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

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Presentation on theme: "Hip and Arthritis: Treatment Alternatives To Remain Active Scott M. Sporer, M.D. Midwest Orthopaedics at RUSH Assistant Professor RUSH University Medical."— Presentation transcript:

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) 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 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 Radiographic evidence of arthritis in almost all people > 60 10-20% of patients with symptoms 10-20% of patients with symptoms Knee disease twice as prevalent as hip disease in people > 60 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. 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 Women twice as likely to have disease as men Inside portion of the Knee 10x more likely Inside portion of the Knee 10x more likely 60-80% of joint load through medial compartment 60-80% of joint load through medial compartment

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

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

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

9 Laboratory Tests Rarely Required Rarely Required Fluid Aspiration Fluid Aspiration Blood Tests Blood Tests

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

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

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

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

14 Patient Education Exercise Exercise Strengthen muscles around knee Strengthen muscles around knee Helps support the joint Helps support the joint Improve flexibility Improve flexibility Make future surgery easier 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 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 Acetaminophen vs. placebo 73% vs. 5% of knees with improvement in rest pain 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. 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… 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 Possible side Effects Stomach irritation Stomach irritation Kidney damage Kidney damage Ulcers Ulcers Cox-2 Inhibitors Cox-2 Inhibitors Fewer side effects Fewer side effects Expensive Expensive

19 Cox – 2 Recommendations Merck & Co., Inc. - withdrawal of Vioxx on Sept. 30, 2004 increased relative risk for confirmed cardiovascular events 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 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 Not Regulated by FDA Expensive Expensive Unknown Side Effects Unknown Side Effects Effective in several studies Effective in several studies

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

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

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

24 Arthroscopy

25 Surgical Treatment Unicompartment Knee Replacement Unicompartment Knee Replacement Total Knee Replacement Total Knee Replacement

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

27 Radiographs

28

29 Surgical Technique – Minimally Invasive

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

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

32 Total Knee Arthroplasty

33 Surgical Procedure

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

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

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

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

38 How To Decide ? Individual Decision Individual Decision Hurtful not Harmful Hurtful not Harmful Is if affecting you? Is if affecting you? What are your expectations? 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) 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 Cartilage is required to provide a smooth surface for the hip to glide

41 Hip Anatomy

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

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

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

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

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

47 Exercise

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

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

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

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

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

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

54 Surgical Procedure

55 Radiographs

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

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

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

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

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

61 Total Hip Precautions Avoid crossing your legs Avoid crossing your legs Avoid bending your hip greater than 90 degrees Avoid bending your hip greater than 90 degrees Avoid turning foot inward Avoid turning foot inward Keep a wedge or pillow between your knees while in bed Keep a wedge or pillow between your knees while in bed Do lean back slightly when sitting to keep the hip bending < 90 degrees 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 15-20 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) 339-2225


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