osteoarthritis Flashcards
OA:DEFINITION + PATHOPHYSIOLOGY - is it inflammatory?
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.
when does cartilage destruction begin?
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
OA : TYPES
OA is subdivided by etiology into:
Idiopathic ( primary): no known cause
Secondary: OA is directly caused by a known condition
JOINT CHANGES IN OA (know this) (soft narrow bone spurs pit and ulcer)
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
OA: CLINICAL MANIFESTATION - systemic symptoms?
SYSTEMIC SYMPTOMS:
NONE.There is no fatigue, fever or organ involvement as seen in Rheumatoid.
Pain, swelling, point tenderness in one or more joints.
OA: DIAGNOSTICS - A clinical DX of OA is supported by
Typical symptoms
Physical exam
Labs to R/O other causes: RA factor, ESR, Anti-CCP
OA :COLLABORATIVE CARE
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
OA: PHARMACOLOGIC THERAPY (miso for osteo)
Acetaminophen
Topical capsaicin
NSAID
Combination drug of Misoprostol +NSAID
Intra-articular injection of corticosteroids
TJR (Total joint replacement) ARTHROPLASTY - is it successful?
INDICATIONS
Last resort for pts with unbearable pain and limitation
Over all TJR’s are quite successful
Hips and Knees, fingers, wrists, elbows, ankles
Hip is the most commonly replaced joint
TOTAL HIP REPLACEMENT (THR)
THR PRE-OP Teaching
Teach patient about what to expect post-operatively
Total Hip Intra-Operative Procedure (dirty hip)
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
POSSIBLE POST-OP COMPLICATIONS -
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
PREVENTION OF DISLOCATION - position of legs?
Correct positioning
at ALL times post- op.
Abduction of legs (don’t cross)
Turning the patient
check with the surgeon’s
orders.
PREVENTION OF HIP DISLOCATION - bathtubs or driving for how long?
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
PREVENTION OF POST-OP INFECTION AFTER THR
Surgery before “dirty” cases in OR
Prophylactic antibiotics
Monitor for S&S of infection
Fever
WBC’s
Foul discharge
Redness and swelling
pain
ASSESSMENT FOR BLEEDING S/P THR - how much drainage?
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
DJD/OA ASSESSMENTS S/P THR continued - the Ps
NEUROVASCULAR
CSM (color/sensation/motion)
Pain, Parasthesias, Pallor, Pulses, Paralysis
PREVENTION OF DVT (love preventing DVT)
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
PAIN MANAGEMENT S/P TOTAL HIP REPLACEMENT
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
OA - heberden (herb on top)
on top
bouchards (b bottom)
on bottom
what drugs cause OA (Ind OA w/ Colt)
Indocin (NSAID), Colchicine
OA symptoms - worse with activity or rest?
Pain tends to worsen with joint use and relieved with rest . With advanced disease, pain at rest/sleep/ cold weather
OA symptoms - morning stiffness
↓ flexibility: early morning stiffness (common), typically resolves in 30 min or less, more common w/ advanced OA
Possible bony growths in joints (Heberdens)
Crepitus
most common places in body for OA (arthur hands)
Hips and knees, the vertebral column, and the hands are primarily affected.
OA diagnostics - imaging
Xray: narrowing of joint space+ osteophyte (lump around joint) due to bone remodeling
CONTRAINDICATIONS to TJR (total joint replacement)
Infection anywhere in the body (can lead to infected joint)
Advanced osteoporosis (prosthesis insertion can shatter bone)
total hip replacement - cough?
TCDB (turn, cough, deep breath)
RPOVS (routine post op vital signs)
ICS (Incentive- spirometer)
total hip replacement - compression device?
SCD (sequential compression device)
Discuss pain relief methods (PCA, injections….)
Abduction pillows and splints
total hip replacement - bathroom?
Use of bedpan and high bedside commode
OA diagnosis - Arthrocentesis- to evaluate what? (arthritis centisis)
to evaluate synovial fluid: minimally inflammatory or non-inflmmatory process.
secondary OA causes
Trauma
Mechanical stress: sports,
Congenital disorders
Hematological / endocrine disorders (hemophilia)
Drugs
