Total Joints and Arthritis. Marc A. Roux, M.D. Chief of Surgery, Baylor Medical Center at Waxahachie August 25, 2012

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1 Total Joints and Arthritis Marc A. Roux, M.D. Chief of Surgery, Baylor Medical Center at Waxahachie August 25, 2012

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4 Joint Replacement Will focus on Knee and Hip OA amd joint replacement Over 500,000 knee arthroplasties per year Over 285,000 hip arthroplasties per year For all causes including OA, RA, post-traumatic arthritis, avascular necrosis

5 More than 43 million people have some form of arthritis. It is estimated that the number of people affected by arthritis will increase to 60 million by 2020.

6 Total Joint Replacement May be suitable for patients who: Have a painful, disabling joint disease of the knee resulting from a severe form of arthritis Are not likely to achieve satisfactory results from less invasive procedures, medication, physical therapy, or joint fluid supplements Have bone stock that is of poor quality or inadequate for other reconstructive techniques

7 My life got progressively less active, less fun, and less participative. It would be embarrassing to get out of a car because everybody had to help me. Somebody would have to pull me up. I felt like this old woman. Does this sound Familiar?

8 Total Joint Replacement Goals To restore motion To relieve pain Lifestyle improvement

9 Arthritis CC Stiffness Inability to sustain desired lifestyle Joint pain Inactivity Inability to exercise, travel, perform leisure activities/hobies Some types of arthritis can cause swelling Simple tasks are difficult

10 Other Forms of Arthritis 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 Paget s Disease The density and the shape of the bone change

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

12 Evaluation History/Physical Exam Standing Radiographic evaluation Occasionally, additional tests may be needed to confirm the diagnosis. These may include: Blood tests Urine analysis Analysis of joint fluid Magnetic Resonance Imaging (MRI) Bone scan

13 Treatment Options Medication Physical therapy Arthroscopy cleaning the joint Joint fluid supplements (injections that provide temporary pain relief) Brace wear Alignment procedures Partial joint replacement Total joint replacement

14 Medications Aspirin-free pain relievers acetaminophen Nonsteroidal anti-inflammatories (NSAIDs), Cox Corticosteroids injection/pill form Narcotics Non-narcotic pain reliever

15 Glucosamine Supplements All but one published report - favorable outcomes Synergistic effect on NSAID Long-term efficacy / risk unknown Chondroitin Sulfate combination Biological / mechanical role

16 Therapy/Exercise Passive range-of-motion exercises may help: Reduce stiffness Keep joints flexible Isometric exercises help build muscle strength Low impact, progressive exercise Swimming, biking, Ellipitcal trainer

17 Brace Wear

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19 Viscosupplementation Synvisc, Hyaluron, Euflexa, etc. Each product of equal benefit Have not seen one excel over the other One vs multiple injections Patient selection is key to success Medicare/Insurance allowances

20 Arthroscopy Is there a role? Debatable May be of short term benefit Long term prognosis for improvement is poor

21 Osteotomy

22 Osteotomy Patient selection is key Becoming more rare Lost art? Innovation and design has placed this treatment in a less attractive category Many will eventually need joint replacement later

23 Knee

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25 Unicompartmental Joint Replacement Partial joint replacement (uni) is a 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. No ligaments are sacrificed Alignment is restored Patient criteria Weight restrictions Deformity limitations Other compartment involvement Prior ligament tear/loss/reconstruction Inflammatory arthritis diagnosis

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28 Total Joint Replacement The decision to pursue involves discussion with the patient, primary care provider, and orthopedic surgeon Health status Activity level Age Severity of arthritic disease Failure of conservative treatment options Rehab potential

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35 Approaches to TKA Medial parapatellar Midvastus Subvastus Quad Sparing n less pain faster rehab

36 Approaches cntd Patellar slide rather than eversion is the key Faster quad return Slight difference in pain level post-operatively Minimally evasive Patient Education on risks, capabilities Landmarks Computer assisted/navigated Limited indications Prior trauma/deformity Congenital deformity

37 Expectations The clinical outcome reflects the expectation and the energy of the patient Patient selection and education are keys to success Team approach

38 Expectations Motion affects ability to perform everyday activities. Modern systems provide routinely 120 of flexion. Post-operative ROM is dependent of pre-operative ROM Walking 0-65 degrees Climbing Stairs 0-85 Descending Stairs 0-90 Rising from low chair 0-95 Gardening, lining up putt 0-125

39 Design

40 Single radius vs Multi radius Mid-flexion stability

41 Recovery Every individual is different and every treatment plan is different. The length of hospital stay after joint replacement varies and depends on many factors including age and physical ability. Estimated Recovery Schedule: In-hospital Recovery: 2 3 days Significant Functional Improvement: 6 weeks 3 months Maximal Improvement: 6 12 months

42 Return to Activities Return to desk work: 3-4 wks Return to light work: 6-8wks Return to labor type job: wks

43 Return to Activities Athletic activities that place excessive stress on the joint replacement will need to be avoided. Examples of these activities include: Skiing (snow or water) Basketball Baseball Contact sports Running

44 Return to Activities Recreational activities including Bowling, swimming, golfing, cycling, low impact sports.

45 Longevity It is impossible to predict in individual cases how long a joint replacement will last. Many factors determine the outcome including: Old designs: 90-95% satisfaction rate at yrs Longevity related to : Age Weight Activity level Bone strength

46 Longevity Regular Orthopedic follow up is a must Antibiotic prophylaxis AAOS recommendations Due to cost and devastating nature of prosthetic infections the American Academy of Orthopedic Surgeons recommends antibiotic prophylaxis prior to any invasive procedure that has the potential to cause bacteremia This is true for the life of that Prosthesis

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48 Knee Uni-knee replacement: Surfaces are replaced only on one side of knee Suitable if only one half of the knee is diseased Patello-femoral replacement: Surfaces are replaced only on the patella and patella contact region of the femur Suitable if arthritis is limited to patella Total knee joint replacement: Surfaces are replaced on both sides of the knee and patella Suitable for more severe knee disease

49 Hip

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52 Bearing Surfaces

53 Metal ions levels become elevated Increased levels can lead to pseudotumors Overall local and systemic affects are poorly understood Potential local and systemic effects that are poorly understood

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