1 © The CORE Institute. All rights reserved. OSTEOARTHRITIS OF THE HIP & KNEE David Knesek D.O....

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© The CORE Institute. All rights reserved.

OSTEOARTHRITIS OF THE HIP & KNEE

David Knesek D.O.Primary & Revision Joint Replacement Surgery

of the Hip & Knee

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David Knesek D.O.

Undergrad University of Notre DameMed School MSUCOMResidency St. John Providence Health SystemFellowship at University of Chicago for Adult Reconstruction

Employed by CORE Orthopedics MichiganWork primarily out of St. John Providence Southfield and NoviAlso credentialed at Botsford, Henry Ford WB, and DMC Huron Valley

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Disclosures

None

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Special Thanks

Dr. Anvari

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You’re Not Alone

More than 43 million people have some form of arthritis. It is estimated that the number of people affected by arthritis will increase to 60 million by 2020.

Source CDC

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Most Common Types

OsteoarthritisGenetic predisposition?BMI? Activity?

Rheumatic ArthritisPost-traumatic ArthritisAvascular Necrosis

50% caused by ETOH abuse, chronic steroid use, Sickle Cell Disease, HIV, coagulopathy50% idiopathic

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Purpose of Talk

Understanding what causes joint painTreatment OptionsWhat joint replacement involves and the different typesExpectations following joint replacement

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NIH 2010

719,000 TKA performed in US

332,000 THA performed in US

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AAOS 2006

Number of hip and knee surgeries expected to soar by 2030

Hip Arthroplasty increase of 174%Knee Arthoplasty increase of 673%

Why????!Growing aging population (especially 45-64 yo)Increasing Obesity

Correlation to BMI and knee arthritis (not hip)

Younger more active patients with previous injuries and an increase in post traumatic OA

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Von Mow

“The human joint functions so well… that we are totally unaware of it until there is a problem”

-Von Mow

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What is arthritis?

Loss of articular cartilageAvascular, aneural, alymphatic

Increased stress on subchondral boneOsteophyte formationDeformityPain

Peri-articular pain

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What causes arthritis?

Prior trauma: fracture, ligament injuryPrior surgery: menisectomyGenetic predispositionInflammatory arthritis

Rheumatoid Arthritis, Lupus

Avascular necrosis: hip, knee or shoulderCongenital or growth problem“Aging”

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What causes arthritis?

Loss of medial meniscus leads to 75% decrease in contact area and increase in peak contact pressures of up to 235%1

Increase in contact pressures overload the articular cartilage leading to biochemical changes including loss of proteoglycan, increase in proteoglycan synthesis, and increase hydration1

1. McDermott et al. Consequences of menisectomy. JBJS (Br). 2006. 88;1549-1556

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Factors Involved in OsteoarthritisObesity

Trauma

Aging

Genetic andmetabolic diseases

Inflammation

Immune-systemactivity

AbnormalStresses

AbnormalCartilage

COMPROMISED CARTILAGE

Structural changes:Collagen network fractureProteoclycan unraveling

Biomechanical Changes:Inhibitors reduced Proteolytic enzymes increased

CARTILAGE BREAKDOWN

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Symptoms of ArthritisHow does it present?

Usually slow, chronic, and progressiveOccasionally can start abruptly usually after an insulting eventSymptoms usually start with pain, swelling, stiffness which is intermittent at first and then progress to chronic

Can be focal or have vague presentationCan be worse at certain times of day or with certain activities

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Arthritis in Real Life

Healthy Knee Arthritic Knee

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Initial Evaluation

SymptomsMedical History

Family HxMedicationsPrior Sx

Ortho ExamStrength, range of motion, swelling, reflexes, skin condition, neurovascular exam

Xray

Additional TestsBlood testsMRICT ScanBone ScanUrinalysisFluid Aspirate

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Degenerative Arthritis

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Lets start with the Knee

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Treatment Options

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Non-surgical optionsPhysical Therapy – strength and motion

Prehabilitation in preparation for surgery

Activity modificationUse of walking aids

Cane, walker

BracingUnloading brace

Low impact exercise programEliptical, aquatics, yoga

Weight controlMedical weight loss, lap band, normal diet

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Non-surgical optionsMedications

TylenolNSAIDsTopical ointmentsGlucosamine/chondroitinSteroids

Oral

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Non-surgical optionsNSAIDs – ibuprofen, naprosyn, ketolorac, meloxicamLidoderm/Ant-inflammatory PatchesAnelgesic/Anti-imflammatory creamsPain Pills – Recommend Against due to tolerance, addiction, decreasing pain threshold

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Degenerative ArthritisNon-surgical options

InjectionsViscosupplementation or “chicken cartilage”

Enhances PG synthesis, Reduces degredative enzymes (matrix metalloproteinases) ProphylacticSeries of injectionsOnly approved for the knee at this time

CortisoneKenalogueDexamethasoneWith or without lidocaine or marcaine

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Surgical optionse.g. Knee

Arthroscopic debridementCartilage transplantOsteotomyReplacement

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Arthroscopic Debridement of degenerative knee usually reserved for unstable meniscal fragment or loose body

Will address mechanical symptoms but may not alleviate pain

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Cartilage Transplant or Microfracture

Reserved for focal chondral injuries in an otherwise non-arthritic kneeThink Carmelo Anthony, Kobe Bryant, etc.

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Joint Replacement

What is it?Treatment for arthritic or damaged joints AFTER failure of non-operative measuresReplacement of diseased cartilage with metals, ceramics, and plastics

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Lets start with the Knee….

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What is a total knee arthroplasty?

Layman’s termsResurfacing end of femur bone and tibia bone with metal with placement of plastic liner in between

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Total Knee Arthroplasty

PredictablePain ReliefImproves Quality of LifeIt is a replacement: bone and cartilage is cut away

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Knee Arthritis

Degenerative Knee Arthritis

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Joint Replacement Surgery

Partial Knee ReplacementTotal knee replacement

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Joint Replacement Surgery

Partial Knee ReplacementTotal knee replacement

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Joint Replacement

Traditional GoalsPain ReliefImproved FunctionBetter quality of life

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Patient Satisfaction

THA outcomes1

180 pts surveyed 3 years after sx

Pain improvementwalkingPsycheADLsNonessential activities

89% satisfaction74% would refer friend/relative

TKA outcomes2

1703 pts surveyedPain satisfaction 72%-86%Functional satisfaction 70-84%Overall 19% not satisfied (81% satisfied)

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Traditional TKA

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So…how is it done (traditionally)?

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Consider…

Sagittal AlignmentAnatomic axisMechanical axis

Coronal AlignmentPosterior slope

Rotational AlignmentJoint Line PositionPatellofemoral Kinematics

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Partial Knee Replacement

Unicondylar – isolated OA, young, BMI <30MedialLateral

Patella femoral joint - controversial

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Preserves healthy knee structuresIndicated when disease process is predominantly one areaSmall incision can be usedOften out of hospital in 1-2 daysMostly for medial compartment OA, rarely for lateral OA, or PF OACan be revised to TKA

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Results are showing it may be as successful as a TKAStudies show survivorship of around 90% at 15 years outPatients report their knee feels “normal”

1.8 times more likely than total knee recipients to report their knee felt normal2.7 times more likely to be satisfied with ability to perform ADLs.

Very specific requirements to be a candidate

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Joint ReplacementCORE Goals in the new millennium

Pain ReliefImproved FunctionFaster RecoveryImproved Range of MotionDecreased Pain after SurgerySmaller IncisionsLess Trauma to muscle and TendonBetter alignmentImproved longevity

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The Future is Now

What’s new and exciting in Joint Replacement Surgery

Minimally Invasive SurgeryPersonalized Knee replacement using MRI or CT to gain precision in mechanical axis and alignmentCT Navigated KneesRobotic Surgery

THIS IS NOT “EXPERIMENTAL” SURGERY

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Total Knee ReplacementMinimally invasive

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Traditional Incision 8-10 inches

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Minimally Invasive Incision

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Minimally invasive TKA

Potential advantagesLess blood lossLess soft tissue disruptionLess post-op painShorter hospital stayQuicker rehabOverall less cost

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Focus has shifted to less invasive surgeryTKA with <6 inch incisionComponents same size but surgical instruments are specifically designed to prepare femur and tibia with smaller window

Less trauma to musclesIdeal candidates are younger, healthier, not obese, less knee deformity, primary knee surgery versus revision

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Not all patients

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But is it proven?????


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ResultsLaskin CORR 2004

Compared MIS vs. StandardMIS

Less pain12.8 vs. 20 cm incisionQuicker ROMComponent position good in all

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ResultsHaas et al CORR 2004

Retrospective study but matchedMIS

No complicationsBetter ROM at 6,12 weeks and one yearImproved knee society scores

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Personalized Knee Replacement

Patient gets MRI or CT prior to surgeryProgram creates surgical plan including cuts, alignment, sizes, and a 3D imageCustomized guides created that surgeon uses intra-op

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Potential AdvantagesQuicker OR timeLess inventoryMore accurate alignment and positioning leading to a more balanced knee with less complications

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Computer Navigated Knee

Goal of Computer Navigation in Total Knee Arthroplasty:

Minimize the “Outliers”

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Clinical Experience: 240 Patients

-7 -6 -4-5 -3 -1-2 0 1 2 3 4 5 6 7

varus valgus

Patients

Navigated

Standard

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What’s so important about alignment and balance?

Worn out PREMATURELY

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What’s so important about balance and alignment?

Worn out PREMATURELY!

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Computer Balancing and Alignment is now the BEST way to treat your joint as well

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Results

Stockl et alCORR 2004Randomized to nav vs. standardC.T. eval showed significantly improved alignment (esp fem rotation) in navigated group

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Results

Stockl et alCORR 2004Randomized to nav vs. standardC.T. eval showed significantly improved alignment (esp fem rotation) in navigated group

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Results

Kinkl et alImprovement in alignmentExpenseTime

15-20 min more

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Results

Matsumoto et alInt Orthop 200430 matched-paired controlsSignificant improvement in alignment? Femoral size

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MAKO Robotic Arm

FDA approved for partial knee replacementsDeveloping total knee utilization in near future

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MAKORobotic Arm

Relatively new technology which started around 2010No Long Term DataComputer program uses CT scan to map out cartilage removal and implant position

Robotic arm helps to remove cartilage and provides feedback when surgeon is errant allowing extremely precise accuracy

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A Final Word…

MIS = Short Term BenefitsLess Pain, Faster Recovery

Personalized/Navigated/Mako= Long Term BenefitsLonger lasting, better functioning Replacement

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Hip Arthroplasty

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Patient quotes

I couldn’t even walk 1 block before I had to stop and sit down. Motrin and Narcotics used to help but now they barely touch the pain. I don’t feel like going outside anymore.My hip doesn’t move like it used to and I’m embarrassed because I need help getting out of my car.My life is less active and I avoid getting together with friends and family because I’m always in pain.Just walking outside was exhausting. I didn’t feel like getting out of bed.

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Normal vs Arthritic Hip Xray

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What is a Total Hip Arthroplasty?

Layman’s Term Resurfacing cup with metal and plastic and removing arthritic head and replacing it with metal stem and metal vs ceramic head.

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Historical

Devised by Sir Charnley in England in 1962First FDA implant implanted in 1969

Traditionally done through posterior approach with modifications throughout the years including direct lateral, anterolateral, and 2 incision

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Approaches

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Conventional Approaches

Direct LateralAdvantages

Theoretical decrease in dislocationless muscle damage

DisadvantagesLurch or limp from failure or attenuation from abductor repair

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Conventional Approaches

PosteriorAdvantages

Most used and very extensileNo lurch or theoretical damage to abductor tendon

DisadvantagesHistorically higher rate of dislocation (not currently)Most muscle damageLongest Rehab

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Lateral vs PosteriorPalan et al. Corr 2009

Prospective non-randomized multicenter study following 1100 hips for 5 yearsEvaluated

Hip scoresPain, function, etc

Dislocation ratesRevision Rates

Study found no difference between the 2 approaches at 5 years outTake home message

Both approaches work extremely well and 80% of THAs are done with these approaches

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Anterior Supine Intermuscular (ASI)

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Anterior Supine Intermuscularcompared to conventional approaches

Benefits Quicker recovery

Less painLess limpingBetter stair climbing and independent walking at 6 wks

Harris Hip Scores improved at 6 wks, 12 wks, and 1 yr compared to tradional approaches

Less muscle damage1

Can use flouroscopy accurately place implants intra-operatively

1 Bergin et al, JBJS 2011

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Anterior Supine Intermuscularcompared to mini posterior approach

Reduced hospital LOS (2.7 vs 3.9)1

ASI more likely discharge home (84% vs 56%)1

ASI less pain, less narcotics, less assistive devices at 6 wks1

Less variance in Cup position and stem orientation2

1 Zawadsky et al, JOA, 20142 Barret et al, JOA, 2013

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Anterior Supine Intermuscular

ComplicationsTechnically very challengingLarge learning curve which varies from 20-100 patients per the literaturePersistent numbnessPotential increase for more blood lossWound complications and dehiscence

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Anterior Supine Intermuscular“table or no table”

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Post Op Hip or Knee ReplacementWhat to expect…

Hospital Stay around 2 days (1 day for ASI)In hospital physical therapy (PT), pain controlHome PT of about 3 visitsOut-patient PT about a week after surgery

Blood Thinners x 6 weeksPhysician choiceASA, Lovenox, Xarelto

Narcotics x 6 weeksPhysical Therapy for around 2 monthsExpect to be off work for 3 months

Less for ASI

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Expectations

Expectations always discussed in office prior to surgeryUnlimited Low Impact ActivitiesRecommend limited high impact (running, basketball, tennis)Not a normal hip and knee – might always feel a little different

In my experiencePt 80-90% better at 3 months and then continue to progress for a full year Excellent pain reliefBetter quality of life

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On the Horizon

CT Navigated HipsMAKO for Total Knee ArthroplastyRobotic Surgery in addition to computer navigationImproved bearing surfaces“Smart Implants”Obviation of a bearing surface

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Keep Life in Motion!

1 © The CORE Institute. All rights reserved. OSTEOARTHRITIS OF THE HIP & KNEE David Knesek D.O....

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Transcript of 1 © The CORE Institute. All rights reserved. OSTEOARTHRITIS OF THE HIP & KNEE David Knesek D.O....