Osteoporosis, arthritis, and total joint arthroplasty

priority concerns

mobility and immunity (rheumatoid arthritis)

interrelated concepts

pain and inflammation

key concerns for osteoporosis

fracture

key concerns for arthritis

pain, deformity, impaired mobility, psychosocial concerns (isolation, depression), impairment of quality of life

key concerns for total joint arthroplasty

pain, VTE, dislocation, infection

osteoporosis

* chronic disease
* bone loss, decreased bone density, possible fracture
* typically in women
* osteoclastic activity is greater than osteoblastic activity
* leads to thin, fragile bones at risk for fracture
* may be asymptomatic
* back pain with lifting and bending
* fractures
* kyphosis

non-modifiable risk factors of osteoporosis

* older age
* parenteral history of osteoporosis, especially mother
* history of low trauma fracture after 50

modifiable risk factors of osteoporosis

* low body weight, thin build
* chronic low calcium and/or vitamin D intake
* estrogen or androgen deficiency
* current smoking (active or passive)
* high alcohol intake (3 or more drinks/day)
* lack of physical exercise or prolonged immobility (in the 20s-30s, weight-bearing exercise can prevent this)

osteoporosis screening/diagnosis

dual x-ray absorptiometry (DXA scan)

osteoporosis pharmacologic treatment

* calcium and D3- won’t cure, but will help
* intake of these supplements alone is not sufficient, but they are an important part of bone health
* biphosphates: slow bone resorption (fosamax and boniva)

osteoporosis implementation

* patient teaching to prevent falls: keep bed in lowest position, move rugs
* lifestyle practices to decrease additional bone loss
* daily sun exposure to receive vitamin D
* adherence to medication regimen
* encourage exercise

osteoporosis nutrition therapy

* promotion of a single nutrient will not prevent or treat osteoporosis; many are needed for bone health
* emphasize fruits and veggies, low fat dairy, protein sources, increased fiber, moderation in alcohol and caffeine intake
* calcium: dairy, leafy greens, beans, fortified foods, fortified nondairy
* vitamin D: fatty fish (salmon), fortified dairy (cheese), egg yolk, fortified foods

osteoporosis prevention

* patient teaching before age 30
* adequate dietary calcium and vitamin D intake
* smoking cessation
* weight loss
* limit carbonated beverages to

osteoarthritis

* progressive loss of bone and cartilage in 1 or more joints
* decreased water, chondriotin, and cartilage between joints, which leads to narrowing of the joint space and formation of bone spurs (bony projection along the bone edge) that cause joint pain
* irreversible
* can cause joint deformity
* may be surgically treated with joint replacement
* joint pain relieved with rest

in osteoarthritis,

secondary joint inflammation can occur if damage is severe

osteoarthritis is also called

degenerative joint disease

rheumatoid arthritis

* not degenerative
* can occur at earlier ages
* chronic, progressive systemic inflammatory autoimmune condition affecting synovial joints
* can cause fever (signals exacerbation), fatigue
* typically in women
* autoantibodies attack the synovium and cartilage, which causes fluid to accumulate in the joint
* secondary osteoporosis occurs
* other body systems are affected
* can cause joint deformity
* may impact renal function
* may be surgically treated with joint replacement

osteoarthritis differences

* onset greater than 65
* risk factors: aging, obesity, trauma, occupation
* disease pattern: may affect only 1 joint, weight bearing joints, spine, and hands
* not systemic
* crepitus
* normal or slightly elevated ESR (inflammatory marker)

osteoarthritis and rheumatoid arthritis similarities

* female
* risk factor: genetic
* progressive, joint stiffness and pain
* eventual joint deformity after many years

rheumatoid arthritis differences

* onset at 35-45
* risk factors/cause: autoimmune, emotional stress triggers exacerbation
* disease pattern: bilateral, symmetric, affects upper extremities first
* systemic
* early symptoms (fever, fatigue, weakness)
* late symptoms (fatigue, osteoporosis, kidney disease)
* increased rheumatoid factor, antinuclear antibody, and ESR

arthritis planning and implementation

* promote mobility: PT or OT
* mobility aids
* encourage independence
* interventions to address fatigue
* encourage self-management
* participate in physical activity
* don’t skip exercises on bad days
* don’t substitute household chores and activities in place of exercise
* protect joints by adjusting habits of movement such as using 2 hands and carrying objects with large joints
* address psychosocial concerns
* concerns: disfigurement, fear of pain, decreased quality of life, loss of independence
* therapeutic communication
* discuss goals to increase self-esteem
* emphasize strengths
* identify previous effective coping strategies
* consult with mental health professionals or spiritual leaders

osteoarthritis pharmacologic treatment

* acetaminophen: first choice
* topical lidocaine patch
* NSAIDs if tolerable

osteoarthritis non-pharmacologic treatment

* application of heat/cold
* weight loss for obesity
* complementary treatments

osteoarthritis and rheumatoid arthritis pain management

* rest balanced with exercise
* functional position of joints- neutral (not crossing over midline or abducting)
* proper positioning and lifting
* physical therapy

rheumatoid arthritis pharmacologic treatment

* NSAIDs for anti-inflammation
* disease modifying anti-rheumatic drugs (DMARDs)
* biological response modifiers that affect immune response
* glucocorticoids

rheumatoid arthritis nonpharmacologic treatment

* application of cold to inflamed joints
* application of heat to stiff joints
* plasmapheresis (separates components of blood that are harmful (immunoglobulins) and taking them out. The blood is then given back to the patient)

arthritis surgical management

* total joint arthroplasty
* failure of conservative (non-surgical) treatments such as lifestyle changes or meds
* used if there is a severe compromise of client’s functional ability or significant pain is experienced

total joint arthroplasty complications and prevention

* dislocation of hip
* use abducter pillow
* position correctly; don’t bend knees farther than 90 degrees
* perform neurovascular assessment distal to the replacement site Q 4 hours and check for the 5 Ps (pain, pulse, parasthesia, etc)
* flexion: bad for posterior side
* extension: bad for anterior side
* infection: use aseptic technique, monitor temperature, wash hands
* VTE:
* ambulate TID
* leg exercises
* increase fluid intake
* wear SCDs/elastic stockings
* no pillow under operative knee
* cryotherapy
* continuous passive motion machine (CPM): moves leg passively to improve ROM for knees