5 Prevalence of Osteoarthritis Most common form of joint disease worldwideAffects nearly 27 million Americans1Radiographic evidence2>50% at 65 years of age≈80% at 75 years of age and olderSymptomatic osteoarthritis (OA) of knee212% of people aged > 60 yearsOA is the most common form of joint disease worldwide, with age-related prevalence continuing to rise. It is estimated that up to 27 million US adults have osteoarthritis, up from the estimate of 21 million for 1995.Lawrence RC, et al. Arthritis Rheum. 2008;58:26-35.1Helmick, 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),2Manek NJ, Lane NE. Am Fam Physician. 2000;61:3Lawrence RC, et al. Arthritis Rheum. 2008;58:26-35.
6 OA-Related Limitations Will Increase Projected Prevalence of Arthritis-Associated Activity Limitation2523Prevalence (Millions)21Arthritis is the leading cause of disability among Americans older than 15 years,1 and these limitations are expected to continue increasing.2 In 1999, adults with knee OA reported requiring 17.7 days of bed rest, versus only 1.4 days for those without knee OA.3References1. Arthritis Foundation. The facts about arthritis. Available at:2. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associatedactivity limitations. Arthritis Rheum. 2006;54:3. American Academy of Orthopaedic Surgeons. Improving musculoskeletal care inAmerica. Available at:1917200520102015202020252030YearHootman JM, Helmick CG. Arthritis Rheum. 2006;54:
7 Disease Process Progressive loss of articular cartilage Remodeling and hypertrophy of boneBone cysts, osteophytes, spurs
9 Risk Factors for Knee OA AgeGeneticsSystemic factors (e.g., obesity)DemographicOA SEVERITYTrauma/InjuryOverloadInstabilityBiomechanicalRisk factors for knee OA can be categorized as either predisposing or biomechanical.1Age is a predisposing factor: As the US population aged 65 years and older increases, the proportion of those with OA will stay the same.2 Systemic factors, such as obesity, which currently has a 30% prevalence among US adults,1,3 also predispose people to knee OA.Biomechanical risk factors for knee OA include injury, overload, and instability.1 Biochemical factors also contribute to OA severity.References1. Dieppe PA, Lohmander S. Pathogenesis and management of pain in osteoarthritis.Lancet. 2005;365:2. Centers for Disease Control and Prevention. Public health and aging: projectedprevalence of self-reported arthritis or chronic joint symptoms among persons aged>65 years—United States, MMWR. 2003;52:3. Fackelmann K. Aging, obesity contribute to increase in arthritis. Available at:CytokinesMMPsPGsBiochemicalMMPs = matrix metalloproteinases; PGs = proteoglycans.Dieppe PA, Lohmander S. Lancet. 2005;365:
10 Growth in Older Population3 The Graying of AmericaAs the “baby boom” generation ages, the US population aged ≥65 years is increasing1In 2006, all baby boomers were >40 years of age, and almost half were >50 years of age2By 2030, 20% of the US population will be aged ≥65 years2Growth in Older Population3The aging of the US population and the growing weight problem in allage groups have led to an increasing number of patients experiencingosteoarthritis (OA) of the knees.1This results in great costs to society,2 not only from the directimpact of health dollars spent on treating OA, but also indirectly in thedecreased productivity of the population that occurs secondary toimpaired function and mobility. Other health issues arising from agradual deterioration in the patient’s health as a result of impairedactivity levels also impact these costs.ReferencesManek NJ, Lane NE. Osteoarthritis: current concepts in diagnosis and management. Am Fam Physician. 2000;61:Centers for Disease Control and Prevention. Update: direct and indirect costs of arthritis and other rheumatic conditions—United States, MMWR. 2004;53:1. Fackelmann K. USA Today. Available at:2. Freifeld L. License! June 2005:42-88.3. US Census Bureau, Available at:
11 OA Affects Women More Than Men Estimated Prevalence of Diagnosed OAIn the United States, 25.9 million women, versus 16.8 million men, have diagnosed arthritis.1 This discrepancy may be due, in part, to the loss of hormonal support incurred by young female athletes, who often experience delayed menarche or frequent amenorrhea.2 Diagnosed OA = all forms of arthritis.References1. Arthritis Foundation. The facts about arthritis. Available at:2. Chen AL, Mears SC, Hawkins RJ. Orthopaedic care of the aging athlete.J Am Acad Orthop Surg. 2005;13:Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:11
13 OA Pathophysiology: Downward Path Cartilage degradation (from injury, inflammation or metabolic defect)Depletion of proteoglycans and attempted repair by chondrocytesInflammatory responseFurther cartilage breakdown with chondrocyte apoptosisDecrease in concentration and viscosity of synovial fluidDecrease in concentration and average molecular weight of HADecreased lubrication and cushioning of the jointLing SM, Bathon JM. JAGS ;46:Altman RD. The Merck Manual of Diagnosis and Therapy. 16th ed
14 Changes in Articular Cartilage Joint injury and deformityPeriarticular tissue and fluid damageInflammationChronic wear and ageOA pathogenesis is generally thought to be due to damage to the articular cartilage; however, the articular cartilage does not contain nerve fibers and thus may not be the source of OA pain. In contrast, periarticular tissues such as joint capsule, synovium, tendons, ligaments, muscles, and subchondral bone have a rich nerve supply.Courtesy of Robert J. Dimeff, MD
16 Clinical Knee OA Signs and Symptoms Bony enlargement of jointLimited range of motionCrepitus on active motionJoint deformitySymptomsJoint painPain with weight bearingMorning stiffness (<30 minutes)Joint instability or bucklingReduced functionThis slide enumerates some of the more common signs and symptoms of OA; there are others, of course.Adapted from Manek NJ, Lane NE. Am Fam Physician. 2000;61:
18 OA: Clinical Multimodal Management DiagnosisNon-pharmacologic treatment; Simple AnalgesicsOTC/ NSAIDsRX NSAIDs/ GI Protect COX-2 iIA Hyaluronans/ CorticosteroidsCurrently, the new treatment algorithm advocates a patient-specific, multimodal approach to concomitant therapy. This has lead to earlier utilization of HA therapy.Surgical InterventionAdapted 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: ; Kelly MA, et al. Orthopedics. 2003;26:
19 Non-pharmacologic Approaches Patient educationExerciseSupport programsWeight loss (if obese)Physical therapyAcupunctureChiropracticOrthotics/footwearBracesAssistive devicesPatient adherence, outcomes, and ultimate satisfaction are most certainly improved through proper education to ensure an understanding of the disease and its implications.As physicians, we have an opportunity to put safe physical activity and exercise routines, general health issues, and obesity concerns into proper perspective as they relate to the issue of “healthy knees.”((REVIEW THE USE OF NONPHARMACOLOGIC OPTIONS))
20 Pharmacologic Treatment Options Oral medicationsLocalized therapiesAcetaminophenNSAID/COX-2 i(advil, celebrex, naprosyn, topical antiinflamatories.Other AnalgesicsNutraceutical (Glucosamine, Chondroitin, MSM)TopicalInjectionCorticosteroid- Hyaluronan((REVIEW THE USE OF OTC MEDICATIONS AND PRESCRIPTION MEDICATIONS))((DISCUSS risks, benefits, alternatives, and possible complications of the use of pharmacologic agents listed in slide))((TRANSITION TO THE USE OF TOPICAL AND INJECTABLE THERAPIES— trend of patient uneasiness with systemic medications and increasing desire for “localized therapeutic modalities”)) Example: Capsaicin®Corticosteroid injections, although beneficial in acute osteoarthritis (OA) “flares,” have limited duration of action and their use is limited by the adverse consequences associated with repeat injections.HYALURONIC ACID INJECTIONS HAVE BECOME INCREASINGLY POPULAR AS A SAFE AND EFFECTIVE TREATMENT MODALITY FOR OA OF THE KNEES.NSAIDs=nonsteroidal anti-inflammatory drugs: COX-2 i=cyclooxygenase-2 inhibitors.
21 Molecular Weight of Synovial HA Why is HA Important?Found in all tissues and body fluidsLubricationIntra-articular water homeostasisStress distribution because of viscoelastic propertiesMolecular Weight of Synovial HAHealthy KneeKnee With OAAvg kDaAvg kDaHAs are found throughout the human body.The physiologic functions of HAs include lubricating effects, water balance, and stress distribution through viscoelastic properties, which allows the HAs to become increasingly elastic and more efficient at absorbing energy at high shear stresses.The table shows the average molecular weight of synovial HA.
22 Pharmacologic Treatment Options Research on Euflexxa shows 81% of patients satisfied 3 months after injection.
25 Knee Arthroscopy Arthroscopic surgery for the knee as the disease progresses loose fragments and cartilage can build up in the kneeIf the main symptoms are mechanical catching or locking, these can improve for several years with arthroscopic removal of the debris.
26 Cartilage Repair For isolated defects in surface cartilage (potholes) Works on patients age < 50 yrs2 methodsTransplant surface cartilage and boneCulture patients own cartilage cells and replace in defect
27 Cartilage Restoration Center www.cartilagerestorationtexas.com Osteochondral Allograft transplantationAutograft Chondrocyte Transfer (Carticel)
28 Knee resurfacing/ Partial Replacement For patients with limited osteoarthritis or isolated arthritis painPartial knee replacement can be a great optionBICOMPARTMENTALUNICONDYLARPATELLOFEMORALLATERAL
29 Knee ReplacementFor advanced osteoarthritis resurfacing the entire knee or Total Knee Arthroplasty can be a life changing surgeryAdvancements in materials can push the lifespan of implants to 30 yrs or more with reasonable activity
30 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 precisionPre-surgical planning details the technique for bone preparation and customized implant positioning using a CT scan of the patient’s kneeTactile technology with 3-D visualization for controlled resurfacing within the pre-defined planned resection volumeMinimally invasive and bone sparing with minimal tissue trauma for a more rapid recovery and return to an active lifestyle
31 Prevalence of Osteoarthritis Unicondylar MAKOplasty®10% of all TKA patients are estimated with tibiofemoral OA1Lateral OA is estimated to be 10-12% of the unicompartmental market90% of TKA patient candidates chose not to have a TKA2Patellofemoral MAKOplasty®24% of OA patients may present with isolated patellofemoral disease1,3Bicompartmental MAKOplasty®40-65% of OA patients present with tibiofemoral-patellofemoral disease1,3,4LateralDuncan, R., Hay, E., Saklatvala, J, Croft P. (2006) Prevalence of radiographic osteoarthritis: it all depends on your point of view. Rheumatology (45),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.3. 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),4. 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.
32 Treating Osteoarthritis of the Knee with Total Knee Arthroplasty (TKA) TKA limitationsRequires extensive rehabilitationAddresses late stage osteoarthritis (OA)Aggressively removes healthy cartilage when treating early stage osteoarthritis of the kneeMAKOplasty® partial knee resurfacing with the RESTORIS® family of knee implant systemsRestores the natural knee without the confines of conventional instrumentationACL and PCL sparing alternative to TKAPromotes better kinematicsRetained proprioceptionPatients treated with a total knee implant never forget they had a joint replacement and are forced to modify their lifestyle to suit their new knee11. 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): , 2005.
33 MAKOplasty® Partial Knee Resurfacing MAKOplasty® potentially offers the followingbenefits when compared to TKA:Improved surgical outcomesLess implant wear or looseningBone sparingSmaller incisionLess scarringReduced blood lossMinimal hospitalizationRapid recoveryIndividual 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.
34 MAKOplasty® Partial Knee Resurfacing Utilizes surgeon-interactive robotic arm technologyBrings the advantages of minimally invasive partial knee resurfacing to a broader patient population by providing consistently reproducible precisionPre-surgical plans are created using CT scan data for precise pre-operative planning of implant size, orientation and placementSurgeon interactive robotic arm guides the surgeon through each well-defined surgical planIntegrity of implants are based on clinical designs that preserve critical tissue and bone stock for improved outcomes
35 Clinical Results – Knee Society Scores Unicompartmental Knee Arthroplasties43 MAKOplasty® proceduresHt: 67±3 inAge: 73±11 yrsWt: 185±37 lbsBMI: 29±538% ObeseKSS scoreWOMACROMRoche et al 2008
37 Surgery – what is really involved Try non-surgical treatment firstWhen you are ready for long term relief talk to your surgeon about options
38 Surgery – what is really involved Presurgery – minimize your risksControl medical problems (diabetes, heart)Maximize muscle conditioningPlan your scheduleTransportationSleepingbathing
39 Surgery – what is really involved Partial knee replacementOne night or outpatientTotal Knee2-3 day hospital stayUp walking 1st day post opRehab 6 – 12 wksIn and outpatient vs at homeBlood Clot preventionStockings, blood thinners 6 wks
40 Surgery – what is really involved When can I golf?Usually by 2 months after partial and 3 months after total kneeWhen can I exercise?Bicycle, Eliptical, Swimming as soon as skin healsRunning is not recommended with knee implantsWhen 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 overBlood clot risks are increased with long travel so we recommend caution for the first 3 months
41 Surgery – what is really involved Follow up2 weeks from surgeryWe use only internal sutures so there is nothing to removeProgress checks at 6 weeks, 3 months, 6 months and 1 yearRoutine Xrays are recommended with any joint implant every few years even if there are no problems – it is easier to treat any problems early