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Arthritis SeminarSolutions for Knee, Shoulder and Hip

Mark G. Kowall, M.D., M.B.A.

Orthopedic Specialty Associates

Templeton, CaliforniaMarch 5, 2013

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Osteoarthritis

“A Big Problem” More than 40 Million Americans have arthritis (joint inflammation)

27 Million people suffer from Osteoarthritis

40 million by 2020

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Most of us by our 60s & 70sMore women than men after 50

All races equally

Burden of Disease

475,000 Knee Replacements performed annually

Spine

HandsHips

KneesFingers

Osteoarthritis

Feet

Shoulders

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Bone

Joint space filled with Synovial Fluid “the oil” Articular

cartilage“the tread”

Synovial membrane

What is a Joint???

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Healthy Knee

Osteoarthritic Knee

“tread wear”

Cartilage

“Joint Wear”=

“Tread Wear”

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The Knee

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Inside the Knee Joint

Normal Cartilage Advanced Arthritis

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Femoral Head (The “Hip Ball”)

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Causes

Primary Osteoarthritis (Most Common)

Result of aging

Decreased ability of cartilage to repair itself

Ligaments supporting joints weaken

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ObesityJoint Injury

Surgery

Congenital abnormal joints

Gout

Causes

Secondary Osteoarthritis

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Effect of Weight Loss“Take home point”

For each pound of weight loss 4 pound reduction in the forces hitting the knee while walking.

“Less weight, Less load on the knee”

Arthritis and Rheumatism, July 2005

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University of North CarolinaStudy

“Almost 50% of all U.S. adults

and nearly 66% of obese adults will

develop painful arthritis by the age

of 85”

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An Aside Point

Osteoarthritis

Is NOT

Osteoporosis

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Normal Bone Osteoporotic Bone

Osteoporosis

Loss of Bone Density

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Symptoms of arthritisPain in affected joints

Pain worse with prolonged use

Stiffness after periods of inactivity

Grating or “Catching” sensation with movement

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DiagnosisHistoryPhysical Exam

Blood Test- to rule out other diseases

Online “Knee Pain Assessment” (see website)

X-Rays

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Knee X-Ray

Osteoarthritic kneeHealthy knee

“Bald Tire”

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Hip X-Ray

Healthy Hip Osteoarthritic Hip

Tread Gone

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Shoulder X-Ray

Normal AdvancedArthritis

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Treatment

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Goals of Treatment

Make Your Life Better!!!

by

Relieving pain

Increasing motion

Improving strength

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Treatment varies with severity

“Ladder Approach to Treatment”

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1st Rung of LadderMedication

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Medication- NSAIDs

NSAIDs are nonsteroidal anti-inflammatory drugs

Aspirin

Ibuprofen

Naproxen

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Vitamins & Nutritional Supplements

Glucosamine / Chondroitin Sulfate

Some positive results for moderate to advance arthritisRecently, the American Academy of Orthopedic Surgeonsrecommended against its use for patients with

osteoarthritis of the knee (Dec, 2008)

Fish Oil (Omega-3 Fatty Acids)Diet rich in Fruits and Vegetables

Alternative Medicine Techniques

Therapy Symptom  Pain Stiffness Fatigue Inflammation Anxiety/

DepressionBiofeedback u u u    

Visualization u       u

Hypnosis u       u

Relaxation u       u

Yoga u u u   u

u u u   u

Acupuncture u u   u u

Magnets u u   u  

Vegetarian Diet

u u   u  

Herbs & Supplements

u u u u u

Tai Chi

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Next Rung of the Ladder

Injections

Cortisone (steroid)

Visco-Supplementation (Synvisc One,Orthovisc, Hyalgan, Supartz, Euflexxa)

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Joint Protection- Daily Exercise

1.Daily range of motion exercise (Stretching)

2.Strengthening exercises every other day

3.Endurance exercises three times per week

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Exercise Dos

Talk to your doctor first

Consider athletic trainer or physical therapist

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Braces Sleeves neoprene

improve balance?

local warmth

control swelling

high compliance

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Braces Unloaders “unload” or take pressure of the arthritic side of knee

decrease pain

improve walking tolerance

poor compliance

expensive

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External Support Aids

“Unloads” the joint

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When all else fails

to improve pain………..

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Surgery“Top of the Ladder”

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Asking Questions About Surgery

Alternatives

Benefits and for how long?

Risks?

What is procedure called?

How is it done?

Results?

Return to “normal” activity?

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Surgical Options-Arthroscopy

Mini incisions

Outpatient

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Arthroscopy – Debridement(Shaving of articular Cartilage (“tread”)

A means of “smoothing” the coating cartilage

In conjunction to treating meniscus tears

Not designed for treatment of arthritis alone

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Arthroscopy – MicrofractureKnee and Shoulder

small awl used to make holes in bone

promote re-growth of cartilage

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Arthroscopy – “OATS” Procedure

transfer of healthy “tread” to “bald” area

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KneeHip

Surgical Options: Joint Replacement

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Total Knee Replacement

Side view

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Surgical Instrumentation

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Surgical Instrumentation

Femur Tibia

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Implants

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Total Hip Replacement

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Total Hip Replacement

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Total Shoulder Replacement

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Duke University Medical CenterStudy

Hip Replacement Surgery

“Seniors with arthritis who undergo Hip Replacement are twice as likely to show improvements in functioning and ability to care for themselves”

(no age limit on the benefits!!)

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New Technologies

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Laboratory

Recombinant Gene Therapy (synthesize the growth factors which produce new cartilage)

Specific Growth Factors promote cartilage (tread) maintenance and repair

May limit the progression of arthritis

Platelet Rich Plasma (PRP)

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Recent discovery of a natural occurring molecule in the body that can counter the progression of arthritis

Genes and Development

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Traditional TKA vs. High Flex TKA

Designed to safely accommodate flexionup to 125

Designed to safely accommodate flexionup to 155

New Implant Designs

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Gender Specific Knee Implant

Women have a different shaped knee joint

New Implant Designs

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Patient Specific Instrumentation MRI or CT based technology

3D model created of knee

Surgery Planning

Customized pin guides or cutting blocks

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Patient Specific Instrumentation

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Mini-Incision Surgery (Knees)

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Complications

Mini-Incision Surgery for the knee reduces recovery time but increases wound healing problems.

Clinical Orthopedics and Related Research

Mini-Incision and alternative approaches for the hip---controversial!!!!

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Consumer Beware

Bozic K J, et al. Impact of direct to consumer advertising on physician attitudes and behavior in orthopedic surgery American Academy of Orthopedic Surgeons

**Poll of 737 hip and knee surgeons

**Over 75% of surgeons reported that direct-to-consumer (DTC) advertising

negatively impacted their practice and the relationship with patients. **Ads presented a skewed view of procedures and devices by

exaggerating the benefits and down playing risks.

**(Patients) were not more educated about the risks and benefits, not more educated about the alternatives, not more educated about the costs and that they were less open to alternatives after reading or viewing direct-to-consumer advertisements

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Surgical Procedure Animations

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www.ShoulderKneeSpecialists.com Surgical Procedure Animations

Health Library

Important Links

Resources

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Questions????