Total Hip and Knee ArthroplastyWhen to Proceed to Surgery

Scott T. Ball, MDChief, Adult Joint Reconstruction

Associate Professor, Department of Orthopaeic Surgery

University of California, San Diego

Disclosures• DePuy Orthopaedics

• Biocomposites, Inc.

• Conformis

Epidemiology of Arthritis• Of the 250 million adults living in the United States,

50 million adults have a known diagnosis of arthritis.

• 21 million adults have arthritis-attributable activity

limitation.

Data from the National Health Interview Survey (NHIS)

One in Five Adults Suffers with Arthritis

Epidemiology of Arthritis

• Arthritis is the MOST COMMON

cause of disability in the US

• Annual cost = $128 billion in

medical care and lost wages

Data from the National Health Interview

Survey (NHIS)

Epidemiology of Arthritis• OA is a disease with NO cure

• No disease modifying drugs

• Treatment for early OA – Prevent disease progression

• Late disease is NOT just a cartilage problem– Deformity

– Ligaments

– Bone loss

– Stiffness

Radiographic Workup - Knee

• Weight bearing Xrays

• STANDING AP

• Lateral

• Merchant/Sunrise

• Consider Rosenberg view – Valgus knee

Radiographic WorkupNon-WB vs WB XRAY

Radiographic WorkupConsider Rosenberg View

Radiographic Workup - Hip

• Plain xrays

• AP pelvis

• AP/Lateral hip

• Typically not weight

bearing

X-Ray Classification Kellgren-Lawrence Score

X-Ray Classification Kellgren-Lawrence Score

4321

Radiographic Workup - MRI• MRI is NOT indicated in the routine work-up for

moderate/severe OA

• MRI is indicated when the x-ray does not reveal pathology to explain the symptoms– Knee - soft tissue cause for pain

• Meniscal tear

• Ligament injury

• Avascular Necrosis

– Hip –soft tissue cause for pain

• Labral tear

• Avascular Necrosis

• Tendinopathy around the hip

Management of OA

Management of OA

Management of OA

• OARSI– Non-pharmacologic

• Patient education – self help, patient driven

• P.T. – HEP, strength training

• Aerobic exercise – JUST LIKE LBP!!

• Aqua exercise

• Weight loss

• Bracing/Sleeves/Shoe inserts

• Cane

• Tens

• Acupuncture

Appropriate

Appropriate

Appropriate

Appropriate

Appropriate

Appropriate

Appropriate Uncertain

Uncertain

Management of OA

• OARSI– Pharmacologic

• Acetaminophen

• NSAIDS

• Topical NSAIDS

• IA steroid injections

• IA hyaluronate injections

• Glucosamine/CS

• Weak opioids

– Only if non-opioids failed

– Stronger opioids only in exceptional circumstances

Appropriate

Appropriate

Appropriate

Appropriate Uncertain

Uncertain

Uncertain

Management of OA

Management of OA

• AAOS Guidelines SOR1. Self-management educational program Strong

2. Weight loss Moderate

3. Against use of acupuncture/tens/manual Strong

4. Bracing Inconcl.

5. NO lateral heel wedge Moderate

6. No glucosamine/CS Strong

7a. NSAIDS or Tramadol Strong

7b. Tylenol, opioids, pain patches Inconcl.

8. Intra-articular steroids Inconcl.

Management of OA

• AAOS Guidelines SOR9. No HA injections Strong

10. PRP or growth factor injections Inconcl.

11. No needle lavage Moderate

12. No arthroscopy for debridement Strong

13. Arthroscopic meniscectomy Inconcl.

14. Osteotomy Limited

15. No uni-spacer Consensus

Who is a GOOD Candidate for

Hip or Knee Replacement?

• The patient is interested in surgical treatment

• Significant OA (Significant joint space loss)

– Has to be ‘bone-on-bone’ (KL grade 3 or 4)

• BMI < 35 – 40 (depends)

• Failed reasonable non-operative treatments

• Non smoker

• Minimal or no narcotic use

• Reasonable physical condition and motivated

• Medically acceptable surgical candidate

Who is a not a Good Candidate

for Joint Replacement – Mild Arthritis

• Patients with mild arthritis report worse outcomes

• Patients with severe arthritis (bone-on-bone) prior

to surgery report better outcomes

– Better functional improvement

– Better pain improvement

– True for Hip and Knee Replacement

Keurentjes JC, et al. PLoS One. 2013;8(4):e59500.

Tilbury C, et al. Acta Orthop. 2016 Feb;87(1)

KL Grade 2

Not ‘Bone on Bone’

KL Grade 4

Severe w/ Deformity

5 years post-op.

Never has done well.

Now seeking revision.

Never took narcotics.

Back to work < one month.

‘Life changing’ surgery.

Age Criteria• Age is not a criteria for joint replacement

• Extremes of age should be approached with more caution

• Patient age > 90 years– Higher one year morbidity / mortality than other TJA age groups

– No difference compared to rest of the population > 90 years of age

– Miric A, et al. J Arthroplasty. 2015 Aug;30(8):1324-7

• Patient age < 30 years– Mixed group of patients (not ‘arthritis’)

– Mixed implant usage reported

– 10 year survivorship 70% - 90% higher revision rate

– Tsukanaka M, et al. Acta Orthop. 2016 Oct;87(5):479-84.

– Lie S A, et al. J Bone Joint Surg (Br) 2004; 86(4): 504–9.

95 year old male

Escaped Nazi Germany in 1939

Left THA at age 85 – doing well

Right hip totally debilitating

13 year old female

Slipped capitofemoral epiphysis (SCFE)

Left hip with AVN and screw penetration into joint

Summary

• When to proceed with Joint Replacement Surgery

– The joint is BAD ENOUGH – Bone-on-Bone

– The patient needs to be HEALTHY ENOUGH

– Failed reasonable non-surgical treatments

• Weight loss

• Appropriate low impact activity

• Acetamenophin / NSAIDs – not narcotics

• IA steroid injection

• Cane

– Age should be respected by but not used as strict

criteria for surgery

Thank You