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On : Mar 14, 2014

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  • Slide 1 - Introduction to Orthopaedics: OPTIONS FOR HIP AND KNEE ARTHRITIS Stephen P. England, M.D. Park Nicollet Orthopedics
  • Slide 2 - What is Arthritis? Wear/loss of articular cartilage Similar to wearing the tread off a car tire Osteoarthritis – wear and tear / aging Inflammatory arthritis – systemic disease Post-traumatic arthritis – following injury Others
  • Slide 3 - How can I prolong the life of my hip or knee? Weight Management Activity Modification Medications – Systemic Inflammatory Arthritis Glucosamine ??
  • Slide 4 - What can help me live with my pain? Weight Management Activity Modification – Bike, Swim Physical Therapy – Motion, Strength Assistive Devices – Cane , Crutches, Walker, Scooter, Wheelchair
  • Slide 5 - What can help me live with my pain? Oral Medications Analgesic – Over the Counter, Prescription Glucosamine/Chondroitin Other “Alternative” Treatments Injectable Medications Cortisone Synvisc, Hyalgan Braces
  • Slide 6 - Unloader Brace Shifts weight off bad side of knee over to good side of knee Must have a good side Must be willing to wear brace(cumbersome) Best for those who enjoy specific activities – Golf, Tennis, Hiking, Walking
  • Slide 8 - How do I know when to have surgery? Need a diagnosis – Not all joint pain is caused by arthritis, not all arthritis is the same Fibromyalgia Not surgically treatable Makes surgery less predictable History, physical exam, x-ray Plain x-ray usually sufficient to make the diagnosis MRI and other tests occasionally helpful
  • Slide 9 - How do I know when to have surgery? Decision is almost always up to the patient M.D. should lay out the options, surgical and non-surgical M.D. may give advice, but should rarely tell you what to do – it’s your choice Others may help you decide (friends, family, primary care physician), but ultimately you make the call Consider the following questions
  • Slide 10 - Procedure Questions What exactly is the procedure? What are the goals? How likely is it to work? What is the recovery like? What are the risks/complications? What are my other options?
  • Slide 11 - Personal Questions What is my age? What is my occupation? What activities do I enjoy? What health problems do I have and how do these affect my surgical risk? What support system do I have to help me during recovery? HOW MUCH PAIN AND DISABILITY DO I HAVE?
  • Slide 12 - Surgical Options Arthroscopy Osteotomy Arthrodesis (Fusion) Arthroplasty (Replacement)
  • Slide 13 - HIP Osteotomy, arthrodesis, arthroscopy rarely used Arthroplasty common
  • Slide 14 - KNEE Arthroscopy common Osteotomy – popularity waxes and wanes Arthrodesis – rarely used Arthroplasty - common
  • Slide 15 - Arthrodesis (Fusion) Eliminates pain Creates a different disability Lasting result Commonly used before arthroplasty developed Young patient – heavy, laborer Salvage - infection
  • Slide 16 - Osteotomy Used most commonly in the knee Shifts weight from bad side of joint to good side (like unloader brace) Must have a good side of the joint Not appropriate for systemic inflammatory arthritis
  • Slide 17 - Osteotomy Most commonly done by removing a wedge of bone from femur or tibia and placing a plate to hold bones in place Young patient trying to avoid arthroplasty Intended as a temporizing procedure, not a permanent solution - reported results variable Takes a long time to recover – crutches, brace, therapy
  • Slide 18 - Osteotomy Not as popular currently as durability of arthroplasty improves May make subsequent arthroplasty more difficult
  • Slide 20 - Arthoscopy Visualize joint through a fiberoptic tube inserted through small skin incision Common in knee, uncommon in hip (technically difficult) Arthoscopy is a way of doing an operation, NOT the operation itself, which may involve many things – DON’T COMPARE YOURSELF TO OTHERS!
  • Slide 21 - Arthroscopy Other small incisions – insert shavers, cutting devices, graspers Smooth joint surfaces Trim meniscus tears Remove loose bodies Remove diseased synovium – systemic inflammatory arthritis
  • Slide 22 - Arthroscopy Brief day surgery procedure Various anesthetics, frequently regional Minimal risks/complications Recovery varies but usually fairly rapid – return to activities as tolerated Doesn’t burn any bridges Helps evaluate the status of the joint, may help guide future treatment decisions
  • Slide 23 - Arthroscopy Results UNPREDICTABLE! Works best with less advanced arthritis Two specific groups do best Sudden symptom change – goal is to return to baseline (not eliminate all pain) Strong catching/locking symptoms – goal is to stop catching/locking (not eliminate all pain)
  • Slide 25 - Arthroplasty (Replacement) One of the most successful operations in all of medicine Modern form originated in 60s and 70s Over 500,000 hips and knees done each year in the U.S.
  • Slide 26 - What is the procedure? Hip – Socket replaced with metal and plastic socket, ball replaced with metal ball attached to stem that goes down the femur Knee – End of femur covered with metal cap, top of tibia covered with metal and plastic plate, patella resurfaced with plastic button
  • Slide 27 - What are the goals of the procedure and how likely is it to work? Pain relief – very reliable Functional improvement – reliable but need to consider other factors which may limit function (other bad joints, poor balance, deconditioning, medical problems) Good and excellent results 95% - 97%
  • Slide 28 - What are the complications/risks? Infection Bleeding / need for transfusion Nerve injury “Blood Clots” – DVT, PE Anesthesia – regional techniques (spinal, epidural) becoming more common Dislocation (Hip) Differing leg lengths (Hip) Stiffness (Knee)
  • Slide 29 - What are the complications/risks? Many complications related to medical conditions / health problems Even the most healthy patient can suffer a complication
  • Slide 30 - Long Term Problems The replacement is a mechanical device with a limited lifespan Failure eventually results in pain Revision surgery has higher complication rates and lower success rates Will I need a revision procedure? How long will I live? How long will it last? (guess = 10-20 years)
  • Slide 31 - What is the recovery like? Historically long and difficult, but variable Surgery 1-2 hours Hospital 3-4 days Home or transitional care A lot of Rehab (especially knees) Walker/crutches 2-3 weeks, Cane 3-4 weeks Limited only by your pain and ability to progress May improve for up to one year
  • Slide 32 - What is the recovery like? Newer techniques may offer more rapid and less painful recovery “MIS” = “Minimally Invasive Surgery” Better term = “LESS Invasive Surgery” Same operation through smaller incision Not appropriate for all patients ? Not appropriate for all surgeons - ? Higher complication rate An easier recovery is nice, but cannot compromise the reliable long term success seen historically
  • Slide 34 - “What do you recommend, Doctor?” Know your diagnosis Know your options, surgical and non-surgical Know yourself Seek advice from others – primary M.D. Ask your surgeon questions Trust your instincts – make sure you feel comfortable with your choice and your surgeon It’s YOUR decision (almost always)
  • Slide 35 - THANK YOU !
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