Koco Eaton, M.D. Team Physician – Tampa Bay Rays and Tampa Bay Buccaneers

 The knee joint is made up of the articulations of the femur, tibia and patella  The cartilage covering the ends of the bone provides a smooth, non-stick surface  The normal joint is bathed in synovial fluid

 Wearing away of the cartilage on the ends of the bone  Knee pain, typically worse at night  Stiffness and swelling in the knee  Decrease in usual activities due to pain  Loss of joint space on x-ray

ARTHRITIS Not age- dependent Can limit career of any athlete No cure Lots of treatment

GeneticAcute Injury Repetitive long term injury (i.e. running)

Loss of medial joint space

Arthritis is the loss of the cartilage on the end of the bone  Normal knee  Arthritic knee

 Lifestyle modifications  Physical therapy  Heat and ice  Anti-inflammatories  Glucosamine and chondroitin sulfate  Cortisone injections  Hyaluronate therapy (i.e. Supartz or Synvisc)

Increases the strength of muscles around the knee Decreases pressure to the bones Physical Therapy:

 Highly purified sodium hyaluronate  Comes from the comb of a rooster  Used for treatment of knee pain caused by osteoarthritis when medications and/or physical therapy are inadequate  Given as injection(s) in the office

 70% success  Lasts about 6 months

 Platelets contain healing factors  Activates the body’s repair mechanisms  Safe because source is directly from the patient which virtually eliminates any reaction to injection

 32 y/o male underwent knee arthroscopy – grade 4 chondral defect of lateral femoral condyle, microfracture performed to defect  18 months later, this patient underwent another knee arthroscopy for meniscus tear – chondral defect had covered over with fibroblastic tissue

 Mesenchymal stem cells are known to have potential for articular cartilage regeneration  Although studies are promising, this technology is not yet available

 Autologous cartilage implantation (ACI) is a technique of replacing the damaged cartilage by transplanting healthy cartilage. It is indicated in patients with full thickness large areas of articular cartilage damage. However, it is not recommended for patients having generalized osteoarthritis.

 Osteochondral autograft transplantation system (OATS) is a surgical procedure where plugs of cartilage is taken from the non- weight bearing areas of knee, from the same individual and transferred to the damaged areas of the joint. This method is used to treat smaller cartilage defects since the graft which is taken from the same individual will be limited.

Moseley et. al, NEJM patients 3 groups Arthroscopic debridement Arthroscopic lavage Placebo surgery 24 month follow-up Placebo group did as well as or better than surgery group

Lavage Poor results Therapy and NSAID have better outcome Arthroscopy

Moseley et al, New England Journal of Medicine 2002 Kirkley et al, Journal of Bone and Joint Surgery 2009 Results of arthroscopy for arthritis is equal to non-surgical treatment

 When conservative measures fail, a knee replacement may be necessary to alleviate the pain  Replaces knee joint cartilage with metal and plastic  Last 10 – 15 years  Total vs. partial, inpatient vs. outpatient

Strictly for pain relief Pain at rest Impeding lifestyle

TOTAL KNEE REPLACEMENT  Femoral and tibial components are made of a cobalt chrome  Spacer and back side of patella are made of plastic

 For knees with normal alignment  Arthritis in one part of the knee

PARTIAL KNEE REPLACEMENT  A single compartment is replaced  Less invasive than TKR  Can be performed as an outpatient procedure

PARTIAL KNEE REPLACEMENT  Indicated only for patients who:  Have single compartment arthritis  Are not obese  Have good alignment  Have an average activity level Just like a little black dress…it is not for everyone!

 Inpatient:  Hospital 2-3 days, then home or rehab  Traditional  Best for most patients  Appropriate for patients who need more assistance, are elderly, or have comorbidities  Outpatient:  Same day surgery  Cutting edge  Selective criteria  Patients need to be motivated, fit, otherwise healthy, able to go home with assistance

Multi-modal pain management  Femoral nerve block: local anesthetic injected around peripheral nerves under ultrasound guidance (lasts hours)  Continuous adductor canal block: catheter inserted into adductor canal delivers local anesthetic continually for approximately 48 hours BOTH METHODS RESULT IN LESS OPIOID USE!

Arthritis is a common problemNo cure yet Many treatment options that can be combined to optimize outcome