Introduction to Orthopaedics: OPTIONS FOR HIP AND KNEE ARTHRITIS Stephen P. England, M.D. Park Nicollet Orthopedics
Dec 17, 2015
Introduction to Orthopaedics: OPTIONS FOR HIP AND KNEE ARTHRITIS
Stephen P. England, M.D.Park Nicollet Orthopedics
What is Arthritis? Wear/loss of articular cartilage Similar to wearing the tread off a car
tire Osteoarthritis – wear and tear / aging Inflammatory arthritis – systemic
disease Post-traumatic arthritis – following injury Others
How can I prolong the life of my hip or knee? Weight Management Activity Modification Medications – Systemic Inflammatory
Arthritis Glucosamine ??
What can help me live with my pain? Weight Management Activity Modification – Bike, Swim Physical Therapy – Motion, Strength Assistive Devices – Cane , Crutches,
Walker, Scooter, Wheelchair
What can help me live with my pain? Oral Medications
Analgesic – Over the Counter, Prescription Glucosamine/Chondroitin Other “Alternative” Treatments
Injectable Medications Cortisone Synvisc, Hyalgan
Braces
Unloader Brace Shifts weight off bad side of knee over
to good side of knee Must have a good side Must be willing to wear
brace(cumbersome) Best for those who enjoy specific
activities – Golf, Tennis, Hiking, Walking
QUESTIONS
NON-SURGICAL OPTIONS
How do I know when to have surgery? Need a diagnosis – Not all joint pain
is caused by arthritis, not all arthritis is the same
Fibromyalgia Not surgically treatable Makes surgery less predictable
History, physical exam, x-ray Plain x-ray usually sufficient to make
the diagnosis MRI and other tests occasionally
helpful
How do I know when to have surgery? Decision is almost always up to the
patient M.D. should lay out the options,
surgical and non-surgical M.D. may give advice, but should
rarely tell you what to do – it’s your choice
Others may help you decide (friends, family, primary care physician), but ultimately you make the call
Consider the following questions
Procedure Questions What exactly is the procedure? What are the goals? How likely is it to work? What is the recovery like? What are the risks/complications? What are my other options?
Personal Questions What is my age? What is my occupation? What activities do I enjoy? What health problems do I have and
how do these affect my surgical risk? What support system do I have to
help me during recovery?HOW MUCH PAIN AND
DISABILITY DO I HAVE?
Surgical Options Arthroscopy Osteotomy Arthrodesis (Fusion) Arthroplasty (Replacement)
HIP Osteotomy, arthrodesis, arthroscopy
rarely used Arthroplasty common
KNEE Arthroscopy common Osteotomy – popularity waxes and
wanes Arthrodesis – rarely used Arthroplasty - common
Arthrodesis (Fusion) Eliminates pain Creates a different disability Lasting result Commonly used before arthroplasty
developed Young patient – heavy, laborer Salvage - infection
Osteotomy Used most commonly in the knee Shifts weight from bad side of joint to
good side (like unloader brace) Must have a good side of the joint Not appropriate for systemic
inflammatory arthritis
Osteotomy Most commonly done by removing a
wedge of bone from femur or tibia and placing a plate to hold bones in place
Young patient trying to avoid arthroplasty
Intended as a temporizing procedure, not a permanent solution - reported results variable
Takes a long time to recover – crutches, brace, therapy
Osteotomy Not as popular currently as durability of
arthroplasty improves May make subsequent arthroplasty
more difficult
QUESTIONS
ARTHRODESISOSTEOTOMY
Arthoscopy Visualize joint through a fiberoptic tube
inserted through small skin incision Common in knee, uncommon in hip
(technically difficult) Arthoscopy is a way of doing an
operation, NOT the operation itself, which may involve many things – DON’T COMPARE YOURSELF TO OTHERS!
Arthroscopy Other small incisions – insert shavers,
cutting devices, graspers Smooth joint surfaces Trim meniscus tears Remove loose bodies Remove diseased synovium – systemic
inflammatory arthritis
Arthroscopy Brief day surgery procedure Various anesthetics, frequently regional Minimal risks/complications Recovery varies but usually fairly rapid –
return to activities as tolerated Doesn’t burn any bridges Helps evaluate the status of the joint,
may help guide future treatment decisions
Arthroscopy Results UNPREDICTABLE! Works best with less advanced arthritis Two specific groups do best
Sudden symptom change – goal is to return to baseline (not eliminate all pain)
Strong catching/locking symptoms – goal is to stop catching/locking (not eliminate all pain)
QUESTIONS
ARTHROSCOPY
Arthroplasty (Replacement) One of the most successful operations in
all of medicine Modern form originated in 60s and 70s Over 500,000 hips and knees done each
year in the U.S.
What is the procedure? Hip – Socket replaced with metal and
plastic socket, ball replaced with metal ball attached to stem that goes down the femur
Knee – End of femur covered with metal cap, top of tibia covered with metal and plastic plate, patella resurfaced with plastic button
What are the goals of the procedure and how likely is it to work? Pain relief – very reliable Functional improvement – reliable but need
to consider other factors which may limit function (other bad joints, poor balance, deconditioning, medical problems)
Good and excellent results 95% - 97%
What are the complications/risks? Infection Bleeding / need for transfusion Nerve injury “Blood Clots” – DVT, PE Anesthesia – regional techniques
(spinal, epidural) becoming more common
Dislocation (Hip) Differing leg lengths (Hip) Stiffness (Knee)
What are the complications/risks? Many complications related to medical
conditions / health problems Even the most healthy patient can
suffer a complication
Long Term Problems The replacement is a mechanical device
with a limited lifespan Failure eventually results in pain Revision surgery has higher complication
rates and lower success rates Will I need a revision procedure?
How long will I live? How long will it last? (guess = 10-20 years)
What is the recovery like? Historically long and difficult, but variable Surgery 1-2 hours Hospital 3-4 days Home or transitional care A lot of Rehab (especially knees) Walker/crutches 2-3 weeks, Cane 3-4 weeks Limited only by your pain and ability to
progress May improve for up to one year
What is the recovery like? Newer techniques may offer more rapid
and less painful recovery “MIS” = “Minimally Invasive Surgery” Better term = “LESS Invasive Surgery” Same operation through smaller incision Not appropriate for all patients ? Not appropriate for all surgeons - ?
Higher complication rate An easier recovery is nice, but cannot
compromise the reliable long term success seen historically
QUESTIONS
ARTHROPLASTY
“What do you recommend, Doctor?”Know your diagnosisKnow your options, surgical and non-surgicalKnow yourselfSeek advice from others – primary M.D.Ask your surgeon questions Trust your instincts – make sure you feel
comfortable with your choice and your surgeon
It’s YOUR decision (almost always)
THANK YOU !