Harvard Medical School
Department of Continuing Education
42nd Annual Advances in Arthroplasty Course
“Registries in Action: Your Best World‐Wide Source of Evidence‐Based
Orthopaedics for Biological and Prosthetic Solutions ”
How much arthritis is
too much for arthroscopy?
Richard E Field PhD FRCS FRCS(Orth)
Consultant Orthopaedic Surgeon – Epsom & St Helier NHS Trust
Director of Research – South West London Elective Orthopaedic Centre
Affiliations
Consultant Surgeon – Epsom & St Helier NHS Trust
Director of Research – South West London Elective Orthopaedic Centre
Hon Senior Lecturer – St George’s Hospital Medical School
Member
– London Orthopaedic Advisory Panel
Assistant Editor
– Bone and Joint 360
Council member
– British Hip Society
Board member
– International Society for Hip Arthroscopy
Consultant
– Stryker, Medacta and Smith & Nephew Endo
Research funding – Stryker, Medacta, Smith & Nephew, Medtronics,
Corin, JRI & MatOrtho
What advice did you give Andy Murray?
Win the last point
How Much Arthritis is Too Much for
Hip Arthroscopy?
When you can’t meet the
patient’s expectations
Pain Relief
Restored
Mobility
Restored
Mobility
Pain Relief
Durability
How much pain relief?
How much mobility?
For how long?
The benchmark is
hip replacement
Personal series
•>1300 sequential THR cases
•Patient completed postal questionnaires
•Pre-op
•Post–op at 6months, 1 year and 2 years
Pain relief following THR?
100,0
96,6
94,8
94,2
90,0
80,0
70,0
60,0
50,0
Yes
40,0
No
30,0
20,0
10,0
3,4
5,2
5,8
At 1 year
At 2 years
0,0
At 6 months
Decreased analgesic requirements
following THR?
80,0
71,3
70,5
70,5
70,0
60,0
50,0
Yes
40,0
No
25,8
30,0
25,3
22,7
20,0
10,0
3,7
6,0
4,1
At 6 months
At 1 year
At 2 years
0,0
N/A
Restored function following THR?
100,0
94,1
94,4
93,9
90,0
80,0
70,0
60,0
50,0
Yes
40,0
No
30,0
20,0
10,0
5,9
6,1
5,6
At 1 year
At 2 years
0,0
At 6 months
For how long does recovery continue?
100,0
90,1
90,0
80,0
70,7
70,0
60,0
49,648,0
50,0
Better
Same
40,0
Worse
27,4
30,0
20,0
10,0
8,7
0,0
At 6 months
At 1 year
At 2 years
Patient satisfaction?
100,0
96,3
96,4
98,1
90,0
80,0
70,0
60,0
50,0
Yes
40,0
No
30,0
20,0
10,0
3,8
3,6
1,9
0,0
6 months
1 year
2 years
THR benchmark
1.
2.
3.
4.
5.
6.
95% chance of relieving their pain
95% chance that they won’t need analgesics
94% chance of increasing the activity levels
96% chance that they will be satisfied
These goals will be met by 6 months
50% will still be improving at two years
By an large arthroscopy patients
will accept decreased durability in
exchange for unrestricted activity
Marathons
Squash/Raquets
Soccer
Tennis
Golf
Swimming
Walking
THR
Arthroscopy
ARTHROSCOPY BENCHMARKS
POST-OP RECOVERY
By 3 weeks after surgery
70% of arthroscopy patients
•
•
•
•
No longer require analgesics
No longer use walking aids
Are able to drive their car
Have returned to work
Return to sports
Everyone progresses at a different rate and each sport has specific
rehabilitation requirements.
It will take 8-10 months to regain
pre-injury fitness
Understanding the
Pathogenesis
Rim
Wear
Rim
Damage
Algorithm to repair
the damaged joint
The labro-acetabular complex
35
Algorithm for management of
labrochondral damage
1. Remove cause of damage
Algorithm for management of
labrochondral damage
1. Remove source of damage
2. Clear subchondral cysts and remove their
sclerotic walls
Algorithm for management of
labrochondral damage
1. Remove source of damage
2. Clear cysts and remove their sclerotic walls
3. Graft the cyst
Arthroscopy 2010;26(2): 279-285
Bone Grafting of
acetabular defect
Algorithm for management of
labrochondral damage
1.
2.
3.
4.
Remove source of damage
Clear the cyst and remove the sclerotic wall
Graft the cyst
Restore the labrochondral integrity
What is the limit of articular cartilage
loss that can be recovered?
3cm2
What’s the prognosis
R Villar practice data 1989 -2012
FAI
Better (%)
No change (%)
Worse (%)
80
15
5
R Villar practice data 1989 -2012
Better (%)
No change (%)
Worse (%)
FAI
80
15
5
Mild OA
70
20
10
R Villar practice data 1989 -2012
Better (%)
No change (%)
Worse (%)
Default
80
15
5
Mild OA
70
20
10
Severe OA
40
45
15
• >55 years no
joint space
narrowing
• 40-55 years
Tonnis 1-2a
• <40 Any
degree of
degeneration
Degree of OA
Safran’s Law
For Arthroscopic Intervention
Patient Age
How much arthritis is
too much for arthroscopy?
When joint degeneration is
associated with severe deformity
Joint space narrowing to <2mm
With the development of
chains of Subchondral Cysts
Evolving extreme solutions
Cysts do heal after THR
Equine Model
Remove & Graft
Medial femoral condyle
Lameness – 25% return to athletic activity without surgery
Extra-articular approach, poor results attributed to inadequate clearance of
cyst and removal of sclerotic cyst wall
Intra-articular curettage and grafting achieves 75% return to athletic activity
Oper Tech Sports Med 16:194-200
Mosaicplasty of
femoral head
(A) Recipient plug prepared
(B) Plug inserted into prepared hole with the press fit technique.
(C) Completed insertion of plug
Oper Tech Sports Med 16:201-206
Mosaicplasty & ACI
of femoral head
FT chondral defect of the femoral head initially treated with open autologous osteochondral mosaicplasty
Patient then underwent autologous chondrocyte implantation after disease progression
Larger Femoral Cysts
Jamali et al.,
Arthroscopy, 2010
Grafting
ORTHOPEDICS | ORTHOSuperSite.com
2 Patient case series
Used fresh-stored, non irradiated osteochondral allografts obtained from the
Musculoskeletal Transplant Foundation:
•Patient 1: the donor graft consisted of an allograft acetabulum
•Patient 2: a medial tibial plateau donor graft
Arthroscopic assisted solution
A new technique for arthroscopic grafting of subchondral cystic
defects was proposed by Andrade during the Smith & Nephew
Extreme Hip Product Development Workshop, Newcastle, UK,
October 2009. This technique was implemented by Field et al,
April 2010.
The proceduress were undertaken between 22nd
April and 1st July 2010
TruFit plugs of 11, 7, 9 and 11mm diameter were
implanted (Off-licence)
Male 63
Female 54
Female 31
Female 45
Biopsy from bone plug at 5 months
Bone
Fibrous tissue
In conclusion, too much
arthritis for arthroscopy is:
• When the labrochondral complex
cannot be repaired or reconstructed
• When joint congruency cannot be
restored
• When joint space is <2mm
• When chains of subchondral cysts
extend beneath the subchondral plate
Thank you