General Orthopedics

Topics

• Amputations 

• Chronic Inflammatory Conditions 

• Complementary and Alternative Treatment of Osteoarthritis 

At the end of this week, participants will be able to understand the following key elements:

• Describe the assessment, management and treatment of patients with amputations 

• Discuss chronic inflammatory conditions  

• Identify complementary and alternative options for the treatment of osteoarthritis.  

Assignments/Readings  

Section 1 Pages:  15-58 

Case Study Assignment 

Discussion Board Participation 

Case Study Week 3 - All case study assignments must be emailed to kmmyrick@mgh.harvard.edu) by 11:59 PM the evening before our live session.

Case Study: Treatment of Osteoarthritis in a 72-Year-Old Male

Patient Profile:

- Name: Mr. John Mitchell

- Age: 72 years

- Occupation: Retired school teacher

- Past Medical History: Hypertension, type 2 diabetes, chronic kidney disease (stage 3), history of peptic ulcer disease

- Family History: Father had osteoarthritis

- Medications: Metformin 500 mg BID, lisinopril 10 mg daily, omeprazole 20 mg daily

- Social History: Former smoker (quit 10 years ago), drinks alcohol occasionally, walks for exercise 3 times per week

Chief Complaint:

Mr. Mitchell presents with worsening right hip pain over the last 3 years. He describes the pain as constant, aching, and worse with activity. It is now affecting his ability to walk and perform daily tasks. He denies any significant trauma to the hip.

History of Present Illness:

- The pain started gradually and has progressively worsened over time.

- He experiences stiffness in the morning, lasting about 20 minutes, which improves with movement.

- Over-the-counter acetaminophen provides limited relief, and NSAIDs were previously used but discontinued due to concerns about his kidney disease and history of peptic ulcer disease.

- He is interested in exploring treatment options, but he is concerned about the safety of medications given his chronic conditions.

Physical Examination:

- BMI: 28 kg/m² (overweight)

- Vital Signs: BP 142/88 mmHg, HR 80 bpm, RR 16/min

- Examination of the right hip shows:

  - Tenderness over the anterior and lateral aspects of the hip joint

  - Decreased range of motion, particularly with internal rotation and abduction

  - No signs of erythema or warmth

  - Mild antalgic gait noted

Imaging:

- X-ray of the right hip shows moderate osteoarthritis with joint space narrowing and osteophyte formation.

Diagnosis:

Osteoarthritis of the right hip

Treatment Considerations:

Mr. Mitchell has multiple comorbidities, including chronic kidney disease, hypertension, and a history of peptic ulcer disease, which limit the use of certain medications like NSAIDs. He has tried acetaminophen with minimal success and expresses interest in understanding his pharmacologic and non-pharmacologic treatment options.

Questions for Case Assessment:

1. What are the key factors from Mr. Mitchell’s medical history that would influence your choice of pharmacologic treatment for his osteoarthritis, and why are these factors important?

2. Given Mr. Mitchell’s comorbid conditions, what medications would you avoid, and what alternatives would you consider for managing his osteoarthritis pain?

3. Describe non-pharmacologic treatment strategies that would be appropriate for Mr. Mitchell’s osteoarthritis. How would these options complement or replace pharmacologic treatment?

4. What role do intra-articular corticosteroid injections or other interventional treatments play in managing osteoarthritis in older adults with multiple comorbidities, and when would these options be appropriate?

5. Considering Mr. Mitchell’s medical history and functional limitations, when would surgical options, such as hip replacement, be indicated? What factors would guide your decision-making in recommending surgery?