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Maximizing Patient Satisfaction With Osteoarthritis Knee Pain Richard Rhodes, MD, FAAOS Board Certified – Orthopedic Surgery Board Certified – Orthopedic.

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Presentation on theme: "Maximizing Patient Satisfaction With Osteoarthritis Knee Pain Richard Rhodes, MD, FAAOS Board Certified – Orthopedic Surgery Board Certified – Orthopedic."— Presentation transcript:

1 Maximizing Patient Satisfaction With Osteoarthritis Knee Pain Richard Rhodes, MD, FAAOS Board Certified – Orthopedic Surgery Board Certified – Orthopedic Sports Medicine Texas Health Presbyterian Allen, McKinney, Plano

2 The Knee Rotating Hinge Joint Ends of Bone covered with smooth surface (hyaline) cartilage Soft structural meniscus cartilage helps match surface contours Ligaments provide stability

3 The Knee Any of the knee structures can be damaged and cause pain Today ‘s talk will be about the surface cartilage

4 Osteoarthritis Introduction Risk Factors Physiology Treatment

5 Most common form of joint disease worldwide –Affects nearly 27 million Americans 1 –Radiographic evidence 2 >50% at 65 years of age ≈80% at 75 years of age and older –Symptomatic osteoarthritis (OA) of knee 2 12% of people aged > 60 years 1 Helmick, 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), Manek NJ, Lane NE. Am Fam Physician. 2000;61: Lawrence RC, et al. Arthritis Rheum. 2008;58: Prevalence of Osteoarthritis

6 OA-Related Limitations Will Increase Hootman JM, Helmick CG. Arthritis Rheum. 2006;54: Projected Prevalence of Arthritis-Associated Activity Limitation Year Prevalence (Millions)

7 Disease Process Progressive loss of articular cartilage Remodeling and hypertrophy of bone Bone cysts, osteophytes, spurs

8 Osteoarthritis Introduction Risk Factors Physiology Treatment

9 Risk Factors for Knee OA MMPs = matrix metalloproteinases; PGs = proteoglycans. Dieppe PA, Lohmander S. Lancet. 2005;365: Demographic Biochemical Biomechanical OA SEVERITY AgeAge GeneticsGenetics Systemic factors (e.g., obesity)Systemic factors (e.g., obesity) CytokinesCytokines MMPsMMPs PGsPGs Trauma/InjuryTrauma/Injury OverloadOverload InstabilityInstability

10 The Graying of America As the “baby boom” generation ages, the US population aged ≥65 years is increasing 1 In 2006, all baby boomers were >40 years of age, and almost half were >50 years of age 2 By 2030,  20% of the US population will be aged ≥65 years 2 Growth in Older Population 3 1.Fackelmann K. USA Today. Available at: 2.Freifeld L. License! June 2005: US Census Bureau, Available at:

11 OA Affects Women More Than Men Estimated Prevalence of Diagnosed OA Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:

12 Osteoarthritis Introduction Risk Factors Physiology Treatment

13 OA Pathophysiology: Downward Path Ling SM, Bathon JM. JAGS. 1998;46: Altman RD. The Merck Manual of Diagnosis and Therapy. 16 th ed Cartilage degradation (from injury, inflammation or metabolic defect) Depletion of proteoglycans and attempted repair by chondrocytes Inflammatory response Further cartilage breakdown with chondrocyte apoptosis Decrease in concentration and viscosity of synovial fluid Decrease in concentration and average molecular weight of HA Decreased lubrication and cushioning of the joint

14 Changes in Articular Cartilage Joint injury and deformity Periarticular tissue and fluid damage Inflammation Chronic wear and age Courtesy of Robert J. Dimeff, MD

15 Pain in Knee OA Mechanism is unclear Does not correlate with cartilage damage Joint capsule (stretch) Synovial membrane (synovitis) Periarticular bursae, ligaments, muscle spasm Periosteum stretching Subchondral bone Osteophytes Microfractures Increased intra-osseous pressure Creamer P, et al. Lancet. 1997;350: ; Rice JR, et al. Rheum Dis Clin North Am. 1999;25: ©2007 Girish P. Joshi, MD. Presented and reprinted with permission from Dr. Joshi.

16 Clinical Knee OA Signs and Symptoms Adapted from Manek NJ, Lane NE. Am Fam Physician. 2000;61: Symptoms Joint pain Pain with weight bearing Morning stiffness (<30 minutes) Joint instability or buckling Reduced function Signs Bony enlargement of joint Limited range of motion Crepitus on active motion Joint deformity

17 Osteoarthritis Introduction Risk Factors Physiology Treatment

18 OA: Clinical Multimodal Management American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43: ; Kelly MA, et al. Orthopedics. 2003;26: Adapted from ACR Guidelines and recommendations of the Hyaluronans Clinical Consensus Group of orthopedic surgeons. Diagnosis Surgical Intervention Non- pharmacologic treatment; Simple Analgesics OTC/ NSAIDs RX NSAIDs/ GI Protect COX-2 i IA Hyaluronans/ Corticosteroids

19 Non-pharmacologic Approaches Patient education Exercise Support programs Weight loss (if obese) Physical therapy Acupuncture Chiropractic Orthotics/footwear Braces Assistive devices

20 Pharmacologic Treatment Options NSAIDs=nonsteroidal anti-inflammatory drugs: COX-2 i=cyclooxygenase-2 inhibitors. Oral medicationsLocalized therapies Acetaminophen NSAID/COX-2 i( advil, celebrex, naprosyn, topical antiinflamatories. Other Analgesics Nutraceutical (Glucosamine, Chondroitin, MSM) Topical Injection –Corticosteroid - Hyaluronan

21 Why is HA Important? Found in all tissues and body fluids Lubrication Intra-articular water homeostasis Stress distribution because of viscoelastic properties Molecular Weight of Synovial HA Healthy KneeKnee With OA Avg kDa Avg kDa

22 Pharmacologic Treatment Options Research on Euflexxa shows 81% of patients satisfied 3 months after injection.

23 Osteoarthritis Introduction Risk Factors Physiology Treatment

24 Principles of Operative Management Arthroscopic surgery Cartilage restoration Joint alignment procedures Joint resurfacing Partial joint replacement Total joint replacement

25 Knee Arthroscopy Arthroscopic surgery for the knee –as the disease progresses loose fragments and cartilage can build up in the knee –If 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 yrs 2 methods –Transplant surface cartilage and bone –Culture patients own cartilage cells and replace in defect –

27 Cartilage Restoration Center Osteochondral Allograft transplantation Autograft Chondrocyte Transfer (Carticel)

28 Knee resurfacing/ Partial Replacement For patients with limited osteoarthritis or isolated arthritis pain Partial knee replacement can be a great option BICOMPARTMENTAL PATELLOFEMORAL UNICONDYLAR LATERAL

29 Knee Replacement For advanced osteoarthritis resurfacing the entire knee or Total Knee Arthroplasty can be a life changing surgery Advancements 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 precision Pre-surgical planning details the technique for bone preparation and customized implant positioning using a CT scan of the patient’s knee Tactile technology with 3-D visualization for controlled resurfacing within the pre-defined planned resection volume Minimally invasive and bone sparing with minimal tissue trauma for a more rapid recovery and return to an active lifestyle

31 31 Prevalence of Osteoarthritis Unicondylar MAKOplasty ® –10% of all TKA patients are estimated with tibiofemoral OA 1 –Lateral OA is estimated to be 10-12% of the unicompartmental market –90% of TKA patient candidates chose not to have a TKA 2 Patellofemoral MAKOplasty ® –24% of OA patients may present with isolated patellofemoral disease 1,3 Bicompartmental MAKOplasty ® –40-65% of OA patients present with tibiofemoral-patellofemoral disease 1,3,4 1.Duncan, 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), 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. Lateral

32 32 Treating Osteoarthritis of the Knee with Total Knee Arthroplasty (TKA) TKA limitations –Requires extensive rehabilitation –Addresses late stage osteoarthritis (OA) –Aggressively removes healthy cartilage when treating early stage osteoarthritis of the knee MAKOplasty ® partial knee resurfacing with the RESTORIS ® family of knee implant systems –Restores the natural knee without the confines of conventional instrumentation –ACL and PCL sparing alternative to TKA –Promotes better kinematics –Retained proprioception Patients treated with a total knee implant never forget they had a joint replacement and are forced to modify their lifestyle to suit their new knee 1 1. 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 33 MAKOplasty ® Partial Knee Resurfacing Improved surgical outcomes Less implant wear or loosening Bone sparing Smaller incision Less scarring Reduced blood loss Minimal hospitalization Rapid recovery Individual 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. MAKOplasty ® potentially offers the following benefits when compared to TKA:

34 34 MAKOplasty ® Partial Knee Resurfacing Utilizes surgeon-interactive robotic arm technology Brings the advantages of minimally invasive partial knee resurfacing to a broader patient population by providing consistently reproducible precision Pre-surgical plans are created using CT scan data for precise pre-operative planning of implant size, orientation and placement Surgeon interactive robotic arm guides the surgeon through each well-defined surgical plan Integrity of implants are based on clinical designs that preserve critical tissue and bone stock for improved outcomes

35 35 Clinical Results – Knee Society Scores 43 MAKOplasty ® procedures Ht: 67±3 in Age: 73±11 yrs Wt: 185±37 lbs BMI: 29±5 38% Obese KSS score WOMAC ROM Roche et al 2008 Unicompartmental Knee Arthroplasties

36 36 Clinical Results-Radiographic Outcomes

37 37 Surgery – what is really involved Try non-surgical treatment first When you are ready for long term relief talk to your surgeon about options

38 38 Surgery – what is really involved Presurgery – minimize your risks –Control medical problems (diabetes, heart) –Maximize muscle conditioning –Plan your schedule Transportation Sleeping bathing

39 39 Surgery – what is really involved Partial knee replacement –One night or outpatient Total Knee –2-3 day hospital stay Up walking 1 st day post op Rehab 6 – 12 wks –In and outpatient vs at home Blood Clot prevention –Stockings, blood thinners 6 wks

40 40 Surgery – what is really involved When can I golf? –Usually by 2 months after partial and 3 months after total knee When can I exercise? –Bicycle, Eliptical, Swimming as soon as skin heals –Running is not recommended with knee implants When 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 over –Blood clot risks are increased with long travel so we recommend caution for the first 3 months

41 41 Surgery – what is really involved Follow up –2 weeks from surgery –We use only internal sutures so there is nothing to remove –Progress checks at 6 weeks, 3 months, 6 months and 1 year –Routine Xrays are recommended with any joint implant every few years even if there are no problems – it is easier to treat any problems early

42 42 Want to Learn More?

43 Questions? Literature from many of the treatment options mentioned available.

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