Innovative Treatments for Hip and Knee Pain
Transcript of Innovative Treatments for Hip and Knee Pain
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Innovative Treatments for Hip and Knee Pain
C. Brian Blackwood, MDBoulderCentre for Orthopedics
Co-Medical Director Joint Programwww.boulderhipandknee.com
303-622-3265
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My TrainingUndergrad- Carroll College- Helena, MTMedical School- University of WashingtonResidency- University of New MexicoFellowship in Joint Replacement-
Coon Joint Replacement Institute St Helena, CA
* First Surgeon with Fellowship training specifically in Robotic Joint Replacement
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Medical License: CO and MTDisclosures: Consultant for Stryker Robotics
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• Focus on minimally invasive surgical techniques combined with advanced technology
• 99% of cases done under spinal anesthesia• Avg LOS: TKA 1 days, THA 1 days• 91% of patients discharged to home with
outpatient PT• Now doing Outpatient Surgery Center
About my practice…
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Lowest Complication Rate in Boulder
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What is Arthritis?
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Osteoarthritis- Worn out articular cartilage
Inflammatory Arthritis- Systemic Process ex: Rheumatoid, Psoriatic, etc.
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Hip Stages
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X-ray Showing Arthritis
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Other Causes of “Hip Pain”• Bursitis: Lateral/Side pain. Worse when you
lay on that side• Back pain: Can radiate down to hip and cause
hip pain symptoms• Hernia: Abdominal opening causing pain in
the groin
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Primary Hip and Knee Replacement Projection 2005-2030
Kurtz, S, Projections of Primary and Revision Hip and Knee Arthroplasty in the US 2005-2030, JBJS, 2007;89:780-785.
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New Generation of Patients
Patients are getting both younger and older. They have different expectations.
• Want to maintain their quality of life and active lifestyles
Patients are often better informed today.• Internet allows access to more information• BUT BEWARE THE INTERNET (and Stem Cells)
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How Can I Avoid/Delay a Joint Replacement?
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Treatment Options for Knee and Hip Pain
• Rest, ice, and heat applications
• Medications for inflammation and pain
• Lifestyle modification• Physical therapy• Joint fluid supplements• Knee arthroscopy• Total joint replacement
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AAOS Guidelines
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RICE and NSAIDsRest, Ice, Compression, Elevation
Ibuprofen, Alleve, Tylenol, Celebrex
Topical compounds
Glucosamine
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Activity Modification and Weight Loss
Avoiding high impact activities, i.e., running, jumping
Weight Loss: Goal BMI<40
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Joint InjectionsCortisone
Visco-supplementation
Platelet rich plasma (PRP)
Stem Cells
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“Chicken Shots”- Hyaluronic acid injections
*Covered by most insurance in kneesbut not hips
Visco-supplementation
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Injections of concentrated blood products to enhance healing
*Not covered by insurance, expensive
PRP: Platelet Rich Plasma
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Obtain stem cells, concentrate them and inject them into the joint to decrease inflammation and promote healing.
*Not covered by insurance, very expensive
The Promise of Stem Cells
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My Future?
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Stem Cell Results:
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Stem Cells =Snake Oil?
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STEM CELLS?
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Consequences of Delaying Surgery• Surgery is a difficult decision
− Duke Study: 88% pts decline Joint Replacement
• OA is a degenerative disease
• Better outcomes are reported in patients who had a total joint operation earlier in the disease process1
• At 2 years post-operation, patients who chose surgery earlier in disease process vs. those who waited1
− Had improved function− Had reduced pain
1. Fortin PR, et al. Arthritis Rheum. 2002;46:3327-3330.
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New Opportunities in Arthroplasty• Improvements in hip and knee replacement
materials − Success rates >90% 1
• Partial vs. total knee replacements
• Minimally invasive procedure techniques
• New designs
1. American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/topic.cfm?topic=A00389, accessed Dec. 15, 2010, and http://www.niams.nih.gov/Health_Info/Hip_Replacement/default.asp#8.
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What is Mako?
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Computer Navigated, Robotic Arm Assisted
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Early Arthritis• Damage and pain
isolated to one compartment of the knee, usually medial or lateral.
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Early Arthritis• Damage and pain
isolated to one compartment of the knee, usually medial or lateral.
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Early Arthritis• Can also be isolated
to the patella femoral joint.
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Mid-stage Arthritis• Occurs in 2 of the 3
compartments of the knee, most commonly the medial and patella femoral.
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Mid-stage Arthritis• Occurs in 2 of the 3
compartments of the knee, most commonly the medial and patella femoral.
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Makoplasty Procedure
• The patient must have the correct indications for the procedure.
• A CT scan is then performed to make a 3D model of the patients knee.
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Makoplasty ProcedureThe model is then used to plan for the placement of the components.
We are able to plan to 0.1 degrees and 0.1 mm.
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Robotic process (cont.)• Then a pin is
placed into the distal femur and proximal tibia for placement of tracking device.
• Center of hip is then found.
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Surgical Technique
• Anatomic landmarks on the femur and tibia are used to calculate the position of the knee in space.
• This information is then combined with CT and pre-op plan.
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Surgical Technique
• Anatomic landmarks on the femur and tibia are used to calculate the position of the knee in space.
• This information is then combined with CT and pre-op plan.
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Surgical Technique (cont.)• After obtaining
anatomic landmarks, evaluation of coronal and sagittal alignment, flexion and extension laxity and ROM can be measured.
• Infinitely Personalized Process.
Implant Tracking
Joint Balancing
Cartilage Mapping
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Bone Preparation• Done through a
minimal incision to allow for less tissue damage.
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Surgical Technique (cont.)• After finalizing
operative plan a high speed burr is used to make the femoral and tibial cuts.
• The haptic feedback increases and will not allow you to go outside of the planned resection.
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Surgical Technique (cont.)
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Clinical benefitsPre-op Post-op
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Makoplasty
• Less invasive• Accurate• Reproducible• Bone
conserving
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50Confidential. Do Not Copy or Distribute. For Internal Use Only.
MAKTKA-PRE-35_Rev-1_13844
Patient satisfaction: Mako Partial Knee6
This prospective, single-center, level I, blinded, randomized controlled trial compared Mako Partial Knee and Biomet Oxford.
Early results showed higher functional outcomes scores and less early post-operative pain for Mako Partial Knee vs. manual procedures with Biomet Oxford.
0%
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Mako UKA(Restoris MCK)
Manual UKA(Oxford)
% patients with “excellent” American Knee Society score (>160) at three months
57%
31%
Med
ian
Pain
VAS
scor
e 0-
100
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Patient satisfaction: Mako Partial Knee7-9
Mako Partial Knee showed high patient satisfaction at two-year and five-year follow-up.
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Satisfied Neutral Dissatisfied Verydissatisfied
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Satisfied Neutral Dissatisfied Verydissatisfied
Mako Partial Knee satisfaction – 2 year Mako Partial Knee satisfaction – 5 year
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Survivorship: Mako Partial Knee
Mako Partial Knee showed low revision rate at two-year follow-up.
• Average cost of a revision following a non-robotic primary knee replacement in the US: >$39,00012
• Revision subsequent to a robotic arm-assisted primary knee arthroplasty surgery in the US: $22,94112
0.0%
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4.8% 4.5%
1.2%
Manual PKA (Australian registry)10
Manual PKA (Swedish Registry)11
Coon, et al. (robotic PKA)7
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Mako Total Knee
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Total Knee Joint Replacement
• End surface of femur replaced with metal
• End surface of tibia replaced with metal
• Plastic liner is inserted between femur and tibia
• Patella is resurfaced with plastic
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Normal Knee X-ray Arthritic Knee X-ray
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Replaced Knee X-rayAnterior View Lateral View
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Variability of manual instrumentation
Placement of the IM rod Alignment of cutting guides
Placement of extramedullary guides sawblade excursion and toggle
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Bigger opportunity to move the needle13,14
81% 99%
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Overall patient satisfaction Survivorship
Primary TKA
18%
“satisfied” or “very satisfied” WOMAC score
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Mako Total Knee workflow
Pre–op planning Array placement
Ligament balancing assessmentIntra-op plan adjustments
Bone resection
Bone registration
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Preop Planning
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Array Placement
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CT guided bone registration
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Dynamic pre-resection balancing
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Joint Balancing
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Distal Femur and Posterior Chamfer
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Early Clinical results
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Minimally Invasive TKA
• Provide early and exceptional analgesia• Low trauma surgery• Early discharge and rapid rehab
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Prevent the Bad Effects
• Pre-emptive analgesia− Celebrex− Spinal Anesthetic
• Pre-emptive anti nausea− Pepcid
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Operative Management
• SPINAL anesthetic • IV sedation• Capsular injection
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Post-Operative Management
• Early ROM with PT • Ambulation same day
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Post-Operative Management
• Gait training POD1• Stairs and PT
instruction• Possible outpatient
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Update on Hip Arthroplasty
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• The bearing affects− Performance− Flexibility− Durability− Longevity
• Options for bearings in hip replacements− Ceramic-on-ceramic− Metal-on-plastic− Metal-on-metal− Ceramic-on-plastic
Femoral head and acetabular insert in hips
The bearing surface: The two parts that glide together throughout motion
The Very Important Bearing Surface Hip Arthroplasty
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MIS Hip ReplacementDirect Anterior Approach
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What is the ‘Direct Anterior Approach’?
• The direct anterior approach is a minimally invasive hip replacement technique that allows the surgeon good access to the hip without detaching any muscles or tendons.
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Traditional vs. Direct Anterior Approach
Traditional Hip Replacement• 8-12 inch incision• Surgical approach - side (lateral)
or back (posterior)• Disturbance of the joint and
connecting tissues
MIS with Direct Anterior Approach• 4-5 inch incision• Surgical approach – front (anterior)• Muscles or tendons not detached
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Why I Do The Direct Anterior Approach?
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Why Direct Anterior?
• Hip closer to the front of the body
• Surgical anatomy
• Doesn’t detach any major muscles
• Minimal risk to nerves
• Truly MIS
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Why Direct Anterior?
• Less pain• Quicker restoration of
function• Shorter hospital stay• Probably more economical
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Direct Anterior Hip Replacement
Why?• Ideal soft tissue interval• Ease of patient position• Simple socket
instrumentation
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Direct Anterior Hip Replacement
Why Not?• Unfamiliar territory• Femoral exposure is
difficult• Specialized equipment
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How it’s done
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Special Instruments
Retractors
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Special Equipment
Lighting Arch table
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Typical Precautions: Traditional vs. Direct Anterior
Direct Anterior Approach• Under doctor’s supervision, may
be immediately allowed to move their hips
• May potentially avoid restrictions associated with traditional hip replacement1
Traditional Hip Replacement• Do not cross legs• Do not bend hip more than a right
angle• Do not turn feet excessively
inward or outward • Use a pillow between your legs
when sleeping
1. http://www.anteriorhip.org/anterior-hip-replacement.html accessed Nov 2010.
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Potential Benefits of MIS with Direct Anterior Approach
• Decreased hospital stay and quicker rehabilitation.2
• Smaller incision and reduced muscle disruption may allow patients a shorter recovery time and less scarring.1
• Potential for less blood loss, less time in surgery, and reduced post-operative pain.1,3,4
• Risk of dislocation reduced. 2
• May allow for a more natural return to function and activity.1, 3
1. Wenz, J, Gurkan, I. ,Jibodh, S., “Mini-Incision Total Hip Arthroplasty: A Comparative Assessment of Peri-operative Outcomes,” Orthopedics Magazine, 2002.
2. www.anteriorhip.org/anterior-hip-replacement.html accessed Nov 2010.3. Keggi, Kristaps, I., “Total Hip Arthroplasty Through a Minimally Invasive Anterior Surgical Approach,” JBJS, Vol. 85-A. 2003.4. Baerga-Varela, L., Malanga, G.A., “Rehabilitation after Minimally Invasive Surgery.” Hozack, W., Krismer, M., Nogler, M., Bonutti, P., Rachbauer, F.,
Schaffer, J., Donnelly, W., ed. Minimally Invasive Total Joint Arthroplasty. New York, NY: Springer-Verlag; 2004: 2-5.
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Advantages of Direct Anterior
• MIS approach is better for patients• No Hip Precautions• Improved Control over Component
Position
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The Use of Technology in Hip Replacement
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Why Navigation?• Increased level of precision• Confidence in component position• Recovery room film is too late for changes• Optimize surgical results
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rTHA- Better Plan
Reduced Mode
mTHA- Plain x-ray rTHA- 3D CT
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rTHA vs. mTHA: Multicenter studyMGH, University of Wisconsin, HSS (Malchau, Padgett, Dounchis, Illgen, Marchand)
96
Manual THA : N= 188347% inside target zone
1. The John Charnley Award: Risk factors for cup malpositioning: Quality improvement through a joint registry at a tertiary hospital.Clin Orthop Relat Res. 2011 Feb;469(2):319-29.
Robotic THA: N=11996% inside target Zone95% within 4 degrees of plan
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rTHA vs mTHA: Single Surgeon DataA Matched-Pair Study- Dr. Domb – Hinsdale, IL CORR 2013
rTHA (N=50) vs. mTHA (N=50), X-ray analysis (HAS)
rTHA vs. mTHA- 100% vs. 80% in Lewinnek “Safe Zone”
97
Conventional THA Robotic assisted THA
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Technique with Technology
Surgical goals of hip replacement • Pain relief• Restoration of function/lifestyle• Optimize patient outcomes• Economics
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DA THA
• Provide early and exceptional analgesia• Low trauma surgery• Early discharge and rapid rehab
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Prevent the Bad Effects • Pre-emptive analgesia− Celebrex− Spinal Anesthesia
• Pre-emptive anti nausea− Pepcid
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Operative Management
• IV sedation• Capsular injection
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Post-Operative Management• Gait training POD1• Stairs and PT
instruction• Ideally same day
ambulation
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10,000 Miles in 18 mos after THA
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Summary rTHA more accurate than mTHA- multiple
studies
Improved accuracy with rTHA correlated with improved clinical outcomes at 1 year Lower dislocation rate
Less LLD
Less blood loss
Excellent PROM Better HHS and UCLA activity scores than mTHA
Robotic assisted THA: Longer OR time than mTHA, no infections
Cost benefit analysis requires further study
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Risks of Surgery• Including but not
limited to:• Bleeding• Infection• Damage to nerves and
vessels
• Blood clots (DVT)• Blood clots in lungs (PE)And rare things like:• Stroke• Heart attack and • Death
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COVID Protocol• Elective Surgery has
been going since April 2020. There are no current plans to stop but that may change.
• Every patient gets COVID test and all staff follow proper PPE protocol.
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107Confidential. Do Not Copy or Distribute. For Internal Use Only.
MAKTKA-PRE-35_Rev-1_13844
Questions?
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C. Brian Blackwood, MDBoulderCentre for Orthopedics
Co-Medical Director Joint Programwww.boulderhipandknee.com
303-622-3265
Innovative Treatments for Hip and Knee Pain