Mater GP Education Orthopaedics workshop · Monoarthralgia Septic, Reactive, Crystal PVNS, trauma...

Mater GP EducationOrthopaedics workshopPanel Discussion

Dr Anubhav Sathu

Dr Ali Kahlor

Dr Jerry Van de Pol

materhealth.org.au

Case Studies

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Case study

Age

Gender Male

Level of physical activity Low – very little exercise

Injury or complaint Pain in both knees

Comorbidities? Obesity and hypertension

Background Previous attempts to lose weight have failed. Strenuous exercise causing joint stress when young. Family history of osteoarthritis.

Question for the panel How can I best encourage the patient to take part in his management and how to know if he requires more treatment than I am giving him?

Case studies

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Mater GP Orthopaedics workshop

Participation

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Case study Age 59

Gender Female

Level of physical activity Low

Injury or complaint Knee pain

Comorbidities? Breast cancer – second time in left breast after 10 years and prophylactic mastectomy in right. Overweight.

Background Child care worker. Stiffness in knees, medial joint pain and supra-patellar pain 7/10, crepitus, antalgic gait, mild bowing, No night pain, now weight loss, no fevers. There is a suprapatellar swelling/effusion. Hip/groin pain occasionally, mild back pain she thinks from her work – similar to usual. No back tenderness

Question for the panel When do you order imaging?

Imaging Supplementary imaging is available by request

Case study Imaging


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Imaging

When and what

Imaging

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Imaging

When and what

Imaging

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Case study

Age 56

Female Female

Level of physical activity Mild

Injury or complaint Hips – pain worse in right side

Comorbidities? HTN, dyslipidaemia

Background Jane as had hip pain for 10 years, gradually worsening. Janes’s BMI is 23, non smoker, no ETOH. Jane lives with her husband and works as a receptionist. Her mother had similar OA, THR at 60 yrs of age.

Question for the panel What is the best day-to-day support for Jane, and when to refer to THR in public system if Janes does not have private health insurance.

Case studies Referral Process


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Timing of surgery

Current CPC

Referral process

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Referral

Triage OPD

OPSC

Surgeon

OT

More Info

Case study

Age 65

Gender Male

Level of physical activity Moderate

Injury or complaint Cannot play tennis

Comorbidities? Overweight

Background nil

Question for the panel What is the easiest way forward?

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Case studies Sport

Which one?

A- CBT

B- Weight Loss

C- Analgesia

D- Stop playing tennis

Sport

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Case study

Age 35

Gender Male

Level of physical activity Moderate

Injury or complaint ACL/MCL Rupture

Comorbidities? T2DM, Obesity

Background Poor compliance with DM meds, does realise importance but prefers exercise and is gaining weight due to inability to train

Question for the panel Suitable exercises pre and post – Surgery/Rehab. How long before can return to kick boxing

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Case studies ACL

ACL

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Case study 6

Age 46

Gender Female

Level of physical activity Moderate (3-4 per week)

Injury or complaint Bilateral foot pain – plantar fasciitis, pain and stiffness in foot and ankle joints, some degenerative joint issues.

Comorbidities? Overweight (actively reducing), Tibial nail (L) 12 yrs post tib/fib fracture, HLAB27 with family hx OA (Father Bilateral hip replacement by age 50) otherwise healthy. Occasional random localised tendinopathies, managed conservatively (wrist, shoulder, achilles).

Background Has had general foot pain 10+ years on-off proportionate to increased activity. Previous ballroom dancer but had to cease due to foot issues including ball of foot numbness and pain. Moreton’s neuroma excluded. Multiple alternative therapies trialled with limited success (podiatry, physio, needling/acupuncture, ESW, stretching and flexibility) but nothing long term. Weight loss is helping, but progress slowed by ongoing chronic foot pain during exercise. Is considering tibial nail removal.

Case studies IM Nail Removal


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Case study 6 continued

Question for the panel One therapist suggested foot issues may stem from rigidity in tibia, and lack of bone ‘flexibility’ during impact activities.

Is this a likely cause and what impact would removal of nail have on this? What is the success rate and recovery timeframes of tibial nail removal where the fibula was translocated?

What long term indications should be red flags for the patient given her HLAB27 status and family history?

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Case study

Age 65

Gender Female

Level of physical activity Difficulty in walking

Injury or complaint

Comorbidities? Biomechanical foot problems

Background Live in country, likes to keep fit and control wt, feeling flat as cannot walk

Question for the panel Ankle replacement or Arthrodesis as had an arthroscopy will get max one year out of it

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Case studies Ankle Arthritis

Non op

Operative

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Case study

Age 22

Gender Male

Level of physical activity High

Injury or complaint Playing soccer – ‘sprained ankle’

Comorbidities? Nil

Background Painful knee and ankle 3 weeks after ankle sprain

Question for the panel When to refer?

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Case studies Ankle

Maisonneuve

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Case study

Age 58

Gender Male

Level of physical activity Manages ADOL only

Injury or complaint Bilateral hip pain, osteoarthritis.

Comorbidities? CAD, Peripheral vascular disease

Background Awaiting clearance from cardiologist before orthopaedic surgeon can operate.

Question for the panel How do I manage his pain until hip replacement can be done?

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Case studies Pain Mx

Case study

Age 70’s

Gender Female

Level of physical activity Limited to housework

Injury or complaint B/L OA knee

Comorbidities? RA – managed with plaquenil and methotrexate, depression-Rx with Zoloft. Asthma Symbicort, cab a few years ago, recently presenting with unstable angina frequently and undergoing investigations for the same.

Background Her spouse has COPD and dementia, whom she looks after at home. Has adequate levels of at home care but spouse reluctant to use respite care. She does most of the chores at home, and has to help dress him or clean him if he soils his clothes. recent ESR and CRP normal. Uses Norspan 10 mcg patch weekly for management of pain from OA (both hips and knees)

Question for the panel How would you manage pain and persuade her to come off norspan when it manages her pain well to a level she can look after herspouse and do housework. Both are reluctant for him to move to aged care. They do not have any family living close by to look afterher husband.

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Case study

Age 71

Gender Male

Level of physical activity Low level physical activity, no pain at rest but significant pain on standing and walking

Injury or complaint Bilateral knee pain

Comorbidities? Nil

Background Worked as carpet layer for many years. Always on his knees. No injury but progressive bilateral

knee pain causing severe incapacity last 5-6 months. Past treatment simple analgesia+ local

heat + anti-inflammatory mediation but poor pain relief.

Xrays show bilateral marked degenerative osteoarthritis medial and lateral compartment as

well as patello-femoral. Suitable candidate for total knee replacement. Referral to local

hospital for orthopaedic assessment for TKR. Intra-articular HCLA offered and carried out

giving good immediate relief but unfortunately of short duration any by 6 weeks the pain had

returned to pre-injection levels. The hospital has notified that he has been placed on category

3 with a 12 month wait period.

Question for the panel Analgesia not helping. started with physiotherapy with the aim of increasing strength and

range of movement ( and ? gain some pain

relief). Given Tramadol 100mg x1 daily. So far ( at 3 weeks ) physiotherapy has given

improvement in the range of movement but minimal effect on pain level.

How do we best manage pain while waiting for surgical treatment?

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Non Pharmacological

CBT

Land based exercises

Exercise bike simplest

?Taping / braces / insoles

Pharmacological

Paracetamol

NSAIDS

Opioids

IA Steroids and others /Oral

others?

Pain Management

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Case study

Age 49

Gender Male

Level of physical activity Factory worker

Injury or complaint Left knee pain

Comorbidities? Obesity

Background 2d onset of left knee pain , progressed to a severe pain. Associated swelling and redness in second day. Painful to weight bear. Nopast h/o knee injuries

Question for the panel What are the inflammatory conditions which should be considered in Rx ?

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Case studies Inflammatory

Inflammatory Conditions

Monoarthralgia

Septic, Reactive, Crystal

PVNS, trauma

Polyarthralgia

RA – Morning stiffness,3 joints, Symmetrical, Hand joints, Nodules, RF, Xray

Inflammatory

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Case study

Age 52

Gender Female

Level of physical activity Good

Injury or complaint Painful hip region

Comorbidities? Otherwise fit

Background Has had a THR and a bleed in the gluteus medius from ? Movement strain

Question for the panel For the other hip she has had especially lateral pains. What are the best exercises, stretches and modalities for management: ? Orthotics helpful

Case study Troch bursitis


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Trochanteric Bursitis

(Gluteus Medius Tendinopathy)

Trochanteric Bursitis

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Case study

Age 63

Gender Male

Level of physical activity Active. He enjoys walking, running and skiing

Injury or complaint Bilateral hip pain. Limiting activities and nocturnal waking due to pain.

Comorbidities? Hyperlipidaemia - Takes Rosuvastatin.

Background as aware of hip pain in his late 30's. He has maintained his exercise until now, however, his

ability to exercise has become compromised due to his bilateral hip pain. He is 188cm tall,

weighs 82 k. He walks with antalgic gate and has stooped posture due to fixed flexion

deformity which on the left is 15 degrees and on the right is 5 degrees. He appears to have a

pelvic tilt with elevation on the right side, probably due to his contracture. He has severe

obligatory external rotation of both hips - left greater than the right. He only has a further 10

degrees of rotation bilaterally. Provocation causes significant discomfort, and he has no

neuro-vascular deficits. Pelvic and hip X-rays show severe advance OA

Question for the panel Which operative procedure is most appropriate for this patient?

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Case studies Hip

Case study

Age 82

Gender Female

Level of physical activity Mobilised with walking stick

Injury or complaint Left knee pain

Comorbidities? MI, HTN, T2DM, osteoarthritis

Background Left TKR 2013MI 2007, stent in LAD

Question for the panel Best effective non-surgical treatment options for high risk patient with chronic knee pain. Is there any role for intra articular infections (stem cells or platelet rich plasma/PRP)?

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Case studies - Injections

PRP

Stem Cells

Collagen (Synvisc)

Steroids

Injections

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Case study

Age 45

Gender Female

Level of physical activity Limited

Injury or complaint Shoulder weakness and pain

Comorbidities? T2DM, obesity,

Background Difficulty working, overhead activities

Question for the panel What is the best way to manage if you suspect a cuff tear?

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Case studies Shoulder

Cuff tear

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Case study

Age 75

Gender Female

Level of physical activity Limited

Injury or complaint Shoulder pain

Comorbidities? Renal impairment

Background Slow deterioration in shoulder function associated with pain. Hard to function with ADL’s, and household chores

Question for the panel When to do a shoulder replacement, what’s the difference between reverse and standard shoulder replacement.

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Case studies Shoulder

Shoulder OA

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Case study

Age 52

Gender Female

Level of physical activity Limited – frequent rets required

Injury or complaint Knee pain

Comorbidities? T2DM, obesity, anticoagulation therapy

Background Weight increasing due to decreased physical activity

Question for the panel How to manage OA when in combination with obesity.

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Case studies Obesity

Case study

Age 60

Gender Female

Level of physical activity Working full time, but no other forms of physical activity

Injury or complaint Hip pain that has prevented her from going to work

Comorbidities? Obesity with a lap band already in place

Background Ultimately she has had a hip replacement with good results, however remains obese.She is planning to take her superannuation to have further bariatric surgery for the weight as her other hip is also giving her pain.

Question for the panel Would it have been more appropriate to have this patient lose weight first, before the first hip replacement?

Why is there not more emphasis on weight loss programs to allow this to occur, which would most likely reduce the health cost?

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Case studies Obesity

Obesity

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Obesity and Arthritis

Thanks

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Mater GP Education Orthopaedics workshop · Monoarthralgia Septic, Reactive, Crystal PVNS, trauma...

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