Total Hip and Knee Arthroplasty When to Proceed to Surgery Scott T. Ball, MD

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1 Total Hip and Knee Arthroplasty When to Proceed to Surgery Scott T. Ball, MD Chief, Adult Joint Reconstruction Associate Professor, Department of Orthopaeic Surgery University of California, San Diego

2 Disclosures DePuy Orthopaedics Biocomposites, Inc. Conformis

3 Epidemiology of Arthritis Of the 250 million adults living in the United States, 50 million adults have a known diagnosis of arthritis. 21 million adults have arthritis-attributable activity limitation. Data from the National Health Interview Survey (NHIS) One in Five Adults Suffers with Arthritis

4 Epidemiology of Arthritis Arthritis is the MOST COMMON cause of disability in the US Annual cost = $128 billion in medical care and lost wages Data from the National Health Interview Survey (NHIS)

5 Epidemiology of Arthritis OA is a disease with NO cure No disease modifying drugs Treatment for early OA Prevent disease progression Late disease is NOT just a cartilage problem Deformity Ligaments Bone loss Stiffness

6 Radiographic Workup - Knee Weight bearing Xrays STANDING AP Lateral Merchant/Sunrise Consider Rosenberg view Valgus knee

7 Radiographic Workup Non-WB vs WB XRAY

8 Radiographic Workup Consider Rosenberg View

9 Radiographic Workup - Hip Plain xrays AP pelvis AP/Lateral hip Typically not weight bearing

10 X-Ray Classification Kellgren-Lawrence Score

11 X-Ray Classification Kellgren-Lawrence Score

12 Radiographic Workup - MRI MRI is NOT indicated in the routine work-up for moderate/severe OA MRI is indicated when the x-ray does not reveal pathology to explain the symptoms Knee - soft tissue cause for pain Meniscal tear Ligament injury Avascular Necrosis Hip soft tissue cause for pain Labral tear Avascular Necrosis Tendinopathy around the hip

13 Management of OA

14 Management of OA

15 Management of OA OARSI Non-pharmacologic Patient education self help, patient driven P.T. HEP, strength training Aerobic exercise JUST LIKE LBP!! Aqua exercise Weight loss Bracing/Sleeves/Shoe inserts Cane Tens Acupuncture Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate Appropriate U certai U certai

16 Management of OA OARSI Pharmacologic Acetaminophen NSAIDS Topical NSAIDS IA steroid injections IA hyaluronate injections Glucosamine/CS Weak opioids Only if non-opioids failed Appropriate Appropriate Appropriate Appropriate U certai U certai U certai Stronger opioids only in exceptional circumstances

17 Management of OA

18 Management of OA AAOS Guidelines SOR 1. Self-management educational program Strong 2. Weight loss Moderate 3. Against use of acupuncture/tens/manual Strong 4. Bracing Inconcl. 5. NO lateral heel wedge Moderate 6. No glucosamine/cs Strong 7a. NSAIDS or Tramadol Strong 7b. Tylenol, opioids, pain patches Inconcl. 8. Intra-articular steroids Inconcl.

19 Management of OA AAOS Guidelines SOR 9. No HA injections Strong 10. PRP or growth factor injections Inconcl. 11. No needle lavage Moderate 12. No arthroscopy for debridement Strong 13. Arthroscopic meniscectomy Inconcl. 14. Osteotomy Limited 15. No uni-spacer Consensus

20 Who is a GOOD Candidate for Hip or Knee Replacement? The patient is interested in surgical treatment Significant OA (Significant joint space loss) Has to be bone-on-bone (KL grade 3 or 4) BMI < (depends) Failed reasonable non-operative treatments Non smoker Minimal or no narcotic use Reasonable physical condition and motivated Medically acceptable surgical candidate

21 Who is a not a Good Candidate for Joint Replacement Mild Arthritis Patients with mild arthritis report worse outcomes Patients with severe arthritis (bone-on-bone) prior to surgery report better outcomes Better functional improvement Better pain improvement True for Hip and Knee Replacement Keurentjes JC, et al. PLoS One. 2013;8(4):e Tilbury C, et al. Acta Orthop Feb;87(1)

22 KL Grade 2 Not Bone on Bone KL Grade 4 Severe w/ Deformity 5 years post-op. Never has done well. Now seeking revision. Never took narcotics. Back to work < one month. Life changing surgery.

23 Age Criteria Age is not a criteria for joint replacement Extremes of age should be approached with more caution Patient age > 90 years Higher one year morbidity / mortality than other TJA age groups No difference compared to rest of the population > 90 years of age Miric A, et al. J Arthroplasty Aug;30(8): Patient age < 30 years Mixed group of patients (not arthritis ) Mixed implant usage reported 10 year survivorship 70% - 90% higher revision rate Tsukanaka M, et al. Acta Orthop Oct;87(5): Lie S A, et al. J Bone Joint Surg (Br) 2004; 86(4):

24 95 year old male Escaped Nazi Germany in 1939 Left THA at age 85 doing well Right hip totally debilitating

25

26 13 year old female Slipped capitofemoral epiphysis (SCFE) Left hip with AVN and screw penetration into joint

27

28 Summary When to proceed with Joint Replacement Surgery The joint is BAD ENOUGH Bone-on-Bone The patient needs to be HEALTHY ENOUGH Failed reasonable non-surgical treatments Weight loss Appropriate low impact activity Acetamenophin / NSAIDs not narcotics IA steroid injection Cane Age should be respected by but not used as strict criteria for surgery

29 Thank You

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