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Sports and the Total Joint Patient

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

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Sports and the Total Joint Patient

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  1. Sports and the Total Joint Patient Brandon Broome, MD Steadman Hawkins Clinic of the Carolinas

  2. Why is this so important? • 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

  3. Outline • Pre-arthroplasty decision making • Post-arthroplasty restrictions

  4. End Stage Arthtitis Not arthroscopy, osteotomy candidate! • Bone on Bone • Subchondral sclerosis • Cysts, osteophytes • Options: • Activity modifications • Injections • PT • Bracing • Meds

  5. Pre-Arthroplasty Activity 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)

  6. Bracing • Knee sleeves can give feeling of stability, improved proprioception • Unloader if unicompartmental, <10 degrees of laxity (selective use) • Heel wedges (controversial)

  7. Injection Options VS.

  8. Injection Options Jackson et al., JBJS, 2002 93% 71%

  9. Corticosteroid Injections 2005 • 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 Safe on cartilage (human studies)

  10. Which to Use? • 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 SOLUBILITY prednisolones triamcinolones betamethasone

  11. Viscosupplementation 2000 • 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

  12. Viscosupplementation • Anti-inflammatory (decreased cAMP, arachidonic acid, prostaglandin) • Increases HA production • Analgesic-substance P blockade • Local reactions rare, seen with avian based preparations

  13. Viscosupplementation 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

  14. Medications • 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

  15. Joint Supplements • 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

  16. Post-Arthroplasty Decisions

  17. Return to Sport after Total Joint Replacement • 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

  18. Literature • 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%)

  19. Tennis after TJA 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)

  20. Return to Sport after Total Joint Replacement 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

  21. Return to Sport after Total Joint Replacement

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