osteoarthritis

Question 1

OA:DEFINITION + PATHOPHYSIOLOGY - is it inflammatory?

Answer 1

Previously thought to be a normal consequence of aging, hence the term DJD.
It is a slowly progressive NON-INFLAMMATORY disease of the synovial joints.
It involves the formation of new joint tissue in response to cartilage destruction.
OA affects about 21 million and the incidence is thought to increase as the population ages.

Question 2

when does cartilage destruction begin?

Answer 2

Biomechanical, metabolic, hormonal and genetic factors contribute to the progressive erosion of the articular cartilage in joints.
cartilage destruction starts begins 20-30s with the majority affected by 40s

Question 3

OA : TYPES

Answer 3

OA is subdivided by etiology into:
Idiopathic ( primary): no known cause
Secondary: OA is directly caused by a known condition

Question 4

JOINT CHANGES IN OA (know this) (soft narrow bone spurs pit and ulcer)

Answer 4

In DJD (degenerative joint disease) the articular cartilage becomes soft, yellow, and thin
Joint space narrows and osteophytes (bone spurs) form.
Fissures, pitting, and ulcers and synovitis develop
Cartilage and bone erodes

Question 5

OA: CLINICAL MANIFESTATION - systemic symptoms?

Answer 5

SYSTEMIC SYMPTOMS:
NONE.There is no fatigue, fever or organ involvement as seen in Rheumatoid.
Pain, swelling, point tenderness in one or more joints.

Question 6

OA: DIAGNOSTICS - A clinical DX of OA is supported by

Answer 6

Typical symptoms
Physical exam
Labs to R/O other causes: RA factor, ESR, Anti-CCP

Question 7

OA :COLLABORATIVE CARE

Answer 7

NO SPECIFIC TREATMENT FOR DJD/OA
Usually confined to a few joints
Generally not crippling
Treatment:
Anti-inflammatory meds
Analgesics
Weight control
Canes, walkers, splints
If joint destruction extensive and pain severe
TJR (total joint replacement) surgery is an option

Question 8

OA: PHARMACOLOGIC THERAPY (miso for osteo)

Answer 8

Acetaminophen
Topical capsaicin
NSAID
Combination drug of Misoprostol +NSAID
Intra-articular injection of corticosteroids

Question 9

TJR (Total joint replacement)
ARTHROPLASTY - is it successful?

Answer 9

INDICATIONS
Last resort for pts with unbearable pain and limitation
Over all TJR’s are quite successful
Hips and Knees, fingers, wrists, elbows, ankles

Question 10

Hip is the most commonly replaced joint

Answer 10

TOTAL HIP REPLACEMENT (THR)
THR PRE-OP Teaching
Teach patient about what to expect post-operatively

Question 11

Total Hip Intra-Operative Procedure (dirty hip)

Answer 11

Patients typically go early in morning, before “dirty” OR procedures
IV antibiotic prophylaxis, stay on if pt comes out with a drain
Prosthesis
Cemented (vs) Noncemented
Cemented prosthesis
Deteriorates in about 10 yrs
Non Cemented last for life

Question 12

POSSIBLE POST-OP COMPLICATIONS -

Answer 12

Thromboembolic disease:
Without thromboprophylaxis, peri-op mortality from PE occurs 2-3 %
With thromboprophyaxis , there is a 0.01% post-op fatal PE at 90 days postop.
Infection: incidence in primary THR 1%
Dislocation: incidence ranges from 0-2 %
Majority occurs posteriorily typically with flexion and adduction and internal rotation of the limb
Implant failure and fracture
Leg length discrepancy: number # reason for law suits against orthopedic surgeons performing THR

Question 13

PREVENTION OF DISLOCATION - position of legs?

Answer 13

Correct positioning
at ALL times post- op.
Abduction of legs (don’t cross)
Turning the patient
check with the surgeon’s
orders.

Question 14

PREVENTION OF HIP DISLOCATION - bathtubs or driving for how long?

Answer 14

Prevent Hip Flexion
Elevated toilet seats
NO tub baths or driving a car for 4 –6 wks.
Reach bars, long-handled shoehorns, sock pullers

Physical Therapy initiated post-op day 0

Question 15


PREVENTION OF POST-OP INFECTION AFTER THR

Answer 15

Surgery before “dirty” cases in OR
Prophylactic antibiotics
Monitor for S&S of infection
Fever
WBC’s
Foul discharge
Redness and swelling
pain

Question 16

ASSESSMENT FOR BLEEDING S/P THR - how much drainage?

Answer 16

RPOVS (routine post op VS)
Dressing and drains
Duvall, JP (Jackson Pratt), Hemovac, Penrose
Drainage is usually < 50 ml every 8 hours
Check hip for hematoma

Question 17

DJD/OA ASSESSMENTS S/P THR continued - the Ps

Answer 17

NEUROVASCULAR

CSM (color/sensation/motion)
Pain, Parasthesias, Pallor, Pulses, Paralysis

Question 18

PREVENTION OF DVT (love preventing DVT)

Answer 18

Risk for DVT is high ( incidence as high as 70% and as low as 8%)
Anticoagulants (Lovenox)
Physical Therapy ASAP
TEDS (anti-embolitic stockings)
SCD: (sequential compression device) on non-operative leg, both if patient can tolerate

Question 19

PAIN MANAGEMENT S/P TOTAL HIP REPLACEMENT

Answer 19

Pain is usually less than prior to surgery
Usually can DC parenteral meds on POD 1 pending patient tolerance, always advocate for a good oral pain med regimen early

Question 20

OA - heberden (herb on top)

Answer 20

on top

Question 21

bouchards (b bottom)

Answer 21

on bottom

Question 22

what drugs cause OA (Ind OA w/ Colt)

Answer 22

Indocin (NSAID), Colchicine

Question 23

OA symptoms - worse with activity or rest?

Answer 23

Pain tends to worsen with joint use and relieved with rest . With advanced disease, pain at rest/sleep/ cold weather

Question 24

OA symptoms - morning stiffness

Answer 24

↓ flexibility: early morning stiffness (common), typically resolves in 30 min or less, more common w/ advanced OA
Possible bony growths in joints (Heberdens)
Crepitus

Question 25

most common places in body for OA (arthur hands)

Answer 25

Hips and knees, the vertebral column, and the hands are primarily affected.

Question 26

OA diagnostics - imaging

Answer 26

Xray: narrowing of joint space+ osteophyte (lump around joint) due to bone remodeling

Question 27

CONTRAINDICATIONS to TJR (total joint replacement)

Answer 27

Infection anywhere in the body (can lead to infected joint)
Advanced osteoporosis (prosthesis insertion can shatter bone)

Question 28

total hip replacement - cough?

Answer 28

TCDB (turn, cough, deep breath)
RPOVS (routine post op vital signs)
ICS (Incentive- spirometer)

Question 29

total hip replacement - compression device?

Answer 29

SCD (sequential compression device)
Discuss pain relief methods (PCA, injections….)
Abduction pillows and splints

Question 30

total hip replacement - bathroom?

Answer 30

Use of bedpan and high bedside commode

Question 31

OA diagnosis - Arthrocentesis- to evaluate what? (arthritis centisis)

Answer 31

to evaluate synovial fluid: minimally inflammatory or non-inflmmatory process.

Question 32

secondary OA causes

Answer 32

Trauma
Mechanical stress: sports,
Congenital disorders
Hematological / endocrine disorders (hemophilia)
Drugs