Presentation on theme: "Alternatives to joint replacement for Knee Arthritis Matthew Busam, MD July 17, 2008."— Presentation transcript:
Alternatives to joint replacement for Knee Arthritis Matthew Busam, MD July 17, 2008
Is there anything else you can do???? We must remember several key points… – Treatment is based on symptoms, not X-rays or MRIs – No surgery is minor surgery – Not everything is fixed or improved with a shot or a scope – A total knee replacement is a great operation that can dramatically improve a persons quality of life.
Goals Review arthritis Review therapeutic, medical, and surgical alternatives to joint replacement in the knee with arthritis.
Athritis Inflammatory or non-inflammatory degeneration of normal joint anatomy and function resulting in pain and functional disability.
Causes Often after injury, even remote – old trick knee Post surgical- total menisectomies Obesity- – Knee joint experiences 4-8 times body weight with activity. Genetics
Not caused by… Sports in the absence of injury – Not even running long distances – In fact, regular exercise helps prevent joint problems Concrete floors
General goals for patients with arthritis Help alleviate symptoms Allow activity Prevent or slow progression of disease
Non-medical options Weight loss – Losing even 10 lbs can decrease the force on an arthritic knee by lbs! Exercise – Strengthening the muscles around the knee can dramatically improve knee function and reduce the loads experienced by the arthritic bone.
What is a Supplement? U.S. Food and Drug Administration (FDA) – dietary supplements: subcategory of food, providing manufacturers with greater leeway and less oversight than products in the pharmaceutical category – Asterisk syndrome: product is advertised to promote and maintain joint strength,* joint flexibility,* joint lubrication,* range of motion,* production of lubricating fluid,* and renewal of cartilage and connective tissue.* The asterisk at the bottom of the page has the following disclaimer: *These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
Supplements Patented ingredients help support, ease, and rebuild joints…. Soothe away joint pain and watch as your skin regains a nourished, youthful appearance…. Its like oil for your jointsit helps promote full range of motion and flexibility. New Miracle Relief Formula eliminates even the worst pain...almost instantly!
Supplements Glucosamine Chondroitin Others
Glucosamine One meta-analysis of randomized, placebo-controlled clinical trials from January 1980 to March 2002 found glucosamine to have highly significant efficacy for all outcomes, including joint space narrowing and Western Ontario MacMaster University Osteoarthritis Index (WOMAC).meta-analysis Structural and Symptomatic Efficacy of Glucosamine and Chondroitin in Knee Osteoarthritis A Comprehensive Meta-analysis Florent Richy, MSc; Olivier Bruyere, MSc; Olivier Ethgen, MSc; Michel Cucherat, MSc, PhD; Yves Henrotin, MSc, PhD; Jean-Yves Reginster, MD, PhD Arch Intern Med. 2003;163:
Glucosamine Another study reported on 1,583 patients with symptomatic knee osteoarthritis who were randomly assigned to take glucosamine, chondroitin, a combination of glucosamine and chondroitin, celecoxib, or placebo over 24 weeks. Overall rate of response to glucosamine, chondroitin, and the combination were not found to be significantly better than placebo, although patients with moderate to severe pain at baseline were observed to respond significantly better with the combination.study N Engl J Med Feb 23;354(8):
Glucosamine: Side effects Primary side effects of all salts of glucosamine are mild gastrointestinal complaints such as constipation, diarrhea, cramping, gas, heartburn, and nausea. Glucosamine sulfate has been associated with drowsiness and headache. The effects of glucosamine on nursing or pregnant women have not been well-studied. Glucosamine may increase blood sugar levels. Although studies of glucosamine on patients with diabetes are inconclusive, it is believed that higher doses may prompt the pancreas to produce less insulin, so caution is advised. Because glucosamine is often made from shellfish and the source of the product is not required to be on the label, individuals who are allergic to seafood are advised to exercise caution as well.
Biomechanics Basic concept is to realign the mechanical axis to unload the arthritic compartment
Biomechanics Mechanical axis is center of hip to center of ankle mortise Normally just medial to tibial spines Normal knee 60% BW through MFC
PTO Indications Age < 60 Single compartment involvement 10º - 15º varus on WB x-ray Arc of motion 90º Flexion contracture < 15 º Sufficient strength and motivation for rehab
PTO Contraindications More than 20° correction Lateral tibial subluxation > 1 cm Medial bone loss > 2-3 mm Severe medial/lateral ligamentous instability (varus thrust) Inflammatory arthritis
PTO Relative Contraindications Work comp with previous partial menisectomy Cosmetic asymmetry 30% over ideal body weight Mild patellofemoral arthrosis
Medial VS Lateral PTO Medial – Avoids peroneal n. and fibular osteotomy – Two plane correction (slope) – Technically easier – Easier to revise to TKA Lateral – Correct larger deformity – No bone graft – Known results – Earlier union?
DFO Summary Good palliative procedure Results appear to last longer than PTO Less common Smaller studies
Osteochondral Allografts Results Success ranges from 76-86% Garrett Corr 94 16/17 asymtomatic at 3 years Long term survivorship – 95% -5 year – 71% -10 years – 66% -20 years Ghavazi JBJS 1997
Osteochondral Allografts Gross – b/t txd 123, with fresh small allografts – 5 year result 95% demonstrated successful results – results deteriorated over time with 66% successful results at 20 years Cole Ortho Spec Ed 2000
Chondrocyte Transplantation Technique – cartilage harvested from upper medial fem condyle – sent to lab & cultured – transplanted several weeks later – periosteal flap from upper tibia obtained to cover the defect and sutured in place, sealed with fibrin glue