Arthritis Seminar
Solutions for Knee, Shoulder and Hip
Mark G. Kowall, M.D., M.B.A.
Orthopedic Specialty Associates
Templeton, California
1
March 5, 2013
Osteoarthritis
“A Big Problem”
More than 40 Million Americans
have arthritis (joint inflammation)
27 Million people suffer from Osteoarthritis
40 million by 2020
2
Burden of Disease
All races equally
More women than men after 50
Most of us by our 60s & 70s
475,000 Knee Replacements performed annually
3
Osteoarthritis
Spine
Shoulders
Hips
Hands
Fingers
Knees
Feet
What is a Joint???
Bone
Joint space
filled with
Synovial Fluid
“the oil”
5
Synovial
membrane
Articular
cartilage
“the tread”
“Joint Wear”
=
“Tread Wear”
Cartilage
Healthy
Knee
6
Osteoarthritic
Knee
“tread wear”
The Knee
7
Inside the Knee Joint
Normal Cartilage
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Advanced Arthritis
Femoral Head
(The “Hip Ball”)
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Causes
Primary Osteoarthritis (Most Common)
Result of aging
Decreased ability of cartilage to repair
itself
Ligaments supporting joints weaken
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Causes
Secondary Osteoarthritis
Obesity
Surgery
Joint Injury
Gout
Congenital abnormal joints
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Effect of Weight Loss
“Take home point”
For each pound of weight loss  4
pound reduction in the forces hitting
the knee while walking.
“Less weight, Less load on the knee”
Arthritis and Rheumatism, July 2005
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University of North Carolina
Study
“Almost 50% of all U.S. adults
and nearly 66% of obese adults will
develop painful arthritis by the age
of 85”
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An Aside Point
Osteoarthritis
Is NOT
Osteoporosis
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Osteoporosis
Loss of Bone Density
Normal Bone Osteoporotic Bone
15
Symptoms of arthritis
Pain in affected joints
Pain worse with prolonged
use
Stiffness after periods of
inactivity
Grating or “Catching” sensation
with movement
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Diagnosis
History
Physical Exam
 Blood Test- to rule out
other diseases
 Online “Knee Pain Assessment”
(see website)
 X-Rays
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Knee X-Ray
“Bald Tire”
Healthy knee
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Osteoarthritic knee
Hip X-Ray
Tread Gone
Healthy Hip
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Osteoarthritic Hip
Shoulder X-Ray
Normal
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Advanced
Arthritis
Treatment
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Goals of Treatment
Make Your Life Better!!!
by
Relieving pain
 Increasing motion
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 Improving strength
Treatment varies with severity
“Ladder Approach to Treatment”
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1st Rung of LadderMedication
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Medication- NSAIDs
NSAIDs are nonsteroidal antiinflammatory drugs
Aspirin
Ibuprofen
Naproxen
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Vitamins &
Nutritional Supplements
Glucosamine / Chondroitin Sulfate
Some positive results for moderate to advance arthritis
Recently, the American Academy of Orthopedic Surgeons
recommended against its use for patients with
osteoarthritis of the knee (Dec, 2008)
Fish Oil (Omega-3 Fatty Acids)
Diet rich in Fruits and Vegetables
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Alternative Medicine Techniques
Therapy
Symptom
Pain
Biofeedback
Stiffness
u
u
Fatigue
Inflammation
Anxiety/
Depression
u
Visualization
u
u
Hypnosis
u
u
Relaxation
u
u
Yoga
u
u
u
u
u
u
u
u
Acupuncture
u
u
u
Magnets
u
u
u
Vegetarian
Diet
Herbs &
Supplements
u
u
u
u
u
Tai Chi
u
u
u
u
Next Rung of the Ladder
Injections
Cortisone (steroid)
Visco-Supplementation
(Synvisc One,Orthovisc,
Hyalgan, Supartz, Euflexxa)
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Joint Protection- Daily
Exercise
1.Daily range of motion exercise
(Stretching)
2.Strengthening exercises every other
day
3.Endurance exercises three times per
week
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Exercise Dos
Talk to your doctor first
Consider athletic trainer
or physical therapist
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Braces
Sleeves
 neoprene
 improve balance?
 local warmth
 control swelling
 high compliance
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Braces
Unloaders
 “unload” or take pressure of the arthritic side of knee
 decrease pain
 improve walking tolerance
 poor compliance
 expensive
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External Support Aids
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“Unloads” the joint
When all else fails
to improve pain………..
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Surgery
“Top of the Ladder”
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Asking Questions About Surgery
Alternatives
Benefits and for how long?
Risks?
What is procedure called?
How is it done?
Results?
Return to “normal” activity?
36
Surgical Options-Arthroscopy
Mini incisions
Outpatient
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Arthroscopy – Debridement
(Shaving of articular Cartilage (“tread”)
 A means of “smoothing” the coating cartilage
 In conjunction to treating meniscus tears
 Not designed for treatment of arthritis alone
38
Arthroscopy – Microfracture
Knee and Shoulder
 small awl used to make holes in bone
 promote re-growth of cartilage
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Arthroscopy – “OATS” Procedure
 transfer of healthy “tread” to “bald” area
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Surgical Options:
Joint Replacement
Knee
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Hip
Total Knee Replacement
Side view
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Surgical Instrumentation
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Surgical Instrumentation
Femur
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Tibia
Implants
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Total Hip Replacement
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Total Hip Replacement
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Total Shoulder Replacement
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Duke University Medical Center
Study
Hip Replacement Surgery
“Seniors with arthritis who undergo
Hip Replacement are twice as likely
to show improvements in functioning
and ability to care for themselves”
(no age limit on the benefits!!)
49
New Technologies
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Laboratory
 Recombinant Gene Therapy (synthesize the growth factors
which produce new cartilage)
 Specific Growth Factors promote cartilage (tread)
maintenance and repair
 May limit the progression of arthritis
 Platelet Rich Plasma (PRP)
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Recent discovery of a natural
occurring molecule in the body
that can counter the progression
of arthritis
Genes and Development
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New Implant Designs
Traditional TKA vs. High Flex TKA
Designed to
safely
accommodate
flexion
up to 125
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Designed to
safely
accommodate
flexion
up to 155
New Implant Designs
Gender Specific Knee Implant
Women have a different shaped knee joint
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Patient Specific Instrumentation
 MRI or CT based technology
 3D model created of knee
 Surgery Planning
 Customized pin guides or cutting
blocks
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Patient Specific Instrumentation
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Mini-Incision Surgery (Knees)
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Complications
 Mini-Incision Surgery for the knee
reduces recovery time but increases
wound healing problems.
Clinical Orthopedics and Related Research

Mini-Incision and alternative approaches
for the hip---controversial!!!!
58
Consumer Beware
Bozic K J, et al. Impact of direct to consumer advertising on physician
attitudes and behavior in orthopedic surgery American Academy of Orthopedic Surgeons
**Poll of 737 hip and knee surgeons
**Over 75% of surgeons reported that direct-to-consumer (DTC) advertising
negatively impacted their practice and the relationship with patients.
**Ads presented a skewed view of procedures and devices by
exaggerating the benefits and down playing risks.
**(Patients) were not more educated about the risks and benefits, not more
educated about the alternatives, not more educated about the costs and
that they were less open to alternatives after reading or viewing direct-toconsumer advertisements
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Surgical Procedure Animations
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Resources
www.ShoulderKneeSpecialists.com
 Surgical Procedure Animations
 Health Library
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 Important Links
Questions????
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