Transcript Surgical Options for Hip and Knee Arthritis

Introduction to Orthopaedics:
OPTIONS FOR HIP AND KNEE ARTHRITIS
Stephen P. England, M.D.
Park Nicollet Orthopedics
What is Arthritis?
 Wear/loss
of articular cartilage
 Similar to wearing the tread off a car tire
 Osteoarthritis – wear and tear / aging
 Inflammatory arthritis – systemic disease
 Post-traumatic arthritis – following injury
 Others
How can I prolong the life of
my hip or knee?
 Weight
Management
 Activity Modification
 Medications – Systemic Inflammatory
Arthritis
 Glucosamine ??
What can help me live with
my pain?
 Weight
Management
 Activity Modification – Bike, Swim
 Physical Therapy – Motion, Strength
 Assistive Devices – Cane , Crutches,
Walker, Scooter, Wheelchair
What can help me live with
my pain?
 Oral



Medications
Analgesic – Over the Counter, Prescription
Glucosamine/Chondroitin
Other “Alternative” Treatments
 Injectable


Medications
Cortisone
Synvisc, Hyalgan
 Braces
Unloader Brace
 Shifts
weight off bad side of knee over to
good side of knee
 Must have a good side
 Must be willing to wear
brace(cumbersome)
 Best for those who enjoy specific activities
– Golf, Tennis, Hiking, Walking
QUESTIONS
NON-SURGICAL OPTIONS
How do I know when to have
surgery?
 Need
a diagnosis – Not all joint pain is
caused by arthritis, not all arthritis is the
same
 Fibromyalgia


Not surgically treatable
Makes surgery less predictable
 History, physical exam, x-ray
 Plain x-ray usually sufficient to
make
the diagnosis
 MRI and other tests occasionally
helpful
How do I know when to have
surgery?
 Decision
is almost always up to the
patient
 M.D. should lay out the options,
surgical and non-surgical
 M.D. may give advice, but should
rarely tell you what to do – it’s your
choice
 Others may help you decide (friends,
family, primary care physician), but
ultimately you make the call
 Consider the following questions
Procedure Questions
 What
exactly is the procedure?
 What are the goals?
 How likely is it to work?
 What is the recovery like?
 What are the risks/complications?
 What are my other options?
Personal Questions
 What
is my age?
 What is my occupation?
 What activities do I enjoy?
 What health problems do I have and
how do these affect my surgical risk?
 What support system do I have to help
me during recovery?
 HOW MUCH PAIN AND DISABILITY DO I
HAVE?
Surgical Options
 Arthroscopy
 Osteotomy
 Arthrodesis
(Fusion)
 Arthroplasty (Replacement)
HIP
 Osteotomy,
arthrodesis, arthroscopy rarely
used
 Arthroplasty common
KNEE
 Arthroscopy
common
 Osteotomy – popularity waxes and wanes
 Arthrodesis – rarely used
 Arthroplasty - common
Arthrodesis (Fusion)
 Eliminates
pain
 Creates a different disability
 Lasting result
 Commonly used before arthroplasty
developed
 Young patient – heavy, laborer
 Salvage - infection
Osteotomy
 Used
most commonly in the knee
 Shifts weight from bad side of joint to
good side (like unloader brace)
 Must have a good side of the joint
 Not appropriate for systemic inflammatory
arthritis
Osteotomy
 Most
commonly done by removing a
wedge of bone from femur or tibia and
placing a plate to hold bones in place
 Young patient trying to avoid arthroplasty
 Intended as a temporizing procedure, not
a permanent solution - reported results
variable
 Takes a long time to recover – crutches,
brace, therapy
Osteotomy
 Not
as popular currently as durability of
arthroplasty improves
 May make subsequent arthroplasty more
difficult
QUESTIONS
ARTHRODESIS
OSTEOTOMY
Arthoscopy
 Visualize
joint through a fiberoptic tube
inserted through small skin incision
 Common in knee, uncommon in hip
(technically difficult)
 Arthoscopy is a way of doing an
operation, NOT the operation itself, which
may involve many things – DON’T
COMPARE YOURSELF TO OTHERS!
Arthroscopy
 Other
small incisions – insert shavers,
cutting devices, graspers
 Smooth joint surfaces
 Trim meniscus tears
 Remove loose bodies
 Remove diseased synovium – systemic
inflammatory arthritis
Arthroscopy
 Brief
day surgery procedure
 Various anesthetics, frequently regional
 Minimal risks/complications
 Recovery varies but usually fairly rapid –
return to activities as tolerated
 Doesn’t burn any bridges
 Helps evaluate the status of the joint, may
help guide future treatment decisions
Arthroscopy
 Results
UNPREDICTABLE!
 Works best with less advanced arthritis
 Two specific groups do best


Sudden symptom change – goal is to return
to baseline (not eliminate all pain)
Strong catching/locking symptoms – goal is
to stop catching/locking (not eliminate all
pain)
QUESTIONS
ARTHROSCOPY
Arthroplasty (Replacement)
 One
of the most successful operations in
all of medicine
 Modern form originated in 60s and 70s
 Over 500,000 hips and knees done each
year in the U.S.
What is the procedure?
 Hip
– Socket replaced with metal and
plastic socket, ball replaced with metal
ball attached to stem that goes down the
femur
 Knee – End of femur covered with metal
cap, top of tibia covered with metal and
plastic plate, patella resurfaced with
plastic button
What are the goals of the
procedure and how likely is it
to work?
 Pain
relief – very reliable
 Functional improvement – reliable but need to
consider other factors which may limit function
(other bad joints, poor balance,
deconditioning, medical problems)
 Good and excellent results 95% - 97%
What are the
complications/risks?
 Infection
 Bleeding / need for transfusion
 Nerve injury
 “Blood Clots” – DVT, PE
 Anesthesia – regional techniques
(spinal, epidural) becoming more
common
 Dislocation (Hip)
 Differing leg lengths (Hip)
 Stiffness (Knee)
What are the
complications/risks?
 Many
complications related to medical
conditions / health problems
 Even the most healthy patient can suffer
a complication
Long Term Problems
 The
replacement is a mechanical device
with a limited lifespan
 Failure eventually results in pain
 Revision surgery has higher complication
rates and lower success rates
 Will I need a revision procedure?


How long will I live?
How long will it last? (guess = 10-20 years)
What is the recovery like?








Historically long and difficult, but variable
Surgery 1-2 hours
Hospital 3-4 days
Home or transitional care
A lot of Rehab (especially knees)
Walker/crutches 2-3 weeks, Cane 3-4 weeks
Limited only by your pain and ability to
progress
May improve for up to one year
What is the recovery like?
 Newer
techniques may offer more rapid
and less painful recovery
 “MIS” = “Minimally Invasive Surgery”
 Better term = “LESS Invasive Surgery”
 Same operation through smaller incision
 Not appropriate for all patients
 ? Not appropriate for all surgeons - ?
Higher complication rate
 An easier recovery is nice, but cannot
compromise the reliable long term
success seen historically
QUESTIONS
ARTHROPLASTY
“What do you
recommend, Doctor?”
 Know
your diagnosis
 Know your options, surgical and
non-surgical
 Know yourself
 Seek advice from others – primary
M.D.
 Ask your surgeon questions
 Trust your instincts – make sure you
feel comfortable with your choice
THANK YOU !