Rheumatology

Avascular Necrosis (AVN), also known as osteonecrosis, is a condition in which bone tissue dies due to reduced or interrupted blood supply. Over time, the affected bone may weaken or collapse and cause joint dysfunction, leading to pain and limited mobility. It often affects weight-bearing joints like the hips, knees, and shoulders but can occur in any bone. This condition requires timely diagnosis and treatment to prevent complications and improve quality of life. This comprehensive guide will explore osteonecrosis in depth, including its symptoms, causes, diagnostic methods, treatment options, and ways to reduce risk. Avascular Necrosis (AVN or Osteonecrosis) condition is often classified into two categories: Traumatic Avascular Necrosis: Caused by physical injury, such as fractures or dislocations that impair blood supply. Non-Traumatic Avascular Necrosis: Arises from other factors like steroid use, alcohol abuse, or medical conditions affecting blood flow. Avascular Necrosis (AVN or Osteonecrosis) Symptoms Symptoms of avascular necrosis depend on the stage of the disease and the affected joint. They may start subtly and progress over time. Early-Stage Symptoms of Avascular Necrosis (AVN or Osteonecrosis) Mild Pain: Initial discomfort may be felt during weight-bearing activities like walking or running. The pain usually subsides with rest. Joint Stiffness: Affected joints may feel tight or less flexible, particularly in the morning or after periods of inactivity. Limited Range of Motion: Difficulty bending, rotating, or fully extending the joint. Advanced Symptoms of Avascular Necrosis (AVN or Osteonecrosis) Persistent Pain: As the condition worsens, pain becomes constant and may occur even when the joint is at rest. Swelling: Inflammation around the joint may lead to visible swelling. Bone Collapse: The affected bone weakens, causing deformities and joint instability. Joint Dysfunction: Movement becomes difficult, severely impacting daily activities and quality of life. Avascular Necrosis (AVN or Osteonecrosis) Causes Osteonecrosis (avascular necrosis) results from reduced blood flow to the bone. Several factors can contribute to this condition: Traumatic Avascular Necrosis Causes Bone Fractures or Joint Dislocations: Physical injuries can damage nearby blood vessels, cutting off the blood supply to the bone. Non-Traumatic Avascular Necrosis Causes Prolonged Steroid Use: Corticosteroids can form fatty deposits in blood vessels, obstructing blood flow. Alcohol Intake: Excessive drinking increases fat levels in the blood, contributing to blockages. Fatty Deposits in Blood Vessels: Cholesterol buildup can narrow or block vessels supplying blood to the bone. Medical Conditions: Diseases such as lupus, sickle cell anaemia, diabetes, and HIV/AIDS affect circulation and increase risk. Avascular Necrosis (AVN or Osteonecrosis) Diagnosis Early diagnosis is critical to preventing bone collapse and joint damage. The diagnostic process includes: Clinical Examination A healthcare provider evaluates symptoms such as pain, stiffness, and limited range of motion. They may ask about risk factors, medical history, and recent injuries. Imaging Tests X-rays: Useful in advanced stages to detect bone damage or collapse. MRI (Magnetic Resonance Imaging): The most sensitive test for early detection, capable of identifying changes in bone marrow before structural damage occurs. CT Scans (Computed Tomography): Provide detailed cross-sectional images showing the extent of bone damage. Bone Scans: Use radioactive tracers to highlight areas of reduced blood flow in the bone. Avascular Necrosis (AVN or Osteonecrosis) Treatment The treatment approach depends on the severity of the disease and the patient’s overall health. Non-Surgical Treatments for Avascular Necrosis (AVN or Osteonecrosis) Medications Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Relieve pain and reduce inflammation. Bone-Strengthening Drugs: Bisphosphonates slow bone damage and improve density. Blood Thinners: Prevent clots and improve blood flow. Physical Therapy: Gentle exercises strengthen muscles around the joint and improve mobility. Electrical Stimulation: Enhances bone repair by stimulating new bone growth. Surgical Treatments for Avascular Necrosis (AVN or Osteonecrosis) Core Decompression: This involves removing a part of the inner bone to reduce pressure and improve blood flow. Bone Grafting: Replaces damaged bone with healthy tissue from another site. Osteotomy: Reshapes the bone to redistribute weight and reduce stress on the affected area. Joint Replacement: In advanced cases, replacing the affected joint with an artificial one restores function. Regenerative Medicine: Stem cell therapy and other innovative treatments aim to repair damaged tissue and stimulate bone growth. Risk Factors of Avascular Necrosis (AVN or Osteonecrosis)  Certain factors increase the likelihood of developing avascular necrosis: Lifestyle Factors: Smoking, obesity, and excessive alcohol consumption impair blood flow. Medications: Long-term corticosteroid use is a significant risk factor. Chronic Conditions: Sickle cell anaemia, lupus, and diabetes affect circulation and bone health. Trauma: Fractures or joint injuries that damage blood vessels can trigger the condition. Complications of Avascular Necrosis (AVN or Osteonecrosis) If left untreated, avascular necrosis (osteonecrosis) can lead to: Bone Collapse: Structural weakening causes deformities and severe pain. Arthritis: Cartilage damage results in joint inflammation and dysfunction. Chronic Pain: Persistent discomfort affects daily life and emotional well-being. Prevention of Avascular Necrosis (AVN or Osteonecrosis) While some risk factors cannot be eliminated, certain measures can help reduce the likelihood of developing osteonecrosis: Limit Alcohol Consumption: Avoid excessive drinking to prevent fatty deposits in blood vessels. Quit Smoking: Smoking reduces blood flow and delays healing. Monitor Steroid Use: Use corticosteroids only under medical supervision and for the shortest duration possible. Maintain a Healthy Lifestyle: Regular exercise, a balanced diet, and managing cholesterol levels support overall bone health. Early Diagnosis: Seek medical attention for persistent joint pain or stiffness to detect and address issues early. Outlook Avascular necrosis is a serious but manageable condition. With early diagnosis, appropriate treatment, and lifestyle modifications, patients can maintain joint function and improve their quality of life. If you experience joint pain or stiffness, consult a healthcare professional for a thorough evaluation and personalised care plan. Frequently Asked Questions 1. Who is at risk of developing Avascular Necrosis (AVN or Osteonecrosis)? People who use steroids long-term, consume excessive alcohol or have chronic diseases like lupus or sickle cell anaemia are at higher risk. 2. Can osteonecrosis be prevented? While not all cases are preventable, lifestyle changes like limiting alcohol, quitting smoking, and managing risk factors can reduce risk. 3. What are the complications of untreated osteonecrosis? Untreated osteonecrosis can lead to bone collapse, arthritis, and chronic pain, significantly affecting quality of life. 4. What type of doctor treats Avascular Necrosis (AVN or Osteonecrosis)? Orthopaedic specialists are the primary doctors treating avascular necrosis (osteonecrosis). In some cases, vascular or rehabilitation specialists may also be involved. 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Gout is a clinical manifestation of inflammatory arthritis that produces pain and swelling in different joints in the body. The symptoms occur in flares that last a week or two before disappearing. Alternate Name of Gout Gouty Arthritis Associated Anatomy of Gout Several joints (Big toe, ankle, knee, lesser toe joints) Sacs that act as a cushion and connect soft tissues and bones (Bursae) Membranes surrounding tendons offer protection (Tendon sheaths) Kidneys (High uric acid can induce stone formation damaging the kidney). Types of Gout NA Gout Causes High uric acid (Some with high uric acid may remain asymptomatic) Family history of gout, consuming foods (mostly animal proteins) rich in purines (purine breaks down to urate) and fructose, sweetened drinks, alcohol, etc. Gout Symptoms Gout symptoms frequently start in the big toe (metatarsophalangeal joint) or a lower part of the leg. Gout develops when serum uric acid levels are high causing needle-shaped crystals to grow in and around the joints. As a result, the joint becomes inflamed and arthritic. Symptoms of the affected joints are as follows Intense pain Swelling Redness Heat These symptoms alternate between sudden flare and remission. Generally, symptoms of the joints are unilateral, which usually affects one joint. Gout Diagnosis Physical examination Examining the affected joints for swelling, erythema, edema, etc. Laboratory test Checking the serum uric acid level Ultrasound Evaluating crystal deposition and other underlying causes Microscopy Aspired liquid from joints can be examined under the microscope to find urate crystals. Differential Diagnosis of Gout Pseudogout (calcium pyrophosphate deposition) Rheumatoid Arthritis Psoriatic Arthritis Palindromic Rheumatism Reactive Arthritis. Stages of Gout The progression of gout is separated into four phases: Asymptomatic hyperuricemia High uric acid without gouty arthritis. Acute gouty arthritis Onset and flares of pain, restricted range of motion, swelling, erythema, and swelling of the involved joint. Intercritical gout A period between remission and recurrence when the secondary causes of hyperuricemia and prevention must be addressed. Chronic tophaceous gout Deposition of sodium urate crystals (tophi) under the skin. Gout Treatment Gout is managed both by medication and lifestyle modification. Medication Flares can be managed by nonsteroidal anti-inflammatory drugs (NSAIDs) (eg., ibuprofen), anti-inflammatory drugs (eg., colchicine), steroids, and uric acid lowering drugs (febuxostat, allopurinol, and pegloticase). Lifestyle changes Weight loss, dietary modification, less alcohol consumption, avoiding purine-rich food (e.g., red meat), and stopping medications associated with hyperuricemia (like diuretics). Prevention Follow-up with a physician to prevent the formation of tophi (uric acid crystals under the skin) and kidney stones. Risk Factor of Gout Age: People at an older age are at increased risk. Younger people rarely have gout, but they have a severe form. Gender: Gout is three to four times as prevalent among males than females. Family history Lifestyle: Alcohol consumption, eating a high-purine, high-fructose diet increase risk of gout. Heavy metal exposure: Research showed an association between chronic lead exposure and the risk of gout. Medications: Certain medications, such as diuretics, salicylate-containing drugs, cyclosporine, niacin in excess, and a low dose of aspirin, elevate the uric acid level. Obesity: Being overweight and having high levels of body fat may increase the risk of gout. Other comorbidities: Some common health conditions increase the risk of gout, which are as follows Renal impairment/kidney stone Hypertension Diabetes Abnormal cell proliferating conditions, such as hemolytic anemia, psoriasis, and certain types of cancers Kelley-Seegmiller syndrome or Lesch-Nyhan syndrome (Deficient in enzyme regulating urate level). Complication of Gout Without treatment, gout can lead to several complications as follows Chronic gout Obliteration of the joint surface, joint deformity Painless tophi (in the helix of the ear, over the large, thick, protruding part of the ulna, or on the heel cord) Kidney stones and other kidney dysfunctions Gout Preventions Primary Prevention of Gout Gout can be prevented by following some management protocols: Limiting alcohol intake Avoiding purine-rich food (red meat, organ meat, codfish, shellfish, etc.) Consuming a non-dairy, low-fat diet Maintaining permissible BMI Stop smoking Daily workout Staying hydrated Secondary Prevention of Gout After remission from arthritic pain, uric acid lowering drugs should be taken and secondary causes of hyperuricemia must be addressed. Epidemiology of Gout One to two percent of men in the western world are affected by gout. The prevalence of gout is 0.12% in India. Gout develops at a higher rate in men and rarely occurs in premenopausal women. Expected Prognosis of Gout An acute gout episode normally disappears in five to seven days without any clinical attention. However, 60% of patients experience a recurrence within a year. Gout patients are more likely to develop other metabolic diseases, such as hypertension and diabetes. Along with metabolic syndromes, renal disease and cardiovascular disease increases mortality. Natural Progression of Gout If not treated and allowed to progress naturally, gout can lead to erosion and destruction of the affected joint. It may cause the formation of urate crystal deposits under the skin. Pathophysiology of Gout Uric acid accumulates and crystalizes in an aberrant purine metabolism causing gout. The crystal in monosodium urate form precipitates creating deposits (tophi) in joints, tendons, and surrounding tissues. Crystal protected by proteinaceous sheath prevents contact with cells and thereby prevents inflammation. Minor joint trauma, medical or surgical stress, or sudden fluctuations in uric acid levels might cause naked crystals to burst out of protein-protected tophi. They cause a local immune-mediated inflammatory response causing major symptoms of gout, such as pain, erythema, and swelling. Related Blogs Painful Joints - Symptoms, Causes, Management and Prevention Tips Foot Pain: Common Reasons and Solutions Understanding Blood Cancer & Its Symptoms Understanding Kidney Stone Causes and Key Prevention Strategies What to Expect After Your Knee Replacement Surgery Common Causes Of Acute Liver Failure You Need To Know

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Rheumatoid arthritis (RA) is an autoimmune condition that involves the immune system attacking the joints and causing inflammation in the lining (the synovium) of the joints. Associated Anatomy of Rheumatoid Arthritis Joints on both sides of the body; can involve any of them: Hands Knees Wrists Fingers Ankles Feet Toes Eventually, RA may affect other parts of the body, such as the eyes, heart, lungs, skin, and blood vessels. Alternative Names of Rheumatoid Arthritis Rheumatoid arthritis is known as RA or referred to as rheumatism. Types of Rheumatoid Arthritis Some additional types of RA include: Seropositive RA: When blood tests are positive for RF or rheumatoid factor, suggesting immune reaction to the tissues. Seronegative RA: If blood tests are negative for antibodies or RF you are seronegative, and need further examination to rule out RA. Juvenile RA: Type affecting children under 16 years of age. Rheumatoid Arthritis Causes The exact causes of RA have yet to be known. Researchers believe that a combination of genetic, hormonal, or environmental factors seems to trigger the immune system to attack the joints. As per some experts, viruses or bacteria modulate our immune system, making it attack our joints. Some others point out habits like smoking. Rheumatoid Arthritis Symptoms Some common symptoms that may be observed in RA include: Pain and swelling in joints Redness on joints Joints feel warm to touch Bumps or nodules under the skin (rheumatoid nodules) Stiffness, particularly in the mornings or after sitting for a long time. Fatigue and weakness Fever Stages of Rheumatoid Arthritis There are four stages of Rheumatoid arthritis: Stage 1: Early RA is characterized by some inflammation in the tissue around the joint(s), with some pain and stiffness. However, there are no evident changes in the bones on the X-ray. Stage 2: The inflammation starts to damage the cartilage in the joints, resulting in a decreased range of motion. Stage 3: Severe inflammation that damages the bones. It is likely to have more pain, stiffness, and further decreased range of motion and some physical changes. Stage 4: Although inflammation may not be evident, the joints keep deteriorating in this stage. You may experience severe pain, swelling, stiffness, and loss of mobility. Rheumatoid Arthritis Diagnosis The differential diagnosis of RA comprises: Fibromyalgia Lyme Disease Psoriatic Arthritis Myelodysplastic Syndrome (MDS) Osteoarthritis Reactive arthritis Paraneoplastic Syndromes Relapsing Polychondritis Polymyalgia Rheumatica Sarcoidosis Systemic Lupus Erythematosus (SLE) Sjogren Syndrome Typical Tests for Diagnosing RA There is no certain test to diagnose RA. It includes a combination of things like: Check up for location and symmetry of painful joints, specifically the hand joints, and the presence of nodules under the skin. Blood tests: To assess the number of red blood cells (usually low in RA), C-reactive protein (CRP) levels, Cyclic citrulline antibody test (anti-CCP), and Erythrocyte sedimentation rate (ESR). Rheumatoid factor (RF): Positive in 80% of people Antinuclear antibody test (ANA): This test detects the presence of autoimmune disease. X-ray Ultrasounds MRI scans Rheumatoid Arthritis Treatment Treatment options for Rheumatoid Arthritis comprise: Anti-inflammatory drugs like ibuprofen, aspirin, or naproxen Topical pain relievers Corticosteroids Pain relievers like acetaminophen (Tylenol) Some medications like disease-modifying antirheumatic drugs (DMARDs) Biologic response modifiers for severe cases of RA, where other medications don't help Adequate rest and exercise for joints. Surgery, if RA is very severe Lifestyle changes, occupational therapy Nutritious diet Risk Factors of Rheumatoid Arthritis RA is most likely to happen: If a person has a family history. Women are more likely to develop RA than men. Middle-aged are more likely to get RA. Smoking increases the risk of getting RA and can aggravate the condition. Obesity Possible Complications of Rheumatoid Arthritis RA may lead to several complications by affecting other organs and tissues like: Eyes: Dryness, pain, inflammation, and unclear vision Mouth: Dryness, infection, and gum inflammation. Skin: Rheumatoid nodules or lumps under the skin covering bony areas. Lungs: Inflammation and scarring may cause shortness of breath and lung disease. Blood vessels: Inflammation causing damage to the nerves, skin, and other organs. Blood: Reduced RBC count causing anemia Heart: Inflammation can affect the heart muscle and the associated areas. Painful joints: Reduced mobility of joints causes weight gain, making you likely to develop high cholesterol, diabetes, heart disease, and high blood pressure. Rheumatoid Arthritis Prevention Although it is difficult to prevent RA altogether, certain lifestyle changes can delay its onset and minimize its impact on the quality of life. Some preventive measures are: Quitting smoking Limiting alcohol intake Minimizing bone loss by ensuring a nutritious diet rich in calcium and vitamin D. Taking supplements for bone health if required. Improving oral health Maintaining healthy weight Staying active Taking early action if RA symptoms are observed. Epidemiology of Rheumatoid Arthritis More than 0.5 to 1% of adults (5 to 50 adults in 1 lakh people) are affected by RA every year. RA is 2.5 to 3 times more common in females than males; however, men show more severe symptoms than women. This condition primarily affects the middle-aged population, between 30 to 60 years of age. Some cases of RA are noted after people turn 60, known as later-onset rheumatoid arthritis (LORA). Although less common, even children or young adults (between 16 and 40 years) are likely to get this condition, which is called young-onset rheumatoid arthritis (YORA). RA is relatively rare in under-aged men. Expected Prognosis of Rheumatoid Arthritis Many effective medications and treatment approaches help reduce your pain and inflammation and slow down the progress of the disease. Early diagnosis and aggressive treatment play a vital role in the prognosis of RA. Pathophysiology of Rheumatoid Arthritis RA is a chronic inflammatory condition in which specific cells of the immune system mistakenly target the healthy body tissues, especially the cartilages, which act as a shock absorber in the joints. Unlike wear and tear damage of arthritis, RA affects the joints and tissues that line them (called synovium), causing severe inflammation, pain, and swelling in the joints eventually causing bone erosion and joint deformity. Natural Progression of Rheumatoid Arthritis The damage to cartilage resulting from uncontrolled inflammation in RA can cause a formation of a cushy layer of tissues to cover the end of the bones, resulting in deformation of the joints (misshapenness). It causes chronic or long-lasting pain and may further lead to a lack of balance (unsteadiness). Eventually, the bone erodes and can lead to fusion of the joint (an effort taken by the body to prevent constant irritation). Inflammation associated with RA can affect other body parts like skin, eyes, lungs, heart, and mouth, causing physical disability. Related Blogs How To Cure Rheumatoid Arthritis Permanently? Arthritis Diet: What to Eat And What To Avoid Painful Joints - Symptoms, Causes, Management and Prevention Tips A Knee for Knee Arthritis: Understanding Knee Replacement Surgery Knee Replacement Surgery - What To Expect & How to prepare for it? Basics of Back Pain: Reasons You Should be Aware

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