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Orthopedics Symposium for the Primary‐Care Physician 11/04/2016
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When a good knee goes badHow I like to think about knee arthritis
LAURA MATSEN KO, MDWWW.SEATTLEJOINTSURGEONS.COM
Orthopedics Symposium for the Primary‐Care Physician 11/04/2016
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About me
• Born & Raised in Seattle• Whitman College• Oregon Health & Sciences
– Medical School– Residency
• Joints Fellowship with Paul Duwelius MD
• Joints Fellowship at Rothman Institute
• Orthopedic Family
Orthopedics Symposium for the Primary‐Care Physician 11/04/2016
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It all starts with the anatomy of this wonderful and complex joint
Actually three joints in one– Patellofemoral– Tibiofemoral
• Medial• Lateral
Orthopedics Symposium for the Primary‐Care Physician 11/04/2016
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Arthritis is the loss of the knees’s
normal articular cartilage
• Inflammatory• Osteoarthritic• Post traumatic• Post septic• Post surgical
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Patterns of knee osteoarthritis
Varus
Patellofemoral
Valgus
Bow legs Knock kneesGuys/OA Gals/RA
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The picture of knee arthritis
• Pain• Stiffness• Deformity• Tenderness• Swelling• Joint space narrowing on standing x‐rays
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I find it’s just as important to know
the patientthat has the knee
arthritis as to know the
arthritisthat the patient has
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Is the knee pain from the knee?
Hip kneeSpine knee
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What can x‐rays tell us?
Standing AP PA (30 deg)
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MRI usually not needed
I use it when the knee symptoms are worse than what plain x‐rays would suggest
Avascular necrosis
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My steps in treatment of arthritis
Weight lossAnti‐inflammatory medsActivity modification
Low impact
Physical therapy+/‐ Bracing Injections
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Why weight loss?
For each pound of weight lost
5 lbs off each step walking8 lbs off each step running
Slows disease processLowers body‐wide inflammationLessens surgical risk
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Weight loss
• Nutrition, nutrition, nutrition
• Exercise– Cycle– Water aerobics– Tai Chi– Upper body weights
• Bariatric surgery
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Bariatric Surgery effectiveness
• Morbidly obese patients undergoing TKA had lower QALY gained than patients who underwent bariatric surgery 2 years prior to TKA
• Incremental cost‐effectiveness ratio was ~$14,000 per QALY
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Anti‐inflammatories
• OTC NSAIDs vs COX‐2 inhibitors
• If contraindicated (ie warfarin etc)– Tylenol
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Bracing
• Neoprene sleeves– Improves proprioception, minimal support on joint
– “feels good”
• Unloader braces– Consider body type
• Orthotics– Less data
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Activity Modification
• Low impact activities– Cycling *– Rowing– Water aerobics– Cross‐country skiing– Upper body weights
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PT• Give direct guidelines to the therapist
– Encourage teaching of home exercise program• Research shows a modest benefit in relieving symptoms
– Most benefit in patellofemoral disease
• How I see the benefits:– Teaches patient that it’s OK to move!– Strengthening patients – Can improve range of motion– Can be used to teach patient how to properly use a cane
• Required by some insurance companies prior to surgical authorization
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Why cycle an arthritic joint?• Weeping lubrication
– During movement the synovial fluid held in cartilage is squeezed out
– Maintains a layer of fluid on cartilage surface
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HA Injections (synvisc, orthovisc)
• Theory: native knee has hyaluronan– Viscocity
• Studies question efficacy and cost‐effectiveness
• Expensive to health care system– In 12 mo prior to TKA
• 15% patients had HA injection• Accounted for 25% of “treatment specific payment”
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Steroid injections
• Use as a final step• Risk to cartilage
– May inhibit synthesis and deposition of chondroitin sulfate in cartilage
– No more frequently than every 3 months• Diminishing returns• Infection risk
– Native knee– Avoid within 3 months of total knee arthroplasty
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Billboard advertisement seen near O’Hare International Airport in Chicago, June 30, 2016.
Thomas W. Bauer J Bone Joint Surg Am 2016;98:1509-1510
©2016 by The Journal of Bone and Joint Surgery, Inc.
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Stem cell injections
• Amniotic cell injection• Autologous blood
– PRP– Adipose‐derived nucleated cells– Culture expanded cells from bone marrow aspirate
• Allogenic blood• Conclusion:
– few high‐quality clinical studies– Need to publish, including negative results
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Acupuncture
• Meta‐analysis of 10 randomized controlled trials– 13‐16 weeks: superior pain improvement and physical function
– 13‐26 weeks: superior physical function but no difference in pain
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I consider joint replacement when• Pain that is unresponsive to non‐operarive management
• Weight loss• Activity modification• Therapy• Anti‐inflammatories• Injections
• Pain that interferes with life in a big way
• When and only if the patient is a good candidate
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Total Knees ‐ a brief history
Introduced in the 1960’s, now the most commonly replaced joint in the US, approaching 1,000,000/yr
Rate/10,000
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Total Knee Replacement
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The benefit of experience
“Patients managed at hospitals and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events following primary total knee replacement”
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“perioperative adverse events following primary total knee replacement”
MalalignmentInfectionVascular injuryFracture Instability Pain
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“perioperative adverse events following primary total knee replacement”
We strive to avoid them by using our experience and teamwork:
careful patient selection, individualized carepreoperative health optimizationcareful and expeditious surgeryclose monitoring of rehabilitation
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What about robots?Robotic assisted surgery mayimprove accuracy of implant positioningI do not find them necessary for the ususual caseIncreased cost
Buying a robot in the OREach patient requires a CT or MRI with a specific protocol
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Unicompartmental knee replacements
• May provide faster recovery• Theoretical benefit of easier revision to total
– Studies show outcomes of TKA revision vs uniTKA revision to be similar.
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Approaches: “Quad sparing?”
• Nothing is truly quad sparing
Medial parapatellar
Mid VastusSub Vastus
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Implant size
• Gender specific?– No research to support “gender” knees
– We do have narrow sizes• How do we pick the size
– Template the xray– Intra op measurements – Intra op trials
• Size 1‐10 available for both femur and tibia
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Implant material
• Femur and Tibia– Titanium – Cobalt chromium alloy– Ceramic
• Polyethylene spacer– Machining of this material was revolutionized in 2000
• Patella– Okay to not resurface (but most of us do)– Polyethylene button cemented onto bone
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Implant Attachment
• Cement (polymethymethacrylate)– Most common– All types of bone
• Press fit– Avoid in osteoporotic bone– Newer
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Cruciate‐retaining vs Posterior stabilized
• MCL/ LCL/ ACL preserved in majority of primary TKAs
• PCL is controversial– Some surgeons try to preserve
• Leaves more bone• More ‘natural’• PCL not always present
– Some surgeons always sacrifice• Easier to perform= better balanced knee
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One of the reasons I love my job
Getting people active again!
• "I'm 6 months out from my knee replacement surgery with Dr. Matsen Ko. My knee is virtually as good as new now and I treat it as I normally would. I got back on my bike a week short of 2 months. Now I'm routinely riding over a dozen miles several times a week. I'll soon be doing 20 miles on the Centennial Trail. Thank you Doctor, for helping an 86‐year‐old get back in shape."
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Thank you
www.seattlejointsurgeons.com