RA and DJD Lecture from Dr. Shappy Flashcards
Two disadvantages of doing bilateral TKR at the same time:
- not every ortho surgeon is willing to do it
- Blood loss is an issue (that is why she has yet to see a double hip replacement)
Hip precautions for posterior approach THR: (3)
- No Adduction across neutral (can cross ankles as long as hip adduction is avoided
- Hip IR
- Hip Flexion more than 90 degrees
Are the surgical procedures for OA and RA different?
no
they are the same
Another name for OA
DJD
What is a PT’s job with a pt that comes in with OA/DJD?
- Promote healing
- Prevent future injury
- Prevent TKR number from rising
PT has the goal of fixing the knee as best as possible. Then the patient can decide if they want TKR or not. PT wants to buy time!
Progression of OA
- •Loss of cartilage-thinning
- •Hypertrophic changes in bone and joint capsule
- •Synovial inflammation
- •Degeneration of menisci, ligaments, and tendons
- •Narrowing of joint space
- •Osteophyte formation
- •Joint failure
- •Up regulation of inflammatory cytokines
- –IL-1β, TNF-α, and Metalloproteinases that degrade cartilage and the extracellular matrix
- –C-reactive protein and Nitric Oxide also elevated as part of inflammation resulting in chondrocyte apoptosis
Draw Genu varum
Four non pharma options for conservative treatment of OA
- Education,
- weight loss,
- exercise,
- orthotics/braces
inflammatory cytokines in OA
–IL-1β, TNF-α, and Metalloproteinases that degrade cartilage and the extracellular matrix
–C-reactive protein and Nitric Oxide also elevated as part of inflammation resulting in chondrocyte apoptosis
Rheumatologists Classification of functional status of persons with RA:
- Class I - Completely able to perform usual activities of daily living
- Class II - Able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports, household chores)
- Class III - Able to perform usual self-care activities but limited in work and other activities
- Class IV - Limited in ability to perform usual self-care, work, and other activities
PT’s can make more of a difference in this area
What is the life expectancy of a TKR?
10-15 years, but it depends on a lot of things
Draw genu valgum
Primary hyperuricemia (2 things)
- Inherited
- Typically found in middle aged men
A type of gout
Pathogenesis of Gout
- •Uric acid- functions to break down cellular waste
- –Normal: dissolves in blood is processed in kidneys and excreted in urine
- –High production: unable to be filtered and accumulates in tissues like articular cartilage, epiphyseal bone, and periarticular structures
- •Trigger inflammatory response
RA (everything)
- Chronic systemic inflammatory disease presenting with articular and extraarticular findings
- Chronic polyarthritis- destruction of joint tissues
- Autoimmune disorder- autoantibodies attack joint synovium
- Possible interaction between rheumatoid factor and immunoglobulin antibody (massive infiltration of immune cells T-lymphocytes)
- Pannus- a destructive vascular granulation tissue resulting in thickening of synovium
- Prevents joint nutrition and lubrication
- Dissolves collagen, cartilage, subchondral bone and periarticular structures
If TKR pts feel clunking, should you be concerend?
No because the knee replacement is designed that way.
It is supposed to clunk because that is what tells you the patella is tracking in the groove in the right place.
(Rubber cap doesn’t show up on x-ray but it is inserted on the back side of the patella to run in the groove.)
How long does it take to recover from a TKR?
A year to fully recover - not to sit better, to get back to the gym working out the heart.
Can test for RA by ____.
Testing for Rheumatoid factor in the knee fluid.
Obtain the fluid through aspiration.
PT Treatment for RA, 8 general things
- •Pain management
- •ROM
- •Strength
- •Functional modification or mobility training
- •Fitness/wellness activities
- •Family training
- •Patient education
- •Other?
(make wheel-chair last resort)
Hip precautions for anterior approach THR: (3)
- Hip Extension
- Hip Abduction
- Hip ER
Is weight bearing usually okay in THR?
usually weight bearing as tolerated second to pain
Does a hemiarthroplasty usally last without progressing to the need for a total arthroplasty?
no
A full arthroplasty is usually needed later on
How do you approach RA treatment as a PT?
Which joint bothers you today? Focus more on adaptation treatments.
what is a major difference between OA and RA?
RA is a systemic disease that affects multiple joints
OA/DJD usually affects one joint at a time
How much can a TKR cost?
$58K or more
RA Diagnosis
Main diagnosis reason is the presence that Rheumatoid Factor
- •Rheumatoid factor (RF)
- –Antibodies specific to RA
- –RF positive in only 60-70% of RA patients
- •Antinuclear antibody (ANA)
- –Positive in SLE and related conditions
- –ANA positive in 30% of RF-positive RA patients
- –Positive in 10% of normals
- •Inflammatory factors
- –Sedimentation rate, C-reactive protein, and plasma viscosity may all be elevated but may not. Can be attacked with drugs
Can PTs help RA patients more with functional classifications, severity classificatons, or both?
PTs can help more with functional classification factors
treatment of gout
Treat inflammation (and educate patient about drinking lots of fluids and diet, MD may prescribe medications)
What tissues does DJD progress into?
the articular cartilage dsease progresses slowly to affect underlying:
- bone
- soft tissues
- synovial fluid
Prehab definition
presurgical rehab
Joint fusion: what is the mosmt common joint for this?
joint fusion is a treatment option for OA
Great toe is the most fused joint (fused in various positions
Can an elbow total arthroplasty dislocate?
Nope
Draw or imagine Rheumatoid nodules
Maintain joint ROM. Maintain strength. Be careful with too much flexibility. A lot of times in hands they become hypermoble (possibly benign hypermobility syndrome)
Two other Inflammatory Cytokines that are also elevated as part of inflammation resulting in chondrocyte apoptosis
- C-reactive protein
- Nitric Oxide
should you worry more about elbow extension or elbow flexion during elbow rehab?
Elbow flexion because restrictions in flexion causes so many more functional problems than restrictions in extension
what is the purpose of bracing for OA?
Decrease pain
Hinge provides mediolatreal stability
Helps delay the inevitable (TKR) [by unloading joint some?]
Examples of Home Modifications for RA pts (3)
- Shower seat
- Extended handles on the sink
- Removable shower heads
There are people who do home modifications as a job
Point: Thinking adaptive equipment
How does joint movement improve delivery of nutrients to articular cartilage?
Articular cartilage is porous in structure. It absorvs synovial fluid. When we move joint it creates waves of fluid that is forced into the pores
Relevance of the American College of Rehumatology Classification for RA Severity:
These are the things rheumatologist consider.
Establish SEVERITY, which does not neccesarily correlate with functional status
IL
Interleukin
Can THR dislocate?
absolutely! this is why there are hip precautions. There is a large risk early after surgery
Draw microfracturing
Take defect in cartilage and drill little holes in it. Bleeds, scars, fills in (potentially)
Drilling and microfracturing
Drilling and microfracturing: drill on the joint surface to make it bleed and start inflammation and healing. May help develop scar
possible OA treatment
glucosamine and chondroitin sulfates
- Usually taken together as a nutritional supplement.
- Supposed to give nutrition to joint. The same thing mobs are supposed to do
- Pts will ask us about our opinion on it
secondary OA
–known cause ie. trauma, infection, hemarthrosis, osteonecrosis, etc.
STS
Step to Step
(when a patient is walking on stairs, they do not do step over step. They step with one foot to a step and then put the other foot on that same step before moving first foot again)
What is the minimum amount of knee flexion needed to do step over step on 8 inch stairs?
110 degrees
Hemiarthroplasty
the replacement of only one of the articular surfaces
(replace only half the joint)
Pharma Treatements for RA
- •Disease modifying anti-rheumatic drug (DMARD)
- •Anti-tumor necrosis factor (TNF) antibody- TNF inhibitor
- •Immunosuppressive/anti-inflammatory agents
- –Methotrexate- non-biologic DMARD
- –Humira, Enbrel, and Remicade- biologically derived DMARD, TNF inhibitors
- –Corticosteroids, alkylating agents, interleukin suppressors- Immunosuppressive/anti-inflammatory
What can happen to the quads and hamstrings because of TKR surgery?
they can shut down and not fire at first.
Only a little fluid inected into the capsule can cause VMO to shut down
Osteotomy
Osteotomy: Cut of wedge of tibia and femur off.
a possible treatment for OA
Four things that “cause” primary OA:
- Time
- Age
- Obesity
- Trauma
Five examples of assistive devices for RA patients
- Carrot peeler
- Reacher (can have suction cups)
- Pen gripper
- Can use these with stroke patients too
- Hover-round (turning radius is the thing we care about)
Two treatment options for OA
Surgical
Non-surgical (conservative)
Draw Pannus
Pannus: thickened highly vascular soft tissue that gets in the way and blocks nutrition
Two main deformities of the hand in RA
- Swan Neck deformity
- Boutonniere deformity
Does functional status and severity correlate in RA patients?
not neccessarily
Why does OA hurt? (cartilage doesn’t have nerves)
Nociceptors are being stimulated because cartilage is worn away and OA is progressing into the bone.
What percentage of men and women over 65 years old have OA?
How many people in the United States have OA?
60% of men over 65
70% of women over 65
40 million people in the US
RA S/S
- •Joint related
- –Fingers, hands, feet, cervical spine, etc.
- •Non-joint related
- –Fever
- –Malaise
- –Lymph node and spleen enlargement
- –Rashes
- –Raynaud phenomenon: vascular
- Main diagnostic factor: presence of Rehumatoid Factor in joint capsule
Two types of Conservative care options for OA
- Non-Pharmaceutical
- Pharmaceutical
What is DJD?
Slowly progressing articular cartilage disease that progresses underlying:
- bone
- soft tissues
- synovial fluid
can lead to
- loss of mobility
- chronic pain
- deformity
- loss of function
what are bone cysts?
pustules full of inflammatory mediators and dead cells
are often present in DJD
Who will refer RA pts to us?
and how to treat?
If we are a hand therapist (not an OT), we might get referrals from rheumatologist.
Treatment: No easy answer. You have to go shopping for them, and you have to be good at it.
Hands: Maintain joint ROM. Maintain strength. Be careful with too much flexibility. A lot of times in hands they become hypermoble (possibly benign hypermobility syndrome?)
What is Gout?
Type of Arthritis
Elevated uric acid with deposits of uric crystals in joints, soft tissues, and kidneys. Uric acid is supposed to be excreted in urine. It is not because of a dysfunction or more in diet than we were built for. It can be inherited.
Three main types:
- Primary Hyperuricemia - inherited
- Secondary hyperuricemia - metabolic cause
- Idiopathic hyperuricemia - other cause
three main types of gout
Three main types:
- Primary Hyperuricemia - inherited
- typically middle aged men
- Secondary hyperuricemia - metabolic cause
- Idiopathic hyperuricemia - other cause
What are some problems that OA can lead to?
can lead to:
- loss of mobility
- chronic pain
- deformity
- loss fo function
Idiopathic hyeruricemia
- High alcohol consumption
- obesity
- thiazide drugs
- lead toxicity (or other metals - metal on metal hip replacement)
- diet high in purines found in:
- seafood
- meat,
- asparagus,
- beans
(A type of gout)
difference between hip resurfacing and THR
Total hip replacement replaces femoral head and acetabulum
hip resurfacing usually involves placing a cup in the acetabulum and shaving down and covering the head of the femur with a new surface (as opposed to completely cutting it off)
Draw DJD
How does articular cartilage get its nutrients?
Synovial fluid
Articular cartilage is porous in structure. It absorvs synovial fluid. When we move joint it creates waves of fluid that is forced into the pores
Is genu varum or genu valgum harder to brace?
Genu valgum is harder to brace than genu varum
SLE
Systemic Lupus Erythematosus
Two kinds of Total shoulder replacements
Total shoulder
Reverse shoulder
Two mistakes that can happen in THR
- Angle of cup is off
- Ball is too small for cup
The American College of Rheumatology classification for RA severity:
- Stage I
- No damage seen on x-rays, although there may be signs of bone thinning
- Stage II
- On x-ray, evidence of bone thinning around a joint with or without slight bone damage
- Slight cartilage damage possible
- Joint mobility may be limited; no joint deformities observed
- Atrophy of adjacent muscle
- Abnormalities of soft tissue around joint possible
- Stage III
- On x-ray, evidence of cartilage and bone damage and bone thinning around the joint
- Joint deformity without permanent stiffening or fixation of the joint
- Extensive muscle atrophy
- Abnormalities of soft tissue around joint possible
- Stage IV
- On x-ray, evidence of cartilage and bone damage and osteoporosis around joint
- Joint deformity with permanent stiffening or fixation of the joint (ankylosis)
- Extensive muscle atrophy
- Abnormalities of soft tissue around joint possible
What is the single most common joint disease?
OA/DJD
What are RA patients like?
These are the toughest people you will meet. The are good to work with. They usually got this at a young age. They figure it out on their own at first. When they get to you they are desperate. They want to be independent for as long as possible. Very determined patients.
Clinical Presentation of Gout
- Monoarticular inflammatory arthritis
- Great toe most common MTP joint
- Ankle, instep, knee, wrist, elbow and fingers can also occur
- Erythema, warm, painful, hypersensitivity, chills, fever, tachycardia
- Elevated uric acid levels in only 10%
- Diagnosis made on symptoms and response to medication to lower uric acid levels
Seven S/S of OA
- Pain
- Limited ROM
- Swelling- effusion
- Crepitus
- Tenderness on joint line
- Malalignment
- Joint deformity
- Genu valgum
- Genu varum
Synvisc injections
- Something from a rooster’s head (the red part of a chicken - aka the comb & neck) that is injected directly into osteoarthritic knees and acts like healthy, cushioning synovial fluid.
- purpose is to buy time for an OA pt before TKR
RA Pathogenesis
- Initial Changes:
- Inflamed synovium
- End Stage Changes:
- Pannus
- Loss of Cartilage
- Pannus Filled erosion of bone
what is Pannus?
Part of the autoimmune response of RA
- Pannus- a destructive vascular granulation tissue resulting in thickening of synovium
- Prevents joint nutrition and lubrication
- Dissolves collagen, cartilage, subchondral bone and periarticular structures
- thickened highly vascular soft tissue that gets in the way and blocks nutrition
Hip Dislocation Brace, purpose and information
- More of an annoyance to remind pts not to break hip precautions.
- It can be put on too loose, so check this! (She has had pts dislocate in the brace)
Draw Osteotomy
Eight Pharma options for conservative treatment of OA
- NSAIDS,
- COX-2 inhibitors,
- Nitric Oxide inhibitors and antioxidants,
- chondrocyte and bone growth promoters
- metalloproteinase and cytokine inhibitors
- gene therapy
- Synvisc injections
- glucosamine and chondroitin sulfate
How should we think about every patient with OA?
We should think of them as a non-surgical candicate. “the worst thing I can do for you is prepare you for surgery” (prehab)
What is the primary tissue involved in OA?
Slowly progressing articular cartilage disease
Primary DJD
–unknown cause thought to be a defect in articular cartilage
We are gerbils!
Four joints in which a hemiarthroplasty can be performed
- shoulder
- wrist
- hip
- knee
What is a common goal for knee flexion in inpatient PT and why?
90 degrees so pt can do most things
Home and Car Access, examples of considerations for RA pts
- Rise and run requirement for ramps. Medicare will not pay for wheelchair unless there is a ramp with this requirement so they can get in their house.
- If walkers are too wide (like for bathroom door), take off wheels and put them on the inside or go sideways through the door.
- Home evals/modifications is a good business.
Examples of the multifactoral causes of OA
- Genetics (rough literature to try to decipher)
- biomechanical factors,
- nutrition and weight control,
- estrogen use,
- bone density,
- injury,
- smoking,
- ACL injuries especially with meniscal tears,
- twisting type sports,
- job related: kneeling, heavy lifting.
- RA,
- SLE,
- MS,
- polymyositis,
- prolonged immobilization and other conditions that result in joint hypermobility
are RA pts usually on lots of medication or not?
RA patients are on all kinds of drugs usually.
More detailed description of DJD
- Wear-and-tear disease replaced with disease process of subchondral bone, looking at the joint as a whole not simply the articular cartilage destruction but also the random repair due to altered cell function
- Remodeling process- imbalance between catabolic and anabolic repair activity.
- Follows Wolffe’s Law
Four advantages of doing a bilateral TKR at the same time
- Pt cannot compensate on “good” leg, because both legs are painful.
- They will not have a chance to change thier minds about doing second TKR if they have a bad experience with the first one.
- Only have to put under anesthesia once
- Can rehab both knees at the same time
Bouchard’s nodes
Nodes in RA
Can OA and RA interchange between each other?
RA is an autoimmunde disorder that attacks the joints, so OA cannot lead to RA.
However, RA can lead to OA in various joints as RA progresses and the joints degenerate.
What is the purpose of a TKR?
Allow the pt to MOVE again!!
(not so they can sit with less pain). We want to rehab them back to activity
Secondary hyeruricemia
Gout with metabolic cause
How can prolonged immobilization lead to joint hyperombility?
If you don’t stress the ligaments, they will atrophy and joint will become hypermobile.
TNF
Tumor Necrotizing Factor
Three Inflammatory Cytokines that degrade cartilage and the extracellular matrix
- IL-1β
- TNF-α
- Metalloproteinases
Four Surgery examples for OA
- Arthroscopic lavage and debridement,
- drilling and microfracturing
- Osteotomy,
- Joint replacement
- fusion
What did Dr. Shappy say most RA pts will eventually sucumb to?
Pneumonia
Is blood supply good or bad in the articular cartilage?
It is crappy!
Arthroscopic Lavage
Clean joint out. Not all scrapings are a good idea. Look up the research.
