Maximizing Patient Satisfaction in OA of the Knee

taupeselectionMechanics

Nov 14, 2013 (3 years and 9 months ago)

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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

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

The Knee


Any of the knee structures can be damaged
and cause pain


Today ‘s talk will be about the surface
cartilage

Osteoarthritis


Introduction


Risk Factors


Physiology


Treatment


Most common form of joint disease
worldwide


Affects
nearly 27 million American
s
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 cond
iti
ons in the United States.
Arthritis &
Rheumatism 58(1), 15
-
25. 2008

2
Manek NJ, Lane NE.
Am Fam Physician
. 2000;61:1795
-
1804.

3
Lawrence RC, et al.
Arthritis Rheum
. 2008;58:26
-
35.

Prevalence of Osteoarthritis

OA
-
Related Limitations Will Increase

Hootman JM, Helmick CG.
Arthritis Rheum.
2006;54:226
-
229.

Projected Prevalence of Arthritis
-
Associated

Activity Limitation


17


19


21


23


25

2005

2010

2015

2020

2025

2030

Year

Prevalence (Millions)

Disease Process


Progressive loss of
articular cartilage


Remodeling and
hypertrophy of
bone


Bone cysts,
osteophytes, spurs

Osteoarthritis


Introduction


Risk Factors


Physiology


Treatment

Risk Factors for Knee OA

MMPs = matrix
metalloproteinases
; PGs =
proteoglycans
.

Dieppe PA,
Lohmander

S.
Lancet.
2005;365:965
-
973.

Demographic

Biochemical

Biomechanical

OA

SEVERITY


Age


Genetics


Systemic factors
(e.g., obesity)


Cytokines


MMPs


PGs


Trauma/Injury


Overload


Instability

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,

㈰┠潦⁴o攠啓
population will be aged
≥65 years
2

Growth in Older Population
3

1.

Fackelmann K.
USA Today.
Available at: www.azcentral.com/php
-
bin/clicktrack/print.php?referer=http:...

2.

Freifeld L.
License!

June 2005:42
-
88.

3.

US Census Bureau, 2004. Available at: www.census.gov/ipc/www/usinterimproj.


0
10
20
30
40
50
60
18

44
45

64
65+
Total
Percent
Age (years)
Men
Women
OA Affects Women More Than Men

Estimated Prevalence of Diagnosed OA

Hootman JM, Helmick CG.
Arthritis Rheum.
2006;54:226
-
229.

Osteoarthritis


Introduction


Risk Factors


Physiology


Treatment

OA Pathophysiology: Downward Path

Ling SM
,
Bathon

JM.
JAGS

. 1998;46:216
-
225.

Altman RD. The Merck Manual of Diagnosis and Therapy. 16
th

ed. 2006.

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

Changes in Articular Cartilage


Joint injury and deformity


Periarticular tissue and fluid
damage


Inflammation


Chronic wear and age

Courtesy of Robert J. Dimeff, MD

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;350:503
-
509; 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.

Clinical Knee OA Signs and Symptoms

Adapted from
Manek

NJ, Lane NE.
Am
Fam

Physician
. 2000;61:1795
-
1804.

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

Osteoarthritis


Introduction


Risk Factors


Physiology


Treatment

OA: Clinical Multimodal
Management

American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:190
-
1915;

Kelly MA, et al.

Orthopedics
. 2003;26:1064
-
1079.

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


Non
-
pharmacologic Approaches


Patient education


Exercise


Support programs


Weight loss (if obese)


Physical therapy


Acupuncture


Chiropractic


Orthotics/footwear


Braces


Assistive devices

Pharmacologic Treatment Options

NSAIDs=
nonsteroidal

anti
-
inflammatory drugs: COX
-
2
i
=cyclooxygenase
-
2 inhibitors.

Oral medications

Localized therapies


Acetaminophen


NSAID/COX
-
2
i
(
advil
,
celebrex
,
naprosyn
, topical
antiinflamatories
.


Other Analgesics


Nutraceutical

(Glucosamine,
Chondroitin
, MSM)


Topical


Injection


Corticosteroid

-

Hyaluronan



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. 5000 kDa

Avg. 1500 kDa

Pharmacologic Treatment Options


Research on Euflexxa shows 81% of
patients satisfied 3 months after injection.



Osteoarthritis


Introduction


Risk Factors


Physiology


Treatment

Principles of Operative Management


Arthroscopic surgery


Cartilage restoration


Joint alignment procedures


Joint resurfacing


Partial joint replacement


Total joint replacement

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.


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


www.cartilagerestorationtexas.com

Cartilage Restoration Center

www.cartilagerestorationtexas.com


Osteochondral Allograft
transplantation


Autograft Chondrocyte Transfer
(Carticel)

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

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


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 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 o
f v
iew.
Rheumatology (45),
757
-
60.

2.
Duke University Center for Demographic Studies (January, 2006). Assessing the impact of medical technology innovations on h
uma
n 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 Tech
nology Innovation.

3.

Ledingham, J., Regan, M., Jones, A., Doherty, M. (1993). Radiographic patterns and associations of osteoarthritis of the k
nee in patients referred to hospital.
Annals of the Rheumatic Diseases

(
52),
520
-
526.

4.

Rolston, L., Sprague, J., Tsai, S., Salehi, A. (2006) A novel bone/ligament sparing prosthesis for the treatment of patellof
emoral and medial compartment osteoarthritis. AAOS 2006 Annual Meeting,
Poster #P181.


Lateral

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 f
unc
tion? Clin
Orthop Relat Res, (431): 157
-
65, 2005.



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


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


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


30
40
50
60
70
80
90
pre-op
6 weeks
3 months
Knee Society Score
Function
Knee
p<0.05
30
40
50
60
70
80
90
pre-op
6 weeks
3 months
Knee Society Score
Function
Knee
p<0.05
p<0.05
Unicompartmental
Knee Arthroplasties

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 1
st

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?



Questions?


Literature from many of the treatment
options mentioned available.