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. Prevalence of Osteoarthritis
Most common form of joint disease worldwide
Affects nearly 27 million Americans1
Radiographic evidence2
>50% at 65 years of age
≈80% at 75 years of age and older
Symptomatic osteoarthritis (OA) of knee2
12% of people aged > 60 years
OA 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 Limitation 25 23
Prevalence (Millions) 21
Arthritis 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.3
References
1. Arthritis Foundation. The facts about arthritis. Available at:
2. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated
activity limitations. Arthritis Rheum. 2006;54:
3. American Academy of Orthopaedic Surgeons. Improving musculoskeletal care in
America. Available at: 19 17
2005
2010
2015
2020
2025
2030
Year
Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:

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
Age
Genetics
Systemic factors (e.g., obesity)
Demographic
OA SEVERITY
Trauma/Injury
Overload
Instability
Biomechanical
Risk factors for knee OA can be categorized as either predisposing or biomechanical.1
Age 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.
References
1. 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: projected
prevalence 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:
Cytokines
MMPs
PGs
Biochemical
MMPs = matrix metalloproteinases; PGs = proteoglycans.
Dieppe PA, Lohmander S. Lancet. 2005;365:

10. Growth in Older Population3
The Graying of America
As the “baby boom” generation ages, the US population aged ≥65 years is increasing1
In 2006, all baby boomers were >40 years of age, and almost half were >50 years of age2
By 2030, 20% of the US population will be aged ≥65 years2
Growth in Older Population3
The aging of the US population and the growing weight problem in all
age groups have led to an increasing number of patients experiencing
osteoarthritis (OA) of the knees.1
This results in great costs to society,2 not only from the direct
impact of health dollars spent on treating OA, but also indirectly in the
decreased productivity of the population that occurs secondary to
impaired function and mobility. Other health issues arising from a
gradual deterioration in the patient’s health as a result of impaired
activity levels also impact these costs.
References
Manek 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 OA
In 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.
References
1. 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

12. Osteoarthritis
Introduction
Risk Factors
Physiology
Treatment

13. OA Pathophysiology: Downward Path
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
Ling SM, Bathon JM. JAGS ;46:
Altman RD. The Merck Manual of Diagnosis and Therapy. 16th ed

14. Changes in Articular Cartilage
Joint injury and deformity
Periarticular tissue and fluid damage
Inflammation
Chronic wear and age
OA 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

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
Management of OA pain might be improved if we have a better understanding of the origin of this pain. However, the mechanisms of OA pain are not clearly understood.
OA 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.
Potential causes of OA pain include changes in joint capsule and synovial membrane. Synovitis, which develops early in OA, is associated with the release of proinflammatory cytokines and other inflammatory mediators, and increase in volume of interstitial fluid in the joint can cause stretching leading to pain. In addition, bursitis, damage to the ligaments and muscle spasm may contribute to OA pain. Other possible origins of OA pain include periosteal stretching, subchondral turnover and changes in vascularity, and bone marrow lesions. Bone-related causes such as the development of osteophytes, microfractures, and increased osseous pressure also may be contributing factors.
Creamer P, et al. Lancet. 1997;350: ; Rice JR, et al. Rheum Dis Clin North Am. 1999;25:15-30.
©2007 Girish P. Joshi, MD. Presented and reprinted with permission from Dr. Joshi.

16. Clinical Knee OA Signs and Symptoms
Bony enlargement of joint
Limited range of motion
Crepitus on active motion
Joint deformity
Symptoms
Joint pain
Pain with weight bearing
Morning stiffness (<30 minutes)
Joint instability or buckling
Reduced function
This 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:

17. Osteoarthritis
Introduction
Risk Factors
Physiology
Treatment

18. OA: Clinical Multimodal Management
Diagnosis
Non-pharmacologic treatment; Simple Analgesics
OTC/ NSAIDs
RX NSAIDs/ GI Protect COX-2 i
IA Hyaluronans/ Corticosteroids
Currently, the new treatment algorithm advocates a patient-specific, multimodal approach to concomitant therapy. This has lead to earlier utilization of HA therapy.
Surgical Intervention
Adapted 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 education
Exercise
Support programs
Weight loss (if obese)
Physical therapy
Acupuncture
Chiropractic
Orthotics/footwear
Braces
Assistive devices
Patient 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 medications
Localized therapies
Acetaminophen
NSAID/COX-2 i(advil, celebrex, naprosyn, topical antiinflamatories.
Other Analgesics
Nutraceutical (Glucosamine, Chondroitin, MSM)
Topical
Injection
Corticosteroid
- 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 fluids
Lubrication
Intra-articular water homeostasis
Stress distribution because of viscoelastic properties
Molecular Weight of Synovial HA
Healthy Knee
Knee With OA
Avg kDa
Avg kDa
HAs 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.

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 www.cartilagerestorationtexas.com
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
UNICONDYLAR
PATELLOFEMORAL
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. Prevalence of Osteoarthritis
Unicondylar MAKOplasty®
10% of all TKA patients are estimated with tibiofemoral OA1
Lateral OA is estimated to be 10-12% of the unicompartmental market
90% of TKA patient candidates chose not to have a TKA2
Patellofemoral MAKOplasty®
24% of OA patients may present with isolated patellofemoral disease1,3
Bicompartmental MAKOplasty®
40-65% of OA patients present with tibiofemoral-patellofemoral disease1,3,4
Lateral
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),
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 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 knee1
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. MAKOplasty® Partial Knee Resurfacing
MAKOplasty® potentially offers the following
benefits when compared to TKA:
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.

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. Clinical Results – Knee Society Scores
Unicompartmental Knee Arthroplasties
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

36. Clinical Results-Radiographic Outcomes

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

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

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