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2015: Osteoarthritis and Total Joint Replacement-Meyer


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Osteoarthritis and Total Joint Replacement

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2015: Osteoarthritis and Total Joint Replacement-Meyer

  1. 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
  2. 2. Disclosures • None
  3. 3. Overview of Osteoarthritis • 27 million Americans with osteoarthritis • 1/3 adults >age 60 have knee OA • #1/#2 cause of disability • Limits activities of daily living (ADL’s) • $128 billion to US economy –Medical care –Lost wages/productivity
  4. 4. 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
  5. 5. Overview of Osteoarthritis • Causes –Hereditary (genetic predisposition) –OBESITY –Post-traumatic –Aging
  6. 6. Workup • Plain xrays – Knee »STANDING AP!!!!! »Lateral »Merchant/Sunrise »Consider Rosenberg view
  7. 7. Workup • Plain xrays – Hip »AP pelvis »AP/Lateral hip »Not typically weight bearing
  8. 8. AP Pelvis
  9. 9. AP Pelvis
  10. 10. AP Pelvis
  11. 11. Weight-Bearing Xrays
  12. 12. Weight-Bearing Xrays
  13. 13. Merchant View
  14. 14. Rosenberg View 30 deg
  15. 15. Rosenberg View
  16. 16. 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
  17. 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
  18. 18. Management of OA
  19. 19. Management of OA
  20. 20. Management of OA • OARSI – Non-pharmacologic » Patient education – self help, patient driven » P.T. – HEP, strength training » Aerobic exercise – JUST LIKE LBP!! » Aqua exercise » Weight loss » Bracing/Sleeves/Shoe inserts » Cane » Tens » Acupuncture Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Uncertain Uncertain
  21. 21. Management of OA • OARSI – Pharmacologic » Acetaminophen » NSAIDS » Topical NSAIDS » IA steroid injections » IA hyaluronate injections » Glucosamine/CS » Weak opioids • Only if non-opioids failed • Stronger opioids only in exceptional circumstances Appropriate Appropriate Appropriate Appropriate Uncertain Uncertain Uncertain
  22. 22. Management of OA
  23. 23. 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.
  24. 24. 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
  25. 25. 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
  26. 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. 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. 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. 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
  30. 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. 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. 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. 33. Management of OA • No benefit to arthroscopy compared to P.T. and medical therapy
  34. 34. Management of OA • Mensicus tears COMMON in OA of the knee –81% of surgical patients had debridement of meniscus
  35. 35. Management of OA • Attributing pain to meniscus tear is difficult –52% had catching/locking –88% joint line pain
  36. 36. Management of OA • No difference at 6 months • 30% cross-over • Bottom line – try physical therapy first
  37. 37. Management of OA • Total Joint Arthroplasty
  38. 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. 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
  40. 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!
  41. 41. Total Joint Arthroplasty • Widely successful • Rapid improvement in pain/function (90%) • Durable
  42. 42. 68 yo male
  43. 43. 6 weeks postop
  44. 44. Overview of Total Joint Replacement The Perfect Operation?
  45. 45. How long do they last?
  46. 46. How long do they last?
  47. 47. How long do they last?
  48. 48. How long do they last? • In general total hips and knees fail about 0.5% to 1% per year (durable!)
  49. 49. Why do they fail? • Knee –Infection 25% –Implant loosening/breakage 20% • Hip –Dislocation 22% –Implant loosening 20% –Infection 15%
  50. 50. 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
  51. 51. 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
  52. 52. 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
  53. 53. Referral Criteria • Osteoarthritis Hip and Knee –Total Joint Arthroplasty (TKA, THA) »Significant OA (complete JS loss) »BMI <35 – 40 (depends) »Failed reasonable non-operative treatments »Non smoker »Active and conditioned
  54. 54. Referral Criteria • Osteoarthritis Hip and Knee –Total Joint Arthroplasty (TKA, THA) »Minimal opioid use - detox »Stable medical conditions »Stable psychiatric conditions – motivated »Patient desire! »Age NOT contraindication •Younger – more strict criteria
  55. 55. Referral Criteria It is apparent that the risk of infection, morbidity and mortality is markedly increased by co-morbid conditions. Any of the following conditions will typically render a patient not eligible for an elective total joint replacement due to the high risk of complications.
  56. 56. Referral Criteria 1. Morbid obesity – BMI over 40 (although most patients will be counseled to have BMI <35) 2. Uncontrolled diabetes mellitus: Hgb A1c > 8 3. Active smoking – patients should be willing to quit at least 4-6 weeks prior to surgery (in most cases) and must be tobacco free for 6 weeks postop 4. Drug/Alcohol abuse – must clean/sober for 6 months 5. Homelessness – must have a clean and safe environment in which to recover
  57. 57. Referral Criteria 6. Patients on large doses of opioids for arthritis (must be willing to taper off). Patients on chronic opioid therapy for other chronic pain syndromes are typically not included in this group 7. Active infection elsewhere – dental (broken, loose, infected teeth or periodontal disease), skin, urinary tract, etc 8. Malnutrition and/or significant de-conditioned state 9. Active malignancy undergoing chemotherapy 10. HIV with CD-4 count < 200 and/or high viral load
  58. 58. Referral Criteria 11. Severe COPD 12. Skin lesions at or near the operative site 13. Venous stasis with recurrent ulcerations or cellulitis 14. Alzheimer’s disease (most cases)
  59. 59. 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
  60. 60. 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 – No smoking – Weight loss – Drug and alcohol free – Medical co-morbidities stable – able to participate in rehab – Stable psychiatric and social situation – Motivated • Complications/poor outcomes can be disastrous
  61. 61. Thank You! Questions?