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2016: Osteoarthritis and Total Joint Replacement-Meyer
- 1. OSTEOARTHRITIS AND TOTAL JOINTREPLACEMENT 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
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- 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
- 7. Overview of Osteoarthritis •Causes –Hereditary (genetic predisposition) –OBESITY –Post-traumatic –Aging
- 8. Workup • Plain xrays –Knee »STANDING AP!!!!! »Lateral »Merchant/Sunrise »Consider Rosenberg view
- 9. Workup • Plain xrays –Hip »AP pelvis »AP/Lateral hip »Not typically weight bearing
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- 15. Workup • MRI isNOT 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. • 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
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- 19. 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
- 20. 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
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- 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
- 37. Management of OA •Total Joint Arthroplasty
- 38. Overview of TotalJoint 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 TotalJoint 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 TotalJoint Replacement • Future demand? –By 2020: »1.4 million TKA »500,000 THA »200,000 revisions –By 2030: »4.5 million total joints!
- 41. Total Joint Arthroplasty •Widely successful • Rapid improvement in pain/function (90%) • Durable
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- 46. Overview of TotalJoint Replacement The Perfect Operation?
- 47. How long dothey last?
- 48. How long dothey last?
- 49. How long dothey last?
- 50. How long dothey last? • In general total hips and knees fail about 0.5% to 1% per year (durable!)
- 51. Why do theyfail? • Knee –Infection 25% –Implant loosening/breakage 20% • Hip –Dislocation 22% –Implant loosening 20% –Infection 15%
- 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 • Patientsatisfaction – 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 TotalJoint 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/TKAReferral 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
- 81. Summary • OA ischronic 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 jointarthroplasty 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
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