Introduction to Orthopaedics: OPTIONS FOR HIP AND KNEE ARTHRITIS

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Introduction to Orthopaedics OPTIONS FOR HIP AND
KNEE ARTHRITIS

• Stephen P. England, M.D.
• Park Nicollet Orthopedics

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What is Arthritis?

• Wear/loss of articular cartilage
• Similar to wearing the tread off a car tire
• Osteoarthritis wear and tear / aging
• Inflammatory arthritis systemic disease
• Post-traumatic arthritis following injury
• Others

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How can I prolong the life of my hip or knee?

• Weight Management
• Activity Modification
• Medications Systemic Inflammatory Arthritis
• Glucosamine ??

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What can help me live with my pain?

• Weight Management
• Activity Modification Bike, Swim
• Physical Therapy Motion, Strength
• Assistive Devices Cane , Crutches, Walker,
  Scooter, Wheelchair

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What can help me live with my pain?

• Oral Medications
• Analgesic Over the Counter, Prescription
• Glucosamine/Chondroitin
• Other Alternative Treatments
• Injectable Medications
• Cortisone
• Synvisc, Hyalgan
• Braces

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Unloader Brace

• Shifts weight off bad side of knee over to good
  side of knee
• Must have a good side
• Must be willing to wear brace(cumbersome)
• Best for those who enjoy specific activities
  Golf, Tennis, Hiking, Walking

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QUESTIONS

• NON-SURGICAL OPTIONS

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How do I know when to have surgery?

• Need a diagnosis Not all joint pain is caused
  by arthritis, not all arthritis is the same
• Fibromyalgia
• Not surgically treatable
• Makes surgery less predictable
• History, physical exam, x-ray
• Plain x-ray usually sufficient to make the
  diagnosis
• MRI and other tests occasionally helpful

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How do I know when to have surgery?

• Decision is almost always up to the patient
• M.D. should lay out the options, surgical and
  non-surgical
• M.D. may give advice, but should rarely tell you
  what to do its your choice
• Others may help you decide (friends, family,
  primary care physician), but ultimately you make
  the call
• Consider the following questions

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Procedure Questions

• What exactly is the procedure?
• What are the goals?
• How likely is it to work?
• What is the recovery like?
• What are the risks/complications?
• What are my other options?

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Personal Questions

• What is my age?
• What is my occupation?
• What activities do I enjoy?
• What health problems do I have and how do these
  affect my surgical risk?
• What support system do I have to help me during
  recovery?
• HOW MUCH PAIN AND DISABILITY DO I HAVE?

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Surgical Options

• Arthroscopy
• Osteotomy
• Arthrodesis (Fusion)
• Arthroplasty (Replacement)

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HIP

• Osteotomy, arthrodesis, arthroscopy rarely used
• Arthroplasty common

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KNEE

• Arthroscopy common
• Osteotomy popularity waxes and wanes
• Arthrodesis rarely used
• Arthroplasty - common

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Arthrodesis (Fusion)

• Eliminates pain
• Creates a different disability
• Lasting result
• Commonly used before arthroplasty developed
• Young patient heavy, laborer
• Salvage - infection

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Osteotomy

• Used most commonly in the knee
• Shifts weight from bad side of joint to good side
  (like unloader brace)
• Must have a good side of the joint
• Not appropriate for systemic inflammatory
  arthritis

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Osteotomy

• Most commonly done by removing a wedge of bone
  from femur or tibia and placing a plate to hold
  bones in place
• Young patient trying to avoid arthroplasty
• Intended as a temporizing procedure, not a
  permanent solution - reported results variable
• Takes a long time to recover crutches, brace,
  therapy

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Osteotomy

• Not as popular currently as durability of
  arthroplasty improves
• May make subsequent arthroplasty more difficult

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QUESTIONS

• ARTHRODESIS
• OSTEOTOMY

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Arthoscopy

• Visualize joint through a fiberoptic tube
  inserted through small skin incision
• Common in knee, uncommon in hip (technically
  difficult)
• Arthoscopy is a way of doing an operation, NOT
  the operation itself, which may involve many
  things DONT COMPARE YOURSELF TO OTHERS!

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Arthroscopy

• Other small incisions insert shavers, cutting
  devices, graspers
• Smooth joint surfaces
• Trim meniscus tears
• Remove loose bodies
• Remove diseased synovium systemic inflammatory
  arthritis

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Arthroscopy

• Brief day surgery procedure
• Various anesthetics, frequently regional
• Minimal risks/complications
• Recovery varies but usually fairly rapid return
  to activities as tolerated
• Doesnt burn any bridges
• Helps evaluate the status of the joint, may help
  guide future treatment decisions

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Arthroscopy

• Results UNPREDICTABLE!
• Works best with less advanced arthritis
• Two specific groups do best
• Sudden symptom change goal is to return to
  baseline (not eliminate all pain)
• Strong catching/locking symptoms goal is to
  stop catching/locking (not eliminate all pain)

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QUESTIONS

• ARTHROSCOPY

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Arthroplasty (Replacement)

• One of the most successful operations in all of
  medicine
• Modern form originated in 60s and 70s
• Over 500,000 hips and knees done each year in the
  U.S.

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What is the procedure?

• Hip Socket replaced with metal and plastic
  socket, ball replaced with metal ball attached to
  stem that goes down the femur
• Knee End of femur covered with metal cap, top
  of tibia covered with metal and plastic plate,
  patella resurfaced with plastic button

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What are the goals of the procedure and how
likely is it to work?

• Pain relief very reliable
• Functional improvement reliable but need to
  consider other factors which may limit function
  (other bad joints, poor balance, deconditioning,
  medical problems)
• Good and excellent results 95 - 97

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What are the complications/risks?

• Infection
• Bleeding / need for transfusion
• Nerve injury
• Blood Clots DVT, PE
• Anesthesia regional techniques (spinal,
  epidural) becoming more common
• Dislocation (Hip)
• Differing leg lengths (Hip)
• Stiffness (Knee)

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What are the complications/risks?

• Many complications related to medical conditions
  / health problems
• Even the most healthy patient can suffer a
  complication

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Long Term Problems

• The replacement is a mechanical device with a
  limited lifespan
• Failure eventually results in pain
• Revision surgery has higher complication rates
  and lower success rates
• Will I need a revision procedure?
• How long will I live?
• How long will it last? (guess 10-20 years)

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What is the recovery like?

• Historically long and difficult, but variable
• Surgery 1-2 hours
• Hospital 3-4 days
• Home or transitional care
• A lot of Rehab (especially knees)
• Walker/crutches 2-3 weeks, Cane 3-4 weeks
• Limited only by your pain and ability to progress
• May improve for up to one year

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What is the recovery like?

• Newer techniques may offer more rapid and less
  painful recovery
• MIS Minimally Invasive Surgery
• Better term LESS Invasive Surgery
• Same operation through smaller incision
• Not appropriate for all patients
• ? Not appropriate for all surgeons - ? Higher
  complication rate
• An easier recovery is nice, but cannot compromise
  the reliable long term success seen historically

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QUESTIONS

• ARTHROPLASTY

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What do you recommend, Doctor?

• Know your diagnosis
• Know your options, surgical and non-surgical
• Know yourself
• Seek advice from others primary M.D.
• Ask your surgeon questions
• Trust your instincts make sure you feel
  comfortable with your choice and your surgeon
• Its YOUR decision (almost always)

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THANK YOU !