Treatments of Hip and Knee Arthritis

Bill K. Huang, MDEverett Bone and Joint

Providence Regional Medical Center Everett

Background

• Board-certified orthopedic surgeon• Fellowship training in adult joint reconstruction• Clinical focus

– Hip and knee arthroplasty– Revision hip and knee arthroplasty– Resurfacing arthroplasty– Cartilage allograft

Practice Philosophy

• To provide latest, safest, and the most comprehensive care to patients with hip and knee arthritis

• To help hip and knee arthritis patients to return to normal functions

• To listen to concerns, welcome input and feedback

Objectives

• Review the background of arthritis and joint replacement

• Review treatment alternatives• Introduce surgical concepts• Answer questions

What is arthritis?

They all have arthritis

Major cause of lost work time and serious disability

Articular Cartilage

• “ ..ulcerated cartilage is universally allowed to be a very troublesome disease…when it is destroyed, it is never recovered…” William Hunter 1743

Arthritis• Loss of cartilage in a

joint– Pain– Inflammation– Stiffness

Arthritis• Pain• Stiff• Swollen• Loss of functions

– Walking– Climbing stairs– Putting on socks

• Declining quality of life

Normal Functioning Joint(A joint is where the ends of two or more bones meet)

• Healthy cartilage• Well lubricated• Full motion• Pain free

Arthritic Joint

• Damage to cartilage• Loss of lubricating mechanism• Loss of motion• Pain

Types of Arthritis

• Osteoarthritis (OA)– Most common – Slowly progressive, degenerative, cartilage gradually

wears away– Middle-aged and older people

• Inflammatory arthritis– Most common is called rheumatoid arthritis (RA)– Inflammatory condition that destroys joint cartilage– Can occur at any age, multiple joints affected

• Post-traumatic arthritis – Develops after an injury, usually many years after– Similar to osteoarthritis

Osteoarthritis

• Multifactorial disease of the joint– Abnormal anatomy– Genetics– Abnormal biology– Overuse

Diagnosis

• History• Physical

examination• X-ray• MRI

Normal Hip

Osteoarthritc Hip

Normal Knee

Osteoarthritic Knee

Arthritis Progression

• Early stages may show no symptoms

• Subtle changes on X-ray• Most over age of 60 will show

X-ray changes– 1/3 shows symptoms

Arthritis Progression

• Cartilage begins to soften• Lose ability to absorb impact• More easily damaged by use

or injury• May completely wear away

– “bone on bone”• Joint loses its shape

Arthritis Progression• Bony erosion• Deformity

– “bow-legged” – “knock-knee”

• Contracture– Inability to fully straighten or

bend

How can my life change with treatment?

• Change in pain symptoms• Return to mobility• Regaining a sense of your former lifestyle

Treatment Plan

• Patient education• Weight reduction• Activity modification• Medication• Ambulation aid• Surgery

Conservative, non-surgical

Surgical

Analgesics

• Provides pain relief• Does not reduce inflammation• Non-narcotic• Narcotic• Discuss options with your

physician

Non-steroidal Anti-inflammatory (NSAIDS)

• Relief can take several months

• Many varieties– Over-the-counter– Prescription

• Marketing has become very overbearing

• Discuss options with your physician

Non-steroidal Anti-inflammatory (COX-2)

• COX-2 inhibitors• Marketed heavily• NOT more effective than older

drugs• Slightly less GI side effects• Discuss options with your

physician

Glucosamine/Chondroitin Sulfate

• Does it grow new cartilage?– No– May be anti-inflammatory– No uniform standards– Few side effects– Not FDA approved

Cortisone Injections

• Steroid injection with local anesthetic• Anti-inflammatory at site of problem• Variable pain relief (few days to months)• Law of diminishing returns• No more than 3-4 per year

Lubricating Injections

• Approved for knee arthritis only

• “rooster comb” shots• Hyaluronan• Series of injections• Variable pain relief

– Works better in mild to moderate arthritis

• Small chance of reaction

Arthroscopy Surgery

• Less invasive– Faster recovery

• Remove damaged tissue

• Variable effectiveness in treatment of arthritic joints– At best, temporary relief

Replacement Surgery

• Total hip replacement• Hip resurfacing• Total knee replacement• Partial knee replacement

FactsIn 2003, more than 638,000 hip or knee replacement surgeries were performed.The number of joint replacements continues to go up each year.

Baby boomers fueling boom in knee, hip surgeriesMay 23, 2011 11:38 AM ETSAN DIEGO (AP) - We're becoming a nation of bum knees, worn-out hips and sore shoulders, and it's not just the Medicare set. Baby boomer bones and joints also are taking a pounding, spawning a boom in operations to fix them.Knee replacement surgeries have doubled over the last decade and more than tripled in the 45-to-64 age group, new research shows. Hips are trending that way, too.

Projected Hip and Knee Replacements in USA

Kurtz et al. JBJS 2007

Goals of Joint Replacement Surgery

• Relieve pain• Improve motion• Return to more active/ fulfilling lifestyle• Improve quality of life

Should I have a joint replacement?

• YES, if:– “conservative treatments of my arthritis have

failed”– “the quality of my life is affected by joint pain”– “I understand the procedure, its expected

outcome, and risks ”

Should I have a joint replacement?

• NO, if:– “my family says I should have it”– “my friends say I should have it”– “I better get it done before it gets too bad”– “I better get it done before I get too old”

Getting Ready for Surgery• Evaluation by internist

– Pre-admission clinic (PACS)– Primary care MD

• Meet with therapist and case manager– Evaluate need for home

therapy vs. rehabilitation after surgery

– Joint Replacement Class• Anemia evaluation• Prepare for homecoming

after surgery

Hip Replacement

Hip Replacement• Incision made on the

side of the thigh• Socket is re-shaped to fit

new cup implant that replaces the diseased socket

• New cup is placed in the socket

Hip Replacement• Femur is prepared

for the stem• Hip stem is

implanted and the ball is put in place on top of stem

• Incision is closed

Hip Replacement

“minimally invasive” arthroplasty

• Misnomer– “Nothing minimally invasive about cutting out a

joint”• Incision size is not the most important• Tissue preservation

– Detach or split muscles ?– Inter-muscular plane ??

• Post-operative management– Multi-modal pain control

Muscle sparing approach – total hip

• Direct Anterior– Preservation of hip

deltoid – Inter-muscular plane

• Between sartoris and tensor fascia lata

• Traditional– Muscle splitting

• Gluteus maximus– Detach muscle from

trochanter• Posterior – short

external rotators• Anterorlateral –

gluteus medius

Direct Anterior Approach

Potential Benefits – Anterior Approach

• Improved hip stability– Lower dislocation rate

• Anterior – < 0.5%• Traditional 2 to 5%

• Faster recovery due to preserved muscle attachment

• Accurate implant placement– Intra-operative X-ray guidance

Matta JM et al. CORR 2005

• Improved materials– X-linked plastic

• Newer bearings– Metal articulation– Ceramic articulation– Oxinium

• Improved technology– Larger femoral head

Too “young” for hip replacement?

Better Longevity

• Significantly better laboratory wear results– Possible longer implant life

• Improved bio-mechanics– More stable joint

• Does have potential down side– Metal ion issues in metal on

metal total hips

Hip Resurfacing

• A form of total hip replacement• Femoral head is preserved• Not everyone is a candidate• metal-on-metal articulation• Discuss with your physician

Hip Resurfacing vs. Hip Replacement

Birmingham Hip Resurfacing

• FDA approved 2006• 10+ years of clinical data

in Europe and Australia– Approx. 96% survivorship

• Many live a very active life style

“recalled” Total Hips• Involves only metal-on-metal total hip

systems• Failure due to metal ion sensitivity

Knee Replacement

The most commonly replaced joint in the human body!

Knee Replacement

• damaged parts of your knee that need repair will be removed

• replaced with metal and plastic implants.

• an implant, especially selected to match your anatomy

Knee Replacement

• The damaged portions of the femur and cartilage are cut away.

• The end of the femur is reshaped to allow the metal femoral component to fit onto it.

Knee Replacement

• The damaged area of the tibia and cartilage are cut away. The tibia is reshaped to receive the metal tibial component.

Knee Replacement

• The metal baseplate is cemented in place and the plastic insert is snapped in to the baseplate.

Advances for “Younger” Patients

• Mobile-bearing– Designed to rotate as

it bends– Imitates natural knee

movement– Possible better wear

Improved Material

• Oxidized zirconium (Oxinium)– Ceramic-metal composite– Better wear rate in

laboratory study• Simulated up to 30 years of

wear• Advertised as “30-year” knee

Improved Techniques

• Mini-Incision Replacement• “minimum invasive”• Reduces incision length and

scar to 3.5 to 4 inches.• Does not “evert” the patella • Less damage to quad tendon• Possible post-operative pain • Likely to speeds rehabilitation

time and returns you to your life more quickly.

Improved Techniques• Computer Navigation

– Define anatomy during surgery

– Guides alignment

Improved Techniques• Computer Navigation

– Intra operative feed back to surgeons

Improved Techniques• Robot assisted Surgery

– “Makoplasty”• Possible improved accuracy• Not proven to be better• Longer surgery time

“Customized” surgery• Customized instruments to fit

the patient’s knee• NOT fitting patient’s knee to

fit a set instruments

“Customized” surgery• Patient-matched Technology

– Use MRI and special X-ray to create a computer model of patients knee

– Custom guides & instruments to match patient’s exact shape and anatomy

– Accurately aligned knee specific to individual’s anatomy

“Customized” surgery• Improve accuracy and

alignment• Decrease surgical time

– Less anasthesia– Decrease risk of infection

• Possible improve long term performance of the prosthesis

“Customized” surgery

Partial Knee Replacement• “Uni”, “Partial”• Less invasive surgery• Replace only damaged

portion of joint• Bone conservation• Typically faster recovery• Not everyone is a

candidate

Unicompartmental Replacement• Either medial or lateral• Preserve patients ligaments

– ACL and PCL

Patellofemoral Replacement• Isolated knee cap arthritis is

replaced• Normal cartilage preserved

Cartilage Transplantation

• Only certain patient• Younger age

Cartilage Transplantation

Cartilage Transplantation

Osteochondral allograft

Changing Expectations

• Patient expectation– Complete pain relief– Quick recovery

• Return to mobility– High activity level such

as sports• Regaining a sense of

former lifestyle

Summary• Very successful surgery• Reliable, predictable outcome• Excellent long-term results• Tremendous improvement

in patient’s quality of life

Summary

• Improved materials• Better techniques• Expanded indications for

“younger” patients with hip and knee arthritis

• Maintain an ACTIVE lifestyle

THANK YOU

Bill K. Huang, MD