CASE PRESENTATION

July 25th, 2018

Secondary Osteoarthritis of the right hip joint

Presented By:
Fadlyansyah Farid, dr

Supervised by :
Rahmat Zulkarnain G., dr., Sp.KFR

Physical Medicine and Rehabilitation Department

Faculty of Medicine Padjadjaran University
Dr. Hasan Sadikin Central Hospital
Bandung
2018
 CASE REPORT

I. IDENTITY

Date of Examination : July 18th, 2018

Name : Mrs. J

Gender : Female

Age : 58 years old

Marital Status : Married

Occupation : Housewife

Education : Senior High School

Referral Diagnosis : Secondary Osteoarthritis of the right hip joint

Hospital Admission : July 10th , 2018

II. AUTOANAMNESIS

Chief complain :

Pain of the right hip joint

History of Present Illness :

Mrs. J felt pain at her right hip joint since 3 years ago, increase when she

walk. Because of her complained, she brought to bone setter. There was no

improvement so she brought to the hospital. In young age, she likes to

consume traditional herbs and medication from the store. She had no prior

compliants of pain and was mobilizing well without any aid. She was an
 active, independent woman. 1 years ago, she was operated with the same

complained on her left hip joint.

III. PHYSICAL EXAMINATION

General Physical Examination

Consciousness : Compos mentis, cooperative

Nutritional status : Body weight: 84 kilograms

Body height : 163 centimetres

Body Mass Index: 31,62

Vital signs : Blood Pressure : 120/80 mmHg

Pulse Rate : 82 bpm

Respiratory Rate : 22 times/minute

Temperature : afebrile

Head : Deformity (-), conjunctiva anemic -/-. Sclera icteric -/-

Lenses : clear +/+

Light reflex : +/+ (direct and indirect)

Eyeball movement : good to all direction

No pareses of cranial nerves

Neck : JVP is not elevated, enlargement of lymph nodes (-)

Thorax :

Lung : Vesicular breathing sound right = left, crackles -/-

wheezing -/-

Tactile Fremitus: right = left

 Percussion: sonor/sonor

Cor : ictus cordis not seen, low amplitude

Upper border: ICS III, left sternal line

Left border: ICS V, 2 cm lateral to left midclavicle line

Right border: ICV V, right sternal line

Normal heart sound S1-S2, murmur (-)

Chest expansion : 1.5 cm/ 1.5 cm/ 1 cm

Abdomen : liver and spleen are not palpable

Normal bowel sound

Ekstremities : Cyanosis (-), CRT <2’

Local Status

Right hip joint:

L : swelling -, Length Leg Discrepancy 1 cm.

F : Tenderness +, neurovascular in normal limit

M : ROM hip joint : Active Flexion 0-30 degree (limited due to pain)

Passive Flexion 0-45 degree (limited due to pain)

Active Abduction 0-10 degree (limited due to pain)

Passive Abduction 0-10 degree (limited due to pain)

Neuromuscular Status

Physiologic reflex : Normal

Pathologic reflex : None

 Sensory : Normal

Proprioception : Normal

Coordination : Normal

Functional Status

Communication : Normal

Mobilization : With wheel chair

Balance : Pain

IV. Supporting Medical Examination

Laboratorium finding
Hb/Ht/Leuko/Trombo : 13.9/39.8/7.38/222
PT/APTT/INR : 9.7/22.5/0.88
Ur/Cr/Ot/Pt : 24/0.74/24/28
X-ray

V. ASSESMENT
 Medical Diagnosis

Clinical Diagnosis : Secondary Osteoarthritis

Location Diagnosis : Right hip joint

Etiological Diagnosis : Degenerative

Treatment : Total hip Arthroplasty

Consult to Physical Medicine and Rehabilitation Department for pre op and

post op management

CASE DISCUSSION

Osteoarthritis (OA) is a chronic joint disorder in which there is progressive

softening and disintegration of articular cartilage accompanied by new growth of

cartilage and bone at the joint margins (osteophytes) and capsular fibrosis. In OA

there is damage of the joint cartilage, this caused pain and pain will cause

immobile with affected to disuse atrophy of muscle and bone, further more cause

instability of the joint.1

 In aging process, all tissue became less elastic / stiff, and if it is forced to

stress it may cause more damage and pain increases, because more immobile etc.

as a circulus vitiosis process .1

Figure 1. Articular cartilage loss

In figure 1, Gross superior view of a femoral head from a patient with

radiographic stage I OA. This shows an area of complete cartilage loss, with

polishing or eburnation of the underlying bone.2

Clinical features of OA such as1 :
1. Pain and tenderness :
a. Usually slow onset of discomfort, with gradual and intermitent increase
b. Poor correlation between symptoms and radiologic findings
c. Diffuse/ sharp and stabbing local pain
d. Originates in joint /periarticular soft tissue
2. Deformities
a. Soft tissue swelling ( mild synovitis or small effusions )
b. Osteophytes
c. Joint laxity
d. Asymmetrical joint destruction leading to angulation
3. Movement abnormalities
a. ‘Gelling’: stiffness after periods of inactivity, passes over within

minutes of using joint again

b. Coarse crepitus: palpate/hear
c. Reduced ROM: capsular thickening and bony changes in joint
Radiological features:
  Cartilage loss
 Subchondral sclerosis
 Cysts
 Osteophytes
 Extensive OA with complete loss of the joint space in a concentric

pattern and subchondral bone destruction (Figure 2.)

Figure 2. Loss of joint space in OA

The treatment goal is to return the patient to his or her pre-morbid status of

function. Increase in the average lifespan and improved medical facilities have

greatly increased the incidence of these disease.3

The treatment principles is education, physiotheraphy, aids and appliances,

medical treatment and surgical treatment. All indication must be include in the

treatment princiles. If the patient have pain that affecting work, sleep, walking and

leisure activities, it is the indication of the surgery.3,4

Important factors to consider in choosing any treatment modality are

intrinsic, age, general medical condition, type of OA, avability of the facilities and

socio-economic status.2,3
The vascular anatomy of the proximal femur plays a key role in

determining the optimal treatment modality, such that OA classification and

reporting should address the likelihood of vascular compromise. Intracapsular

often place the tenuous femoral head blood supply at particular risk for

compromise, thereby resulting in AVN.1,5

Post operative care
Goals of the treatment for 0-1week after surgery :
a. Allow soft tissue healing
b. Reduce pain, inflammation, and swelling
c. Increase motor control and strength
d. Increase independence with bed mobility, transfers, and gait
e. Educate patient regarding weight bearing
f. Patient to work toward full passive knee extension at 0 o and work toward

increasing flexion ROM to 900

 REFERRENCE

1. Solomon L, Warwick D.J and Nayagam S. Apleys system of

orthopaedics and fractures. 8th edition. New York : Oxford

University Press Inc. 2001.

2. Moore l, Keith, Dalley, Arthur F. Lower Limb in Clinically Oriented

Anatomy, 5th ed, Philadelphia : William & Wilkins, 2006 : 555-566.

3. Padang C: Improvement in Arthritis Therapy with Novel Drug

Delivery System, Dalam Simposium Rheumatologi Today, Bandung,

November 1994.

4. Sacks S. : Surgery for Arthritis, Arthritis today, The Journal

Assosiation Volume IX No.2, Johanesburg, South Africa, Desember

2012.

5. W. Muller, F. Schilling, K.L. Schmidt: Rheumatic Therapy in Medical

Practice, Part 3 Therapy of Individual Rheumatic Disease, Future

Aspect of Rheumatic Therapy, F Hoffman-La Roche Ltd., Switzerland,

120-121.