Arthritis, Joint Arthroplasty

Osteoarthritis

slowly progressive noninflammatory disorder

gradual loss of articular cartilage

decreased strength and functionality

narrowed joint space

What joints are affected by osteoarthritis?

Synovial joints (diarthrodial)

Osteophytes

bone spurs (bony outgrowths)

caused by OA 

What is lost in OA?

proteoglycans that provide fluid in the joints 

Is osteoarthritis asymmetrical or symmetrical?

asymmetrical, can only be specific joints

What are risk factors of OA?

Obesity - more toll on the joint

Repetitive actions 

ACL injury 

Decreased estrogen 

What does cartilage look like when it has been affected by OA?

smooth white translucent cartilage becomes dull, yellow, and granular 

What happens when cartilage becomes thinner?

Joint destruction

Bone on bone 

Pain and muscle spasm 

What increases pain with OA?

Activity

Overactivity →

Joint swelling

What happens during a period of rest with OA?

Gelling phenomenon

Gelling phenomenon

stiffness after periods of rest or unchanged position

crepitation (grating) 

How long does morning stiffness last?

30 minutes

What is crepitation

a grating sensation caused by loose cartilage particles in the joint cavity 

causes stiffness 

What simple activity may someone with OA have difficulty with?

Sitting down and getting up 

What joints are often affected?

DIP - distal inerphalangeal joint of the fingers

PIP - proximal interphalangeal joints of fingers
MCP - metacrpophalangeal joint of the thumb

Heberden nodes

DIP joints

osteophyte formation and loss of space 

Bouchard’s node

PIP joint

osteophyte formation and loss of joint space

What deformities can happen to the legs from OA?

Hip (1 shorter than the other)

Varus deformity (Bowlegged)

Valgus deformity (Knock knee) 

Does OA have inflammation?

No

Diagnostic studies for OA?

Xray

Bone scan 

CT 

MRI 

Synovial fluid analysis - clear, yellow, no inflammation 

Erythrocyte sedimentation rate (ESR) → normal 

CBC 

Liver function tests (to rule out other conditions)

Is there a cure for OA?

No

What drug slows the progression of OA or supports joint healing?

Disease-Modifying Osteoarthritis drugs (DMOADs)

interprofessional care for OA?

manage pain and inflammation

prevent disability

maintain and improve joint function - “move it or lose it”

heat & cold

how to manage pain & preserve joint function 

keep joints in a functional position 

avoid immobilization for > 1 week 

balance rest and activity 

weight management 

assistive devices 

when to use ice vs heat

ice for swelling

heat for stiffness - increases flexibility and blood flow 

examples of heat therapy for OA?

hot packs

whirlpool baths 

ultrasound 

paraffin wax dips 

exercise for OA

aerobics 

ROM 

muscle strengthening 

warming up - decreases injury 

tai chi - balance exercises 

can braces or splints be beneficial for OA?

yes 

drug therapy for OA

NSAIDs

Capsaicin cream 

Diclofenac gel (NSAID) 

Camphor, eucalyptus oil, menthol, topical salicylates

Steroid intraarticular injections 

DMAODs 

What do NSAIDs do? What drug can they be combined with?

Inhibits production of cyclooxygenase → decreases prostaglandins 

Misoprostol (Cytotect) - prevents NSAID induced ulcers 

what does capsaicin cream do?

topical cream that interferes with substance P → blocks pain impulses 

What steroids should not be used for OA?

systemic steroids → worsens OA

Arthroplasty (hip/knee)

Reconstruction/replacement of articulating surfaces with a synovial joint 

lasts 10-15 years

Relieves pain, ROM, corrects deformity

Total hip arthroplasty

cobalt-chrome ball in polyethylene socket

when is a total hip replacement cemented or uncemented?

cemented in older adults who are unlikely to have revisions

uncemented in younger adults; hydroxyapatite for bone ingrowth - more secure

hip resurfacing arthroplasty

reshape femoral head & cap it with a metal prothesis

complications of hip resurfacing arthroplasty

fracture of head of femur & metal ion release

hip arthroplasty nursing interventions

neurovascular assessment

abduction pillow to prevent adduction 

total hip precautions 

what medication is given for surgery?

analgesics (opioids, NSAIDs) 

antibiotics (30 min before surgery and 24 hours after) 

anticoagulants (LMWH) 

neurovascular assessment

pain, pulse, pallor, paresthesia, paralysis

checking for blood flow

O2 

total hip precautions

prevents dislocation

• abduction pillow 

• avoid flexion of the hip > 90 degrees

• do not cross legs 

• externally rotate toes 

• elevated straight chairs with arms 

what side should you turn the pt to?

unaffected side, not to operative side

signs of a hip dislocation or subluxation 

a “pop” 

unequal length of legs 

abnormal rotation of the hips 

pain 

inability to bear weight 

hip flexion should be <90 degrees for…

2-3 months

legs should never be ___ after a hip replacement

crossed over midline

home management for hip replacement

raised toilet 

pull bars 

remove scatter rugs 

non-skid socks and shoes 

knee arthroplasty

distal femur component, tibia plate, and/or patellar button

what should you do after a knee arthroplasty

compression dressing after surgery

immobilize the knee in extension 

remove dressing before discharge 

what to do if a pt is unable to perform a straight-leg raise

knee immobilizer to maintain extension for four weeks

use for ambulation and at rest 

nursing interventions for a knee arthroplasty 

neurovascular assessment 

prevent flexion contractures 

physical therapy 

how do you prevent flexion contractures

limit positions of flexion

no pillows under knee 

physical therapy for knee arthroplasty

increase strength & obtain 90 degree knee flexion

isometric quadriceps setting 

straight leg raises 

complications of joint surgery 

excessive blood loss 

wound infection 

deep vein thrombosis/pulmonary embolism

is bone marrow vascular or avascular

vascular

signs of excessive blood loss

hypotension

bleeding 

hypovolemia 

how to prevent wound infection after surgery

monitor temperature and WBCs

prophylactic antibodies until drain removed

rheumatoid arthritis

chronic, systemic, autoimmune disease

inflammation of connective tissue in the synovial joints 

is RA symmetrical?

yes

RA has periods of ____ and ____

remission and exacerbation

in RA, what does the antigen trigger?

Antigen → abnormal IgG → autoantibodies

rheumatoid factor (RF) + IgG →

immune complexes → deposited in the synovial membranes → complement activation → damages cartilage & synovium 

what increase risk of RA

smoking

what joints are affected first with RA?

small joints

effusions

common in RA

leakage of fluid in the site 

what are the clinical manifestations of the onset of RA?

subtle onset → systemic

fatigue 

weight loss 

anorexia 

generalized stiffness 

how are small joints & cervical spine affected of RA

pain

stiffness 

limited movement 

inflammation 

symmetrical 

stiffness after inactivity

morning stiffness (60 minutes to a few hours)

what causes deformity in RA

inflammation + fibrosis = deformity

what causes subluxation (partial dislocation) in RA?

muscle atrophy + tendon destruction = subluxation

extraarticular manifestations of RA

atherosclerosis

rheumatoid nodules

cataracts

vision loss

sjogren’s syndrome

heart & lungs 

Sjogren syndrome

tear-producing (lacrimal) glands, making the eyes feel dry and gritty

felty syndrome

enlarged spleen and low white blood cell count

how can the heart and lungs be affected by RA

pleural effusion

pericarditis 

pericardial effusion 

cardiomyopathy 

how is RA diagnosed 

rheumatoid factor 

active inflammation 

autoimmune 

synovial fluid analysis 

what antibody can diagnose RA

antibodies to citrullinated peptide (Anti-CCP)

what levels show inflammation

erythrocyte sedimentation rate (ESR)

C-Reactive protein (CRP)

what level shows an autoimmune response in RA?

antinuclear antibody (ANA)

what does synovial fluid look like in pts with RA

cloudy with fibrin

drug therapy for RA

DMARDs (disease-modifying antirheumatic drugs)

BRM (biologic response modifiers)

Immunosuppressants

Corticosteroids

NSAIDs and salicylates

What do DMARDs do? (Disease-modifying antirheumatic drugs)

slows progression of disease

examples of DMARDs

methotrexate

sulfasalazine

hydroxychloroquine 

what do BRMs do? (biologic response modifiers)

inhibit inflammatory response

examples of tissue necrosis factor inhibitors

Enbrel

Remicade 

Humira

example of an immunosuppresent for RA 

azathioprine 

what are corticosteroids used for in RA?

used for flairs

what are NSAIDs and salicylates used for with RA

pain and inflammation

why is balanced nutrition important for pts with RA?

fatigue, pain, and depression → anorexia

limited endurance and mobility → difficulty with food preparation

what can cause weight gain with RA?

corticosteroid therapy

decreased mobility 

surgical therapy for RA 

synovectomy (joint lining) 

arthroplasty (total joint replacement) 

how to promote good body alignment in pts with RA

promote extension/avoid flexion

no pillows under knees 

small flat pillow under head 

how to maintain rest/activity balance with RA?

maintain mobility

daytime rest & 8-10 hours at night 

how to promote joint protection with RA

energy conservation

work simplification 

devices 

delegation 

cold & heat therapy for RA

cold - 10-15 minutes at a time for pain

heat - moist heat for 20 minutes at a time for stiffness 

exercise for RA 

physical therapy 

flexibility, strength, and endurance 

joint motion 

gentle ROM 

in warm water