Transcript Alternatives to joint replacement for Knee Arthritis

Alternatives to joint replacement
for Knee Arthritis
Matthew Busam, MD
July 17, 2008
Is there anything else you can do????
• We must remember several key points…
– Treatment is based on symptoms, not X-rays or
MRI’s
– No surgery is “minor surgery”
– Not everything is fixed or improved with a shot or
a scope
– A total knee replacement is a great operation that
can dramatically improve a persons quality of life.
Still, Is there anything else??
• YES.
– Physical therapy
– Oral medications
– Supplements
– Injections
• Corticosteroids
• Hyaluronic Acids
– Arthroscopic treatments
– Osteotomies
Goals
• Review “arthritis”
• Review therapeutic, medical, and surgical
alternatives to joint replacement in the knee
with arthritis.
Athritis
• Inflammatory or non-inflammatory
degeneration of normal joint anatomy and
function resulting in pain and functional
disability.
Causes
• Often after injury, even remote
– “old trick knee”
• Post surgical- total menisectomies
• Obesity– Knee joint experiences 4-8 times body weight with
activity.
• Genetics
Not caused by…
• Sports in the absence of injury
– Not even running long distances
– In fact, regular exercise helps prevent joint
problems
• Concrete floors
General goals for patients with
arthritis
• Help alleviate symptoms
• Allow activity
• Prevent or slow progression of disease
Non-medical options
• Weight loss
– Losing even 10 lbs can decrease the force on an
arthritic knee by 40-80 lbs!
• Exercise
– Strengthening the muscles around the knee can
dramatically improve knee function and reduce
the loads experienced by the arthritic bone.
What is a Supplement?
• U.S. Food and Drug Administration (FDA)
– dietary supplements: subcategory of “food,” providing manufacturers
with greater leeway and less oversight than products in the
pharmaceutical category
– Asterisk syndrome: product is advertised to promote and maintain
“joint strength,* joint flexibility,* joint lubrication,* range of motion,*
production of lubricating fluid,* and renewal of cartilage and
connective tissue.*” The asterisk at the bottom of the page has the
following disclaimer: “*These statements have not been evaluated by
the Food and Drug Administration. This product is not intended to
diagnose, treat, cure, or prevent any disease.”
Supplements
• “Patented ingredients help support, ease, and
rebuild joints….”
• “Soothe away joint pain and watch as your skin
regains a nourished, youthful appearance….”
• “It’s like oil for your joints—it helps promote full
range of motion and flexibility.”
• “New Miracle Relief Formula eliminates even the
worst pain...almost instantly!”
Supplements
• Glucosamine
• Chondroitin
• Others
Glucosamine
• One meta-analysis of randomized, placebo-controlled clinical trials from
January 1980 to March 2002 found glucosamine to have “highly
significant efficacy” for all outcomes, including joint space narrowing and
Western Ontario MacMaster University Osteoarthritis Index (WOMAC).
• Structural and Symptomatic Efficacy of Glucosamine and Chondroitin in
Knee Osteoarthritis A Comprehensive Meta-analysis
• Florent Richy, MSc; Olivier Bruyere, MSc; Olivier Ethgen, MSc; Michel
Cucherat, MSc, PhD; Yves Henrotin, MSc, PhD; Jean-Yves Reginster, MD,
PhD
• Arch Intern Med. 2003;163:1514-1522.
Glucosamine
• Another study reported on 1,583 patients with symptomatic
knee osteoarthritis who were randomly assigned to take
glucosamine, chondroitin, a combination of glucosamine and
chondroitin, celecoxib, or placebo over 24 weeks. Overall rate
of response to glucosamine, chondroitin, and the combination
were not found to be significantly better than placebo,
although patients with moderate to severe pain at baseline
were observed to respond significantly better with the
combination.
• N Engl J Med. 2006 Feb 23;354(8):795-808
Glucosamine: Side effects
• Primary side effects of all salts of glucosamine are mild gastrointestinal
complaints such as constipation, diarrhea, cramping, gas, heartburn, and
nausea. Glucosamine sulfate has been associated with drowsiness and
headache. The effects of glucosamine on nursing or pregnant women have
not been well-studied.
• Glucosamine may increase blood sugar levels. Although studies of
glucosamine on patients with diabetes are inconclusive, it is believed that
higher doses may prompt the pancreas to produce less insulin, so caution
is advised.
• Because glucosamine is often made from shellfish and the source of the
product is not required to be on the label, individuals who are allergic to
seafood are advised to exercise caution as well.
Osteotomy
Biomechanics
• Basic concept
is to realign
the mechanical
axis to unload
the arthritic
compartment
Biomechanics
• Mechanical axis is
center of hip to
center of ankle
mortise
• Normally just
medial to tibial
spines
• Normal knee 60%
BW through MFC
PTO Indications
•
•
•
•
•
•
Age < 60
Single compartment involvement
10º - 15º varus on WB x-ray
Arc of motion  90º
Flexion contracture < 15 º
Sufficient strength and motivation for rehab
PTO Contraindications
•
•
•
•
More than 20° correction
Lateral tibial subluxation > 1 cm
Medial bone loss > 2-3 mm
Severe medial/lateral ligamentous instability
(varus thrust)
• Inflammatory arthritis
PTO Relative Contraindications
• Work comp with previous partial
menisectomy
• Cosmetic asymmetry
• 30% over ideal body weight
• Mild patellofemoral arthrosis
Medial VS Lateral PTO
• Medial
– Avoids peroneal n. and
fibular osteotomy
– Two plane correction
(slope)
– Technically easier
– Easier to revise to TKA
• Lateral
–
–
–
–
Correct larger deformity
No bone graft
Known results
Earlier union?
PTO Complications
• Nonunion
0-5%
• Malunion/
Undercorrection
• Patella baja
80%
• Infection
1-9%
• Peroneal palsy 5%
• Stiffness
• Lateral ligament laxity
• Popliteal/Ant tib artery
injury
• DVT
• Intraarticular fracture
• Compartment
syndrome
• AVN
PTO Summary
•
•
•
•
Good palliative procedure
Poor results with under- or over-correction
Results decrease at 5-10 years
Morbidity
– Patella baja
– Deformity
– Peroneal nerve
– Delayed union
Distal Femoral Osteotomy
Distal Femoral Osteotomy
• Lateral compartment arthritis
– Majority osteoarthritis
– RA, neurologic (polio), collagen vascular disease,
trauma
– Primary DJD- 5 times more women
DFO Indications
• Isolated lateral compartment arthrosis
• Valgus deformity >12° or valgus joint line tilt >
10°
• Arc of motion > 90°
• Good rehab potential
DFO Contraindications
•
•
•
•
Rheumatoid arthritis
Tricompartmental or severe PF arthritis
Flexion contracture > 30°
Severe instability
DFO Complications
•
•
•
•
•
•
Delayed or nonunion
Malunion
Infection
Arthrofibrosis
DVT/PE
Neurovascular injury
DFO Summary
• Good palliative procedure
• Results appear to last longer than PTO
• Less common  Smaller studies
Osteochondral Allografts Results
• Success ranges from 76-86%
• Garrett Corr ‘94 16/17 asymtomatic at 3 years
• Long term survivorship
– 95% -5 year
– 71% -10 years
– 66% -20 years
Ghavazi JBJS 1997
Osteochondral Allografts
• Gross
– b/t 72-92 tx’d 123 ,
with fresh small
allografts
– 5 year result 95%
demonstrated
successful results
– results deteriorated
over time with 66%
successful results at 20
years
Cole Ortho Spec Ed 2000
Chondrocyte Transplantation
• Technique
– cartilage harvested from
upper medial fem
condyle
– sent to lab & cultured
– transplanted several
weeks later
– periosteal flap from
upper tibia obtained to
cover the defect and
sutured in place, sealed
with fibrin glue