Arthritis: How Do I Know and What Do I Do?

Robert Cusick, M.D.October 7, 2008

Oct. 7, 2008Oct. 7, 2008

My ‘Brief’ History

Born and raised in Chicago

University of Illinois

Residency in Wichita

Fellowship in Phoenix

Live and work in Wichita

Oct. 7, 2008Oct. 7, 2008

Kansas Joint and Spine Institute

Oct. 7, 2008Oct. 7, 2008

Kansas Joint and Spine Institute

6 Physicians3 Joint Replacement Surgeons2 Spine Surgeons1 Sports Surgeon

NE WichitaEmploy 35-40 StaffPhysical/Aquatic

Therapy Center

Oct. 7, 2008Oct. 7, 2008

Reasons for this Presentation

Frequent advances in the fieldInformation overload (news, internet, friends and relatives)New surgeries, new techniques, improving rehabilitation protocolsOpportunity for patients to ask questions

Oct. 7, 2008Oct. 7, 2008

Objectives

Defining ArthritisInjury vs. Wear and Tear?

Will it go away?Treatment OptionsLifetime Sentence?Next Steps?

Oct. 7, 2008Oct. 7, 2008

Types of Arthritis

Oct. 7, 2008Oct. 7, 2008

Osteoarthritis

Classic “wear and tear” arthritisProgresses as patients ageCommon in knees, hips, shoulders

Oct. 7, 2008Oct. 7, 2008

Osteoarthritis“Wearing off” of cartilageCauses inflammation/pain/swellingLeads to stiffness

Oct. 7, 2008Oct. 7, 2008

Rheumatoid Arthritis

Approximately 10% of all arthritisInflammation leads to joint damageAntibodies to the joint surface

Oct. 7, 2008Oct. 7, 2008

Rheumatoid Arthritis

Progresses throughout lifeManaged with aggressive medications by rheumatologistOften results in joint replacement

1212

Common Injuries

1212

1313Oct. 7, 2008Oct. 7, 2008

Knee Injuries

Knee SprainMedial Collateral, Lateral CollateralNon-Operative Treatment8-12 weeks to heal

1313

1414Oct. 7, 2008Oct. 7, 2008

Knee Injuries

Meniscus TearVERY common injuryAdolescent >> Later lifeNot always injury‘Sudden’ onset

1414

1515Oct. 7, 2008Oct. 7, 2008

Meniscus TearSudden, sharp painsCatching, lockingTreated with arthroscopyFull recovery typical

1515

1616Oct. 7, 2008Oct. 7, 2008

Arthroscopy

1616

1717Oct. 7, 2008Oct. 7, 2008

Hip Injuries

TendonitisBursitis (Hip Pointer)Labral InjuryFracture

1717

1818Oct. 7, 2008Oct. 7, 2008

Psoas Tendonitis

Groin painPain with hip flexionDue to overuse, new activitiesTreated with meds, physical therapy

1818

1919Oct. 7, 2008Oct. 7, 2008

Trochanteric Bursitis

Very common cause of hip painLateral pain, tenderness

1919

2020Oct. 7, 2008Oct. 7, 2008

Trochanteric Bursitis

Typically secondary to another issueTreated with NSAID’s, rest, heat/ice, topicals, massage, injections, PT

2020

2121Oct. 7, 2008Oct. 7, 2008

Labral Injury

Sudden onsetGroin painCatching, lockingTreated with arthroscopyFull recovery typical

2121

2222Oct. 7, 2008Oct. 7, 2008

Hip Fractures

Several different typesMiddle age and olderDue to fall, injuryTreated with surgeryDecreasing mortality

2222

2323

Outlook for Arthritis

2323

2424Oct. 7, 2008Oct. 7, 2008

Arthritis Prognosis

Generally progressiveWax and wane

ActivityWeather (barometer)Medical conditions

Increasing stiffness, pain

2424

Oct. 7, 2008Oct. 7, 2008

Prevalence of Arthritis

Treatments for Arthritis

Oct. 7, 2008Oct. 7, 2008

Nonoperative Treatments

Activity modificationsNon-steroidal anti-inflammatories

Ibuprofen, Naproxen, Aspirin, etc

Ice/HeatBracingPhysical Therapy/Aquatic TherapyInjections

Oct. 7, 2008Oct. 7, 2008

Nonoperative Treatments

Activity ModificationAvoidance of stairsFrequently resting when ambulatingCane for supportLifestyle changes due to pain

Oct. 7, 2008Oct. 7, 2008

Nonoperative Treatments

Non-steroidal anti-inflammatoriesAspirin >> GI Problems, BleedingIbuprofen, Naproxen >> GI?Celebrex, Mobic >> Cost, BP problems?Lodine, Relafen, Daypro >> GI? Effective?

Oct. 7, 2008Oct. 7, 2008

Nonoperative TreatmentsIce/Heat

Ice: Can minimize swellingHeat: Can break-up swellingVarying effects for different patients

BracingSimple >> support, compression, warmthCustom (unloader) bracing

Expensive, cumbersome, uncomfortableExpensive, cumbersome, uncomfortableRarely longRarely long--termterm

Oct. 7, 2008Oct. 7, 2008

Unloader Bracing

Oct. 7, 2008Oct. 7, 2008

Nonoperative Treatments

Physical TherapyExercises

Improve mobilityImprove mobilityIncrease strengthIncrease strengthDecrease swellingDecrease swelling

Modalities-Ultrasound, IonophoresisDecrease painDecrease painDecrease swellingDecrease swellingImprove functionImprove function

Oct. 7, 2008Oct. 7, 2008

Nonoperative Treatments

Aquatic Therapy

Oct. 7, 2008Oct. 7, 2008

Aquatic TherapyEarly, aggressive ROM exercisesMinimal impact, non-loaded hip and knee therapyResistance=improved strengthOcclusive dressings required 2-3 weeks

Oct. 7, 2008Oct. 7, 2008

Injection TherapySteroid Injection

Cortisone, Celestone, DepomedrolUsually mixed with local anesthetic (Lidocaine)Typically effective very quicklyCan be repeated every 3-4 mosInexpensive, easy to administerMost common injection

Oct. 7, 2008Oct. 7, 2008

Viscosupplementation

Synvisc, Hyalgan, Supartz, EuflexaHyaluronic acid injections-intraarticularTypically 3 injections over 3 weeksMechanism of action

Direct lubricantStimulates synovium to produce natural lubricant

Pain=incorrect location

Oct. 7, 2008Oct. 7, 2008

Nutritional Supplements

Glucosamine/Chondroitin SulfateProven useful through reliable researchVarying degrees of active ingredient2-3 mos. prior to determining utility

MSMMechanism not well understoodTreats RA, snoring, muscle spasm, cancerNot regulated, not proven

Surgical Treatments for Arthritis

Total Hip Arthroplasty

Oct. 7, 2008Oct. 7, 2008

Oct. 7, 2008Oct. 7, 2008

“Traditional” THA

Posterolateral approach8-12” incision2-3 hr. procedureFrequent transfusions5-8 day hospitalizationStrict restrictions for life

Oct. 7, 2008Oct. 7, 2008

New Techniques

Oct. 7, 2008Oct. 7, 2008

Minimally Invasive Surgerytotal hip replacement (MIS)

Promises faster recovery, less surgery, less pain, equal resultsGoogle returns 547,000 resultsPopular in large cities (marketing?)MIS standard incision vs. two

incision technique

Oct. 7, 2008Oct. 7, 2008

MIS Total Hip Replacement

Oct. 7, 2008Oct. 7, 2008

MIS Hip Controversies

Longer surgery (2-3 hrs. vs. 1 hr.)X-ray exposureSerious complications

FractureMalposition of componentsNeurovascular injuryMuscle damageEarly revisions?

Oct. 7, 2008Oct. 7, 2008

MIS ContributionsMore aggressive rehabilitation

Intra-operative soft tissue management

Comprehensive post-operative pain management protocol

Earlier return to function

Oct. 7, 2008Oct. 7, 2008

Bearing Surfaces

Oct. 7, 2008Oct. 7, 2008

Worn Components and Osteolysis

Oct. 7, 2008Oct. 7, 2008

Different Bearing Options

Oct. 7, 2008Oct. 7, 2008

Hip Resurfacing

Oct. 7, 2008Oct. 7, 2008

Replacement vs. Resurfacing

Oct. 7, 2008Oct. 7, 2008

Hip Resurfacing

Younger, more active patientsFewer long term restrictionsCostly: very expensive componentsUnproven track recordLikely to increase in popularity in the U.S. as it has in other countries

Total Knee Arthroplasty

Oct. 7, 2008Oct. 7, 2008

X-Ray Evaluation

Oct. 7, 2008Oct. 7, 2008

Misconceptions

Oct. 7, 2008Oct. 7, 2008

Recent Advances

Oct. 7, 2008Oct. 7, 2008

Minimally Invasive TKA

5-8 year historyMarketing tool?Google returns 292,000 resultsFaster recovery?Less surgery?

Oct. 7, 2008Oct. 7, 2008

MIS-Lessons Learned

Quadriceps mechanism preservationAggressive pain managementEARLY physical therapyShorter hospitalization

Oct. 7, 2008Oct. 7, 2008

Computer Assisted Navigation

Oct. 7, 2008Oct. 7, 2008

Navigation in TKA

Not roboticsExtra information during surgeryTrackers around knee to pinpoint landmarksPrecision cuts, placement of prosthesisNOT for every patient, yet

Oct. 7, 2008Oct. 7, 2008

Navigation

Oct. 7, 2008Oct. 7, 2008

Navigation Goals

Standard surgery despite varied anatomyReproducible alignmentCorrection of complex deformitiesLess invasive surgery?

Oct. 7, 2008Oct. 7, 2008

Total Joint Aftercare

RehabPhysical TherapyDVT ProphylaxisRestrictionsExpectations

Oct. 7, 2008Oct. 7, 2008

Inpatient Rehab

Rarely required after uncomplicated TKA, THATypically older, less healthy individuals living aloneTypical stay 5-8 days‘Step-down’ between inpatient and home

Oct. 7, 2008Oct. 7, 2008

Physical Therapy

More critical after knee replacement2X/day in hospital, then 3X/wk X 3 wks.Full weight-bearing immediatelyGoal=less pain, increase ROM

Oct. 7, 2008Oct. 7, 2008

ROM Requirements

Oct. 7, 2008Oct. 7, 2008

Long Term Restrictions

NO impact activities (jumping, jogging)Limited squatting (flexion, adduction, internal rotation-HIP)Kneeling permittedLifting up to 75 lbs, 50 lbs repetitivePermitted: biking, doubles tennis, light blue/green slope skiingDental prophylaxis-for life?

Oct. 7, 2008Oct. 7, 2008

Current Expectations

Immediate full weight bearing (day of surgery)2-3 days in hospitalWalker 1 week, cane 1-2 weeks3 weeks out-patient physical therapyReturn to work/driving 4-6 weeks15-20+ years before wear becomes an issue

Oct. 7, 2008Oct. 7, 2008

Bilateral Total Knee Replacement

Patient selection criticalHealthy, motivated patientsVery unhealthy patients (one anesthetic)Risk comparable or less than two staged surgeriesPatient satisfaction improving

Oct. 7, 2008Oct. 7, 2008

Operative Treatment Summary

Total Hip AdvancesLess invasive surgeryNew bearing surfacesAlternative procedures

Total Knee AdvancesLess invasive surgeryComputer assisted navigationRapid rehab protocols

Oct. 7, 2008Oct. 7, 2008

Current InnovationsSummary

Hip ResurfacingYounger patientsHigh level activities

Computer NavigationHigh accuracyLonger lasting?

Aquatic TherapyLow impact rehabBetter ROM?

7272

Living With Arthritis

7272

7373Oct. 7, 2008Oct. 7, 2008

What to Expect

Slowly progressive pain, stiffness“Good and bad” daysMulti-modal treatment

Different combinations for different patientsPatient and symptom specific

Not hereditaryNot ‘destined’ for surgery

7373

7474Oct. 7, 2008Oct. 7, 2008

What to Do

STAY ACTIVE!!!Talk to your doctor

7474

7575Oct. 7, 2008Oct. 7, 2008

Where To Get Information

Arthritis Foundationwww.Arthritis.org

American Academy of Orthopedic Surgeonsorthoinfo.aaos.org

Dr Robert Cusickwww.KJSI.com

7575

Oct. 7, 2008Oct. 7, 2008

Questions?

Thank YouRobert Cusick, MD

www.KJSI.com