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Treatments of Hip and Knee Arthritis by EBJ Proliance Surgeons
- 1. Treatments of Hip and Knee Arthritis Bill K. Huang, MD Everett Bone and Joint Providence Regional Medical Center Everett
- 2. 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
- 3. 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
- 4. Objectives • Review the background of arthritis and joint replacement • Review treatment alternatives • Introduce surgical concepts • Answer questions
- 6. They all have arthritis
- 7. Major cause of lost work time and serious disability
- 8. Articular Cartilage • “ ..ulcerated cartilage is universally allowed to be a very troublesome disease…when it is destroyed, it is never recovered…” William Hunter 1743
- 9. Arthritis • Loss of cartilage in a joint – Pain – Inflammation – Stiffness
- 10. Arthritis • Pain • Stiff • Swollen • Loss of functions – Walking – Climbing stairs – Putting on socks • Declining quality of life
- 11. Normal Functioning Joint (A joint is where the ends of two or more bones meet) • Healthy cartilage • Well lubricated • Full motion • Pain free
- 12. Arthritic Joint • Damage to cartilage • Loss of lubricating mechanism • Loss of motion • Pain
- 13. 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
- 14. Osteoarthritis • Multifactorial disease of the joint – Abnormal anatomy – Genetics – Abnormal biology – Overuse
- 15. Diagnosis • History • Physical examination • X-ray • MRI
- 16. Normal Hip
- 18. Normal Knee
- 20. 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
- 21. 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
- 22. Arthritis Progression • Bony erosion • Deformity – “bow-legged” – “knock-knee” • Contracture – Inability to fully straighten or bend
- 23. How can my life change with treatment? • Change in pain symptoms • Return to mobility • Regaining a sense of your former lifestyle
- 24. Treatment Plan • Patient education • Weight reduction • Activity modification • Medication • Ambulation aid • Surgery Conservative, non-surgical Surgical
- 25. Analgesics • Provides pain relief • Does not reduce inflammation • Non-narcotic • Narcotic • Discuss options with your physician
- 26. 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
- 27. 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
- 28. Glucosamine/Chondroitin Sulfate • Does it grow new cartilage? – No – May be anti-inflammatory – No uniform standards – Few side effects – Not FDA approved
- 29. 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
- 30. 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
- 31. Arthroscopy Surgery • Less invasive – Faster recovery • Remove damaged tissue • Variable effectiveness in treatment of arthritic joints – At best, temporary relief
- 32. Replacement Surgery • Total hip replacement • Hip resurfacing • Total knee replacement • Partial knee replacement
- 33. Facts In 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 surgeries May 23, 2011 11:38 AM ET SAN 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.
- 34. Projected Hip and Knee Replacements in USA Kurtz et al. JBJS 2007
- 35. Goals of Joint Replacement Surgery • Relieve pain • Improve motion • Return to more active/ fulfilling lifestyle • Improve quality of life
- 36. 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 ”
- 37. 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”
- 38. 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
- 39. Hip Replacement
- 40. 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
- 41. 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
- 42. Hip Replacement
- 43. “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
- 44. 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
- 46. 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
- 47. • Improved materials – X-linked plastic • Newer bearings – Metal articulation – Ceramic articulation – Oxinium • Improved technology – Larger femoral head Too “young” for hip replacement?
- 48. 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
- 49. 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
- 50. Hip Resurfacing vs. Hip Replacement
- 51. 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
- 52. “recalled” Total Hips • Involves only metal-on-metal total hip systems • Failure due to metal ion sensitivity
- 53. Knee Replacement The most commonly replaced joint in the human body!
- 54. 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
- 55. 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.
- 56. Knee Replacement • The damaged area of the tibia and cartilage are cut away. The tibia is reshaped to receive the metal tibial component.
- 57. Knee Replacement • The metal baseplate is cemented in place and the plastic insert is snapped in to the baseplate.
- 58. Advances for “Younger” Patients • Mobile-bearing – Designed to rotate as it bends – Imitates natural knee movement – Possible better wear
- 59. 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
- 60. 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.
- 61. Improved Techniques • Computer Navigation – Define anatomy during surgery – Guides alignment
- 62. Improved Techniques • Computer Navigation – Intra operative feed back to surgeons
- 63. Improved Techniques • Robot assisted Surgery – “Makoplasty” • Possible improved accuracy • Not proven to be better • Longer surgery time
- 64. “Customized” surgery • Customized instruments to fit the patient’s knee • NOT fitting patient’s knee to fit a set instruments
- 65. “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
- 66. “Customized” surgery • Improve accuracy and alignment • Decrease surgical time – Less anasthesia – Decrease risk of infection • Possible improve long term performance of the prosthesis
- 68. Partial Knee Replacement • “Uni”, “Partial” • Less invasive surgery • Replace only damaged portion of joint • Bone conservation • Typically faster recovery • Not everyone is a candidate
- 69. Unicompartmental Replacement • Either medial or lateral • Preserve patients ligaments – ACL and PCL
- 70. Patellofemoral Replacement • Isolated knee cap arthritis is replaced • Normal cartilage preserved
- 71. Cartilage Transplantation • Only certain patient • Younger age
- 74. Changing Expectations • Patient expectation – Complete pain relief – Quick recovery • Return to mobility – High activity level such as sports • Regaining a sense of former lifestyle
- 75. Summary • Very successful surgery • Reliable, predictable outcome • Excellent long-term results • Tremendous improvement in patient’s quality of life
- 76. Summary • Improved materials • Better techniques • Expanded indications for “younger” patients with hip and knee arthritis • Maintain an ACTIVE lifestyle
- 77. THANK YOU Bill K. Huang, MD