introduction to orthopaedics: options for hip and knee arthritis stephen p. england, m.d. park...

Introduction to Orthopaedics: OPTIONS FOR HIP AND KNEE ARTHRITIS

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

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

How can I prolong the life of my hip or knee? Weight Management Activity Modification Medications – Systemic Inflammatory

Arthritis Glucosamine ??

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

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

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

QUESTIONS

NON-SURGICAL OPTIONS

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

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 – it’s your choice

Others may help you decide (friends, family, primary care physician), but ultimately you make the call

Consider the following questions

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?

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?

Surgical Options Arthroscopy Osteotomy Arthrodesis (Fusion) Arthroplasty (Replacement)

HIP Osteotomy, arthrodesis, arthroscopy

rarely used Arthroplasty common

KNEE Arthroscopy common Osteotomy – popularity waxes and

wanes Arthrodesis – rarely used Arthroplasty - common

Arthrodesis (Fusion) Eliminates pain Creates a different disability Lasting result Commonly used before arthroplasty

developed Young patient – heavy, laborer Salvage - infection

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

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

Osteotomy Not as popular currently as durability of

arthroplasty improves May make subsequent arthroplasty

more difficult

QUESTIONS

ARTHRODESISOSTEOTOMY

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 – DON’T COMPARE YOURSELF TO OTHERS!

Arthroscopy Other small incisions – insert shavers,

cutting devices, graspers Smooth joint surfaces Trim meniscus tears Remove loose bodies Remove diseased synovium – systemic

inflammatory arthritis

Arthroscopy Brief day surgery procedure Various anesthetics, frequently regional Minimal risks/complications Recovery varies but usually fairly rapid –

return to activities as tolerated Doesn’t burn any bridges Helps evaluate the status of the joint,

may help guide future treatment decisions

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)

QUESTIONS

ARTHROSCOPY

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.

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

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%

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)

What are the complications/risks? Many complications related to medical

conditions / health problems Even the most healthy patient can

suffer a complication

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)

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

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

QUESTIONS

ARTHROPLASTY

“What do you recommend, Doctor?”Know your diagnosisKnow your options, surgical and non-surgicalKnow yourselfSeek advice from others – primary M.D.Ask your surgeon questions Trust your instincts – make sure you feel

comfortable with your choice and your surgeon

It’s YOUR decision (almost always)

THANK YOU !