Total Joint Replacement. Hip and Knee Pain Lawrence P. Johnson, MD Merrimack Valley Orthopedic Associates Lowell General Hospital

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1 Hip and Knee Pain Lawrence P. Johnson, MD Merrimack Valley Orthopedic Associates Lowell General Hospital

2 This talk will touch upon the following topics: Understanding the Causes of Hip and Knee pain Treatment Options What Joint Surgery Involves Realistic Expectations After Joint

3 My Background : Graduate of Dartmouth College, Hanover New Hampshire Graduate of Columbia University College of Physicians and Surgeons, New York City General Surgery Residency PGY1 &2 : Parkland Hospital /University of Texas Southwestern Medical School Dallas Orthopedic Residency at Tufts University, Boston Spine Surgery Fellowship: U. Alabama/Birmingham

4 About My Practice In practice with Merrimack Valley Orthopedic Associates, Lowell and Chelmsford, since 1986, Prior Chief of Orthopedics at Lowell General Hospital Multiple Orthopedic Interests : Joint Surgery Spine surgery Sports Medicine Trauma

5 My Personal Interests Total Joint FAMILY SKIING BIKING HIKING TRAVEL READING POLITICS PHOTOGRAPHY HAITI MISSION TRIP X 2 ANYTHING THAT S FUN!

6 The Landscape : Nearly 21 million Americans suffer from osteoarthritis, a degenerative joint disease that is a leading cause of joint replacement surgery. 43 MILLION Americas have some form of arthritis and that number is expected to increase to 60 million by 2020 Source:

7 Joint Degeneration Pain from arthritis and joint degeneration can: Be constant or come and go Occur with movement or after a period of motionlessness Be located in one spot or in many parts of the body Be worse during certain times of the day or during certain activities

8 Most Common Types of Arthritis Osteoarthritis most common, basically assosciated with genetics, aging i.e. wear and tear Rheumatoid Arthritis :#1 inflammatory arthritis Post-traumatic Arthritis : due to fractures Avascular Necrosis : bone death

9 OA Symptoms May develop suddenly or very slowly Arthritis can cause pain and stiffness Some types of arthritis may cause swelling (knee) Simple tasks may be difficult to do : putting on shoes and socks, getting in and out of cars, doing stairs, etc.

10 Rheumatoid Arthritis, Post-traumatic Arthritis, Avascular Necrosis Rheumatoid Arthritis Membranes or tissues lining the joint become inflamed Post-traumatic Arthritis Irregularities lead to more wear on the joint Avascular Necrosis Bone may collapse and damage the cartilage

11 R.A. : Facts Rheumatoid arthritis is the most crippling form of arthritis: affects approximately 2.1 million Americans two to three times more women than men average onset for rheumatoid arthritis is between the ages of 20 and 45 years old Source: CDC

12 Your Hip Joint A joint is formed by the ends of 2 or more bones. The hip must bear the full force of your weight and consists of two main parts: A ball (femoral head) at the top of your thigh bone (femur) A rounded socket (acetabulum) in your pelvis Normal hip joint, showing healthy articular cartilage

13 What Causes Hip Joint Pain? One of the most common causes of joint pain is arthritis. The most common types of arthritis are: Osteoarthritis (OA) Rheumatoid Arthritis (RA) Post-traumatic Arthritis Avascular Necrosis Diseased hip joint, showing worn cartilage

14 Normal Hip X-ray Arthritic Hip X-ray

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16 Replaced Hip X-ray Total Joint

17 Your Knee Joint Femur thigh bone Cartilage tissue between bones that provides cushioning Patella knee cap Tibia shin bone Synovium tissue that provides lubricating fluid to joint Ligament flexible tissue that holds knee joint together

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20 Normal Knee X- ray Arthritic Knee X-ray

21 Preparing for your Doctor s Visit The Orthopaedic Evaluation A thorough medical history (it s important to bring previous medical records with you) A physical examination X-rays (MRI usually unecessary to help diagnose joint arthritis unless determining avascular necrosis) Additional tests, as needed

22 The Orthopaedic Evaluation Medical History A list of all medications you are currently taking Information on prior surgeries and/or treatments Associated medical diagnoses Family history

23 PHYSICAL EXAMINATION Size and length Strength Range of motion Swelling Reflexes Skin condition Gait

24 The Orthopaedic Evaluation X-ray Evaluation Your X-ray may reveal: Narrowing of the joint space Cysts in the bone Spurs on the edge of the bone Areas of bony thickening called sclerosis Deformity or incorrect alignment

25 The Orthopaedic Evaluation Additional Diagnostic Tests may include: Blood tests : CBC, ESR,PT/INR Urinanalysis Analysis of joint fluid MRI : rarely Bone scan : Very rarely

26 Treatment Options Medication Physical therapy Arthroscopy cleaning the joint : rarely useful in the hip, controversial in the knee Joint fluid supplements (injections that provide temporary pain relief) Partial joint replacement Total joint replacement

27 Medications Aspirin-free pain relievers acetaminophen Nonsteroidal anti-inflammatories (NSAIDs) Corticosteroids injection/pill form Quick, effective pain relief Only used a several times a year; they can weaken bone and cartilage

28 Injection Therapy Simple and easy Surprisingly efficacious for many Two main types: Cortisone and viscosupplementation

29 Joint Fluid Supplements Injections that provide temporary relief For patients whose joint pain does not improve with medication or physical therapy injections may provide temporary relief. Typically these are cortisone shots or viscosupplementation shots (i.e. Synvisc,Orthovisc or Hyalgan)

30 Physical Therapy Passive range-of-motion exercises may help: Reduce stiffness Keep joints flexible Isometric ( pushing ) exercises help build muscle strength Isotonic exercises ( pulling ) further increase muscle strength and preserve function Daily walking, using a cane or other assistive device

31 Non Arthroplasty Knee Surgical Procedures for arthritis Arthroscopy : Chondroplasty Microfracture procedure O.A.T.S. procedure Joint realignment/osteotomycarticel/cartilage regeneration

32 Partial Joint Partial joint replacement is a surgical procedure in which only the damaged or diseased surfaces of the joint are replaced, leaving much of the natural bone and soft tissue in place. Post-operative pain may be reduced* Recovery period may be shorter than total knee replacement* * Newman, John H., Unicompartmental Knee, The Knee, 7 (2000), pp

33 Unicondylar Knee Total Joint

34 Joint Joint replacement is a treatment option when pain: Is severe Interferes with daily activities Interferes with work BASICALLY, IT S WHEN YOU HAVE PAIN, PAIN, PAIN!!!

35 Total Joint : Revolutionary Treatment for Damaged Joints Total joint replacements of the hip and knee have been performed since the 1960s. Today, these procedures have been found to result in significant restoration of function and reduction of pain in 90% to 95% of patients.

36 Early Charnley Total Hip Perfected in the 1950 s and 60 s By John Charnley in England A triumph of materials engineering Metal, Dental cement and polyethylene

37 Your Surgery Typically hip and knee replacement surgery takes less than 2 hours Excellent anaesthesiology monitoring team Antibiotics are utilized TXA as well

38 Joint Preoperative Dental procedures : dental infections can sometimes cause an infected total joint Blood thinners may need to be stopped temporarily Preop scrubbing with phisohex or other special soaps

39 Daniel J Severe Hip Pain Due to Osteoarthritis

40 DJ s Painful Hip Painful limp Stiff hip Inability to put on shoes and socks Difficult sleep Stairs and cars very difficult

41 Welcome To The OR! We re a TEAM!!! Nurses, Scrub techs,anaesthe siologists,xray techs

42 The LGH Orthopedic OR Large Bright Well equipped Excellent imaging

43 DJ s Total Hip Total Joint

44 Daniel J 2 weeks after Hip Total Joint

45 Knee Arthritis Cartilage Loss Joint Effusion Synovial Proliferation Bone Spurs

46 Total Knee Total Joint

47 Knee Instrumentation Different Size Cutting Blocks Because every knee is different!

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49 Replaced Knee X-ray Anterior (front) View Lateral (side) View

50 Recovery Rehabilitation Exercise program to be performed in bed and in the therapy department. Joint Class The physical therapist or another member of the staff works with the patient to help you: Regain muscle strength Increase range of motion

51 Recovery After Joint Surgery Every individual is different and every treatment plan is different. Estimated Recovery Schedule: In-hospital Recovery: 2 3 days, trend is towards decreasing length of stay Crutches/walker/ cane for 2 to 6 weeks Maximal Improvement: 6 12 months,largely dependent on pace of muscle strengthening The length of hospital stay after joint replacement varies and depends on many factors including age and physical ability.

52 Lowell General s Joint Program Total Joint

53 After Surgery Limitations For approximately 12 weeks after surgery certain limitations are placed on your activities. When fully recovered, most patients can return to work. Some types of work may not be advisable for individuals with a joint replacement: Construction work Certain types of carpentry Occupations that involve repeated high climbing

54 Limitations After Surgery Athletic activities that place excessive stress on the joint replacement will need to be avoided. Examples include: Skiing (snow or water) there are exceptions Basketball Baseball Contact sports Running Frequent jumping Total Joint

55 Complications Many varieties : Infection, DVT, PE, Leg length difference, instability, etc. Discuss these with your surgeon 90-95% success rate with Joint Surgeries!

56 Realistic Expectations Lifestyle Total Joint

57 Thank You! Time for Questions