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