Arthroplasty for Knee Arthritis Demetris Delos MD

Shoulder and Knee Surgery

Outline

• The Problem of Arthritis and Joint pain • Nonoperative Solutions • Surgical Solutions • My approach

What is Arthritis?

• Cartilage – Smooth, resilient surface

lining the ends of bones contacting one another

– Low coefficient of friction

• Arthritis = Loss of cartilage on both sides of the joint – Exposes underlying bone

(which has nerve endings)

Arthritis of the Knee

• Knee Joint (hinged/rolling)

• Cartilage – Femur (thigh bone) – Tibia (shin bone) – Patella (kneecap)

Scope of the Problem

• Arthritis is VERY common – Estimated 54.4 million

adults annually (22.7%)

• The number of older adults is increasing – Older individuals are more

active and WANT TO STAY THAT WAY

• Younger adults with OA are also looking for good options

Symptoms

• Pain • Swelling • Increasing Stiffness

CONSERVATIVE TREATMENT

The Basics

• Activity Modification • Weight Loss • Bracing/Orthotics

– Unloader braces • Use in pts w unicompartment dz, passively correctable

– Foot orthotics • Lateral wedge orthotic for varus knee

• Anti-inflammatories – Serious GI side effects in 2-4% of chronic users

• Physical Therapy – Exercise can reduce pain and improve function in pts w early OA

• Other treatments – Acupuncture etc

Weight Loss and Hip/Knee Pain

• Hip and knee joints are exquisitely sensitive to body weight

• Each pound of body weight lost = 4 pound reduction in knee joint stress

• *Obesity is risk factor for complications with surgery*

Physical Therapy

• Studies have repeatedly shown that therapy can reduce pain and improve function in patients with arthritis

• Muscle strengthening can improve pain

• Aerobic exercise can improve function

Bracing (for knee)

• Unloader braces can improve symptoms of arthritis

• Have not been shown to prevent the advance of arthritis

• Can be costly – $500-$1000

• Useful for athletes who wish to participate in high impact sports

Corticosteroid Injection

• Can provide temporary relief

• Can cause local side effects – Skin color change – Fatty atrophy

• Probably most useful for the acutely inflamed/painful joint

Viscosupplementation (“Gel shots”)

• Anti-inflammatory/anabolic/analgesic/chondroprotective potential

• Improved results compared to placebo and steroid in some studies in terms of pain relief

• Insurance starting to limit their use

PRP Injection

• PRP=Platelet rich plasma

• Obtain a sample of your blood; place in centrifuge, collect portion with platelets (and growth factors)

PRP Injection for Arthritis

• Usually a single injection into knee (sometimes more)

• Several studies have shown improved outcomes compared to – Placebo (saline injection) – Hyaluronic acid

• Seems to be superior to other injections for OA

• Currently, not covered by insurance

Stem cell treatment for arthritis

• 20-30 minute procedure • More invasive

– Can be retrieved from bone marrow (pelvis)

– Adipose tissue (liposuction or knee fat pad)

– Blood • Limited data, for now

– Appears safe – Some studies with

improved pain scores, outcomes and MRI changes

Placental tissue (stem cells/growth factors) for arthritis

• Placental tissue (from normal deliveries) – Rich in stem cells – Rich in growth factors – Can determine number

of cells/activity – No significant human

data

SURGERY (FOR KNEE ARTHRITIS)

Unicondylar/Unicompartmental Knee Replacement

• Replacing one of the three compartments of knee (medial, lateral, PF)

• Advantages – Easier recovery than

osteotomy or TKR – Immediate weightbearing – Retain ligaments of knee

(ACL) • Disadvantages

– Technically challenging – Less predictable than TKR

Total Knee Replacement

• Replace all three compartments of knee

• Advantages – Early weightbearing – Relatively predictable

outcomes – Longer lasting

• Disadvantages – Remove more bone and

ligaments

Rehab

• Immediate full weightbearing • Gait training • Strengthening and range of motion without

limitation • Home exercise program • Return to activities in 2-3 months

– Recommend low impact activities (skiing, doubles tennis, biking)

Conclusions

• Number of younger patients with OA is significant

• Number of older patients w OA that are still active is increasing

• Treatment needs to be tailored to age, expectations and activity levels

THANK YOU FOR YOUR ATTENTION!