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 ARTHRODESIS OSTEOTOMY

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 = 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 diagnosis  Know your options, surgical and non-surgical  Know yourself  Seek 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 !