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 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 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), 15-25. 2008 2Manek NJ, Lane NE. Am Fam Physician. 2000;61:1795-1804. 3Lawrence RC, et al. Arthritis Rheum. 2008;58:26-35. OA-Related Limitations Will Increase Projected Prevalence of Arthritis-Associated Activity Limitation Prevalence (Millions) 25 23 21 19 17 2005 2010 2015 2020 Year Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:226-229. 2025 2030 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 Demographic • Age • Genetics • Systemic factors (e.g., obesity) • Trauma/Injury Biomechanical • Overload • Instability Biochemical • Cytokines • MMPs • PGs MMPs = matrix metalloproteinases; PGs = proteoglycans. Dieppe PA, Lohmander S. Lancet. 2005;365:965-973. OA SEVERITY 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 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. OA Affects Women More Than Men Estimated Prevalence of Diagnosed OA 60 Men Women Percent 50 40 30 20 10 0 18 – 44 45 – 64 65+ Age (years) Hootman JM, Helmick CG. Arthritis Rheum. 2006;54:226-229. Total Osteoarthritis • Introduction • Risk Factors • Physiology • Treatment 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 . 1998;46:216-225. Altman RD. The Merck Manual of Diagnosis and Therapy. 16th ed. 2006. 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 Signs • 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 Adapted from Manek NJ, Lane NE. Am Fam Physician. 2000;61:1795-1804. Osteoarthritis • Introduction • Risk Factors • Physiology • Treatment OA: Clinical Multimodal Management Diagnosis Nonpharmacologic treatment; Simple Analgesics OTC/ NSAIDs RX NSAIDs/ GI Protect COX-2 i IA Hyaluronans/ Corticosteroids 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;43:190-1915; Kelly MA, et al. Orthopedics. 2003;26:1064-1079. Non-pharmacologic Approaches • Patient education • Acupuncture • Exercise • Chiropractic • Support programs • Orthotics/footwear • Weight loss (if obese) • Braces • Physical therapy • Assistive devices Pharmacologic Treatment Options Oral medications Localized therapies • Acetaminophen • Topical • NSAID/COX-2 i(advil, • Injection celebrex, naprosyn, topical antiinflamatories. • Other Analgesics – Corticosteroid - Hyaluronan • Nutraceutical (Glucosamine, Chondroitin, MSM) NSAIDs=nonsteroidal anti-inflammatory drugs: COX-2 i=cyclooxygenase-2 inhibitors. 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 UNICONDYLAR BICOMPARTMENTAL PATELLOFEMORAL 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 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 Lateral 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 1. 2. 3. 4. Duncan, R., Hay, E., Saklatvala, J, Croft P. (2006) Prevalence of radiographic osteoarthritis: it all depends on your point of view. Rheumatology (45), 757-60. 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. 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),520526. 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. 31 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): 157-65, 2005. 32 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. 33 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 34 Clinical Results – Knee Society Scores p<0.05 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 80 Knee Society Score • • • • • • • • • 90 Function Knee 70 60 50 40 30 pre-op Roche et al 2008 35 6 weeks 3 months Clinical Results-Radiographic Outcomes 36 Surgery – what is really involved • Try non-surgical treatment first • When you are ready for long term relief talk to your surgeon about options 37 Surgery – what is really involved • Presurgery – minimize your risks – Control medical problems (diabetes, heart) – Maximize muscle conditioning – Plan your schedule • Transportation • Sleeping • bathing 38 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 39 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 40 months 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 41 Want to Learn More? 42 Questions? • Literature from many of the treatment options mentioned available.