Osteoarthritis, Rheumatoid Arthritis, Joint Replacements

Osteoarthritis is sometimes called

degenerative joint disease

What is the most common form of arthritis

osteoarthritis

Pathophysiology of osetoarthritis

Progressive Disease that results in:
•Increased cytokines & enzymes
•Cartilage breakdown
•Bony Spur development
•Increased edema

What anatomical structures are affected by osteoarthritis

Subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles

Prevalence of osteoarthritis

4 million (14%) of Canadians 20 years and older live with diagnosed OA

Incidence of osteoarthritis

220,000 newly diagnosed in 2016-17

Risk factors for osteoarthritis

•Age
•Biological Sex
•Obesity
•Anatomical Factors
•Muscle Weakness
•Joint Injury

Primary osteoarthritis

•Absence of specific trigger
•Strong genetic component

secondary osteoarthritis

Presence of specific trigger that exacerbates cartilage breakdown
-Injury
-Occupational Stress/Obesity
-Inactivity
-Inflammatory or other diseases

Osteoarthritis is most common in

•Knees, hips, lower back, neck, hands, feet
-large, weight bearing joints
-more likely to show up unilaterally

Symptoms of osteoarthritis

-pain
-audible noises
-swelling
-deformity

pain symptoms of osteoarthritis

Typically, movement-based pain
Decreases with rest
Morning Stiffness
Loss of ROM
Pain limited function
Structural limitations

crepitation

Cracking, scraping, knocking, grinding (audible noises of joint)

diagnostic procedures for osteoarthritis

-symptomology
-physical examination
-radiographs
-MRI

conservative management of osteoarthritis

•Avoid exacerbating activities
•Avoid overloading the joint
•Improve strength
•Weight loss
•Bracing
•Gait Aids

goal of management of osteoarthritis

minimize pain and functional loss

pharmacology used for osteoarthritis

•Acetaminophen and oral NSAIDs initially
•Topical NSAIDs (Voltaren/Diclofenac)
•Intra-articular injections
•Hyaluronic acid/Hyaluronan injections (e.g. Synvisc)
•Platelet-rich plasma injections (PRP)
•Corticosteroid injections (potential cytotoxic effect)
-stem cell treatments
-joint replacements

rheumatoid arthritis is a

systemic autoimmune disease

pathophysiology/etiology of rheumatoid arthritis

•Considered that genetic predisposition and an environmental trigger leads to an autoimmune response
•Resulting inflammatory response results in thickened synovium, erosion of articular cartilage, and joint ossification

Epidemiology (prevalence/incidence of rheumatoid arthritis)

•Most common chronic inflammatory joint disease worldwide
•Increases mortality due to associated comorbidities
~375,000 (1.2%) of Canadians 16 years and older live with
diagnosed RA
~23,000 newly diagnosed cases in 2016-17
•Much more common in Females than Males

Risk factors of rheumatoid arthritis

•Genetic Predisposition
•Female
•Air pollution
•Low Vitamin D intake
•Smoking
•Obesity

clinical presentation of rheumatoid arthritis

•Often presents bilaterally (symmetrical)
•Common in small joints of hands and feet
•Not as common in hips or lumbar spine
•Very common to have cervical spine involvement (80-90%)
•Does NOT affect L-Sp, T-Sp, DIPs

Signs & symptoms of rheumatoid arthritis

•Joint swelling, stiffness, deformity, & point tenderness
•Presence of other conditions (carpal tunnel, tenosynovitis, & others)
•Morning stiffness that can last >1 hour
•Joint involvement can occur insidiously
•Can progress over a long period or very quickly
•Common to have flare ups
•Hand/finger deformities
•MCP ulnar drift

diagnostic procedures for

•Physical Examination combined with Signs & Symptoms
•Morning Stiffness in joints > 1 hour
•Multiple swollen and tender joints
•Symptoms lasting longer than 6 weeks

lab evaluation of rheumatoid arthritis

•Rheumatoid Factor
•45%-75% of patients with RA test positive (does not mean
conclusive diagnosis as other conditions result in a positive
rheumatoid factor)
•Anti-citrullinated protein antibodies (ACPA)
•Acute-phase reactants, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
•All may be elevated in RA

Radiographs of rheumatoid arthritis

May not show early joint changes due to RA

MRI's and rheumatoid arthritis

Can detect RA earlier in course of disorder based on being more sensitive to identifying synovitis and joint effusion

pharmacology for rheumatoid arthritis

•Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
•E.g. Methotrexate, Prednisone
•Will help slow disease progression
•Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
•Pain control

Conservative management for rheumatoid arthritis

•Avoid exacerbating activities
•Avoid overloading the jointImprove strength
•Weight loss
•Bracing
•Gait Aids
•Management of flare-ups
•Education and pain relieving modalities

course of osteoarthritis

•No Cure
•Has comorbidities related to inactivity, but not as severe as RA
•Medications do not have as severe of side effects
•Not as extreme of a mortality rate
•Total joint replacement often is successful for severe OA

course of rheumatoid arthritis

-No Cure
-Common to have comorbidities
-Be aware of these in therapy
-Can be controlled by medications, but:
-Medications might lead to side-effect that negatively impact health
-Mortality is 3x higher than general population

considerations for osteoarthritis

-Referral to MD can wait until conservative methods fail
-Common in females
-Symptomology typically relative to loading/activity

considerations for rheumatoid arthritis

-Early recognition and referral to MD paramount
-Early pharmacological interventions result in better outcomes
-Much more common in females
-Flare-ups more common

Hip replacement indications

70% Osteoarthritis
26.4% Acute Hip Fracture
2.2% Osteonecrosis
<1%
-Old hip fracture
-Tumor
-Inflammatory Arthritis
-Hip dysplasia
-Infection

Knee replacement indications

•99% Osteoarthritis
•0.4% Inflammatory Arthritis
•<0.1%
•Osteonecrosis, Fracture, Tumor, Infection

Indications for joint replacements

•Failure of more conservative measures
•If pain persists despite medication
•Pain worsens with walking even when using an appropriate
gait aid
•Inability to perform ADLs despite therapy
•Pain interferes with sleep
•Expected benefits outweigh the estimated risks

TKA in Canada

2020-2021: 55,285 replacements

THA in Canada

2020-2021: 55,300 replacements

risk factors for poor outcomes of joint replacements

•Age
•Sex (males)
•Malnutrition
•Diabetes
•Obesity
•Depression
•Other comorbidities
•Smoking

joint replacement procedure

-takes between 1 and 2 hours
-preformed by orthopedic surgeon

different approaches for hip replacement

lateral, anterior, posterior

Prehabilitation for joint replacements

•Equipment Preparation
•2-Wheeled Walker, Bath Aids, Toilet Aids
•Strengthening Exercises
•Education on Expectations

what can patients expect with joint replacement rehabilitation

•To be standing and taking steps within 24 hours
•To be discharged in 24-48 hours (unless there are complications)
•To use a 2-Wheeled Walker for ambulation for 6-8 weeks

knee replacement patients can expect to

work on flexion and extension ROM

hip replacement patients can expect to

possibly adhere to movement restrictions

Longevity of knee replacements

•90% last at least 10 years
•80% last at least 20 years

longevity of hip replacements

•85% last at least 15 years
•79% last at least 20 years
•77% last at least 25 years