1 Arthritis Seminar Solutions for Knee, Shoulder and Hip Mark G. Kowall, M.D., M.B.A. Orthopedic Specialty Associates Templeton, California March 5, 2013

2 Osteoarthritis “A Big Problem” More than 40 Million Americans have arthritis (joint inflammation) 27 Million people suffer from Osteoarthritis 40 million by million by 2020

3 Most of us by our 60s & 70s More women than men after 50 All races equally Burden of Disease 475,000 Knee Replacements performed annually

Spine Hands Hips Knees Fingers Osteoarthritis Feet Shoulders

5 Bone Joint space filled with Synovial Fluid “the oil” Articular cartilage “the tread” Synovial membrane What is a Joint???

6 Healthy Knee Osteoarthritic Knee “tread wear” Cartilage “Joint Wear” = “Tread Wear”

7 The Knee

8 Inside the Knee Joint Normal CartilageAdvanced Arthritis

9 Femoral Head (The “Hip Ball”)

10 Causes Primary Osteoarthritis (Most Common) zResult of aging zDecreased ability of cartilage to repair itself zLigaments supporting joints weaken

11 Obesity Joint Injury Surgery Congenital abnormal joints Gout Causes Secondary Osteoarthritis

12 Effect of Weight Loss “Take home point” zFor each pound of weight loss  4 pound reduction in the forces hitting the knee while walking. z“Less weight, Less load on the knee” Arthritis and Rheumatism, July 2005

13 University of North Carolina Study z“Almost 50% of all U.S. adults and nearly 66% of obese adults will develop painful arthritis by the age of 85”

14 An Aside Point Osteoarthritis Is NOT Osteoporosis

15 Normal BoneOsteoporotic Bone Osteoporosis Loss of Bone Density

16 Symptoms of arthritis zPain in affected joints zPain worse with prolonged use zStiffness after periods of inactivity zGrating or “Catching” sensation with movement

17 Diagnosis zHistory zPhysical Exam z Blood Test- to rule out other diseases zOnline “Knee Pain Assessment” (see website) z X-Rays

18 Knee X-Ray Osteoarthritic kneeHealthy knee “Bald Tire”

19 Hip X-Ray Healthy HipOsteoarthritic Hip Tread Gone

20 Shoulder X-Ray Normal Advanced Arthritis

21 Treatment

22 Goals of Treatment Make Your Life Better!!! by zRelieving pain z Increasing motion z Improving strength

23 Treatment varies with severity “Ladder Approach to Treatment”

24 1 st Rung of Ladder  Medication

25 Medication- NSAIDs zNSAIDs are nonsteroidal anti- inflammatory drugs yAspirin yIbuprofen yNaproxen

26 Vitamins & Nutritional Supplements zGlucosamine / Chondroitin Sulfate Some positive results for moderate to advance arthritis Recently, the American Academy of Orthopedic Surgeons recommended against its use for patients with osteoarthritis of the knee (Dec, 2008)  Fish Oil (Omega-3 Fatty Acids)  Diet rich in Fruits and Vegetables

Alternative Medicine Techniques TherapySymptom PainStiffnessFatigueInflammationAnxiety/ Depression Biofeedback uuu Visualization u u Hypnosis u u Relaxation u u Yoga uuu u uuu u Acupuncture uu uu Magnets uu u Vegetarian Diet uu u Herbs & Supplements uuuuu Tai Chi

28 Next Rung of the Ladder Injections zCortisone (steroid) zVisco-Supplementation (Synvisc One,Orthovisc, Hyalgan, Supartz, Euflexxa)

29 Joint Protection- Daily Exercise 1.Daily range of motion exercise (Stretching) 2.Strengthening exercises every other day 3.Endurance exercises three times per week

30 Exercise Dos zTalk to your doctor first zConsider athletic trainer or physical therapist

31 Braces Sleeves  neoprene  improve balance?  local warmth  control swelling  high compliance

32 Braces Unloaders  “unload” or take pressure of the arthritic side of knee  decrease pain  improve walking tolerance  poor compliance  expensive

33 External Support Aids “Unloads” the joint

34 When all else fails to improve pain………..

35 Surgery “Top of the Ladder”

36 Asking Questions About Surgery zAlternatives zBenefits and for how long? zRisks? zWhat is procedure called? zHow is it done? zResults? zReturn to “normal” activity?

37 Surgical Options-Arthroscopy zMini incisions zOutpatient

38 Arthroscopy – Debridement (Shaving of articular Cartilage (“tread”)  A means of “smoothing” the coating cartilage  In conjunction to treating meniscus tears  Not designed for treatment of arthritis alone

39 Arthroscopy – Microfracture Knee and Shoulder z small awl used to make holes in bone z promote re-growth of cartilage

40 Arthroscopy – “OATS” Procedure z transfer of healthy “tread” to “bald” area

41 Knee Hip Surgical Options: Joint Replacement

42 Total Knee Replacement Side view

43 Surgical Instrumentation

44 Surgical Instrumentation Femur Tibia

45 Implants

46 Total Hip Replacement

47 Total Hip Replacement

48 Total Shoulder Replacement

49 Duke University Medical Center Study zHip Replacement Surgery “Seniors with arthritis who undergo Hip Replacement are twice as likely to show improvements in functioning and ability to care for themselves” (no age limit on the benefits!!)

50 New Technologies

51 Laboratory zRecombinant Gene Therapy (synthesize the growth factors which produce new cartilage) zSpecific Growth Factors promote cartilage (tread) maintenance and repair zMay limit the progression of arthritis zPlatelet Rich Plasma (PRP)

52 Recent discovery of a natural occurring molecule in the body that can counter the progression of arthritis Genes and Development

53 Traditional TKA vs. High Flex TKA  Designed to safely accommodate flexion up to 125   Designed to safely accommodate flexion up to 155  New Implant Designs

54 Gender Specific Knee Implant Women have a different shaped knee joint New Implant Designs

55 Patient Specific Instrumentation zMRI or CT based technology z3D model created of knee zSurgery Planning zCustomized pin guides or cutting blocks

56 Patient Specific Instrumentation

57 Mini-Incision Surgery (Knees)

58 Complications  Mini-Incision Surgery for the knee reduces recovery time but increases wound healing problems. Clinical Orthopedics and Related Research  Mini-Incision and alternative approaches for the hip---controversial!!!!

59 Consumer Beware Bozic K J, et al. Impact of direct to consumer advertising on physician attitudes and behavior in orthopedic surgery American Academy of Orthopedic Surgeons **Poll of 737 hip and knee surgeons **Over 75% of surgeons reported that direct-to-consumer (DTC) advertising negatively impacted their practice and the relationship with patients. **Ads presented a skewed view of procedures and devices by exaggerating the benefits and down playing risks. **(Patients) were not more educated about the risks and benefits, not more educated about the alternatives, not more educated about the costs and that they were less open to alternatives after reading or viewing direct-to- consumer advertisements

60 Surgical Procedure Animations

61 Surgical Procedure Animations Health Library Important Links Resources

62 Questions????