sports and the total joint patient
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Sports and the Total Joint Patient. Brandon Broome, MD Steadman Hawkins Clinic of the Carolinas. Why is this so important?. By 2030, THA growth of 174%, TKA 674% Surge in those aged 45-65 Younger, more active patients - PowerPoint PPT PresentationTRANSCRIPT
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Brandon Broome, MDSteadman Hawkins Clinic of
the Carolinas
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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
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Pre-arthroplasty decision making
Post-arthroplasty restrictions
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Bone on Bone Subchondral
sclerosis Cysts, osteophytes Options:
• Activity modifications
• Injections• PT• Bracing• Meds
Not arthroscopy, osteotomy candidate!
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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)
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Knee sleeves can give feeling of stability, improved proprioception
Unloader if unicompartmental, <10 degrees of laxity (selective use)
Heel wedges (controversial)
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VS.
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Jackson et al., JBJS, 2002
71%93%
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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)
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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
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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
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Anti-inflammatory (decreased cAMP, arachidonic acid, prostaglandin)
Increases HA production
Analgesic-substance P blockade
Local reactions rare, seen with avian based preparations
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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
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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
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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
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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
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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%)
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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)
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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
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