arthritis: how do i know and what do i do?wichita.kumc.edu/media/livelearn/100708.pdf · oct. 7,...
TRANSCRIPT
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Arthritis: How Do I Know and What Do I Do?
Robert Cusick, M.D.October 7, 2008
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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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Oct. 7, 2008Oct. 7, 2008
Kansas Joint and Spine Institute
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
Objectives
Defining ArthritisInjury vs. Wear and Tear?
Will it go away?Treatment OptionsLifetime Sentence?Next Steps?
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Oct. 7, 2008Oct. 7, 2008
Types of Arthritis
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Oct. 7, 2008Oct. 7, 2008
Osteoarthritis
Classic “wear and tear” arthritisProgresses as patients ageCommon in knees, hips, shoulders
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Oct. 7, 2008Oct. 7, 2008
Osteoarthritis“Wearing off” of cartilageCauses inflammation/pain/swellingLeads to stiffness
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Oct. 7, 2008Oct. 7, 2008
Rheumatoid Arthritis
Approximately 10% of all arthritisInflammation leads to joint damageAntibodies to the joint surface
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Oct. 7, 2008Oct. 7, 2008
Rheumatoid Arthritis
Progresses throughout lifeManaged with aggressive medications by rheumatologistOften results in joint replacement
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1212
Common Injuries
1212
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1313Oct. 7, 2008Oct. 7, 2008
Knee Injuries
Knee SprainMedial Collateral, Lateral CollateralNon-Operative Treatment8-12 weeks to heal
1313
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1414Oct. 7, 2008Oct. 7, 2008
Knee Injuries
Meniscus TearVERY common injuryAdolescent >> Later lifeNot always injury‘Sudden’ onset
1414
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1515Oct. 7, 2008Oct. 7, 2008
Meniscus TearSudden, sharp painsCatching, lockingTreated with arthroscopyFull recovery typical
1515
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1616Oct. 7, 2008Oct. 7, 2008
Arthroscopy
1616
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1717Oct. 7, 2008Oct. 7, 2008
Hip Injuries
TendonitisBursitis (Hip Pointer)Labral InjuryFracture
1717
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1818Oct. 7, 2008Oct. 7, 2008
Psoas Tendonitis
Groin painPain with hip flexionDue to overuse, new activitiesTreated with meds, physical therapy
1818
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1919Oct. 7, 2008Oct. 7, 2008
Trochanteric Bursitis
Very common cause of hip painLateral pain, tenderness
1919
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2020Oct. 7, 2008Oct. 7, 2008
Trochanteric Bursitis
Typically secondary to another issueTreated with NSAID’s, rest, heat/ice, topicals, massage, injections, PT
2020
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2121Oct. 7, 2008Oct. 7, 2008
Labral Injury
Sudden onsetGroin painCatching, lockingTreated with arthroscopyFull recovery typical
2121
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2222Oct. 7, 2008Oct. 7, 2008
Hip Fractures
Several different typesMiddle age and olderDue to fall, injuryTreated with surgeryDecreasing mortality
2222
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2323
Outlook for Arthritis
2323
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2424Oct. 7, 2008Oct. 7, 2008
Arthritis Prognosis
Generally progressiveWax and wane
ActivityWeather (barometer)Medical conditions
Increasing stiffness, pain
2424
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Oct. 7, 2008Oct. 7, 2008
Prevalence of Arthritis
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Treatments for Arthritis
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Oct. 7, 2008Oct. 7, 2008
Nonoperative Treatments
Activity modificationsNon-steroidal anti-inflammatories
Ibuprofen, Naproxen, Aspirin, etc
Ice/HeatBracingPhysical Therapy/Aquatic TherapyInjections
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Oct. 7, 2008Oct. 7, 2008
Nonoperative Treatments
Activity ModificationAvoidance of stairsFrequently resting when ambulatingCane for supportLifestyle changes due to pain
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
Unloader Bracing
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Oct. 7, 2008Oct. 7, 2008
Nonoperative Treatments
Physical TherapyExercises
Improve mobilityImprove mobilityIncrease strengthIncrease strengthDecrease swellingDecrease swelling
Modalities-Ultrasound, IonophoresisDecrease painDecrease painDecrease swellingDecrease swellingImprove functionImprove function
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Oct. 7, 2008Oct. 7, 2008
Nonoperative Treatments
Aquatic Therapy
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Oct. 7, 2008Oct. 7, 2008
Aquatic TherapyEarly, aggressive ROM exercisesMinimal impact, non-loaded hip and knee therapyResistance=improved strengthOcclusive dressings required 2-3 weeks
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
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
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Surgical Treatments for Arthritis
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Total Hip Arthroplasty
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Oct. 7, 2008Oct. 7, 2008
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Oct. 7, 2008Oct. 7, 2008
“Traditional” THA
Posterolateral approach8-12” incision2-3 hr. procedureFrequent transfusions5-8 day hospitalizationStrict restrictions for life
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Oct. 7, 2008Oct. 7, 2008
New Techniques
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
MIS Total Hip Replacement
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
MIS ContributionsMore aggressive rehabilitation
Intra-operative soft tissue management
Comprehensive post-operative pain management protocol
Earlier return to function
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Oct. 7, 2008Oct. 7, 2008
Bearing Surfaces
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Oct. 7, 2008Oct. 7, 2008
Worn Components and Osteolysis
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Oct. 7, 2008Oct. 7, 2008
Different Bearing Options
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Oct. 7, 2008Oct. 7, 2008
Hip Resurfacing
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Oct. 7, 2008Oct. 7, 2008
Replacement vs. Resurfacing
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Oct. 7, 2008Oct. 7, 2008
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
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Total Knee Arthroplasty
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Oct. 7, 2008Oct. 7, 2008
X-Ray Evaluation
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Oct. 7, 2008Oct. 7, 2008
Misconceptions
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Oct. 7, 2008Oct. 7, 2008
Recent Advances
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Oct. 7, 2008Oct. 7, 2008
Minimally Invasive TKA
5-8 year historyMarketing tool?Google returns 292,000 resultsFaster recovery?Less surgery?
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Oct. 7, 2008Oct. 7, 2008
MIS-Lessons Learned
Quadriceps mechanism preservationAggressive pain managementEARLY physical therapyShorter hospitalization
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Oct. 7, 2008Oct. 7, 2008
Computer Assisted Navigation
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
Navigation
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Oct. 7, 2008Oct. 7, 2008
Navigation Goals
Standard surgery despite varied anatomyReproducible alignmentCorrection of complex deformitiesLess invasive surgery?
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Oct. 7, 2008Oct. 7, 2008
Total Joint Aftercare
RehabPhysical TherapyDVT ProphylaxisRestrictionsExpectations
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
ROM Requirements
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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
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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Oct. 7, 2008Oct. 7, 2008
Operative Treatment Summary
Total Hip AdvancesLess invasive surgeryNew bearing surfacesAlternative procedures
Total Knee AdvancesLess invasive surgeryComputer assisted navigationRapid rehab protocols
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Oct. 7, 2008Oct. 7, 2008
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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7373Oct. 7, 2008Oct. 7, 2008
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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7474Oct. 7, 2008Oct. 7, 2008
What to Do
STAY ACTIVE!!!Talk to your doctor
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7575Oct. 7, 2008Oct. 7, 2008
Where To Get Information
Arthritis Foundationwww.Arthritis.org
American Academy of Orthopedic Surgeonsorthoinfo.aaos.org
Dr Robert Cusickwww.KJSI.com
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Oct. 7, 2008Oct. 7, 2008
Questions?
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Thank YouRobert Cusick, MD
www.KJSI.com