Maximizing
Patient Satisfaction
With Osteoarthritis
Knee Pain
Richard Rhodes, MD, FAAOS
Board Certified – Orthopedic Surgery
Board Certified – Orthopedic Sports Medicine
Texas Health Presbyterian
Allen, 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
Prevalence of Osteoarthritis
• 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.
OA-Related Limitations Will Increase
Projected Prevalence of Arthritis-Associated
Activity Limitation
Prevalence (Millions)
25
23
21
19
17
2005
2010
2015
2020
Year
Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:226-229.
2025
2030
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
Demographic
• Age
• Genetics
• Systemic factors
(e.g., obesity)
• Trauma/Injury
Biomechanical • Overload
• Instability
Biochemical
• Cytokines
• MMPs
• PGs
MMPs = matrix metalloproteinases; PGs = proteoglycans.
Dieppe PA, Lohmander S. Lancet. 2005;365:965-973.
OA
SEVERITY
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.
OA Affects Women More Than Men
Estimated Prevalence of Diagnosed OA
60
Men Women
Percent
50
40
30
20
10
0
18 – 44
45 – 64
65+
Age (years)
Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:226-229.
Total
Osteoarthritis
• Introduction
• Risk Factors
• Physiology
• Treatment
OA Pathophysiology: Downward Path
Cartilage degradation
(from injury, inflammation or metabolic defect)
Depletion of proteoglycans and
attempted repair by chondrocytes
Inflammatory response
Further cartilage breakdown with
chondrocyte apoptosis
Decrease in concentration and
viscosity of synovial fluid
Decrease in concentration and
average molecular weight of HA
Decreased lubrication and
cushioning of the joint
Ling SM, Bathon JM. JAGS . 1998;46:216-225.
Altman RD. The Merck Manual of Diagnosis and Therapy. 16th ed. 2006.
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 OA
Mechanism 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
Signs
• Bony enlargement
of joint
• Limited range of motion
• Crepitus on active motion
• Joint deformity
Symptoms
• Joint pain
• Pain with weight
bearing
• Morning stiffness
(<30 minutes)
• Joint instability
or buckling
• Reduced function
Adapted from Manek NJ, Lane NE. Am Fam Physician. 2000;61:1795-1804.
Osteoarthritis
• Introduction
• Risk Factors
• Physiology
• Treatment
OA: Clinical Multimodal
Management
Diagnosis
Nonpharmacologic
treatment;
Simple
Analgesics
OTC/
NSAIDs
RX NSAIDs/
GI Protect
COX-2 i
IA
Hyaluronans/
Corticosteroids
Surgical Intervention
Adapted from ACR Guidelines and recommendations of the Hyaluronans Clinical Consensus Group of orthopedic surgeons.
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:190-1915;
Kelly MA, et al. Orthopedics. 2003;26:1064-1079.
Non-pharmacologic Approaches
• Patient education
• Acupuncture
• Exercise
• Chiropractic
• Support programs
• Orthotics/footwear
• Weight loss (if obese)
• Braces
• Physical therapy
• Assistive devices
Pharmacologic Treatment Options
Oral medications
Localized therapies
• Acetaminophen
• Topical
• NSAID/COX-2 i(advil,
• Injection
celebrex, naprosyn, topical
antiinflamatories.
• Other Analgesics
– Corticosteroid
- Hyaluronan
• Nutraceutical
(Glucosamine,
Chondroitin, MSM)
NSAIDs=nonsteroidal anti-inflammatory drugs: COX-2 i=cyclooxygenase-2 inhibitors.
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 Center
www.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
UNICONDYLAR
BICOMPARTMENTAL
PATELLOFEMORAL
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
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
Lateral
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.
2.
3.
4.
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.
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.
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),520526.
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.
31
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.
32
MAKOplasty® Partial Knee Resurfacing
MAKOplasty® potentially offers the following
benefits when compared to TKA:
 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.
33
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
34
Clinical Results – Knee Society Scores
p<0.05
Unicompartmental
Knee Arthroplasties
43 MAKOplasty® procedures
Ht: 67±3 in
Age: 73±11 yrs
Wt: 185±37 lbs
BMI: 29±5
38% Obese
KSS score
WOMAC
ROM
80
Knee Society Score
•
•
•
•
•
•
•
•
•
90
Function
Knee
70
60
50
40
30
pre-op
Roche et al 2008
35
6 weeks
3 months
Clinical Results-Radiographic Outcomes
36
Surgery – what is really involved
• Try non-surgical treatment first
• When you are ready for long
term relief talk to your surgeon
about options
37
Surgery – what is really involved
• Presurgery – minimize your
risks
– Control medical problems
(diabetes, heart)
– Maximize muscle conditioning
– Plan your schedule
• Transportation
• Sleeping
• bathing
38
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
39
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
40
months
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
41
Want to Learn More?
42
Questions?
• Literature from many of the treatment
options mentioned available.