Minimally Invasive (MI) Knee Replacement: Is it right for you?

Anatomy of the Knee Made up of three bones: Femur (thigh bone) Tibia (lower leg bone) Patella (kneecap) Source “Anatomy of the Knee ”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes A painful knee can severely affect your ability to lead a full active life. Over the last twenty five years, major advancements in artificial knee replacement have greatly improved the outcome of the surgery. The knee is made up of three bones: the femur (thigh bone), the tibia (lower leg bone) and the patella (kneecap).

A Healthy Knee Joint Knee formed by ends of the femur, tibia and patella Cartilage provides padding between the bones and helps assure an effortless, smooth gliding movement of the joint Joint capsule provides fluid for smooth movement

Causes of Knee Pain Osteoarthritis (wear and tear) Rheumatoid arthritis Post-traumatic arthritis caused by: Fractures Ligament injuries Meniscus cartilage tears Source “Causes of Arthritis of the Knee ”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes There are many conditions that can result in degeneration of the knee joint. Osteoarthritis is the most common reason that patients need to undergo knee replacement surgery. This condition is commonly referred to as "wear and tear arthritis." Osteoarthritis can occur with no previous history of injury to the knee joint - the knee simply "wears out." Abnormalities of knee joint function resulting from fractures of the knee, torn cartilage and torn ligaments can lead to degeneration many years after the injury. The mechanical abnormality leads to excessive wear and tear - just like the out-of-balance tire that wears out too soon on your car.

What is Osteoarthritis? Degenerative condition that is not part of the normal aging process May result from overuse or injury Most common type of arthritis

The Arthritic Knee Deterioration of cartilage Bone on bone Spurs, pitting, grinding Deformity Pain, impaired activity

Knee Joint Healthy knee joint Arthritic knee joint

How Can My Life Change with Treatment? A return to mobility Regaining a sense of your old lifestyle Reduce or eliminate pain

Non-Surgical Treatment Options for Knee Pain: Over-the-Counter Medications Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) Can reduce pain, swelling and redness Relief can take several months Examples: ibuprofen (Advil®, Motrin®) naproxen (Aleve®) Aspirin Reduce joint pain and inflammation Form of NSAIDs Common side effects of NSAIDs, aspirin, and acetaminophen are abdominal cramps or pain, abdominal discomfort, bloating and gas, constipation, diarrhea, dizziness, fluid retention and swelling, headache, heartburn, indigestion, itching, loss of appetite, nausea, nervousness, rash, ringing in ears, stomach pain, and vomiting. Source “Over-the-Counter Medicines can Reduce Joint Pain”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes Over-the-counter (OTC) arthritis medicines can be a very important part of your comprehensive arthritis treatment plan. Over-the-counter arthritis medicines are used to reduce the swelling, redness, joint pain and inflammation. At this time, there is no known cure for arthritis. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are usually the first drug to be used to treat arthritis. These drugs reduce inflammation, but are not steroids like cortisone, consequently the name nonsteriodal anti-inflammatory. NSAIDs can reduce joint pain, swelling, tenderness and redness. NSAIDs may take several months for relief of symptoms to be noticed. Currently, the only NSAIDs that are over-the-counter are ibuprofen (Advil®, Motrin®, and others), naproxen (Aleve®), and aspirin. Aspirin: Aspirin has been used since eighteenth century England to treat arthritis. It can reduce joint pain and inflammation in arthritis sufferers. Aspirin is a form of  NSAID.

Non-Surgical Treatment Options for Knee Pain: Over-the-Counter Medications Acetaminophen Reduces pain and lowers fever Does not decrease or reduce inflammation of arthritis Examples: Tylenol® Datril® Extra Strength Tempra® Common side effects of NSAIDs, aspirin, and acetaminophen are abdominal cramps or pain, abdominal discomfort, bloating and gas, constipation, diarrhea, dizziness, fluid retention and swelling, headache, heartburn, indigestion, itching, loss of appetite, nausea, nervousness, rash, ringing in ears, stomach pain, and vomiting. Source “Over-the-Counter Medicines can Reduce Joint Pain”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes Over-the-counter (OTC) arthritis medicines can be a very important part of your comprehensive arthritis treatment plan. Over-the-counter arthritis medicines are used to reduce the swelling, redness, joint pain and inflammation. At this time, there is no known cure for arthritis. Acetaminophen – Tylenol®, Datril® Extra Strength, Tempra®, and others: Acetaminophen is a painkiller and lowers fever. However, it is not an anti-inflammatory drug so it does not decrease or reduce inflammation of arthritis.

Non-Surgical Treatment Options for Knee Pain: Prescription Medications NSAIDS Most popular type for osteoarthritis treatment Analgesics Provide pain relief, but do not reduce inflammation Source “Prescription Medications to Reduce Arthritis”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes NSAIDs are the most popular type of prescription drug for the treatment of osteoarthritis.   Some of the NSAIDs your doctor may prescribe may include one of the following: Ibuprofen (Prescription: Motrin®; Non-prescription: Motrin IB, Advil®, Nuprin®) Naproxen (Naprosyn®, Naprelan®) Naproxen sodium (Prescription: Anaprox®; Non-prescription: Aleve®) Oxaprozin (Daypro®) Sulindac (Clinoril®) Analgesics Unlike NSAIDs, analgesics do not fight inflammation, but instead are used to provide arthritis pain relief. Acetaminophen is the most commonly used analgesic and is available without prescription. Other types of analgesics that require a prescription include: Acetaminophen with codeine (Fioricet®, Phenaphen® with Codeine, Tylenol® with Codeine) Oxycodone (OxyContin®, Roxicodone®) Hydrocodone with acetaminophen (Vicodin®, Dolacet®) Propoxyphene hydrochloride (PP-Cap®, Darvon®) Tramadol (Ultram®)

Non-Surgical Treatment Options for Knee Pain: Prescription Medications Biological Response Modifiers Treat rheumatoid arthritis May postpone injury to the joints Glucocorticoids or Corticosteroids Fight inflammation DMARDS Slow joint destruction Every drug has possible side effects. Be sure to talk with your doctor about possible side effects before taking a new medication. If you notice a side effect, contact your doctor immediately to discuss whether or not you should continue to take that medication. Source “Prescription Medications to Reduce Arthritis”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes Biological Response Modifiers Once given as part of a second-line treatment strategy for rheumatoid arthritis, biological response modifiers are now being used earlier in treatment. These drugs may postpone structural injury in the joints of rheumatoid arthritis patients. Unlike traditional drugs, these biologic agents target the specific area of the immune system that is a factor in the progression of the disease. Etanercept (Enbrel®) Infliximab (Remicade®) Glucocorticoids or Corticosteroids For over 50 years, glucocorticoids have been used to treat rheumatoid arthritis and other types of arthritis.  Glucocorticoids are hormones that fight inflammation and are similar to the naturally occurring hormones in our body. These drugs are available in many forms including pills and injections. Because there are serious side effects to high dosages and long term usage, doctors are now using lower doses to treat inflammation and joint damage. Cortisone Hydrocortisone (Cortef®, Hydrocortone®) Methylprednisolone (Medrol®) Prednisolone (Prelone®) Prednisone (Deltasone®, Orasone®, Prednicen-M®, Sterapred®) Triamcinolone (Aristocort®) DMARDs Over time, DMARDs slow joint destruction in people with rheumatoid arthritis. The effects of DMARDs are generally slow and can take several months to make a difference. Experts are now prescribing DMARDs earlier in the treatment of rheumatoid arthritis and are often using a combination of two or three drugs. Methotrexate is one of the most widely used DMARDs on the market and has been used for over twenty years. Approximately half of all people with rheumatoid arthritis are taking methotrexate®. Other DMARDs include: Injectable gold Penicillamine (Depen®) Azathioprine (Imuran®) Chloroquine Hydroxychloroquine (Plaquenil®) Sulfasalazine (Azulfidine®)   Side Effects Every drug has possible side effects. Be sure to talk with your doctor about possible side effects before taking a new medication. If you notice a side effect, contact your doctor immediately to discuss whether or not you should continue to take that medication. Your doctor may change your medication or reduce the amount of the drug you are taking. Only your doctor will be able to advise you on the best possible course of treatment.

Non-Surgical Treatment Options for Knee Pain: Injection Therapy Cortisone Injections Helps reduce swelling and discomfort from arthritis Temporary pain relief Risk of infection Following the injection, there may occasionally be increased pain or an inflammatory reaction to the injected medication Hyaluronic Acid (HA) Injections Restores lubrication and fluid in the joint Creates a shock absorber between the bones Following the injection, there may occasionally be increased pain or an inflammatory reaction to the injected medication. Source “Injections to Treat Knee Pain Caused by Arthritis”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes Corticosteroids, also known as glucocorticoids, refer to a group of naturally occurring human hormones. These hormones, commonly referred to as “cortisone”, can be artificially produced in the laboratory and purified for injection into inflamed or arthritic joints, due to rheumatoid arthritis, osteoarthritis, or trauma. For knee arthritis, cortisone injections into the joint can often help reduce the inflammation for two to three months.   Hyaluronic acid (HA) injections are designed to replenish the acid in your knee joint. These injections have been available for use for 2 or more years in the United States. Used for years in Canada and Europe, this jelly-like medication reduces knee pain by deadening nerve endings in the knees.  It also acts like natural cartilage by creating a shock absorber between the bones and easing the pain associated with weight bearing and joint movement. Hyaluronic acid is injected directly into the knee with a needle. It can produce relief for varying periods, but can be beneficial for at least three months.

Non-Surgical Treatment Options for Knee Pain Lifestyle Changes Diet and exercise to control weight Orthotics Assistive devices (walker, cane, etc) Walking Bathrooms Climbing Dressing Source “Knee Arthritis: Assistive Devices to Help Patients with Arthritis Pain”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com “Weight Control Can Help You in Managing Arthritis Pain”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.allaboutarthritis.com Notes While there is no evidence that being overweight causes your arthritis pain and arthritis symptoms, being above your ideal weight can aggravate the problem. Extra pounds add stress to your already painful joints. Weight control isn’t easy, but it is essential to managing arthritis pain.   Exercise not only helps control arthritis symptoms, it will help you control your weight. In fact, exercise and diet are equally important in the process of weight control.   To be healthy, the key is to eat a variety of foods and to avoid too much fat, cholesterol, sugar and sodium. Some people with arthritis pain eat processed foods that are high in fat and salt because it may be easier than cooking a healthy meal. If you have problems cooking, speak to your occupational therapist about how you can perform cooking tasks more easily. It may be as simple as buying new knives and cookware and setting up your kitchen to be more people-friendly. If you do dine out, perhaps you could order only a salad and an appetizer instead of an entrée. Or, share an entrée with a friend.

Surgical Options for Knee Arthritis Arthroscopy Debridement Meniscectomy Chondroplasty Osteotomy Bone cut and re-aligned onto remaining good cartilage Arthroplasty (Joint Replacement) Uni-compartmental knee replacement (partial knee replacement) Tri-compartmental knee replacement (total knee replacement)

Arthroscopic Debridement “clean out” or “scrape bone” Somewhat unpredictable results 50 to 66 percent get relief for some period of time Pain relief may be temporary Best for patients with mechanical symptoms (catching, locking and giving out)

Knee Osteotomy Re-align weight-bearing axis through “good” cartilage Most popular before success of contemporary knee replacement Useful for patients too young, heavy or active for knee implants Early results acceptable, questionable durability

End-Stage Osteoarthritis  Knee Replacement “Gold Standard of Care” Uni-compartmental Knee Replacement “Uni,” “partial replacement” or UKR Tri-compartmental Knee Replacement “Total replacement” or TKR “Minimally invasive” or MITKR

Total Knee Replacement Total knee is affected by arthritis Reduce knee pain Improve the motion Continued advancements in technology, materials, and designs *Solucient, Inc. 2001 Source “Surgical and Reconstructive Treatment Options for Knee Arthritis”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.preservation-uni.com Notes Total (tri-compartmental) knee replacement is a replacement surgery that resurfaces the entire knee joint, providing pain relief and restoration of motion. Since the implants cover more of the bone ends replacing all of the articular cartilage in the knee, total knee replacement requires a larger incision and the removal of more bone than uni-compartmental and minimally invasive procedures. Total knee replacement usually requires a three to five day hospital stay and full recovery can take several months. This treatment option is for a patient who has a knee that has deteriorated in more than one compartment of the knee, or who has a condition that precludes them from uni-compartmental knee replacement.

Total Knee Replacement Resurface joint with 3 components Implant materials include: Cobalt chrome Titanium alloy Ultra high molecular weight polyethylene (medical grade plastic) Preserve bone, ligaments, tendons

Background on Minimally Invasive Knee Replacement Continued evolution to refine techniques to improve safety and cosmetics Smaller incisions Sparing key tendons and muscles Uses traditional implants

Difference Between Traditional and Minimally Invasive Knee Replacement Proven clinical success for decades Full visualization of tissues Larger incision Minimally Invasive Clinical studies in evaluation Potentially less tissue dissection Smaller scar

Minimally Invasive Knee Replacement Same implants as traditional knee replacements Components Femoral Tibial Patellar Reduced tissue trauma

Ideal Candidate for Minimally Invasive Knee Replacement Suffering from arthritis and failure to respond to: Medication/injection Weight management Considerations Medical History Weight Severity of Arthritis Condition of skin Age Activity level

Potential Benefits of Minimally Invasive Knee Replacement Less trauma to the knee Less bleeding Less pain Cosmetically appealing (smaller scar) Shorter hospital stay Quicker recovery than traditional total knee replacement

Potential Complications and Risks Factors that effect risks: Skill of the surgeon Age, weight and health of the patient Patient compliance

Surgical Procedure Incision is made. Damaged bone surfaces from the femur, tibia and patella, as well as worn-out cartilage are removed. Precision instruments and guides help surgeons make cuts at the correct angle. Source “Knee Replacement Surgery”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.jointreplacement.com

Surgical Procedure An implant is attached to each of the three bones (femur, tibia, and patella) Implants are designed to mimic a healthy knee. Incision is closed. Source “Knee Replacement Surgery”. DePuy Orthopaedics, Inc. 2 April, 2003. http://www.jointreplacement.com

The Future of Minimally Invasive Knee Replacement Evolving Clinical studies under way May be enhanced with computer assisted surgery