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OSTEOARTHRITIS OF THE HIP & KNEE
David Knesek D.O.
Primary & Revision Joint Replacement Surgery
of the Hip & Knee
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David Knesek D.O.
Undergrad University of
Notre Dame
Med School MSUCOM
Residency St. John
Providence Health
System
Fellowship at University
of Chicago for Adult
Reconstruction
Employed by CORE
Orthopedics Michigan
Work primarily out of St.
John Providence
Southfield and Novi
Also credentialed at
Botsford, Henry Ford WB,
and DMC Huron Valley
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Disclosures
None
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Special Thanks
Dr. Anvari
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You’re Not Alone
More than 43 million people have some form of
arthritis. It is estimated that the number of
people affected by arthritis will increase to 60
million by 2020.
Source CDC
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Most Common Types
Osteoarthritis
Genetic predisposition?
BMI?
Activity?
Rheumatic Arthritis
Post-traumatic Arthritis
Avascular Necrosis
50% caused by ETOH abuse, chronic steroid use, Sickle
Cell Disease, HIV, coagulopathy
50% idiopathic
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Purpose of Talk
Understanding what causes joint pain
Treatment Options
What joint replacement involves and the
different types
Expectations following joint replacement
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NIH 2010
719,000 TKA performed
in US
332,000 THA performed
in US
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AAOS 2006
Number of hip and knee surgeries expected to
soar by 2030
Hip Arthroplasty increase of 174%
Knee Arthoplasty increase of 673%
Why????!
Growing aging population (especially 45-64 yo)
Increasing Obesity
Correlation to BMI and knee arthritis (not hip)
Younger more active patients with previous injuries and an
increase in post traumatic OA
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Von Mow
“The
human joint
functions so
well… that we are
totally unaware
of it until there is
a problem”
-Von Mow
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What is arthritis?
Loss of articular cartilage
Avascular, aneural,
alymphatic
Increased stress on
subchondral bone
Osteophyte formation
Deformity
Pain
Peri-articular pain
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What causes arthritis?
Prior trauma: fracture, ligament injury
Prior surgery: menisectomy
Genetic predisposition
Inflammatory arthritis
Rheumatoid Arthritis, Lupus
Avascular necrosis: hip, knee or shoulder
Congenital or growth problem
“Aging”
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What causes arthritis?
Loss of medial meniscus leads to 75%
decrease in contact area and increase in
peak contact pressures of up to 235%1
Increase in contact pressures overload
the articular cartilage leading to
biochemical changes including loss of
proteoglycan, increase in proteoglycan
synthesis, and increase hydration1
1. McDermott et al. Consequences of menisectomy. JBJS (Br). 2006. 88;1549-1556
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Factors Involved in Osteoarthritis
Obesity
Aging
Abnormal
Stresses
Abnormal
Cartilage
Genetic and
metabolic diseases
Inflammation
COMPROMISED CARTILAGE
Immune-system
activity
Trauma
Structural changes:
Collagen network fracture
Proteoclycan unraveling
Biomechanical Changes:
Inhibitors reduced
Proteolytic enzymes increased
CARTILAGE BREAKDOWN
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Symptoms of Arthritis
How does it present?
Usually slow, chronic, and
progressive
Occasionally can start
abruptly usually after an
insulting event
Symptoms usually start
with pain, swelling,
stiffness which is
intermittent at first and
then progress to chronic
Can be focal or have
vague presentation
Can be worse at certain
times of day or with
certain activities
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Arthritis in Real Life
Healthy Knee
Arthritic Knee
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Initial Evaluation
Symptoms
Medical History
Family Hx
Medications
Prior Sx
Ortho Exam
Strength, range of motion,
swelling, reflexes, skin
condition, neurovascular
exam
Additional Tests
Blood tests
MRI
CT Scan
Bone Scan
Urinalysis
Fluid Aspirate
Xray
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Degenerative Arthritis
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Lets start with the Knee
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Treatment Options
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Degenerative Arthritis
Non-surgical options
Physical Therapy – strength and motion
Prehabilitation in preparation for surgery
Activity modification
Use of walking aids
Cane, walker
Bracing
Unloading brace
Low impact exercise program
Eliptical, aquatics, yoga
Weight control
Medical weight loss, lap band, normal diet
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Degenerative Arthritis
Non-surgical options
Medications
Tylenol
NSAIDs
Topical ointments
Glucosamine/chondroitin
Steroids
Oral
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Degenerative Arthritis
Non-surgical options
NSAIDs – ibuprofen, naprosyn, ketolorac, meloxicam
Lidoderm/Ant-inflammatory Patches
Anelgesic/Anti-imflammatory creams
Pain Pills – Recommend Against due to tolerance,
addiction, decreasing pain threshold
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Degenerative Arthritis
Non-surgical options
Injections
Viscosupplementation or “chicken cartilage”
Enhances PG synthesis, Reduces degredative enzymes (matrix
metalloproteinases)  Prophylactic
Series of injections
Only approved for the knee at this time
Cortisone
Kenalogue
Dexamethasone
With or without lidocaine or marcaine
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Degenerative Arthritis
Surgical options
e.g. Knee
Arthroscopic debridement
Cartilage transplant
Osteotomy
Replacement
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Degenerative Arthritis
Arthroscopic
Debridement of
degenerative knee
usually reserved for
unstable meniscal
fragment or loose body
Will address mechanical
symptoms but may not
alleviate pain
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Degenerative Arthritis
Cartilage Transplant or
Microfracture
Reserved for focal
chondral injuries in an
otherwise non-arthritic
knee
Think Carmelo Anthony,
Kobe Bryant, etc.
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Joint Replacement
What is it?
Treatment for arthritic or damaged joints AFTER
failure of non-operative measures
Replacement of diseased cartilage with metals,
ceramics, and plastics
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Lets start with the Knee….
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What is a total knee arthroplasty?
Layman’s terms
Resurfacing end of femur
bone and tibia bone with
metal with placement of
plastic liner in between
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Total Knee Arthroplasty
Predictable
Pain Relief
Improves Quality of Life
It is a replacement: bone
and cartilage is cut away
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Knee Arthritis
Degenerative Knee Arthritis
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Joint Replacement Surgery
Partial Knee Replacement
Total knee replacement
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Joint Replacement Surgery
Partial Knee Replacement
Total knee replacement
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Joint Replacement
Traditional Goals
Pain Relief
Improved Function
Better quality of life
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Patient Satisfaction
THA outcomes1
180 pts surveyed 3 years
after sx
Pain improvement
walking
Psyche
ADLs
Nonessential activities
89% satisfaction
74% would refer
friend/relative
TKA outcomes2
1703 pts surveyed
Pain satisfaction 72%86%
Functional satisfaction
70-84%
Overall 19% not satisfied
(81% satisfied)
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Traditional TKA
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So…how is it done (traditionally)?
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Consider…
Sagittal Alignment
Anatomic axis
Mechanical axis
Coronal Alignment
Posterior slope
Rotational Alignment
Joint Line Position
Patellofemoral Kinematics
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Partial Knee Replacement
Unicondylar – isolated OA, young, BMI <30
Medial
Lateral
Patella femoral joint - controversial
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Partial Knee Replacement
Preserves healthy knee structures
Indicated when disease process is predominantly
one area
Small incision can be used
Often out of hospital in 1-2 days
Mostly for medial compartment OA, rarely for
lateral OA, or PF OA
Can be revised to TKA
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Partial Knee Replacement
Results are showing it may be as successful as a TKA
Studies show survivorship of around 90% at 15 years
out
Patients report their knee feels “normal”
1.8 times more likely than total knee recipients to report
their knee felt normal
2.7 times more likely to be satisfied with ability to
perform ADLs.
Very specific requirements to be a candidate
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Joint Replacement
CORE Goals in the new millennium
Pain Relief
Improved Function
Faster Recovery
Improved Range of Motion
Decreased Pain after Surgery
Smaller Incisions
Less Trauma to muscle and Tendon
Better alignment
Improved longevity
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The Future is Now
What’s new and exciting in Joint Replacement
Surgery
Minimally Invasive Surgery
Personalized Knee replacement using MRI or CT to
gain precision in mechanical axis and alignment
CT Navigated Knees
Robotic Surgery
THIS IS NOT “EXPERIMENTAL” SURGERY
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Total Knee Replacement
Minimally invasive
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Traditional Incision 8-10 inches
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Minimally Invasive Incision
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Minimally invasive TKA
Potential advantages
Less blood loss
Less soft tissue disruption
Less post-op pain
Shorter hospital stay
Quicker rehab
Overall less cost
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Minimally invasive TKA
Focus has shifted to less
invasive surgery
TKA with <6 inch incision
Components same size
but surgical instruments
are specifically designed
to prepare femur and
tibia with smaller window
Less trauma to muscles
Ideal candidates are
younger, healthier, not
obese, less knee
deformity, primary knee
surgery versus revision
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Minimally invasive TKA
Not all patients
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Minimally invasive TKA
But is it proven?????
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Minimally invasive TKA
Results
Laskin CORR 2004
Compared MIS vs. Standard
MIS
Less pain
12.8 vs. 20 cm incision
Quicker ROM
Component position good in all
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Minimally invasive TKA
Results
Haas et al CORR 2004
Retrospective study but matched
MIS
No complications
Better ROM at 6,12 weeks and one year
Improved knee society scores
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Personalized Knee Replacement
Patient gets MRI or CT prior to surgery
Program creates surgical plan including cuts,
alignment, sizes, and a 3D image
Customized guides created that surgeon uses
intra-op
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Personalized Knee Replacement
Potential Advantages
Quicker OR time
Less inventory
More accurate alignment and positioning leading to a more
balanced knee with less complications
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Personalized Knee Replacement
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Computer Navigated Knee
Goal of Computer Navigation in Total Knee
Arthroplasty:
Minimize the “Outliers”
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Clinical Experience: 240 Patients
s
Navigated
Standard
varus
-7 -6 -5 -4 -3 -2 -1
valgus
0 1 2
3
4
5
6
7
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What’s so important about alignment and
balance?
Worn out PREMATURELY
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What’s so important about balance and
alignment?
Worn out PREMATURELY!
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Computer Balancing and Alignment is now the
BEST way to treat your joint as well
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Results
Stockl et al
CORR 2004
Randomized to nav vs. standard
C.T. eval showed significantly improved alignment
(esp fem rotation) in navigated group
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Results
Stockl et al
CORR 2004
Randomized to nav vs. standard
C.T. eval showed significantly improved alignment
(esp fem rotation) in navigated group
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Results
Kinkl et al
Improvement in alignment
Expense
Time
15-20 min more
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Results
Matsumoto et al
Int Orthop 2004
30 matched-paired controls
Significant improvement in alignment
? Femoral size
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MAKO
Robotic Arm
FDA approved for partial
knee replacements
Developing total knee
utilization in near future
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MAKO
Robotic Arm
Relatively new
technology which started
around 2010
No Long Term Data
Computer program uses
CT scan to map out
cartilage removal and
implant position
Robotic arm helps to
remove cartilage and
provides feedback when
surgeon is errant allowing
extremely precise
accuracy
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A Final Word…
MIS = Short Term Benefits
Less Pain, Faster Recovery
Personalized/Navigated/Mako= Long Term Benefits
Longer lasting, better functioning Replacement
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Hip Arthroplasty
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Patient quotes
I couldn’t even walk 1 block before I had to stop and
sit down. Motrin and Narcotics used to help but
now they barely touch the pain. I don’t feel like
going outside anymore.
My hip doesn’t move like it used to and I’m
embarrassed because I need help getting out of my
car.
My life is less active and I avoid getting together
with friends and family because I’m always in pain.
Just walking outside was exhausting. I didn’t feel
like getting out of bed.
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Normal vs Arthritic Hip Xray
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What is a Total Hip Arthroplasty?
Layman’s Term
Resurfacing cup with
metal and plastic and
removing arthritic head
and replacing it with
metal stem and metal vs
ceramic head.
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Historical
Devised by Sir Charnley in
England in 1962
First FDA implant
implanted in 1969
Traditionally done
through posterior
approach with
modifications throughout
the years including direct
lateral, anterolateral, and
2 incision
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Approaches
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Conventional Approaches
Direct Lateral
Advantages
Theoretical decrease in
dislocation
less muscle damage
Disadvantages
Lurch or limp from failure or
attenuation from abductor
repair
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Conventional Approaches
Posterior
Advantages
Most used and very
extensile
No lurch or theoretical
damage to abductor tendon
Disadvantages
Historically higher rate of
dislocation (not currently)
Most muscle damage
Longest Rehab
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Lateral vs Posterior
Palan et al. Corr 2009
Prospective nonrandomized multicenter
study following 1100 hips
for 5 years
Evaluated
Hip scores
Pain, function, etc
Dislocation rates
Revision Rates
Study found no
difference between the 2
approaches at 5 years out
Take home message
Both approaches work
extremely well and 80% of
THAs are done with these
approaches
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Anterior Supine Intermuscular (ASI)
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Anterior Supine Intermuscular
compared to conventional approaches
Benefits
Quicker recovery
Less pain
Less limping
Better stair climbing and
independent walking at 6
wks
Less muscle damage1
Can use flouroscopy
accurately place implants
intra-operatively
Harris Hip Scores
improved at 6 wks, 12 wks,
and 1 yr compared to
tradional approaches
1 Bergin et al, JBJS 2011
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Anterior Supine Intermuscular
compared to mini posterior approach
Reduced hospital LOS (2.7 vs 3.9)1
ASI more likely discharge home (84% vs 56%)1
ASI less pain, less narcotics, less assistive devices
at 6 wks1
Less variance in Cup position and stem
orientation2
1 Zawadsky et al, JOA, 2014
2 Barret et al, JOA, 2013
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Anterior Supine Intermuscular
Complications
Technically very
challenging
Large learning curve which
varies from 20-100
patients per the literature
Persistent numbness
Potential increase for
more blood loss
Wound complications and
dehiscence
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Anterior Supine Intermuscular
“table or no table”
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Post Op Hip or Knee Replacement
What to expect…
Hospital Stay around 2
days (1 day for ASI)
In hospital physical
therapy (PT), pain control
Home PT of about 3 visits
Out-patient PT about a
week after surgery
Blood Thinners x 6 weeks
Physician choice
ASA, Lovenox, Xarelto
Narcotics x 6 weeks
Physical Therapy for
around 2 months
Expect to be off work for
3 months
Less for ASI
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Expectations
Expectations always
discussed in office prior to
surgery
Unlimited Low Impact
Activities
Recommend limited high
impact (running, basketball,
tennis)
Not a normal hip and knee
– might always feel a little
different
In my experience
Pt 80-90% better at 3
months and then continue
to progress for a full year
Excellent pain relief
Better quality of life
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On the Horizon
CT Navigated Hips
MAKO for Total Knee Arthroplasty
Robotic Surgery in addition to computer
navigation
Improved bearing surfaces
“Smart Implants”
Obviation of a bearing surface
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Keep Life in Motion!
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