Brandon Broome, MDSteadman Hawkins Clinic of

the Carolinas

By 2030, THA growth of 174%, TKA 674%

Surge in those aged 45-65

Younger, more active patients

Medicare/insurance “checkboxes” before arthroplasty—must partner to manage the load

Pre-arthroplasty decision making

Post-arthroplasty restrictions

Bone on Bone Subchondral

sclerosis Cysts, osteophytes Options:

• Activity modifications

• Injections• PT• Bracing• Meds

Not arthroscopy, osteotomy candidate!

AVOID DOING TOO LITTLE TOO LATE! “DOC, WHAT CAN I DO?”

Avoid that which causes pain!

Low impact exercises Stationary bike, pool,

CORE strengthening Strengthening

decreases pain, aerobic helps more long-term (if quit, effects go away)

Knee sleeves can give feeling of stability, improved proprioception

Unloader if unicompartmental, <10 degrees of laxity (selective use)

Heel wedges (controversial)

VS.

Jackson et al., JBJS, 2002

71%93%

Decrease inflammation in synovial tissues

Decrease edema Lowers number of

macrophages/lymphocytes

Can give every 3 months, up to 2 years (study stopped here)

Side effects• Fat atrophy• Tendon rupture• Decreased skin

pigmentation• Crystal deposits

2005

Safe on cartilage (human studies)

Solubility important (lower stays in joint, not the system, higher better for soft tissues)

Crystal structure (betamethasone dissolves quickest, most rapid effect)

Combine with anesthetic--differential and therapeutic effects

Avoid precipitates

prednisolones triamcinolones betamethasone

SOLUBILITY

Hyaluronic acid produced by type B synoviocytes

Mol weight 5x106 daltons

OA is wet, decreased HA concentration, mol weight

Impairs viscoelasticity, nutrient transport, waste removal

2000

Anti-inflammatory (decreased cAMP, arachidonic acid, prostaglandin)

Increases HA production

Analgesic-substance P blockade

Local reactions rare, seen with avian based preparations

SIZE DOES MATTER PRODUCTS BY MOL WT

Higher molecular weights better, match what you started with

Normal HA 5x106 daltons

Synvisc 6x106 dal (cross-linked)

Hyalgan 730,000 dal

Supartz 1.2x106 dal Orthovisc 1.2-

2.9x106 dal Euflexxa 3.6x106

dal

NSAIDS Topical NSAIDS

(mixed reviews, some claim 70-80% response rate)

Glucosamine/ Chondroitin Sulfates• Imbalance of

proteoglycan synthesis/degradation with OA

• Try to tip the scale towards synthesis

Increase GAG growth and metabolism

Increase PG production

Decrease collagenolytic activity of chondrocytes

50-70% improvement across studies

Optimum dose: • Glucosamine 1500

mg/day• Chondroitin 1200

mg/day (less critical)• ASU’s

SAFE

Controversial Preop experience,

level of participation are key

Change intensity level

Avoid contact sports, jogging (joint forces 5x body weight)

Sports specific rehab, time for bony ongrowth

After TKA, 60-65% return to sports (most hold back precautionary)

JBJS-Br 2008: 34.8% preop vs. 61.4% postop(THA, TKA, resurf., uni knees)• No diff between

groups when control for age

Golf after TKA (Am J Sports Med, 2009, Mayo)

• 57% on course w/in 6 months

• 83% with significant pain relief

• Fewer walked afer surgery (28% vs. 14%)

WILL I GRUNT LESS ON THE COURT?

AM J SPORTS MED, 2002, JOHNS HOPKINS

Followed high-level players after TJA for 7 years

Both singles and doubles Played average 3x/week All satisfied (? Amount of wear)

TJA patients rapidly growing, most importantly the 45-65 age group

Decisions made based on patient/surgeon comfort

Alter intensity, frequency level (jogging bad but running bases in softball ok)

Surgical approach, type of implants must be considered