2016: Osteoarthritis and Total Joint Replacement-Meyer
1. OSTEOARTHRITIS AND TOTAL
JOINT REPLACEMENT
R. Scott Meyer, M.D.
Section Chief, Orthopaedic Surgery
VA San Diego Healthcare System
Clinical Professor
Department of Orthopaedic Surgery
UC San Diego Health System
3rd Annual Clinical Geriatrics
Interprofessional Symposium
December 3, 2016
3. Overview of Osteoarthritis
• 27 million Americans with osteoarthritis
• 1/3 adults >age 60 have knee OA
• Knee > hip (3x)
• Women > men
4. Overview of Osteoarthritis
• 22% of all ambulatory care visits
• $128 billion to US economy
–Medical care
–Lost wages/productivity
5. Overview of Osteoarthritis
• Limits activities of daily living
• #1 cause of disability
• Excess mortality compared with
general population
6. Overview of Osteoarthritis
• OA is a disease with NO cure
• No disease modifying drugs
• Treatment for early OA
–Prevent disease progression
• Late disease is NOT just a cartilage problem
–Deformity
–Ligaments
–Bone loss
–Stiffness
15. Workup
• MRI is NOT indicated in moderate/severe OA
• MRI is RARELY indicated in mild OA
– Symptomatic meniscus tear
»Difficult to distinguish clinically
»Common, incidental finding
»Even if meniscal tear is diagnosis still
require standing plain xrays of knee
16.
17. • MRI report
– ACL tear
– Macerated, complex tear of the medial meniscus
– Complex tear of the lateral meniscus
– Signal change in the MCL consistent with partial tear
– Subchondral bone edema and cysts
– Ganglion cyst adjacent to the PCL
– Large popliteal cyst
– Multiple intra-articular bodies
– Large joint effusion
– Diffuse synovial hypertrophy
SEVERE OSTEOARTHRITIS
OF THE KNEE
22. Management of OA
• AAOS Guidelines SOR
1. Self-management educational program Strong
2. Weight loss Moderate
3. Against use of acupuncture/tens/manual Strong
4. Bracing Inconcl.
5. NO lateral heel wedge Moderate
6. No glucosamine/CS Strong
7a. NSAIDS or Tramadol Strong
7b. Tylenol, opioids, pain patches Inconcl.
8. Intra-articular steroids Inconcl.
23. Management of OA
• AAOS Guidelines SOR
9. No HA injections Strong
10. PRP or growth factor injections Inconcl.
11. No needle lavage Moderate
12. No arthroscopy for debridement Strong
13. Arthroscopic meniscectomy Inconcl.
14. Osteotomy Limited
15. No uni-spacer Consensus
24. Management of OA
• HA injections
– AAOS recommends against
» Older supportive studies flawed – publication bias
» MCII (minimum clinically important improvement)
» Recommendation controversial, criticized
• Works for my patients!
• Many studies show efficacy
– 10 CPG: 30% yes, 30% no, 40% inconcl.
– Better studies needed
– Still used widely by surgeons and others
25. Management of OA
• PRP/MSC injections
–Meheux et al. Systematic
Review (Arthroscopy 2016;32(3):495)
»Efficacy up to 12 months
»Better than HA
–Expensive, not covered by
insurance
–What are they doing??
26. Management of OA
• Obesity and OA
–Direct link, particularly with knee OA
–Forces across knee 3X BW with
walking, 6X BW with stairs
–Mal-alignment magnifies the problem
–NOT JUST MECHANICAL
27. Management of OA
• Obesity and OA
–Systemic component
–Fat is an endocrine organ
»Pro-inflammatory cytokines (adipokines)
»Elevated crp, IL-6, etc..
»MES (obesity, HTN, IR, dyslipidemia – now
add OA)
–Obesity linked with PAIN
»Tendons, fascia, FM
28. Management of OA
• Weight loss
–For 1 lb weight loss, 4 lb reduction knee load
»Messier et al. Arth & Rheum 2005
–Losing 11 lbs can reduce your risk of OA by 50%
»Felson et al. Ann Int Med 1992
–Losing 15 lbs can reduce pain by 50%
»Bartlett et al. Arth & Rheum 2004
29. Management of OA
• Weight loss
–Obesity is associated with other co-morbidities
which increase surgical risk
»DM, CAD, etc..
–Obesity increases perioperative risk of
»Infection
»Wound healing
»DVT/PE
–Most patients GAIN WEIGHT after surgery
30. Management of OA
• Opioid therapy
–OARSI - uncertain
–AAOS - Inconclusive
–Cochrane Review – da Costa et. al. 2009
»“The small mean benefit of non-tramadol
opioids are contrasted by significant
increases in the risk of adverse events.”
»“For the pain outcome in particular,
observed effects were of questionable
clinical relevance…” No MCID.
31. Management of OA
• Opioid therapy
–Surgery recommended in most cases of
severe OA
–VERY difficult postoperative care
–Many significant side effects
–Negative prognostic indicator for outcome
–Detox prior to surgery recommended
32. Management of OA
• Role for arthroscopy of the knee?
–Loose body
–“Intra-articular” bodies are incidental
–NOT for meniscus tears
if significant OA
33. Management of OA
• No benefit to arthroscopy compared to P.T.
and medical therapy
34. Management of OA
• Mensicus tears COMMON in OA of the knee
–81% of surgical patients had debridement of
meniscus
35. Management of OA
• Attributing pain to meniscus tear is difficult
–52% had catching/locking
–88% joint line pain
36. Management of OA
• No difference at 6 months
• 30% cross-over
• Bottom line – try physical therapy first
38. Overview of Total Joint Replacement
• 650,000 TKA per year (2010)
• 290,000 THA per year (2010)
–Kurtz et. al. JBJS AM 2014;96:624-630.
• Very high success rate (>90%)
• Significant positive impact on quality of life
39. Overview of Total Joint Replacement
• Low major complication rate (1%)
• Only 10% of patients will require revision
surgery
–10% of 1 million is 100,000 revisions
–Revisions are expensive and less
predictable outcome and more
complications
40. Overview of Total Joint Replacement
• Future demand?
–By 2020:
»1.4 million TKA
»500,000 THA
»200,000 revisions
–By 2030:
»4.5 million total joints!
50. How long do they last?
• In general total hips and knees fail
about 0.5% to 1% per year (durable!)
51. Why do they fail?
• Knee
–Infection 25%
–Implant loosening/breakage 20%
• Hip
–Dislocation 22%
–Implant loosening 20%
–Infection 15%
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61. Are patients happy?
• Outcomes THA
–90% patient satisfaction
–95% would undergo same operation again
• Outcomes TKA
–80% patient satisfaction
–90% would undergo same operation again
62. TKA Outcomes
• Patient satisfaction – why not everyone?
–Expectations
–Persistent pain
From: Scott et al. JBJS(B) 2010;92(9):1253-58
Bourne et al. CORR 2010;468:57-63
63. Overview of Total Joint
Replacement
• Patients must be properly indicated
• Not for everyone
• Still have not solved long term failures and need
for revisions
–Prosthetic joint infection
–Revisions are complicated
–Revisions have poorer outcomes
• Risks uncommon but can be devastating
64. THA/TKA Referral Criteria
• Significant OA (complete JS loss)
• BMI <35 – 40 (depends)
• Failed reasonable non-operative treatments
• Non smoker
• Active and conditioned
65. THA/TKA Referral Criteria
• Minimal opioid use (for OA) – detox
• Clean and sober for 4-6 months
• Stable medical conditions
• Stable psychiatric conditions – motivated
• Patient desire!
• Age NOT contraindication
–Younger – more strict criteria
–Eldery – consider comorbidities/dementia
66. • Nerve/vascular injury
THA/TKA Referral Criteria
Why so strict?
• DVT/PE
• Iatrogenic fracture
• Knee stiffness
• Infection
• Dislocation of hip
67. Prosthetic Joint Infection (PJI)
• Entire specialty meetings dedicated to PJI
• Entire textbooks dedicated to PJI
• Difficult and complicated problem to treat
• 5 YEAR SURVIVAL WORSE THAN 4 OF THE
5 MOST COMMON CANCERS
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81. Summary
• OA is chronic disease with no cure or
modifying treatments
• Need good plain xrays to determine
disease severity
• MRI not warranted in workup of OA
• Arthroscopic treatment for knee OA is rare
• Use published CPG for non-operative
treatments
82. Summary
• Total joint arthroplasty is a “powerful”
operation with predictable results in most
patients
• Exhaust all reasonable non-operative
treatments
• Patients should be “in shape” for surgery
• Complications/poor outcomes can be
disastrous
