A Minimally Invasive Approach to Knee Arthritis Sponsored by: With assistance from James E. Dowd, MD (Virginia Beach, VA)

2 nd only to heart disease in causing disability2 nd only to heart disease in causing disability 1 million new patients diagnosed each year1 million new patients diagnosed each year Affects 50 percent of people 65 years of age and olderAffects 50 percent of people 65 years of age and older Population of older adults with arthritis will nearly double by 2030Population of older adults with arthritis will nearly double by 2030 Arthritis affects 70 million Americans

The Knee and Osteoarthritis Most common joint affected by osteoarthritisMost common joint affected by osteoarthritis Large weight-bearing jointLarge weight-bearing joint Complex motion patternComplex motion pattern Common site of injuryCommon site of injury

Osteoarthritis is the most common form of arthritis Rheumatoid arthritisRheumatoid arthritis Post-traumatic arthritisPost-traumatic arthritis Inflammatory arthritisInflammatory arthritis Septic arthritisSeptic arthritis All result in loss of joint cartilage

Presenting Symptoms of Arthritis StiffnessStiffness SwellingSwelling Long limb deformityLong limb deformity – (“knock-knee”/ “bow-leg”) CrepitusCrepitus Activity limiting PAIN!Activity limiting PAIN!

Initial Conservative Treatments Tylenol ®Tylenol ® NSAIDsNSAIDs Nutritional supplementsNutritional supplements Physical therapyPhysical therapy Activity modificationActivity modification Weight lossWeight loss

Therapeutic Injections CorticosteroidCorticosteroid –Inter-articular anti- inflammatory agent Viscoelastic SeriesViscoelastic Series –Augment normal joint lubrication –Hyaluronic Acid (HA) ©MMG 2001

The Most Common Complications Cortisone Injections –Allergic reaction, joint swelling and pain several hours after injection and infection Hyaluronic Acid (HA) Injections –Temporary pain, swelling, and/or fluid accumulation in the injected knee These procedures are not for everyone. Results vary in patients.

The Orthopaedic Specialist When conservative treatments no longer resolve activity limiting pain caused by osteoarthritis then...When conservative treatments no longer resolve activity limiting pain caused by osteoarthritis then... Surgical and reconstructive treatments may be appropriateSurgical and reconstructive treatments may be appropriate

Surgical Options for Knee Arthritis ArthroscopyArthroscopy –debridement, meniscectomy, chondroplasty OsteotomyOsteotomy –bone re-alignment ArthroplastyArthroplasty –joint replacement

Arthroscopic Debridement “clean out” or “scrape bone” Somewhat unpredictable resultsSomewhat unpredictable results 50 to 66 percent get relief for some period of time50 to 66 percent get relief for some period of time Best for patients with mechanical symptoms (catching, locking and giving out)Best for patients with mechanical symptoms (catching, locking and giving out)

Knee Osteotomy Re-align weight-bearing axis through “good” cartilage Most popular before success of contemporary knee replacementMost popular before success of contemporary knee replacement Useful for patients too young, heavy or active for knee implantsUseful for patients too young, heavy or active for knee implants Early results acceptable, questionable durabilityEarly results acceptable, questionable durability

The Most Common Complications Arthroscopy –Bleeding, infection and blood clots Osteotomy –Insufficient pain relief, nonunion/malunion, intra-articular fracture, DVT, infection and neurovascular injury These procedures are not for everyone. Results vary in patients.

End-Stage Osteoarthritis  Knee Replacement “Gold Standard of Care” Uni-compartmental Knee ReplacementUni-compartmental Knee Replacement –“Uni,” “partial replacement” or UKR Tri-compartmental Knee ReplacementTri-compartmental Knee Replacement –“total replacement” or TKR

The Knee: 3 Compartments MedialLateral Patella- Femoral

Osteoarthritis in 1 of 3 Compartments: Treatment = UKR

Uni-compartmental Knee Replacement (UKR) 20+ year clinical history20+ year clinical history Less commonly performedLess commonly performed –Growing interest utilizing minimally invasive techniques

Osteoarthritis in 2 of 3 Compartments: Treatment = TKR

Total Knee Replacement (TKR) 30+ year clinical history30+ year clinical history >95 percent of all knee replacements performed>95 percent of all knee replacements performed

Uni-compartmental Knee Replacement Uni-compartmental Knee Replacement (Early Results) Aglietti & Insall – 30 percent revised at 5 to 7 year follow-upAglietti & Insall – 30 percent revised at 5 to 7 year follow-up (Aglietti, Paulo, MD and John Insall, MD. “A Five to Seven Year Follow-up of Unicondylar Arthroplasty.” Journal of Bone and Joint Surgery Dec. 1980: ) Marmor – 65 percent survivorship at 11 year follow-upMarmor – 65 percent survivorship at 11 year follow-up (Marmor, Leonard, MD. “Unicompartmental Knee Arthroplasty Ten- to 13-Year Follow-up Study.” CORR Jan. 1988: ) Scott, et al. – 85 percent survivorship at 10 year follow-upScott, et al. – 85 percent survivorship at 10 year follow-up (Scott, R.D., MD, et al. “Unicompartmental Knee Arthroplasty Eight- to 12- Year Follow-up Evaluation With Survivorship Analysis.” CORR Oct. 1991: )

Uni-compartmental Knee Replacement ( Uni-compartmental Knee Replacement (Early Challenges) TechniquesTechniques ImplantsImplants InstrumentsInstruments

Trusted Innovation Mobile-bearing LCS  Heritage Fixed-bearing P.F.C.  Sigma Heritage

Uni-compartmental Knee Replacement long-term results (fixed-bearing)

Uni-compartmental Knee Replacement long-term results (mobile-bearing)

Potential Patient Benefits with a UKR Procedure Higher patient satisfactionHigher patient satisfaction Quicker recoveryQuicker recovery Better range of motionBetter range of motion Less blood lossLess blood loss Less chance of infectionLess chance of infection Cost savingsCost savings

Uni-compartmental Knee Replacement “Show Me the Data” UKR versus TKR – 23 patients with bothUKR versus TKR – 23 patients with both –Average ROM UKR=123 degrees, TKR=110 degrees –44 percent preferred UKR side, 12 percent preferred TKR (Laurencin, C.T., MD, et al. “Unicompartmental Versus Total Knee Arthroplasty in the Same Patient.” CORR Dec. 1991: ) 81 UKRs versus 120 TKRs81 UKRs versus 120 TKRs –Blood Tx 1 percent with UKRs versus 67 percent with TKR (Rougraff, MD, et al. “A Comparison of Tricompartmental and Unicompartmental Arthroplasty for the Treatment of Gonarthrosis.” CORR Dec. 1991: )

Uni-compartmental Knee Replacement “Show Me the Data” 50 UKRs versus 52 TKRs50 UKRs versus 52 TKRs –UKR = shorter hospitalization –UKR = better knee flexion, 69 percent >120 degrees versus 17 percent TKRs (Newman, MD, et al. “Unicompartmental or Total Knee Replacement? Five-Year Results of a Prospective, Randomised Trial of 102 Osteoarthritic Knees With Unicompartmental Arthritis.” Journal of Bone and Joint Surgery Br. Sept. 1998: ) Swedish Knee RegistrySwedish Knee Registry –Risk of infection 0.8 percent for UKR versus 2 percent for TKR (Knutson, MD, et al. “Revision of Unicompartmental Knee Arthroplasty: Outcome in 1,135 Cases From the Swedish Knee Arthroplasty Study.” Acta Orthop Scand 1998: )

The Most Common Complications Knee Arthroplasty Loosening, deformation or wear of one or more of the components, osteolysis, infection, DVT and fracture of the components or bone. This procedure is not for everyone. As with any surgery, there are risks. Recovery takes time and hard work. The life of a joint replacement depends on weight, activity level, age and other factors. Each patient responds differently.

UKR Today Minimally Invasive Technique! 6 to 8 in. incision reduced to 3 to 4 in.6 to 8 in. incision reduced to 3 to 4 in. Minimal muscle traumaMinimal muscle trauma Extensor mechanism left intactExtensor mechanism left intact

Conservative bone resectionsConservative bone resections Minimal blood lossMinimal blood loss Shorter hospital staysShorter hospital stays UKR Today Minimally Invasive Technique! UKR Today Minimally Invasive Technique!

Postoperative Recovery 24 to 48 hour hospitalization (outpatient?)24 to 48 hour hospitalization (outpatient?) Weight-bearing as toleratedWeight-bearing as tolerated Improved range of motionImproved range of motion Quicker return to activityQuicker return to activity UKR Today Minimally Invasive Technique! 3 weeks postoperative

A Modern Implant System Designed for Minimally Invasive Surgery Implants Instruments GVF-UHMWPE

Elderly patientElderly patient Isolated (uni-compartmental) osteoarthritisIsolated (uni-compartmental) osteoarthritis <250 lbs<250 lbs Good ROM, minimal deformityGood ROM, minimal deformity Relatively sedentary activity levelRelatively sedentary activity level *Deshmukh, R.V., MD and R.D. Scott, MD, “Unicompartmental Knee Arthroplasty: Long Term Results”, CORR - No. 392 (pgs ), Minimally Invasive UKR Who is a (traditional*) candidate?

Minimally Invasive UKR Who is a (relative*) candidate? Younger patients (<65 yrs)Younger patients (<65 yrs) >250 lbs>250 lbs Higher activity expectations (relative)Higher activity expectations (relative) Patella-femoral compartment arthritisPatella-femoral compartment arthritis *Experience of surgeons currently conducting UKR.

Younger patients with end-stage uni-compartmental arthritis as a good conservative option that minimizes bone removal and preserves additional options for future surgery (UKR  TKR)Younger patients with end-stage uni-compartmental arthritis as a good conservative option that minimizes bone removal and preserves additional options for future surgery (UKR  TKR) Elderly patients with end-stage uni-compartmental arthritis that would benefit from less surgery, less down time and less rigorous recoveryElderly patients with end-stage uni-compartmental arthritis that would benefit from less surgery, less down time and less rigorous recovery *Experience of surgeons currently conducting UKR. Minimally Invasive UKR Who is a (good*) candidate?

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