions. In this test, the patient lies on his back with one hand holding the examiner's heel and the other hand holding the knee. The leg is then bent at the knee joint. The lower limb exrotates/endrotates and is slowly extended. If you hear a "click" sound or you can feel it when the knee is

straightened, then the medial meniscus or its posterior part may be torn. Figure 8. McMurray Examination b. Anterior Drawer Test This is a test to detect rupture of the anterior cruciate ligament of the knee. The patient must be in a supine position with the hips flexed 45˚, knees flexed 90˚ and both feet parallel. You do this by moving the tibia upward, there will be a hyperextension movement of the knee joint and the knee joint will feel loose. The examiner's position is in front of the patient's feet. If pushed more than normal (> 5 mm), it means a positive drawer test Figure 9. Anterior Drawer Test Examination 14 c. Posterior Drawer Test Posterior Drawer Test the same as the Anterior Drawer Test, only holding the tibia and then pushing it backwards Figure 10. Examination of the Posterior Drawer Test 14 d. Lachman test Lachman test performed by placing the knee in a flexed position at

the lower leg in and out and fix it. If there is pain in the exorrotation and endorotation distractions, then this is caused by a lesion in the ligament Figure 13. Examination of the Appley Distraction Test 14 g. Test for Medial Stability This test is to assess the instability of the medial collateral ligament. The patient lies supine with the knees fully extended. Grasp the lower leg with one hand placed on the posterior lateral knee and force the distal lower leg laterally. Create valgus forces on the knee and pressure on the medial collateral ligament. The maneuver is performed at 0° and 30° knee flexion. Positive test if pain and/or increased separation at the medial joint line Figure 14. Test for Medial Stability 12 h. Test for lateral stability This test is to assess the instability of the lateral collateral ligament. The patient is in a supine supine position with the knee fully extended. Grasp the lower leg with one hand placed on the posterior

medial knee while forcing the distal lower leg medially. Create varus on the knee and stress on the lateral collateral ligaments. The maneuver is performed at 0° and 30° knee flexion. The test is positive if there is pain and/or increased space at the lateral joint line Figure 15. Test for lateral stability Supporting investigation

1. Radiological Examination A simple investigation that is often performed in OA cases is a radiological examination of the AP/lateral genu in a standing position. Typical features of knee OA are the presence of osteophytes & joint space narrowing. 1,15 The degree of joint damage is based on radiological features based on Kellgren & Lawrence criteria. 16 (A) (B) (C) (d) Figure 16. Kellgren and Lawrence criteria Grade 0: Normal radiology.

• Improve quality of life Management of medical rehabilitation in patients with knee OA includes:

1. KFR specialist The doctor who performs the KFR examination, makes a diagnosis and determines a medical rehabilitation program.
2. Physiotherapy a. Cold Therapy Cold therapy is used to improve blood circulation, reduce inflammation, reduce muscle spasms and joint stiffness so as to reduce pain. Can also use compressed ice on painful joints. Cold therapy techniques, namely ice massage by rubbing ice directly on the treated area for 5-7 minutes, ice compresses for 15-20 minutes, cold compresses (vapocoolant spray) for example with chlorethyl spray, especially for muscle spasms and MTPS (Myofascial Trigger Point Syndrome). ).12, b. Heat Therapy Heat therapy can be divided into 2 types, namely superficial heat therapy and deep heat therapy. Superficial heat therapy, namely heat only affects the cutis or subcutis tissue (hot packs, infrared, warm water compresses, paraffin baths). Deep heat therapy, heat can penetrate deeper into the tissues, to the muscles, bones and joints

1. Microwave diathermy (MWD) Is a therapy using a wavelength between infrared waves and short wave diathermic. The heat obtained from these waves can be used to reduce pain. Diathermy waves are obtained by heating a device called a magnetron. The output is transmitted to a small channel and microwaves are emitted with a frequency of 2,450 cycles/second with a wavelength of 12.25 cm. This therapy is suitable for pain, bacterial infections, and abscesses. The benefit of this therapy is to increase the body's defense system and help relaxation

2. Short wave diathermy (SWD) It is a therapy using electric current with a frequency of 27,120,000 cycles/second with a wavelength of 11 meters. The application method used is the condenser field method and cable method. This method is suitable for use to treat inflammation of shoulder joint pain, elbow joint, cervical degeneration, OA, ligament sprains, low back pain, pain in the heel (plantar fascitis) and sinusitis.
3. Ultra sound diathermy (USD). Is a therapy using sound waves with a frequency of 500,000 to 3,000,000 cycles/second. Ultra sound is produced by the vibrations of certain crystals. In the early stages, the ultrasound application is carried out for 3 to 4 minutes, while in the advanced stages, it is carried out for 6 to 8 minutes. This therapy is suitable for elbow inflammation (tennis elbow), plantar pain (plantar fascitis), muscle and ligament shortening, tendon inflammation, ligament sprains, and chronic wounds. The benefit of this therapy is to relieve pain and speed up wound healing. In the case of OA USD (ultra sound diathermy) is used. 13, c. Electrical Therapy TENS (Transcutaneous Electrical Nerve Stimulation)is a modality used to reduce or eliminate pain. TENS is most often used for acute pain and can also be used for chronic pain. The use of electrical therapy is based on the gate control theory of Melzack and Wall, where large diameter skin nerve fibers are stimulated by TENS and this stimulation mechanism inhibits the transmission of pain stimuli to the spinal cord. The next theory says that TENS works by stimulating endorphins and endogenous opiates d. Hydrotherapy Hydrotherapy is a physical therapy by utilizing the physical properties of water. Using water therapy helps someone heal. The