Brandon Broome, MD Steadman Hawkins Clinic of the Carolinas

 By 2030, THA growth of 174%, TKA 674%  Surge in those aged  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, % 93%

 Decrease inflammation in synovial tissues  Decrease edema  Lowers number of macrophages/lymph ocytes  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 prednisolonestriamcinolonesbetamethasone SOLUBILITY

 Hyaluronic acid produced by type B synoviocytes  Mol weight 5x10 6 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 MATTERPRODUCTS BY MOL WT  Higher molecular weights better, match what you started with  Normal HA 5x10 6 daltons  Synvisc 6x10 6 dal (cross-linked)  Hyalgan 730,000 dal  Supartz 1.2x10 6 dal  Orthovisc x10 6 dal  Euflexxa 3.6x10 6 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 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