Embed Size (px)
Citation preview
MaximizingPatient SatisfactionWith Osteoarthritis
Knee PainRichard Rhodes, MD, FAAOS
Board Certified – Orthopedic SurgeryBoard Certified – Orthopedic Sports Medicine
Texas Health PresbyterianAllen, McKinney, Plano
The Knee
• Rotating Hinge Joint• Ends of Bone covered with smooth surface
(hyaline) cartilage• Soft structural meniscus cartilage helps
match surface contours• Ligaments provide stability
The Knee
• Any of the knee structures can be damaged and cause pain
• Today ‘s talk will be about the surface cartilage
Osteoarthritis
• Introduction• Risk Factors• Physiology• Treatment
• Most common form of joint disease worldwide– Affects nearly 27 million Americans1 – Radiographic evidence2
• >50% at 65 years of age• ≈80% at 75 years of age and older
– Symptomatic osteoarthritis (OA) of knee2
• 12% of people aged > 60 years
1Helmick, C., Felson, D., Lawrence, R., Gabriel, S., et all. Estimates of the Prevalence of Arthritis and Other Rheumatic conditions in the United States. Arthritis & Rheumatism 58(1), 15-25. 2008 2Manek NJ, Lane NE. Am Fam Physician. 2000;61:1795-1804.3Lawrence RC, et al. Arthritis Rheum. 2008;58:26-35.
Prevalence of Osteoarthritis
OA-Related Limitations Will Increase
Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:226-229.
Projected Prevalence of Arthritis-AssociatedActivity Limitation
17
19
21
23
25
2005 2010 2015 2020 2025 2030
Year
Pre
vale
nce
(M
illio
ns)
Disease Process
• Progressive loss of articular cartilage
• Remodeling and hypertrophy of bone
• Bone cysts, osteophytes, spurs
Osteoarthritis
• Introduction• Risk Factors• Physiology• Treatment
Risk Factors for Knee OA
MMPs = matrix metalloproteinases; PGs = proteoglycans.Dieppe PA, Lohmander S. Lancet. 2005;365:965-973.
Demographic
Biochemical
Biomechanical
OASEVERITY
• Age• Genetics • Systemic factors
(e.g., obesity)
•Cytokines•MMPs•PGs
•Trauma/Injury•Overload• Instability
The Graying of America
• As the “baby boom” generation ages, the US population aged ≥65 years is increasing1
• In 2006, all baby boomers were >40 years of age,and almost half were >50 years of age2
• By 2030, 20% of the US population will be aged ≥65 years2
Growth in Older Population3
1. Fackelmann K. USA Today. Available at: www.azcentral.com/php-bin/clicktrack/print.php?referer=http:...2. Freifeld L. License! June 2005:42-88.3. US Census Bureau, 2004. Available at: www.census.gov/ipc/www/usinterimproj.
0
10
20
30
40
50
60
18 – 44 45 – 64 65+ Total
Per
cen
t
Age (years)
Men Women
OA Affects Women More Than Men
Estimated Prevalence of Diagnosed OA
Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:226-229.
Osteoarthritis
• Introduction• Risk Factors• Physiology• Treatment
OA Pathophysiology: Downward Path
Ling SM, Bathon JM. JAGS . 1998;46:216-225. Altman RD. The Merck Manual of Diagnosis and Therapy. 16th ed. 2006.
Cartilage degradation(from injury, inflammation or metabolic defect)
Depletion of proteoglycans andattempted repair by chondrocytes
Inflammatory response
Further cartilage breakdown withchondrocyte apoptosis
Decrease in concentration andviscosity of synovial fluid
Decrease in concentration andaverage molecular weight of HA
Decreased lubrication andcushioning of the joint
Changes in Articular Cartilage
• Joint injury and deformity• Periarticular tissue and fluid
damage• Inflammation• Chronic wear and age
Courtesy of Robert J. Dimeff, MD
Pain in Knee OAMechanism is unclear
• Does not correlate with cartilage damage• Joint capsule (stretch) • Synovial membrane (synovitis) • Periarticular bursae, ligaments, muscle spasm• Periosteum stretching• Subchondral bone• Osteophytes • Microfractures • Increased intra-osseous pressure
Creamer P, et al. Lancet. 1997;350:503-509; Rice JR, et al. Rheum Dis Clin North Am. 1999;25:15-30.©2007 Girish P. Joshi, MD. Presented and reprinted with permission from Dr. Joshi.
Clinical Knee OA Signs and Symptoms
Adapted from Manek NJ, Lane NE. Am Fam Physician. 2000;61:1795-1804.
Symptoms• Joint pain
• Pain with weight bearing
• Morning stiffness (<30 minutes)
• Joint instabilityor buckling
• Reduced function
Signs• Bony enlargement
of joint
• Limited range of motion
• Crepitus on active motion
• Joint deformity
Osteoarthritis
• Introduction• Risk Factors• Physiology• Treatment
OA: Clinical Multimodal Management
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:190-1915; Kelly MA, et al. Orthopedics. 2003;26:1064-1079.
Adapted from ACR Guidelines and recommendations of the Hyaluronans Clinical Consensus Group of orthopedic surgeons.
Diagnosis
Surgical Intervention
Non-pharmacologic
treatment;Simple
Analgesics
OTC/NSAIDs
RX NSAIDs/GI Protect
COX-2 i
IAHyaluronans/
Corticosteroids
Non-pharmacologic Approaches
• Patient education• Exercise• Support programs• Weight loss (if obese)• Physical therapy
• Acupuncture• Chiropractic• Orthotics/footwear• Braces• Assistive devices
Pharmacologic Treatment Options
NSAIDs=nonsteroidal anti-inflammatory drugs: COX-2 i=cyclooxygenase-2 inhibitors.
Oral medications Localized therapies
• Acetaminophen
• NSAID/COX-2 i(advil, celebrex, naprosyn, topical antiinflamatories.
• Other Analgesics
• Nutraceutical(Glucosamine, Chondroitin, MSM)
• Topical
• Injection– Corticosteroid
- Hyaluronan
Why is HA Important?
• Found in all tissues and body fluids • Lubrication• Intra-articular water homeostasis • Stress distribution because of viscoelastic properties
Molecular Weight of Synovial HA
Healthy Knee Knee With OA
Avg. 5000 kDa Avg. 1500 kDa
Pharmacologic Treatment Options
• Research on Euflexxa shows 81% of patients satisfied 3 months after injection.
Osteoarthritis
• Introduction• Risk Factors• Physiology• Treatment
Principles of Operative Management
• Arthroscopic surgery• Cartilage restoration• Joint alignment procedures• Joint resurfacing• Partial joint replacement• Total joint replacement
Knee Arthroscopy
• Arthroscopic surgery for the knee – as the disease progresses loose fragments and cartilage can build
up in the knee – If the main symptoms are mechanical catching or locking, these
can improve for several years with arthroscopic removal of the debris.
Cartilage Repair
• For isolated defects in surface cartilage (potholes)
• Works on patients age < 50 yrs• 2 methods
– Transplant surface cartilage and bone– Culture patients own cartilage cells and replace
in defect – www.cartilagerestorationtexas.com
Cartilage Restoration Centerwww.cartilagerestorationtexas.com
• Osteochondral Allograft transplantation
• Autograft Chondrocyte Transfer (Carticel)
Knee resurfacing/ Partial Replacement
• For patients with limited osteoarthritis or isolated arthritis pain
• Partial knee replacement can be a great option
BICOMPARTMENTAL PATELLOFEMORALUNICONDYLAR LATERAL
Knee Replacement
For advanced osteoarthritis resurfacing the entire knee or Total Knee Arthroplasty can be a life changing surgery
Advancements in materials can push the lifespan of implants to 30 yrs or more with reasonable activity
MAKOplasty® An Important Treatment Option for Early to Mid-Stage Knee Osteoarthritis
• Innovative robotic arm technology, RIO®, assists the surgeon in achieving natural knee kinematics and optimal results with consistently reproducible precision
• Pre-surgical planning details the technique for bone preparation and customized implant positioning using a CT scan of the patient’s knee
• Tactile technology with 3-D visualization for controlled resurfacing within the pre-defined planned resection volume
• Minimally invasive and bone sparing with minimal tissue trauma for a more rapid recovery and return to an active lifestyle
31
Prevalence of Osteoarthritis
• Unicondylar MAKOplasty®
– 10% of all TKA patients are estimated with tibiofemoral OA1
– Lateral OA is estimated to be 10-12% of the unicompartmental market
– 90% of TKA patient candidates chose not to have a TKA2
• Patellofemoral MAKOplasty®
– 24% of OA patients may present with isolated patellofemoral disease1,3
• Bicompartmental MAKOplasty®
– 40-65% of OA patients present with tibiofemoral-patellofemoral disease1,3,4
1. Duncan, R., Hay, E., Saklatvala, J, Croft P. (2006) Prevalence of radiographic osteoarthritis: it all depends on your point of view. Rheumatology (45), 757-60.2. Duke University Center for Demographic Studies (January, 2006). Assessing the impact of medical technology innovations on human capital. Phase 1 Final Report (Part C): Effects of Advanced Medical
Technologies – Musculoskeletal Diseases Medical Technology Assessment Working Group: Prepared for the Institute for Medical Technology Innovation. 3. Ledingham, J., Regan, M., Jones, A., Doherty, M. (1993). Radiographic patterns and associations of osteoarthritis of the knee in patients referred to hospital. Annals of the Rheumatic Diseases (52),520-526.4. Rolston, L., Sprague, J., Tsai, S., Salehi, A. (2006) A novel bone/ligament sparing prosthesis for the treatment of patellofemoral and medial compartment osteoarthritis. AAOS 2006 Annual Meeting, Poster
#P181.
Lateral
32
Treating Osteoarthritis of the Knee with Total Knee Arthroplasty (TKA)
• TKA limitations– Requires extensive rehabilitation – Addresses late stage osteoarthritis (OA)– Aggressively removes healthy cartilage when treating early stage
osteoarthritis of the knee
• MAKOplasty® partial knee resurfacing with the RESTORIS® family of knee implant systems– Restores the natural knee without the confines of conventional
instrumentation– ACL and PCL sparing alternative to TKA– Promotes better kinematics– Retained proprioception
Patients treated with a total knee implant never forget they had a joint replacement and are forced to modify their lifestyle to suit their new knee1
1. Noble, P.c.; Gordon, M.J.; Reddix, R.N.; Conditt, M.A.; and Mathis, K.B.: Does total knee replacement restor normal knee function? Clin Orthop Relat Res, (431): 157-65, 2005.
33
MAKOplasty® Partial Knee Resurfacing
Improved surgical outcomes Less implant wear or loosening Bone sparing Smaller incision Less scarring Reduced blood loss Minimal hospitalization Rapid recovery
Individual results may vary. There are risks associated with any knee surgical procedure, including MAKOplasty®. A doctor can explain these risks to help patients determine if MAKOplasty® is right for them.
MAKOplasty® potentially offers the following benefits when compared to TKA:
34
MAKOplasty® Partial Knee Resurfacing
• Utilizes surgeon-interactive robotic arm technology• Brings the advantages of minimally invasive partial knee resurfacing to a broader patient
population by providing consistently reproducible precision• Pre-surgical plans are created using CT scan data for precise pre-operative planning of
implant size, orientation and placement• Surgeon interactive robotic arm guides the surgeon through each well-defined surgical
plan• Integrity of implants are based on clinical designs that preserve critical tissue and bone
stock for improved outcomes
35
Clinical Results – Knee Society Scores
• 43 MAKOplasty® procedures• Ht: 67±3 in• Age: 73±11 yrs• Wt: 185±37 lbs• BMI: 29±5• 38% Obese• KSS score• WOMAC• ROM
Roche et al 2008
30
40
50
60
70
80
90
pre-op 6 weeks 3 months
Kn
ee
So
cie
ty S
co
re
Function
Knee
p<0.05
30
40
50
60
70
80
90
pre-op 6 weeks 3 months
Kn
ee
So
cie
ty S
co
re
Function
Knee
p<0.05p<0.05Unicompartmental Knee Arthroplasties
36
Clinical Results-Radiographic Outcomes
37
Surgery – what is really involved
• Try non-surgical treatment first• When you are ready for long
term relief talk to your surgeon about options
38
Surgery – what is really involved
• Presurgery – minimize your risks– Control medical problems
(diabetes, heart)– Maximize muscle conditioning– Plan your schedule
• Transportation• Sleeping• bathing
39
Surgery – what is really involved
• Partial knee replacement– One night or outpatient
• Total Knee– 2-3 day hospital stay
• Up walking 1st day post op• Rehab 6 – 12 wks
– In and outpatient vs at home• Blood Clot prevention
– Stockings, blood thinners 6 wks
40
Surgery – what is really involved
• When can I golf?– Usually by 2 months after partial and 3 months
after total knee• When can I exercise?
– Bicycle, Eliptical, Swimming as soon as skin heals
– Running is not recommended with knee implants
• When can I travel?– It is best to remain where you have easy access
to your surgeon for the first 2 weeks once the major risks are over
– Blood clot risks are increased with long travel so we recommend caution for the first 3 months
41
Surgery – what is really involved
• Follow up– 2 weeks from surgery– We use only internal sutures so there is
nothing to remove– Progress checks at 6 weeks, 3 months, 6
months and 1 year– Routine Xrays are recommended with any joint
implant every few years even if there are no problems – it is easier to treat any problems early
42
Want to Learn More?
Questions?
• Literature from many of the treatment options mentioned available.
