Treatments of Hip and Knee Arthritis by EBJ Proliance Surgeons
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Treatments of Hip and Knee Arthritis
Bill K. Huang, MDEverett Bone and Joint
Providence Regional Medical Center Everett
Background
• Board-certified orthopedic surgeon• Fellowship training in adult joint reconstruction• Clinical focus
– Hip and knee arthroplasty– Revision hip and knee arthroplasty– Resurfacing arthroplasty– Cartilage allograft
Practice Philosophy
• To provide latest, safest, and the most comprehensive care to patients with hip and knee arthritis
• To help hip and knee arthritis patients to return to normal functions
• To listen to concerns, welcome input and feedback
Objectives
• Review the background of arthritis and joint replacement
• Review treatment alternatives• Introduce surgical concepts• Answer questions
What is arthritis?
They all have arthritis
Major cause of lost work time and serious disability
Articular Cartilage
• “ ..ulcerated cartilage is universally allowed to be a very troublesome disease…when it is destroyed, it is never recovered…” William Hunter 1743
Arthritis• Loss of cartilage in a
joint– Pain– Inflammation– Stiffness
Arthritis• Pain• Stiff• Swollen• Loss of functions
– Walking– Climbing stairs– Putting on socks
• Declining quality of life
Normal Functioning Joint(A joint is where the ends of two or more bones meet)
• Healthy cartilage• Well lubricated• Full motion• Pain free
Arthritic Joint
• Damage to cartilage• Loss of lubricating mechanism• Loss of motion• Pain
Types of Arthritis
• Osteoarthritis (OA)– Most common – Slowly progressive, degenerative, cartilage gradually
wears away– Middle-aged and older people
• Inflammatory arthritis– Most common is called rheumatoid arthritis (RA)– Inflammatory condition that destroys joint cartilage– Can occur at any age, multiple joints affected
• Post-traumatic arthritis – Develops after an injury, usually many years after– Similar to osteoarthritis
Osteoarthritis
• Multifactorial disease of the joint– Abnormal anatomy– Genetics– Abnormal biology– Overuse
Diagnosis
• History• Physical
examination• X-ray• MRI
Normal Hip
Osteoarthritc Hip
Normal Knee
Osteoarthritic Knee
Arthritis Progression
• Early stages may show no symptoms
• Subtle changes on X-ray• Most over age of 60 will show
X-ray changes– 1/3 shows symptoms
Arthritis Progression
• Cartilage begins to soften• Lose ability to absorb impact• More easily damaged by use
or injury• May completely wear away
– “bone on bone”• Joint loses its shape
Arthritis Progression• Bony erosion• Deformity
– “bow-legged” – “knock-knee”
• Contracture– Inability to fully straighten or
bend
How can my life change with treatment?
• Change in pain symptoms• Return to mobility• Regaining a sense of your former lifestyle
Treatment Plan
• Patient education• Weight reduction• Activity modification• Medication• Ambulation aid• Surgery
Conservative, non-surgical
Surgical
Analgesics
• Provides pain relief• Does not reduce inflammation• Non-narcotic• Narcotic• Discuss options with your
physician
Non-steroidal Anti-inflammatory (NSAIDS)
• Relief can take several months
• Many varieties– Over-the-counter– Prescription
• Marketing has become very overbearing
• Discuss options with your physician
Non-steroidal Anti-inflammatory (COX-2)
• COX-2 inhibitors• Marketed heavily• NOT more effective than older
drugs• Slightly less GI side effects• Discuss options with your
physician
Glucosamine/Chondroitin Sulfate
• Does it grow new cartilage?– No– May be anti-inflammatory– No uniform standards– Few side effects– Not FDA approved
Cortisone Injections
• Steroid injection with local anesthetic• Anti-inflammatory at site of problem• Variable pain relief (few days to months)• Law of diminishing returns• No more than 3-4 per year
Lubricating Injections
• Approved for knee arthritis only
• “rooster comb” shots• Hyaluronan• Series of injections• Variable pain relief
– Works better in mild to moderate arthritis
• Small chance of reaction
Arthroscopy Surgery
• Less invasive– Faster recovery
• Remove damaged tissue
• Variable effectiveness in treatment of arthritic joints– At best, temporary relief
Replacement Surgery
• Total hip replacement• Hip resurfacing• Total knee replacement• Partial knee replacement
FactsIn 2003, more than 638,000 hip or knee replacement surgeries were performed.The number of joint replacements continues to go up each year.
Baby boomers fueling boom in knee, hip surgeriesMay 23, 2011 11:38 AM ETSAN DIEGO (AP) - We're becoming a nation of bum knees, worn-out hips and sore shoulders, and it's not just the Medicare set. Baby boomer bones and joints also are taking a pounding, spawning a boom in operations to fix them.Knee replacement surgeries have doubled over the last decade and more than tripled in the 45-to-64 age group, new research shows. Hips are trending that way, too.
Projected Hip and Knee Replacements in USA
Kurtz et al. JBJS 2007
Goals of Joint Replacement Surgery
• Relieve pain• Improve motion• Return to more active/ fulfilling lifestyle• Improve quality of life
Should I have a joint replacement?
• YES, if:– “conservative treatments of my arthritis have
failed”– “the quality of my life is affected by joint pain”– “I understand the procedure, its expected
outcome, and risks ”
Should I have a joint replacement?
• NO, if:– “my family says I should have it”– “my friends say I should have it”– “I better get it done before it gets too bad”– “I better get it done before I get too old”
Getting Ready for Surgery• Evaluation by internist
– Pre-admission clinic (PACS)– Primary care MD
• Meet with therapist and case manager– Evaluate need for home
therapy vs. rehabilitation after surgery
– Joint Replacement Class• Anemia evaluation• Prepare for homecoming
after surgery
Hip Replacement
Hip Replacement• Incision made on the
side of the thigh• Socket is re-shaped to fit
new cup implant that replaces the diseased socket
• New cup is placed in the socket
Hip Replacement• Femur is prepared
for the stem• Hip stem is
implanted and the ball is put in place on top of stem
• Incision is closed
Hip Replacement
“minimally invasive” arthroplasty
• Misnomer– “Nothing minimally invasive about cutting out a
joint”• Incision size is not the most important• Tissue preservation
– Detach or split muscles ?– Inter-muscular plane ??
• Post-operative management– Multi-modal pain control
Muscle sparing approach – total hip
• Direct Anterior– Preservation of hip
deltoid – Inter-muscular plane
• Between sartoris and tensor fascia lata
• Traditional– Muscle splitting
• Gluteus maximus– Detach muscle from
trochanter• Posterior – short
external rotators• Anterorlateral –
gluteus medius
Direct Anterior Approach
Potential Benefits – Anterior Approach
• Improved hip stability– Lower dislocation rate
• Anterior – < 0.5%• Traditional 2 to 5%
• Faster recovery due to preserved muscle attachment
• Accurate implant placement– Intra-operative X-ray guidance
Matta JM et al. CORR 2005
• Improved materials– X-linked plastic
• Newer bearings– Metal articulation– Ceramic articulation– Oxinium
• Improved technology– Larger femoral head
Too “young” for hip replacement?
Better Longevity
• Significantly better laboratory wear results– Possible longer implant life
• Improved bio-mechanics– More stable joint
• Does have potential down side– Metal ion issues in metal on
metal total hips
Hip Resurfacing
• A form of total hip replacement• Femoral head is preserved• Not everyone is a candidate• metal-on-metal articulation• Discuss with your physician
Hip Resurfacing vs. Hip Replacement
Birmingham Hip Resurfacing
• FDA approved 2006• 10+ years of clinical data
in Europe and Australia– Approx. 96% survivorship
• Many live a very active life style
“recalled” Total Hips• Involves only metal-on-metal total hip
systems• Failure due to metal ion sensitivity
Knee Replacement
The most commonly replaced joint in the human body!
Knee Replacement
• damaged parts of your knee that need repair will be removed
• replaced with metal and plastic implants.
• an implant, especially selected to match your anatomy
Knee Replacement
• The damaged portions of the femur and cartilage are cut away.
• The end of the femur is reshaped to allow the metal femoral component to fit onto it.
Knee Replacement
• The damaged area of the tibia and cartilage are cut away. The tibia is reshaped to receive the metal tibial component.
Knee Replacement
• The metal baseplate is cemented in place and the plastic insert is snapped in to the baseplate.
Advances for “Younger” Patients
• Mobile-bearing– Designed to rotate as
it bends– Imitates natural knee
movement– Possible better wear
Improved Material
• Oxidized zirconium (Oxinium)– Ceramic-metal composite– Better wear rate in
laboratory study• Simulated up to 30 years of
wear• Advertised as “30-year” knee
Improved Techniques
• Mini-Incision Replacement• “minimum invasive”• Reduces incision length and
scar to 3.5 to 4 inches.• Does not “evert” the patella • Less damage to quad tendon• Possible post-operative pain • Likely to speeds rehabilitation
time and returns you to your life more quickly.
Improved Techniques• Computer Navigation
– Define anatomy during surgery
– Guides alignment
Improved Techniques• Computer Navigation
– Intra operative feed back to surgeons
Improved Techniques• Robot assisted Surgery
– “Makoplasty”• Possible improved accuracy• Not proven to be better• Longer surgery time
“Customized” surgery• Customized instruments to fit
the patient’s knee• NOT fitting patient’s knee to
fit a set instruments
“Customized” surgery• Patient-matched Technology
– Use MRI and special X-ray to create a computer model of patients knee
– Custom guides & instruments to match patient’s exact shape and anatomy
– Accurately aligned knee specific to individual’s anatomy
“Customized” surgery• Improve accuracy and
alignment• Decrease surgical time
– Less anasthesia– Decrease risk of infection
• Possible improve long term performance of the prosthesis
“Customized” surgery
Partial Knee Replacement• “Uni”, “Partial”• Less invasive surgery• Replace only damaged
portion of joint• Bone conservation• Typically faster recovery• Not everyone is a
candidate
Unicompartmental Replacement• Either medial or lateral• Preserve patients ligaments
– ACL and PCL
Patellofemoral Replacement• Isolated knee cap arthritis is
replaced• Normal cartilage preserved
Cartilage Transplantation
• Only certain patient• Younger age
Cartilage Transplantation
Cartilage Transplantation
Osteochondral allograft
Changing Expectations
• Patient expectation– Complete pain relief– Quick recovery
• Return to mobility– High activity level such
as sports• Regaining a sense of
former lifestyle
Summary• Very successful surgery• Reliable, predictable outcome• Excellent long-term results• Tremendous improvement
in patient’s quality of life
Summary
• Improved materials• Better techniques• Expanded indications for
“younger” patients with hip and knee arthritis
• Maintain an ACTIVE lifestyle
THANK YOU
Bill K. Huang, MD
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