Upload
diamond-cubitt
View
219
Download
0
Tags:
Embed Size (px)
Citation preview
Hip and Arthritis:Hip and Arthritis:Treatment Alternatives Treatment Alternatives
To Remain ActiveTo Remain Active
Scott M. Sporer, M.D.Scott M. Sporer, M.D.Midwest Orthopaedics at RUSHMidwest Orthopaedics at RUSH
Assistant ProfessorAssistant ProfessorRUSH University Medical CenterRUSH University Medical Center
Central Dupage HospitalCentral Dupage Hospital
What is Arthritis?What is Arthritis?
Loss of Cartilage Loss of Cartilage from the end of the from the end of the thigh bone (femur) thigh bone (femur) or leg bone (tibia)or leg bone (tibia)
Cartilage is Cartilage is required to provide required to provide a smooth surface a smooth surface for the knee to for the knee to glide glide
What is Arthritis ?What is Arthritis ?
EpidemiologyEpidemiology
Radiographic Radiographic evidence of arthritis in evidence of arthritis in almost all people > 60 almost all people > 60
10-20% of patients 10-20% of patients with symptomswith symptoms
Knee disease twice as Knee disease twice as prevalent as hip prevalent as hip disease in people > 60 disease in people > 60
6.1% of adults >30 6.1% of adults >30 have radiographic have radiographic evidence OA with pain evidence OA with pain on most days. on most days.
EpidemiologyEpidemiology
Women twice as likely to have Women twice as likely to have disease as mendisease as men
Inside portion of the Knee 10x more Inside portion of the Knee 10x more likelylikely
60-80% of joint load through medial 60-80% of joint load through medial compartmentcompartment
Knee AnatomyKnee Anatomy
Femur (Thigh Bone)Femur (Thigh Bone) Tibia (Shin Bone)Tibia (Shin Bone) Patella (Knee Cap)Patella (Knee Cap) 3 “Compartments”3 “Compartments”
Clinical PresentationClinical Presentation
HistoryHistory PainPain InstabilityInstability Change in Change in
alignmentalignment Bow KneedBow Kneed Knocked KneedKnocked Kneed
Difficulty walking Difficulty walking Difficulty with Difficulty with
Activities of Daily Activities of Daily LivingLiving
Clinical PresentationClinical Presentation
Physical ExaminationPhysical Examination SwellingSwelling Limited Motion Limited Motion
(contractures)(contractures) LimpLimp Hip and knee Hip and knee
pain/deformitypain/deformity
Laboratory TestsLaboratory Tests
Rarely RequiredRarely Required Fluid AspirationFluid Aspiration
Blood TestsBlood Tests
Radiographic EvaluationRadiographic Evaluation
Best Method To Evaluate ArthritisBest Method To Evaluate Arthritis Plain X-RaysPlain X-Rays
Standing RadiographsStanding Radiographs AP/ LateralAP/ Lateral Schuss/Rosenberg ViewsSchuss/Rosenberg Views
Radiographic EvaluationRadiographic Evaluation
Joint Space Joint Space NarrowingNarrowing
Osteophytes Osteophytes “bone spurs”“bone spurs”
Changes in Changes in AlignmentAlignment
MRI, CT Scan, MRI, CT Scan, Bone Scans add Bone Scans add little informationlittle information
Treatment OptionsTreatment Options Non SurgicalNon Surgical
Weight LossWeight Loss ExerciseExercise Physical TherapyPhysical Therapy Walking AidsWalking Aids InjectionsInjections
SurgicalSurgical Unicomparmental Unicomparmental
Knee ReplacementKnee Replacement Total Knee Total Knee
ReplacementReplacement
Patient EducationPatient Education Use high stoolsUse high stools Avoid high impact Avoid high impact
activitiesactivities Recommend Recommend
swimming and bikingswimming and biking ObesityObesity
2-5 times body weight 2-5 times body weight with walkingwith walking
Patient EducationPatient Education ExerciseExercise
Strengthen Strengthen muscles around muscles around kneeknee
Helps support the Helps support the jointjoint
Improve flexibilityImprove flexibility Make future Make future
surgery easiersurgery easier
MedicationsMedications
“ “ Two systematic reviews have found Two systematic reviews have found that simple analgesics and NSAIDS that simple analgesics and NSAIDS produce short term pain relief in OA. produce short term pain relief in OA. However, no good evidence that However, no good evidence that NSAIDS are superior to simple NSAIDS are superior to simple analgesics such as Acetaminophen”analgesics such as Acetaminophen”-Clinical Evidence 2001-Clinical Evidence 2001
AnalgesicsAnalgesics
Acetaminophen vs. placeboAcetaminophen vs. placebo 73% vs. 5% of knees with 73% vs. 5% of knees with
improvement in rest painimprovement in rest pain
Non-Steroidal Anti-Non-Steroidal Anti-InflammatoryInflammatory
NSAIDS have been found to be NSAIDS have been found to be effective in reducing short term effective in reducing short term pain.pain.
The Cochrane Library, Issue 4, 1999The Cochrane Library, Issue 4, 1999 ““Systematic reviews found no Systematic reviews found no
important differences in effect important differences in effect between different NSAIDS or doses, between different NSAIDS or doses, but found differences in toxicity…”but found differences in toxicity…”
-Clinical Evidence 2001-Clinical Evidence 2001
Non-Steroidal Anti-Non-Steroidal Anti-inflammatory inflammatory
Medications (NSAIDS)Medications (NSAIDS) Possible side Possible side
EffectsEffects Stomach irritationStomach irritation Kidney damageKidney damage UlcersUlcers
Cox-2 InhibitorsCox-2 Inhibitors Fewer side effectsFewer side effects ExpensiveExpensive
Cox – 2 Cox – 2 RecommendationsRecommendations
Merck & Co., Inc. - withdrawal of Vioxx on Merck & Co., Inc. - withdrawal of Vioxx on Sept. 30, 2004 increased relative risk for Sept. 30, 2004 increased relative risk for confirmed cardiovascular events confirmed cardiovascular events
““Patients who are at a high risk for Patients who are at a high risk for gastrointestinal bleeding, have a history of gastrointestinal bleeding, have a history of intolerance to non-selective NSAIDs, or are not intolerance to non-selective NSAIDs, or are not doing well on non-selective NSAIDs may be doing well on non-selective NSAIDs may be appropriate candidates for Cox-2 selective appropriate candidates for Cox-2 selective agents. Individual patient risk for agents. Individual patient risk for cardiovascular events and other risks cardiovascular events and other risks commonly associated with NSAIDs should be commonly associated with NSAIDs should be taken into account”taken into account”
Glucosamine/ Glucosamine/ Chondroitin SulfateChondroitin Sulfate
Not Regulated by FDANot Regulated by FDA ExpensiveExpensive Unknown Side EffectsUnknown Side Effects Effective in several Effective in several
studiesstudies
Cortisone InjectionCortisone Injection
May provide Temporary ReliefMay provide Temporary Relief Decreases inflammationDecreases inflammation May accelerate cartilage May accelerate cartilage
damagedamage Small Risk of InfectionSmall Risk of Infection 78% of patients note 78% of patients note
improvementimprovement
Hyaluronic Acid InjectionHyaluronic Acid Injection
Considered a medical Considered a medical devicedevice
Works best for less Works best for less severe arthritissevere arthritis
Series of 3 to 5 injectionsSeries of 3 to 5 injections Small Risk of InfectionSmall Risk of Infection Allergic ReactionAllergic Reaction 2/32/3rdrd patients note mild patients note mild
improvementimprovement
ArthroscopyArthroscopy
Theory:Theory: Degenerating Degenerating
cartilage releases cartilage releases inflammatory inflammatory mediatorsmediators
Subsequent Subsequent cartilage damagecartilage damage
May be replaced May be replaced by cartilage type by cartilage type tissuetissue
ArthroscopyArthroscopy
Surgical TreatmentSurgical Treatment Unicompartment Knee ReplacementUnicompartment Knee Replacement
Total Knee ReplacementTotal Knee Replacement
Unicompartmental KneeUnicompartmental Knee
Arthritis in only 1 Arthritis in only 1 compartment of kneecompartment of knee
Used in either Young Used in either Young or Old patient or Old patient
Ligaments IntactLigaments Intact No systemic DiseaseNo systemic Disease Weight <200#Weight <200# OccupationOccupation
RadiographsRadiographs
Surgical Technique – Surgical Technique – Minimally InvasiveMinimally Invasive
Why Minimally InvasiveWhy Minimally Invasive
Earlier MobilizationEarlier Mobilization CostCost Shorter Hospital StayShorter Hospital Stay Quicker RehabilitationQuicker Rehabilitation Less Blood LossLess Blood Loss ? Easier conversion to Total ? Easier conversion to Total
knee replacementknee replacement
Total Knee ArthroplastyTotal Knee Arthroplasty
Resurface All Resurface All Three SurfacesThree Surfaces TibiaTibia FemurFemur PatellaPatella
Components fixed Components fixed to bone with to bone with “cement”“cement”
Total Knee ArthroplastyTotal Knee Arthroplasty
Surgical ProcedureSurgical Procedure
Mini 12-14 cm
Quad Snip
Q-S7-10 cm
No Quad
Standard 20-30 cm
Quad Incision
MIS in TKA
Mini/MIS QS TKA
MIS Patient SelectionMIS Patient Selection
Male <250 #, Female < 225#Male <250 #, Female < 225# MotivatedMotivated Range of motion > 90Range of motion > 90˚̊ Flexion Contracture < 10 ˚Flexion Contracture < 10 ˚ Fixed varus <10 ˚ or valgus <15 ˚Fixed varus <10 ˚ or valgus <15 ˚
MIS TKA MIS TKA ContraindicationsContraindications
Deficient or scared skinDeficient or scared skin Severe diabetic; steroidsSevere diabetic; steroids OsteoporosisOsteoporosis Prior major intra-articular surgeryPrior major intra-articular surgery Relative ContraindicationsRelative Contraindications
Extremely MuscularExtremely Muscular Inflammatory arthritisInflammatory arthritis Patella BajaPatella Baja Extremely Large sizesExtremely Large sizes
Total Knee ReplacementTotal Knee Replacement
Long Term Long Term ResultsResults 96% Functioning 96% Functioning
Well at 10 YearsWell at 10 Years
How To Decide ?How To Decide ?
Individual Individual DecisionDecision
Hurtful not Hurtful not HarmfulHarmful
Is if affecting Is if affecting you?you?
What are your What are your expectations?expectations?
Hip ArthritisHip Arthritis
Hip Arthritis?Hip Arthritis?
Loss of Cartilage Loss of Cartilage between the top of between the top of the thigh bone the thigh bone (ball), and the (ball), and the acetabulum (socket) acetabulum (socket)
Cartilage is Cartilage is required to provide required to provide a smooth surface a smooth surface for the hip to glide for the hip to glide
Hip AnatomyHip Anatomy
Clinical PresentationClinical Presentation
HistoryHistory PainPain Difficulty walking Difficulty walking Difficulty with Difficulty with
Activities of Daily Activities of Daily LivingLiving
Radiographic EvaluationRadiographic Evaluation Best Method To Evaluate ArthritisBest Method To Evaluate Arthritis
Plain X-RaysPlain X-Rays Joint Space NarrowingJoint Space Narrowing Osteophytes “bone spurs”Osteophytes “bone spurs”
Treatment OptionsTreatment Options Non SurgicalNon Surgical
Weight LossWeight Loss ExerciseExercise Physical TherapyPhysical Therapy Walking AidsWalking Aids InjectionsInjections
SurgicalSurgical Total Hip ArthroplastyTotal Hip Arthroplasty Minimally Invasive Minimally Invasive
Total Hip ArthroplastyTotal Hip Arthroplasty
Patient EducationPatient Education Avoid high impact Avoid high impact
activitiesactivities Recommend Recommend
swimming and bikingswimming and biking ObesityObesity
2-5 times body weight 2-5 times body weight with walkingwith walking
Patient EducationPatient Education ExerciseExercise
Strengthen muscles Strengthen muscles around hiparound hip
Helps support the jointHelps support the joint Improve flexibilityImprove flexibility Make future surgery Make future surgery
easiereasier
ExerciseExercise
MedicationsMedications
Provide Temporary Relief of PainProvide Temporary Relief of Pain Similar Efficacy among MedicationsSimilar Efficacy among Medications
Non-Steroidal Anti-Non-Steroidal Anti-inflammatory inflammatory
Medications (NSAIDS)Medications (NSAIDS) Possible side Possible side
EffectsEffects Stomach irritationStomach irritation Kidney damageKidney damage UlcersUlcers
Cox-2 InhibitorsCox-2 Inhibitors Fewer side effectsFewer side effects ExpensiveExpensive
Cortisone InjectionCortisone Injection
Used infrequently in Hip Used infrequently in Hip ArthritisArthritis
May help with DiagnosisMay help with Diagnosis Decreases inflammationDecreases inflammation May accelerate cartilage May accelerate cartilage
damagedamage Small Risk of InfectionSmall Risk of Infection
ArthroscopyArthroscopy
Difficult to see Difficult to see inside the hipinside the hip
Results less Results less predictablepredictable
Used for Used for “Mechanical “Mechanical Symptoms”Symptoms”
Rarely Rarely performedperformed
Surgical TreatmentSurgical Treatment
Remove Damaged Remove Damaged CartilageCartilage
Replace with Metal Replace with Metal and Plasticand Plastic
Remove Bone Remove Bone SpursSpurs
““Resurface the Resurface the bone”bone”
Surgical TreatmentSurgical Treatment
Total Hip ReplacementTotal Hip Replacement Resurface the ball and socket with metal and Resurface the ball and socket with metal and
plasticplastic Partial Resurfacing Hip ReplacementPartial Resurfacing Hip Replacement
Resurface only the ball of the hipResurface only the ball of the hip Conventional Surgical ApproachConventional Surgical Approach Minimally Invasive SurgeryMinimally Invasive Surgery
Surgical ProcedureSurgical Procedure
RadiographsRadiographs
Surgical Technique – Surgical Technique – Minimally InvasiveMinimally Invasive
Standard Incision 9-10 InchesStandard Incision 9-10 Inches One 3-4 Inch Incision or two 2 Inch One 3-4 Inch Incision or two 2 Inch
IncisionsIncisions Separate Muscles – Do not Cut MuscleSeparate Muscles – Do not Cut Muscle
Total Hip ReplacementTotal Hip Replacement
Minimally Invasive Minimally Invasive HipHip Select PatientsSelect Patients Potential shorter Potential shorter
recoveryrecovery Potential less Potential less
bleedingbleeding Potential quicker Potential quicker
rehabrehab Long Term Results Long Term Results
UnknownUnknown
Post Operative RecoveryPost Operative Recovery
Physical Therapy Physical Therapy next daynext day
Pain Pump or Pain Pump or Epidural catheter Epidural catheter for pain relieffor pain relief
Full Weight Full Weight BearingBearing
Coumadin to Coumadin to prevent blood clotprevent blood clot
Total Hip ArthroplastyTotal Hip Arthroplasty
Hospital Stay Hospital Stay Standard Approach Standard Approach
5-7 days 5-7 days Minimally Invasive Minimally Invasive
Approach Approach Outpatient – 2 day Outpatient – 2 day
Follow-up CareFollow-up Care Visiting NursesVisiting Nurses Staples removed 2 Staples removed 2
weeksweeks Coumadin for 4-6 Coumadin for 4-6
weeks totalweeks total Physical Therapy 2-3 Physical Therapy 2-3
times per weektimes per week 70% better at 2 weeks70% better at 2 weeks 90% better at 6 weeks90% better at 6 weeks Slow improvement Slow improvement
next 6 monthsnext 6 months
Total Hip PrecautionsTotal Hip Precautions
Avoid crossing your legsAvoid crossing your legs Avoid bending your hip greater Avoid bending your hip greater
than 90 degreesthan 90 degrees Avoid turning foot inward Avoid turning foot inward Keep a wedge or pillow between Keep a wedge or pillow between
your knees while in bedyour knees while in bed Do lean back slightly when sitting Do lean back slightly when sitting
to keep the hip bending < 90 to keep the hip bending < 90 degreesdegrees
Potential ComplicationsPotential Complications
• Loosening
•Infection
•Deep Venous Thrombosis
•Dislocation
Long-Term ExpectationsLong-Term Expectations Resume most Resume most
activitiesactivities Avoid positions of Avoid positions of
risk for dislocationrisk for dislocation Yearly follow-upYearly follow-up Hips last on Hips last on
average 15-20 average 15-20 yearsyears
Plastic insert may Plastic insert may need to be need to be replaced replaced
Thank YouThank You
Scott M. Sporer, M.D., Scott M. Sporer, M.D., M.S.M.S.Midwest OrthopaedicsMidwest Orthopaedics25 N. Winfield Road25 N. Winfield RoadWinfield, Illinois Winfield, Illinois 6019060190(630) 339-2225(630) 339-2225