When a good knee goes bad How I like to think about knee .../media/Images/Swedish/CME... · –...

Orthopedics Symposium for the Primary‐Care Physician 11/04/2016

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When a good knee goes badHow I like to think about knee arthritis

LAURA MATSEN KO, MDWWW.SEATTLEJOINTSURGEONS.COM


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About me

• Born & Raised in Seattle• Whitman College• Oregon Health & Sciences

– Medical School– Residency

• Joints Fellowship with Paul Duwelius MD

• Joints Fellowship at Rothman Institute

• Orthopedic Family


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It all starts with the anatomy of this wonderful and complex joint

Actually three joints in one– Patellofemoral– Tibiofemoral

• Medial• Lateral


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Arthritis is the loss of the knees’s

normal articular cartilage

• Inflammatory• Osteoarthritic• Post traumatic• Post septic• Post surgical


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Patterns of knee osteoarthritis

Varus

Patellofemoral

Valgus

Bow legs Knock kneesGuys/OA Gals/RA


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The picture of knee arthritis

• Pain• Stiffness• Deformity• Tenderness• Swelling• Joint space narrowing on standing x‐rays


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I find it’s just as important to know

the patientthat has the knee

arthritis as to know the

arthritisthat the patient has


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Is the knee pain from the knee?

Hip kneeSpine knee


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What can x‐rays tell us?

Standing AP PA (30 deg)


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MRI usually not needed

I use it when the knee symptoms are worse than what plain x‐rays would suggest

Avascular necrosis


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My steps in treatment of arthritis

Weight lossAnti‐inflammatory medsActivity modification

Low impact

Physical therapy+/‐ Bracing Injections


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Why weight loss?

For each pound of weight lost

5 lbs off each step walking8 lbs off each step running

Slows disease processLowers body‐wide inflammationLessens surgical risk


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Weight loss

• Nutrition, nutrition, nutrition

• Exercise– Cycle– Water aerobics– Tai Chi– Upper body weights

• Bariatric surgery


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Bariatric Surgery effectiveness

• Morbidly obese patients undergoing TKA had lower QALY gained than patients who underwent bariatric surgery 2 years prior to TKA

• Incremental cost‐effectiveness ratio was ~$14,000 per QALY


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Anti‐inflammatories

• OTC NSAIDs vs COX‐2 inhibitors

• If contraindicated (ie warfarin etc)– Tylenol


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Bracing

• Neoprene sleeves– Improves proprioception, minimal support on joint

– “feels good”

• Unloader braces– Consider body type

• Orthotics– Less data


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Activity Modification

• Low impact activities– Cycling *– Rowing– Water aerobics– Cross‐country skiing– Upper body weights


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PT• Give direct guidelines to the therapist

– Encourage teaching of home exercise program• Research shows a modest benefit in relieving symptoms

– Most benefit in patellofemoral disease

• How I see the benefits:– Teaches patient that it’s OK to move!– Strengthening patients – Can improve range of motion– Can be used to teach patient how to properly use a cane

• Required by some insurance companies prior to surgical authorization


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Why cycle an arthritic joint?• Weeping lubrication

– During movement the synovial fluid held in cartilage is squeezed out

– Maintains a layer of fluid on cartilage surface


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HA Injections (synvisc, orthovisc)

• Theory: native knee has hyaluronan– Viscocity

• Studies question efficacy and cost‐effectiveness

• Expensive to health care system– In 12 mo prior to TKA

• 15% patients had HA injection• Accounted for 25% of “treatment specific payment”


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Steroid injections

• Use as a final step• Risk to cartilage

– May inhibit synthesis and deposition of chondroitin sulfate in cartilage

– No more frequently than every 3 months• Diminishing returns• Infection risk

– Native knee– Avoid within 3 months of total knee arthroplasty


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Billboard advertisement seen near O’Hare International Airport in Chicago, June 30, 2016.

Thomas W. Bauer J Bone Joint Surg Am 2016;98:1509-1510

©2016 by The Journal of Bone and Joint Surgery, Inc.


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Stem cell injections

• Amniotic cell injection• Autologous blood

– PRP– Adipose‐derived nucleated cells– Culture expanded cells from bone marrow aspirate

• Allogenic blood• Conclusion:

– few high‐quality clinical studies– Need to publish, including negative results


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Acupuncture

• Meta‐analysis of 10 randomized controlled trials– 13‐16 weeks: superior pain improvement and physical function

– 13‐26 weeks: superior physical function but no difference in pain


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I consider joint replacement when• Pain that is unresponsive to non‐operarive management

• Weight loss• Activity modification• Therapy• Anti‐inflammatories• Injections

• Pain that interferes with life in a big way

• When and only if the patient is a good candidate


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Total Knees ‐ a brief history

Introduced in the 1960’s, now the most commonly replaced joint in the US, approaching 1,000,000/yr

Rate/10,000


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Total Knee Replacement


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The benefit of experience

“Patients managed at hospitals and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events following primary total knee replacement”


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“perioperative adverse events following primary total knee replacement”

MalalignmentInfectionVascular injuryFracture Instability Pain


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“perioperative adverse events following primary total knee replacement”

We strive to avoid them by using our experience and teamwork:

careful patient selection, individualized carepreoperative health optimizationcareful and expeditious surgeryclose monitoring of rehabilitation


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What about robots?Robotic assisted surgery mayimprove accuracy of implant positioningI do not find them necessary for the ususual caseIncreased cost

Buying a robot in the OREach patient requires a CT or MRI with a specific protocol


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Unicompartmental knee replacements

• May provide faster recovery• Theoretical benefit of easier revision to total

– Studies show outcomes of TKA revision vs uniTKA revision to be similar.


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Approaches: “Quad sparing?”

• Nothing is truly quad sparing

Medial parapatellar

Mid VastusSub Vastus


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Implant size

• Gender specific?– No research to support “gender” knees

– We do have narrow sizes• How do we pick the size

– Template the xray– Intra op measurements – Intra op trials

• Size 1‐10 available for both femur and tibia


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Implant material

• Femur and Tibia– Titanium – Cobalt chromium alloy– Ceramic

• Polyethylene spacer– Machining of this material was revolutionized in 2000

• Patella– Okay to not resurface (but most of us do)– Polyethylene button cemented onto bone


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Implant Attachment

• Cement (polymethymethacrylate)– Most common– All types of bone

• Press fit– Avoid in osteoporotic bone– Newer


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Cruciate‐retaining vs Posterior stabilized

• MCL/ LCL/ ACL preserved in majority of primary TKAs

• PCL is controversial– Some surgeons try to preserve

• Leaves more bone• More ‘natural’• PCL not always present

– Some surgeons always sacrifice• Easier to perform= better balanced knee


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One of the reasons I love my job

Getting people active again!

• "I'm 6 months out from my knee replacement surgery with Dr. Matsen Ko. My knee is virtually as good as new now and I treat it as I normally would. I got back on my bike a week short of 2 months. Now I'm routinely riding over a dozen miles several times a week. I'll soon be doing 20 miles on the Centennial Trail. Thank you Doctor, for helping an 86‐year‐old get back in shape."


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Thank you

www.seattlejointsurgeons.com

When a good knee goes bad How I like to think about knee .../media/Images/Swedish/CME... · –...

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