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Arthritis

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Abstract

For the purposes of this manual, the term ‘arthritis’ is used to bring together the diagnosis and management of the disease processes involved in three main categories of joint disease: namely osteoarthritis, immune-mediated polyarthritis and infective arthritis. This chapter describes the classification, pathology, clinical presentation, diagnosis, treatment and prognosis of arthritis.

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Figures

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6.2 Total hip replacement with meticillin-resistant (MRSA) infection affecting the femoral component. The continuous radiolucent zone at the femoral cement–bone interface indicates implant loosening. This case was successfully managed with the extraction of the implants, application of a gentamicin-impregnated collagen preparation (Collatemp EG) within the femoral canal and systemic antibiotics.
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6.3 Infected stifle joint following surgery for cranial cruciate ligament disease. The region around and cranial to the left stifle exhibits swelling, erythema and discharge.
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6.5 Mediolateral view of the stifle of a dog with septic arthritis showing considerable soft tissue swelling/joint effusion and moderate degenerative joint disease.
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6.6 Mediolateral view of the stifle of a dog with septic arthritis following surgery for cranial cruciate rupture managed with an intra-articular graft and bone tunnels. The radiograph shows considerable soft tissue thickening/joint effusion, moderate subchondral bone erosion and widening of the bone tunnels.
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6.7 Mediolateral view of the stifle of a dog with septic arthritis following tibial plateau levelling osteotomy surgery for cranial cruciate ligament rupture. The radiograph shows moderate soft tissue thickening/joint effusion, including in the region of the patellar tendon, and subtle periosteal new bone on the cranial aspect of the tibial tuberosity (intra-articular and extra-articular changes).
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6.8 Mediolateral view of the stifle of a dog with septic arthritis and cranial cruciate ligament rupture. The radiograph shows moderate to marked soft tissue thickening/joint effusion without significant skeletal degenerative changes.
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6.10 (a) Synovial fluid from a stifle with degenerative joint disease. Note that the fluid is slightly yellow and transparent. (b) Synovial fluid from a septic stifle. Note that the fluid is discoloured, cloudy and opaque.
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6.11 Synovial fluid showing (a) intracellular bacterial cocci (arrowed) and (b) intracellular bacterial rods (arrowed). The presence of these organisms confirms the diagnosis of septic arthritis. (Wright–Giemsa stain, original magnification X)
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6.12 Blood culture medium used to culture synovial fluid. This is the best technique to minimize the likelihood of a false-negative result.
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6.13 Aseptic synovial arthrocentesis technique. The skin should be prepared and normal standards of surgical asepsis observed to prevent the introduction of infection. A sterile technique should be used and sterile gloves worn. Surgical drapes could also be considered.
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6.14 Flushing of a joint. The inflow needle has been placed proximolateral to the patella and the egress needle is distomedial.
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6.15 Surgical debridement and placement of drains. Use of drains requires considerable care and attention. Sterility of the drains post surgery must be assured and ensured.
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6.16 (a) Gentamicin-impregnated polymethylmethacrylate (PMME) beads are commercially available. Each bead contains 7.5 mg of gentamicin sulphate. Kits are available to make similar beads at the time of surgery. (b) Mediolateral view of the stifle of a dog with septic arthritis being treated with surgically implanted gentamicin-impregnated PMME beads. The beads require removal once the infection has resolved.
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6.17 Gentamicin-impregnated collagen sponge being inserted into an infected stifle joint. The collagen is broken down and resorbed within 1–7 weeks following implantation and therefore does not require surgical removal. (Courtesy of Dr M Owen)
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6.18 Cellular ‘cross-talk’ in osteoarthritis. COX = cyclo-oxygenase; IL = interleukin; iNOS = inducible nitric oxide synthase; MMP = matrix metalloproteinase; NO = nitric oxide; TIMP = tissue inhibitor of metalloproteinase; TNFα = tumour necrosis factor α.Osteoarthritis is usually not a diagnosis of sufficient accuracy in canine orthopaedics because the disease is usually the result of some other primary joint abnormality (e.g. instability, laxity, fracture). The clinician should seek to identify why a joint has osteoarthritis
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6.19 Staging osteoarthritis can help to guide the clinician with disease management. (Redrawn after )
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6.25 The diagnostic pathway and classification of immune-mediated arthritides. ANA = antinuclear antibody; CSF = cerebrospinal fluid; IMA = immune-mediated arthritis; IMPA = immune-mediated polyarthritis; RF = rheumatoid factor.
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6.26 (a) Mediolateral view of the tarsus and pes of a 1-year-old crossbreed dog with an erosive arthopathy. Note the extensive soft tissue swelling (white arrows), periarticular new bone formation and joint destruction at all joints (arrowheads) with subluxation of the proximal intertarsal joint (red arrow). In particular, note the erosive changes in the distal joints (yellow arrow). (b) Mediolateral view of the tarsus and pes of a 6-year-old Cocker Spaniel with type I IMPA. Note the subtle periarticular soft tissue swelling (yellow arrow) and new bone formation (arrowhead) on the dorsal aspect of the talus.
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6.27 Dorsoplantar view of the tarsus of a cat with the non-erosive form of FCPP. There is periarticular new bone formation but no evidence of erosion. Symmetrical changes were present in the contralateral limb.
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6.29 A simplified treatment algorithm for immune-mediated arthritides. Note that treatment decisions on re-evaluation of patients treated with immunosuppressive agents must also be influenced by the potential side effects of the agents used. The suggestions are guidelines; the duration of treatment and time to taper doses need to be gauged on an individual basis.

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