arthritis: how do i know and what do i do?wichita.kumc.edu/media/livelearn/100708.pdf · oct. 7,...

Arthritis: How Do I Know and What Do I Do?

Robert Cusick, M.D.October 7, 2008

Oct. 7, 2008Oct. 7, 2008

My ‘Brief’ History

Born and raised in Chicago

University of Illinois

Residency in Wichita

Fellowship in Phoenix

Live and work in Wichita

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Kansas Joint and Spine Institute

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Kansas Joint and Spine Institute

6 Physicians3 Joint Replacement Surgeons2 Spine Surgeons1 Sports Surgeon

NE WichitaEmploy 35-40 StaffPhysical/Aquatic

Therapy Center

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Reasons for this Presentation

Frequent advances in the fieldInformation overload (news, internet, friends and relatives)New surgeries, new techniques, improving rehabilitation protocolsOpportunity for patients to ask questions

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Objectives

Defining ArthritisInjury vs. Wear and Tear?

Will it go away?Treatment OptionsLifetime Sentence?Next Steps?

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Types of Arthritis

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Osteoarthritis

Classic “wear and tear” arthritisProgresses as patients ageCommon in knees, hips, shoulders

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Osteoarthritis“Wearing off” of cartilageCauses inflammation/pain/swellingLeads to stiffness

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Rheumatoid Arthritis

Approximately 10% of all arthritisInflammation leads to joint damageAntibodies to the joint surface

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Rheumatoid Arthritis

Progresses throughout lifeManaged with aggressive medications by rheumatologistOften results in joint replacement

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Common Injuries

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Knee Injuries

Knee SprainMedial Collateral, Lateral CollateralNon-Operative Treatment8-12 weeks to heal

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Knee Injuries

Meniscus TearVERY common injuryAdolescent >> Later lifeNot always injury‘Sudden’ onset

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Meniscus TearSudden, sharp painsCatching, lockingTreated with arthroscopyFull recovery typical

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Arthroscopy

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Hip Injuries

TendonitisBursitis (Hip Pointer)Labral InjuryFracture

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Psoas Tendonitis

Groin painPain with hip flexionDue to overuse, new activitiesTreated with meds, physical therapy

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Trochanteric Bursitis

Very common cause of hip painLateral pain, tenderness

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Trochanteric Bursitis

Typically secondary to another issueTreated with NSAID’s, rest, heat/ice, topicals, massage, injections, PT

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Labral Injury

Sudden onsetGroin painCatching, lockingTreated with arthroscopyFull recovery typical

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Hip Fractures

Several different typesMiddle age and olderDue to fall, injuryTreated with surgeryDecreasing mortality

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Outlook for Arthritis

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Arthritis Prognosis

Generally progressiveWax and wane

ActivityWeather (barometer)Medical conditions

Increasing stiffness, pain

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Prevalence of Arthritis

Treatments for Arthritis

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Nonoperative Treatments

Activity modificationsNon-steroidal anti-inflammatories

Ibuprofen, Naproxen, Aspirin, etc

Ice/HeatBracingPhysical Therapy/Aquatic TherapyInjections

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Nonoperative Treatments

Activity ModificationAvoidance of stairsFrequently resting when ambulatingCane for supportLifestyle changes due to pain

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Nonoperative Treatments

Non-steroidal anti-inflammatoriesAspirin >> GI Problems, BleedingIbuprofen, Naproxen >> GI?Celebrex, Mobic >> Cost, BP problems?Lodine, Relafen, Daypro >> GI? Effective?

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Nonoperative TreatmentsIce/Heat

Ice: Can minimize swellingHeat: Can break-up swellingVarying effects for different patients

BracingSimple >> support, compression, warmthCustom (unloader) bracing

Expensive, cumbersome, uncomfortableExpensive, cumbersome, uncomfortableRarely longRarely long--termterm

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Unloader Bracing

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Nonoperative Treatments

Physical TherapyExercises

Improve mobilityImprove mobilityIncrease strengthIncrease strengthDecrease swellingDecrease swelling

Modalities-Ultrasound, IonophoresisDecrease painDecrease painDecrease swellingDecrease swellingImprove functionImprove function

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Nonoperative Treatments

Aquatic Therapy

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Aquatic TherapyEarly, aggressive ROM exercisesMinimal impact, non-loaded hip and knee therapyResistance=improved strengthOcclusive dressings required 2-3 weeks

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Injection TherapySteroid Injection

Cortisone, Celestone, DepomedrolUsually mixed with local anesthetic (Lidocaine)Typically effective very quicklyCan be repeated every 3-4 mosInexpensive, easy to administerMost common injection

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Viscosupplementation

Synvisc, Hyalgan, Supartz, EuflexaHyaluronic acid injections-intraarticularTypically 3 injections over 3 weeksMechanism of action

Direct lubricantStimulates synovium to produce natural lubricant

Pain=incorrect location

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Nutritional Supplements

Glucosamine/Chondroitin SulfateProven useful through reliable researchVarying degrees of active ingredient2-3 mos. prior to determining utility

MSMMechanism not well understoodTreats RA, snoring, muscle spasm, cancerNot regulated, not proven

Surgical Treatments for Arthritis

Total Hip Arthroplasty

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“Traditional” THA

Posterolateral approach8-12” incision2-3 hr. procedureFrequent transfusions5-8 day hospitalizationStrict restrictions for life

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New Techniques

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Minimally Invasive Surgerytotal hip replacement (MIS)

Promises faster recovery, less surgery, less pain, equal resultsGoogle returns 547,000 resultsPopular in large cities (marketing?)MIS standard incision vs. two

incision technique

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MIS Total Hip Replacement

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MIS Hip Controversies

Longer surgery (2-3 hrs. vs. 1 hr.)X-ray exposureSerious complications

FractureMalposition of componentsNeurovascular injuryMuscle damageEarly revisions?

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MIS ContributionsMore aggressive rehabilitation

Intra-operative soft tissue management

Comprehensive post-operative pain management protocol

Earlier return to function

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Bearing Surfaces

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Worn Components and Osteolysis

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Different Bearing Options

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Hip Resurfacing

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Replacement vs. Resurfacing

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Hip Resurfacing

Younger, more active patientsFewer long term restrictionsCostly: very expensive componentsUnproven track recordLikely to increase in popularity in the U.S. as it has in other countries

Total Knee Arthroplasty

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X-Ray Evaluation

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Misconceptions

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Recent Advances

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Minimally Invasive TKA

5-8 year historyMarketing tool?Google returns 292,000 resultsFaster recovery?Less surgery?

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MIS-Lessons Learned

Quadriceps mechanism preservationAggressive pain managementEARLY physical therapyShorter hospitalization

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Computer Assisted Navigation

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Navigation in TKA

Not roboticsExtra information during surgeryTrackers around knee to pinpoint landmarksPrecision cuts, placement of prosthesisNOT for every patient, yet

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Navigation

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Navigation Goals

Standard surgery despite varied anatomyReproducible alignmentCorrection of complex deformitiesLess invasive surgery?

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Total Joint Aftercare

RehabPhysical TherapyDVT ProphylaxisRestrictionsExpectations

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Inpatient Rehab

Rarely required after uncomplicated TKA, THATypically older, less healthy individuals living aloneTypical stay 5-8 days‘Step-down’ between inpatient and home

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Physical Therapy

More critical after knee replacement2X/day in hospital, then 3X/wk X 3 wks.Full weight-bearing immediatelyGoal=less pain, increase ROM

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ROM Requirements

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Long Term Restrictions

NO impact activities (jumping, jogging)Limited squatting (flexion, adduction, internal rotation-HIP)Kneeling permittedLifting up to 75 lbs, 50 lbs repetitivePermitted: biking, doubles tennis, light blue/green slope skiingDental prophylaxis-for life?

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Current Expectations

Immediate full weight bearing (day of surgery)2-3 days in hospitalWalker 1 week, cane 1-2 weeks3 weeks out-patient physical therapyReturn to work/driving 4-6 weeks15-20+ years before wear becomes an issue

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Bilateral Total Knee Replacement

Patient selection criticalHealthy, motivated patientsVery unhealthy patients (one anesthetic)Risk comparable or less than two staged surgeriesPatient satisfaction improving

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Operative Treatment Summary

Total Hip AdvancesLess invasive surgeryNew bearing surfacesAlternative procedures

Total Knee AdvancesLess invasive surgeryComputer assisted navigationRapid rehab protocols

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Current InnovationsSummary

Hip ResurfacingYounger patientsHigh level activities

Computer NavigationHigh accuracyLonger lasting?

Aquatic TherapyLow impact rehabBetter ROM?

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Living With Arthritis

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What to Expect

Slowly progressive pain, stiffness“Good and bad” daysMulti-modal treatment

Different combinations for different patientsPatient and symptom specific

Not hereditaryNot ‘destined’ for surgery

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What to Do

STAY ACTIVE!!!Talk to your doctor

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Where To Get Information

Arthritis Foundationwww.Arthritis.org

American Academy of Orthopedic Surgeonsorthoinfo.aaos.org

Dr Robert Cusickwww.KJSI.com

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Questions?

Thank YouRobert Cusick, MD

www.KJSI.com