hip and arthritis: treatment alternatives to remain active scott m. sporer, m.d. midwest...

Hip and Arthritis:Hip and Arthritis:Treatment Alternatives Treatment Alternatives

To Remain ActiveTo Remain Active

Scott M. Sporer, M.D.Scott M. Sporer, M.D.Midwest Orthopaedics at RUSHMidwest Orthopaedics at RUSH

Assistant ProfessorAssistant ProfessorRUSH University Medical CenterRUSH University Medical Center

Central Dupage HospitalCentral Dupage Hospital

What is Arthritis?What is Arthritis?

Loss of Cartilage Loss of Cartilage from the end of the from the end of the thigh bone (femur) thigh bone (femur) or leg bone (tibia)or leg bone (tibia)

Cartilage is Cartilage is required to provide required to provide a smooth surface a smooth surface for the knee to for the knee to glide glide

What is Arthritis ?What is Arthritis ?

EpidemiologyEpidemiology

Radiographic Radiographic evidence of arthritis in evidence of arthritis in almost all people > 60 almost all people > 60

10-20% of patients 10-20% of patients with symptomswith symptoms

Knee disease twice as Knee disease twice as prevalent as hip prevalent as hip disease in people > 60 disease in people > 60

6.1% of adults >30 6.1% of adults >30 have radiographic have radiographic evidence OA with pain evidence OA with pain on most days. on most days.

EpidemiologyEpidemiology

Women twice as likely to have Women twice as likely to have disease as mendisease as men

Inside portion of the Knee 10x more Inside portion of the Knee 10x more likelylikely

60-80% of joint load through medial 60-80% of joint load through medial compartmentcompartment

Knee AnatomyKnee Anatomy

Femur (Thigh Bone)Femur (Thigh Bone) Tibia (Shin Bone)Tibia (Shin Bone) Patella (Knee Cap)Patella (Knee Cap) 3 “Compartments”3 “Compartments”

Clinical PresentationClinical Presentation

HistoryHistory PainPain InstabilityInstability Change in Change in

alignmentalignment Bow KneedBow Kneed Knocked KneedKnocked Kneed

Difficulty walking Difficulty walking Difficulty with Difficulty with

Activities of Daily Activities of Daily LivingLiving

Clinical PresentationClinical Presentation

Physical ExaminationPhysical Examination SwellingSwelling Limited Motion Limited Motion

(contractures)(contractures) LimpLimp Hip and knee Hip and knee

pain/deformitypain/deformity

Laboratory TestsLaboratory Tests

Rarely RequiredRarely Required Fluid AspirationFluid Aspiration

Blood TestsBlood Tests

Radiographic EvaluationRadiographic Evaluation

Best Method To Evaluate ArthritisBest Method To Evaluate Arthritis Plain X-RaysPlain X-Rays

Standing RadiographsStanding Radiographs AP/ LateralAP/ Lateral Schuss/Rosenberg ViewsSchuss/Rosenberg Views

Radiographic EvaluationRadiographic Evaluation

Joint Space Joint Space NarrowingNarrowing

Osteophytes Osteophytes “bone spurs”“bone spurs”

Changes in Changes in AlignmentAlignment

MRI, CT Scan, MRI, CT Scan, Bone Scans add Bone Scans add little informationlittle information

Treatment OptionsTreatment Options Non SurgicalNon Surgical

Weight LossWeight Loss ExerciseExercise Physical TherapyPhysical Therapy Walking AidsWalking Aids InjectionsInjections

SurgicalSurgical Unicomparmental Unicomparmental

Knee ReplacementKnee Replacement Total Knee Total Knee

ReplacementReplacement

Patient EducationPatient Education Use high stoolsUse high stools Avoid high impact Avoid high impact

activitiesactivities Recommend Recommend

swimming and bikingswimming and biking ObesityObesity

2-5 times body weight 2-5 times body weight with walkingwith walking

Patient EducationPatient Education ExerciseExercise

Strengthen Strengthen muscles around muscles around kneeknee

Helps support the Helps support the jointjoint

Improve flexibilityImprove flexibility Make future Make future

surgery easiersurgery easier

MedicationsMedications

“ “ Two systematic reviews have found Two systematic reviews have found that simple analgesics and NSAIDS that simple analgesics and NSAIDS produce short term pain relief in OA. produce short term pain relief in OA. However, no good evidence that However, no good evidence that NSAIDS are superior to simple NSAIDS are superior to simple analgesics such as Acetaminophen”analgesics such as Acetaminophen”-Clinical Evidence 2001-Clinical Evidence 2001

AnalgesicsAnalgesics

Acetaminophen vs. placeboAcetaminophen vs. placebo 73% vs. 5% of knees with 73% vs. 5% of knees with

improvement in rest painimprovement in rest pain                                                                                                                                                                                       

Non-Steroidal Anti-Non-Steroidal Anti-InflammatoryInflammatory

NSAIDS have been found to be NSAIDS have been found to be effective in reducing short term effective in reducing short term pain.pain.

The Cochrane Library, Issue 4, 1999The Cochrane Library, Issue 4, 1999 ““Systematic reviews found no Systematic reviews found no

important differences in effect important differences in effect between different NSAIDS or doses, between different NSAIDS or doses, but found differences in toxicity…”but found differences in toxicity…”

-Clinical Evidence 2001-Clinical Evidence 2001

Non-Steroidal Anti-Non-Steroidal Anti-inflammatory inflammatory

Medications (NSAIDS)Medications (NSAIDS) Possible side Possible side

EffectsEffects Stomach irritationStomach irritation Kidney damageKidney damage UlcersUlcers

Cox-2 InhibitorsCox-2 Inhibitors Fewer side effectsFewer side effects ExpensiveExpensive

Cox – 2 Cox – 2 RecommendationsRecommendations

Merck & Co., Inc. - withdrawal of Vioxx on Merck & Co., Inc. - withdrawal of Vioxx on Sept. 30, 2004 increased relative risk for Sept. 30, 2004 increased relative risk for confirmed cardiovascular events confirmed cardiovascular events

““Patients who are at a high risk for Patients who are at a high risk for gastrointestinal bleeding, have a history of gastrointestinal bleeding, have a history of intolerance to non-selective NSAIDs, or are not intolerance to non-selective NSAIDs, or are not doing well on non-selective NSAIDs may be doing well on non-selective NSAIDs may be appropriate candidates for Cox-2 selective appropriate candidates for Cox-2 selective agents. Individual patient risk for agents. Individual patient risk for cardiovascular events and other risks cardiovascular events and other risks commonly associated with NSAIDs should be commonly associated with NSAIDs should be taken into account”taken into account”

Glucosamine/ Glucosamine/ Chondroitin SulfateChondroitin Sulfate

Not Regulated by FDANot Regulated by FDA ExpensiveExpensive Unknown Side EffectsUnknown Side Effects Effective in several Effective in several

studiesstudies

Cortisone InjectionCortisone Injection

May provide Temporary ReliefMay provide Temporary Relief Decreases inflammationDecreases inflammation May accelerate cartilage May accelerate cartilage

damagedamage Small Risk of InfectionSmall Risk of Infection 78% of patients note 78% of patients note

improvementimprovement

Hyaluronic Acid InjectionHyaluronic Acid Injection

Considered a medical Considered a medical devicedevice

Works best for less Works best for less severe arthritissevere arthritis

Series of 3 to 5 injectionsSeries of 3 to 5 injections Small Risk of InfectionSmall Risk of Infection Allergic ReactionAllergic Reaction 2/32/3rdrd patients note mild patients note mild

improvementimprovement

ArthroscopyArthroscopy

Theory:Theory: Degenerating Degenerating

cartilage releases cartilage releases inflammatory inflammatory mediatorsmediators

Subsequent Subsequent cartilage damagecartilage damage

May be replaced May be replaced by cartilage type by cartilage type tissuetissue

ArthroscopyArthroscopy

Surgical TreatmentSurgical Treatment Unicompartment Knee ReplacementUnicompartment Knee Replacement

Total Knee ReplacementTotal Knee Replacement

Unicompartmental KneeUnicompartmental Knee

Arthritis in only 1 Arthritis in only 1 compartment of kneecompartment of knee

Used in either Young Used in either Young or Old patient or Old patient

Ligaments IntactLigaments Intact No systemic DiseaseNo systemic Disease Weight <200#Weight <200# OccupationOccupation

RadiographsRadiographs

Surgical Technique – Surgical Technique – Minimally InvasiveMinimally Invasive

Why Minimally InvasiveWhy Minimally Invasive

Earlier MobilizationEarlier Mobilization CostCost Shorter Hospital StayShorter Hospital Stay Quicker RehabilitationQuicker Rehabilitation Less Blood LossLess Blood Loss ? Easier conversion to Total ? Easier conversion to Total

knee replacementknee replacement

Total Knee ArthroplastyTotal Knee Arthroplasty

Resurface All Resurface All Three SurfacesThree Surfaces TibiaTibia FemurFemur PatellaPatella

Components fixed Components fixed to bone with to bone with “cement”“cement”

Total Knee ArthroplastyTotal Knee Arthroplasty

Surgical ProcedureSurgical Procedure

Mini 12-14 cm

Quad Snip

Q-S7-10 cm

No Quad

Standard 20-30 cm

Quad Incision

MIS in TKA

Mini/MIS QS TKA

MIS Patient SelectionMIS Patient Selection

Male <250 #, Female < 225#Male <250 #, Female < 225# MotivatedMotivated Range of motion > 90Range of motion > 90˚̊ Flexion Contracture < 10 ˚Flexion Contracture < 10 ˚ Fixed varus <10 ˚ or valgus <15 ˚Fixed varus <10 ˚ or valgus <15 ˚

MIS TKA MIS TKA ContraindicationsContraindications

Deficient or scared skinDeficient or scared skin Severe diabetic; steroidsSevere diabetic; steroids OsteoporosisOsteoporosis Prior major intra-articular surgeryPrior major intra-articular surgery Relative ContraindicationsRelative Contraindications

Extremely MuscularExtremely Muscular Inflammatory arthritisInflammatory arthritis Patella BajaPatella Baja Extremely Large sizesExtremely Large sizes

Total Knee ReplacementTotal Knee Replacement

Long Term Long Term ResultsResults 96% Functioning 96% Functioning

Well at 10 YearsWell at 10 Years

How To Decide ?How To Decide ?

Individual Individual DecisionDecision

Hurtful not Hurtful not HarmfulHarmful

Is if affecting Is if affecting you?you?

What are your What are your expectations?expectations?

Hip ArthritisHip Arthritis

Hip Arthritis?Hip Arthritis?

Loss of Cartilage Loss of Cartilage between the top of between the top of the thigh bone the thigh bone (ball), and the (ball), and the acetabulum (socket) acetabulum (socket)

Cartilage is Cartilage is required to provide required to provide a smooth surface a smooth surface for the hip to glide for the hip to glide

Hip AnatomyHip Anatomy

Clinical PresentationClinical Presentation

HistoryHistory PainPain Difficulty walking Difficulty walking Difficulty with Difficulty with

Activities of Daily Activities of Daily LivingLiving

Radiographic EvaluationRadiographic Evaluation Best Method To Evaluate ArthritisBest Method To Evaluate Arthritis

Plain X-RaysPlain X-Rays Joint Space NarrowingJoint Space Narrowing Osteophytes “bone spurs”Osteophytes “bone spurs”

Treatment OptionsTreatment Options Non SurgicalNon Surgical

Weight LossWeight Loss ExerciseExercise Physical TherapyPhysical Therapy Walking AidsWalking Aids InjectionsInjections

SurgicalSurgical Total Hip ArthroplastyTotal Hip Arthroplasty Minimally Invasive Minimally Invasive

Total Hip ArthroplastyTotal Hip Arthroplasty

Patient EducationPatient Education Avoid high impact Avoid high impact

activitiesactivities Recommend Recommend

swimming and bikingswimming and biking ObesityObesity

2-5 times body weight 2-5 times body weight with walkingwith walking

Patient EducationPatient Education ExerciseExercise

Strengthen muscles Strengthen muscles around hiparound hip

Helps support the jointHelps support the joint Improve flexibilityImprove flexibility Make future surgery Make future surgery

easiereasier

ExerciseExercise

MedicationsMedications

Provide Temporary Relief of PainProvide Temporary Relief of Pain Similar Efficacy among MedicationsSimilar Efficacy among Medications

Non-Steroidal Anti-Non-Steroidal Anti-inflammatory inflammatory

Medications (NSAIDS)Medications (NSAIDS) Possible side Possible side

EffectsEffects Stomach irritationStomach irritation Kidney damageKidney damage UlcersUlcers

Cox-2 InhibitorsCox-2 Inhibitors Fewer side effectsFewer side effects ExpensiveExpensive

Cortisone InjectionCortisone Injection

Used infrequently in Hip Used infrequently in Hip ArthritisArthritis

May help with DiagnosisMay help with Diagnosis Decreases inflammationDecreases inflammation May accelerate cartilage May accelerate cartilage

damagedamage Small Risk of InfectionSmall Risk of Infection

ArthroscopyArthroscopy

Difficult to see Difficult to see inside the hipinside the hip

Results less Results less predictablepredictable

Used for Used for “Mechanical “Mechanical Symptoms”Symptoms”

Rarely Rarely performedperformed

Surgical TreatmentSurgical Treatment

Remove Damaged Remove Damaged CartilageCartilage

Replace with Metal Replace with Metal and Plasticand Plastic

Remove Bone Remove Bone SpursSpurs

““Resurface the Resurface the bone”bone”

Surgical TreatmentSurgical Treatment

Total Hip ReplacementTotal Hip Replacement Resurface the ball and socket with metal and Resurface the ball and socket with metal and

plasticplastic Partial Resurfacing Hip ReplacementPartial Resurfacing Hip Replacement

Resurface only the ball of the hipResurface only the ball of the hip Conventional Surgical ApproachConventional Surgical Approach Minimally Invasive SurgeryMinimally Invasive Surgery

Surgical ProcedureSurgical Procedure

RadiographsRadiographs

Surgical Technique – Surgical Technique – Minimally InvasiveMinimally Invasive

Standard Incision 9-10 InchesStandard Incision 9-10 Inches One 3-4 Inch Incision or two 2 Inch One 3-4 Inch Incision or two 2 Inch

IncisionsIncisions Separate Muscles – Do not Cut MuscleSeparate Muscles – Do not Cut Muscle

Total Hip ReplacementTotal Hip Replacement

Minimally Invasive Minimally Invasive HipHip Select PatientsSelect Patients Potential shorter Potential shorter

recoveryrecovery Potential less Potential less

bleedingbleeding Potential quicker Potential quicker

rehabrehab Long Term Results Long Term Results

UnknownUnknown

Post Operative RecoveryPost Operative Recovery

Physical Therapy Physical Therapy next daynext day

Pain Pump or Pain Pump or Epidural catheter Epidural catheter for pain relieffor pain relief

Full Weight Full Weight BearingBearing

Coumadin to Coumadin to prevent blood clotprevent blood clot

Total Hip ArthroplastyTotal Hip Arthroplasty

Hospital Stay Hospital Stay Standard Approach Standard Approach

5-7 days 5-7 days Minimally Invasive Minimally Invasive

Approach Approach Outpatient – 2 day Outpatient – 2 day

Follow-up CareFollow-up Care Visiting NursesVisiting Nurses Staples removed 2 Staples removed 2

weeksweeks Coumadin for 4-6 Coumadin for 4-6

weeks totalweeks total Physical Therapy 2-3 Physical Therapy 2-3

times per weektimes per week 70% better at 2 weeks70% better at 2 weeks 90% better at 6 weeks90% better at 6 weeks Slow improvement Slow improvement

next 6 monthsnext 6 months

Total Hip PrecautionsTotal Hip Precautions

Avoid crossing your legsAvoid crossing your legs Avoid bending your hip greater Avoid bending your hip greater

than 90 degreesthan 90 degrees Avoid turning foot inward Avoid turning foot inward Keep a wedge or pillow between Keep a wedge or pillow between

your knees while in bedyour knees while in bed Do lean back slightly when sitting Do lean back slightly when sitting

to keep the hip bending < 90 to keep the hip bending < 90 degreesdegrees

Potential ComplicationsPotential Complications

• Loosening

•Infection

•Deep Venous Thrombosis

•Dislocation

Long-Term ExpectationsLong-Term Expectations Resume most Resume most

activitiesactivities Avoid positions of Avoid positions of

risk for dislocationrisk for dislocation Yearly follow-upYearly follow-up Hips last on Hips last on

average 15-20 average 15-20 yearsyears

Plastic insert may Plastic insert may need to be need to be replaced replaced

Thank YouThank You

Scott M. Sporer, M.D., Scott M. Sporer, M.D., M.S.M.S.Midwest OrthopaedicsMidwest Orthopaedics25 N. Winfield Road25 N. Winfield RoadWinfield, Illinois Winfield, Illinois 6019060190(630) 339-2225(630) 339-2225