1. Hip and Arthritis: Treatment Alternatives To Remain Active
Scott M. Sporer, M.D.
Midwest Orthopaedics at RUSH
Assistant Professor
RUSH University Medical Center
Central Dupage Hospital

2. What is Arthritis?
Loss of Cartilage from the end of the thigh bone (femur) or leg bone (tibia)
Cartilage is required to provide a smooth surface for the knee to glide

3. What is Arthritis ?

4. Epidemiology
Radiographic evidence of arthritis in almost all people > 60
10-20% of patients with symptoms
Knee disease twice as prevalent as hip disease in people > 60
6.1% of adults >30 have radiographic evidence OA with pain on most days.

5. Epidemiology Women twice as likely to have disease as men
Inside portion of the Knee 10x more likely
60-80% of joint load through medial compartment

6. Knee Anatomy Femur (Thigh Bone) Tibia (Shin Bone) Patella (Knee Cap)
3 “Compartments”

7. Clinical Presentation
History
Pain
Instability
Change in alignment
Bow Kneed
Knocked Kneed
Difficulty walking
Difficulty with Activities of Daily Living

8. Clinical Presentation
Physical Examination
Swelling
Limited Motion (contractures)
Limp
Hip and knee pain/deformity

9. Laboratory Tests
Rarely Required
Fluid Aspiration
Blood Tests

10. Radiographic Evaluation
Best Method To Evaluate Arthritis
Plain X-Rays
Standing Radiographs
AP/ Lateral
Schuss/Rosenberg Views

11. Radiographic Evaluation
Joint Space Narrowing
Osteophytes “bone spurs”
Changes in Alignment
MRI, CT Scan, Bone Scans add little information

12. Treatment Options Non Surgical Surgical Weight Loss Exercise
Physical Therapy
Walking Aids
Injections
Surgical
Unicomparmental Knee Replacement
Total Knee Replacement

13. Patient Education Use high stools Avoid high impact activities
Recommend swimming and biking
Obesity
2-5 times body weight with walking

14. Patient Education Exercise Strengthen muscles around knee
Helps support the joint
Improve flexibility
Make future surgery easier

15. Medications
“ Two systematic reviews have found that simple analgesics and NSAIDS produce short term pain relief in OA. However, no good evidence that NSAIDS are superior to simple analgesics such as Acetaminophen”
-Clinical Evidence 2001

16. Analgesics Acetaminophen vs. placebo
73% vs. 5% of knees with improvement in rest pain
                                                                                                                                                                                      

17. Non-Steroidal Anti-Inflammatory
NSAIDS have been found to be effective in reducing short term pain.
The Cochrane Library, Issue 4, 1999
“Systematic reviews found no important differences in effect between different NSAIDS or doses, but found differences in toxicity…”
-Clinical Evidence 2001

18. Non-Steroidal Anti-inflammatory Medications (NSAIDS)
Possible side Effects
Stomach irritation
Kidney damage
Ulcers
Cox-2 Inhibitors
Fewer side effects
Expensive
                         

19. Cox – 2 Recommendations
Merck & Co., Inc. - withdrawal of Vioxx on Sept. 30, 2004 increased relative risk for confirmed cardiovascular events
“Patients who are at a high risk for gastrointestinal bleeding, have a history of intolerance to non-selective NSAIDs, or are not doing well on non-selective NSAIDs may be appropriate candidates for Cox-2 selective agents. Individual patient risk for cardiovascular events and other risks commonly associated with NSAIDs should be taken into account”

20. Glucosamine/ Chondroitin Sulfate
Not Regulated by FDA
Expensive
Unknown Side Effects
Effective in several studies

21. Cortisone Injection May provide Temporary Relief
Decreases inflammation
May accelerate cartilage damage
Small Risk of Infection
78% of patients note improvement

22. Hyaluronic Acid Injection
Considered a medical device
Works best for less severe arthritis
Series of 3 to 5 injections
Small Risk of Infection
Allergic Reaction
2/3rd patients note mild improvement
                                                   

23. Arthroscopy
Theory:
Degenerating cartilage releases inflammatory mediators
Subsequent cartilage damage
May be replaced by cartilage type tissue

24. Arthroscopy

25. Surgical Treatment Unicompartment Knee Replacement
Total Knee Replacement
                             

26. Unicompartmental Knee
Arthritis in only 1 compartment of knee
Used in either Young or Old patient
Ligaments Intact
No systemic Disease
Weight <200#
Occupation

27. Radiographs

29. Surgical Technique – Minimally Invasive

30. Why Minimally Invasive
Earlier Mobilization
Cost
Shorter Hospital Stay
Quicker Rehabilitation
Less Blood Loss
? Easier conversion to Total knee replacement

31. Total Knee Arthroplasty
Resurface All Three Surfaces
Tibia
Femur
Patella
Components fixed to bone with “cement”

32. Total Knee Arthroplasty

33. Surgical Procedure

34. MIS in TKA Mini/MIS QS TKA Mini Standard 20-30 cm Q-S 12-14 cm
Quad Snip
Standard cm
Quad Incision
Q-S
7-10 cm
No Quad

35. MIS Patient Selection Male <250 #, Female < 225# Motivated
Range of motion > 90˚
Flexion Contracture < 10 ˚
Fixed varus <10 ˚ or valgus <15 ˚

36. MIS TKA Contraindications
Deficient or scared skin
Severe diabetic; steroids
Osteoporosis
Prior major intra-articular surgery
Relative Contraindications
Extremely Muscular
Inflammatory arthritis
Patella Baja
Extremely Large sizes

37. Total Knee Replacement
Long Term Results
96% Functioning Well at 10 Years

38. How To Decide ? Individual Decision Hurtful not Harmful
Is if affecting you?
What are your expectations?

39. Hip Arthritis

40. Hip Arthritis?
Loss of Cartilage between the top of the thigh bone (ball), and the acetabulum (socket)
Cartilage is required to provide a smooth surface for the hip to glide

41. Hip Anatomy

42. Clinical Presentation
History
Pain
Difficulty walking
Difficulty with Activities of Daily Living

43. Radiographic Evaluation
Best Method To Evaluate Arthritis
Plain X-Rays
Joint Space Narrowing
Osteophytes “bone spurs”

44. Treatment Options Non Surgical Surgical Weight Loss Exercise
Physical Therapy
Walking Aids
Injections
Surgical
Total Hip Arthroplasty
Minimally Invasive Total Hip Arthroplasty

45. Patient Education Avoid high impact activities
Recommend swimming and biking
Obesity
2-5 times body weight with walking

46. Patient Education Exercise Strengthen muscles around hip
Helps support the joint
Improve flexibility
Make future surgery easier

47. Exercise

48. Medications Provide Temporary Relief of Pain
Similar Efficacy among Medications

49. Non-Steroidal Anti-inflammatory Medications (NSAIDS)
Possible side Effects
Stomach irritation
Kidney damage
Ulcers
Cox-2 Inhibitors
Fewer side effects
Expensive
                         

50. Cortisone Injection Used infrequently in Hip Arthritis
May help with Diagnosis
Decreases inflammation
May accelerate cartilage damage
Small Risk of Infection

51. Arthroscopy Difficult to see inside the hip Results less predictable
Used for “Mechanical Symptoms”
Rarely performed

52. Surgical Treatment Remove Damaged Cartilage
Replace with Metal and Plastic
Remove Bone Spurs
“Resurface the bone”

53. Surgical Treatment Total Hip Replacement
Resurface the ball and socket with metal and plastic
Partial Resurfacing Hip Replacement
Resurface only the ball of the hip
Conventional Surgical Approach
Minimally Invasive Surgery

54. Surgical Procedure

55. Radiographs

56. Surgical Technique – Minimally Invasive
Standard Incision 9-10 Inches
One 3-4 Inch Incision or two 2 Inch Incisions
Separate Muscles – Do not Cut Muscle

57. Total Hip Replacement Minimally Invasive Hip Select Patients
Potential shorter recovery
Potential less bleeding
Potential quicker rehab
Long Term Results Unknown

58. Post Operative Recovery
Physical Therapy next day
Pain Pump or Epidural catheter for pain relief
Full Weight Bearing
Coumadin to prevent blood clot

59. Total Hip Arthroplasty
Hospital Stay
Standard Approach  5-7 days
Minimally Invasive Approach  Outpatient – 2 day

60. Follow-up Care Visiting Nurses Staples removed 2 weeks
Coumadin for 4-6 weeks total
Physical Therapy 2-3 times per week
70% better at 2 weeks
90% better at 6 weeks
Slow improvement next 6 months

61. Total Hip Precautions Avoid crossing your legs
Avoid bending your hip greater than 90 degrees
Avoid turning foot inward
Keep a wedge or pillow between your knees while in bed
Do lean back slightly when sitting to keep the hip bending < 90 degrees

62. Potential Complications
Loosening
Infection
Deep Venous Thrombosis
Dislocation

63. Long-Term Expectations
Resume most activities
Avoid positions of risk for dislocation
Yearly follow-up
Hips last on average years
Plastic insert may need to be replaced

64. Thank You Scott M. Sporer, M.D., M.S. Midwest Orthopaedics
25 N. Winfield Road
Winfield, Illinois 60190
(630)