Osteoarthritis (PDF)

11/27/23, 4:54 AM Realizeit for Student Osteoarthritis (Degenerative Joint Disease) Pathophysiology All joints consist of bone, particularly subchondral bone or the bony plate to which the articular cartilage is attached. This articular cartilage is a lubricated, smooth tissue that protects the bo...

11/27/23, 4:54 AM Realizeit for Student Osteoarthritis (Degenerative Joint Disease) Pathophysiology All joints consist of bone, particularly subchondral bone or the bony plate to which the articular cartilage is attached. This articular cartilage is a lubricated, smooth tissue that protects the bone from damage with physical activity. Between the articular cartilage of the bones forming the joint is a space (called the joint space) that allows for movement. To aid in fluidity, each joint contains synovial fluid to help lubricate and protect the joint’s movement. With OA, the articular cartilage breaks down, leading to progressive damage to the underlying bone and eventual formation of osteophytes (bone spurs) that protrude into the joint space. The result is that the joint space is narrowed, leading to decreased joint movement and the potential for more damage. Consequently, the joint can progressively degenerate. Understanding of OA pathophysiology has been greatly expanded beyond what was previously thought of as simply “wear and tear” related to aging. In addition to the degeneration, an infectious arthritis can occur. See later discussion of septic (infectious) arthritis. Risk factors for the disease and its progression include older age, female gender, and obesity. In addition, certain occupations (e.g., those requiring laborious tasks); engaging in sport activities; and a history of previous injuries, muscle weakness, genetic predisposition, and certain diseases can also place patients at risk for joint destruction. The most prominent modifiable risk factor for OA is obesity. In fact, both quality and quantity of life are reduced with OA, especially when obesity and OA are combined. A program of diet and exercise can help minimize symptoms of OA in patients with obesity (CDC, 2018). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 1/7 11/27/23, 4:54 AM Realizeit for Student Clinical Manifestations The main clinical manifestations of OA are pain, stiffness, and functional impairment. The joint pain is usually aggravated by movement or exercise and relieved by rest. If morning stiffness is present, it is usually brief, lasting less than 30 minutes. The onset is routinely insidious, progressing over multiple years. On physical examination, the affected joint may be enlarged with a decreased range of motion. Although OA occurs most often in weight-bearing joints (hips, knees, cervical and lumbar spine), the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are also often involved causing bony enlargements of the DIP (Heberden’s nodes) and PIP (Bouchard’s nodes) joints. Crepitus may be palpated, especially over the knee. Joint effusion, a sign of inflammation, is usually mild. No systemic manifestations are found. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 2/7 11/27/23, 4:54 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 3/7 11/27/23, 4:54 AM Realizeit for Student Assessment and Diagnostic Findings Blood tests and examination of joint fluid are not useful in the diagnosis of OA but are occasionally indicated to rule out an autoimmune cause for the joint pain, such as RA. X-rays may show a narrowing of the joint space; osteophyte formation; and dense, thickened subchondral bone (O’Neill & Felson, 2018). Medical Management The goals of management are to decrease pain and stiffness and to maintain or, when possible, improve joint mobility. Exercise, especially in the form of cardiovascular aerobic exercise and lower extremity strength training, has been found to prevent OA progression and decrease symptoms of OA. Along with exercise, weight loss, which in turn decreases excess load on the joint, can also be extremely beneficial. Occupational and physical therapy can help the patient adopt self-management strategies (Schmidt, 2018). Wedged insoles, knee braces, and other modalities are being evaluated as possible therapies aimed at treating the abnormalities in biomechanics found in OA. The use of orthotic devices https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 4/7 11/27/23, 4:54 AM Realizeit for Student (e.g., splints, braces) and walking aids (e.g., canes) can improve pain and function by decreasing force on the affected joint (Schmidt, 2018). Patients with arthritis often use complementary, alternative, and integrative health therapies, such as massage, yoga, pulsed electromagnetic fields, transcutaneous electrical nerve stimulation (TENS), and music therapy. These therapies may also include herbal and dietary supplements, other special diets, acupuncture, acupressure, wearing copper bracelets or magnets, and participation in T’ai chi. Research is under way to determine the effectiveness of many of these treatments. To date, there is no definitive evidence showing their superiority to standard care; the American College of Rheumatology (ACR) has encouraged the use of these therapies only if they do not interfere with medications and are found to increase comfort, mobility, and function for patients (Kolasinski, Neogi, Hochberg, et al., 2020). Nursing Management Pain management and optimal functional ability are the major goals of nursing interventions. With those goals in mind, nursing management of the patient with OA includes pharmacologic and nonpharmacologic approaches as well as education. The patient’s understanding of the disease process and symptom pattern is critical to the plan of care. Because patients with OA usually are older, they may have other health problems. Commonly they are overweight, and they may have a sedentary lifestyle. Weight loss and exercise are important approaches to lessen pain and disability. Canes or other assistive devices for ambulation should be considered, and any stigma about the use of these devices should be explored. Exercises such as walking should be begun in moderation and increased gradually. Patients should plan their daily exercise for a time when the pain is least severe or plan to use an analgesic agent, if appropriate, before exercising. Adequate pain management is important for the success of an exercise program. Open discussion regarding the use of complementary, alternative, and integrative health therapies is important to maintain safe and effective practices for patients looking for relief. In moderate to severe OA, when pain is severe or because of loss of function, surgical intervention may be used. The procedures most commonly used are osteotomy (to alter the distribution of weight within the joint) and arthroplasty. Joint arthroplasty refers to the surgical removal of an unhealthy joint and replacement of joint surfaces with metal or synthetic materials. Patients with OA and with severe joint pain and disability may undergo arthroplasty. Other conditions contributing to joint degeneration that might require arthroplasty include RA, trauma, and congenital deformity. Some fractures (e.g., femoral neck fracture) may cause disruption of the blood supply and subsequent avascular necrosis (death of tissue due to insufficient blood supply); management with joint replacement may be elected over open reduction internal https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 5/7 11/27/23, 4:54 AM Realizeit for Student fixation (ORIF). Joints frequently replaced include the hip, knee, and finger joints. More complex joints (shoulder, elbow, wrist, ankle) are replaced less frequently. Total joint arthroplasty, also known as total joint replacement, involves the replacement of all components of an articulating joint. Most joint replacements consist of metal (e.g., stainless steel, cobalt-chromium, titanium) and high-density polyethylene components. In order to achieve fixation of components, the material can be cemented, cementless, or a hybrid of both of these materials. Cemented fixation uses a fast-curing bone cement (polymethylmethacrylate [PMMA]) to hold implants in place. Cementless fixation relies on new bone growing into the surface of the implant by using a press-fit, porous-coated prosthesis. There is also a hybrid fixation technique for total knee arthroplasty (TKA) where the femoral component is inserted without cement, and the tibial and patellar components are inserted with cement. Use of each of these materials and techniques have different benefits and risks. Current research evidence supports the use of either component fixation methods (cemented or cementless) because postoperative functional outcomes, rates of complications, and rates of reoperations are similar (Quinn, Murray, Pezold, et al., 2018). Identifying patient-specific factors that may inform the decision to utilize a particular fixation technique is important. Considerations include gender, age, diagnosis, weight and activity level as well as the presence of healthy bone with adequate blood supply. Issues of cost and cost-effectiveness should also be considered (Quinn et al., 2018). With joint replacement, patients may expect pain relief, return of joint motion, and improved functional status and quality of life. The scope of these improvements depends in part on patients’ preoperative soft tissue condition and general muscle strength. Serious complications seldom occur, and recent innovations in total joint replacement surgery have made this a safer and more routinely performed surgery. Rehabilitation with physical therapy that is initiated within the first 24 hours is associated with decreased hospital length of stay and improved balance and gait function (Quinn et al., 2018). In addition, minimally invasive surgical techniques, biomaterials, postoperative rehabilitation protocols, and multimodal analgesia strategies have led to earlier hospital discharge and quicker recovery (Lee, 2016). The American Joint Replacement Registry (AJRR) monitors the performance of devices and evaluates the costeffectiveness of procedures. The data generated from the AJRR and other registries provide orthopedic researchers and practitioners with the information necessary to improve the quality of health care among patients in need of knee and hip replacement procedures (Dy, Bumpass, Makhni, et al., 2016). Annual reports are provided to hospital system members to facilitate quality improvement programs (American Academy of Orthopaedic Surgeons [AAOS], 2020). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 6/7 11/27/23, 4:54 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 7/7