A Minimally Invasive A Minimally Invasive Approach to Knee ArthritisApproach to Knee Arthritis

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With assistance from James E. Dowd, MD (Virginia Beach, VA)

• 22ndnd only to heart disease only to heart disease in causing disabilityin causing disability

• 1 million new patients 1 million new patients diagnosed each yeardiagnosed each year

• Affects 50 percent of Affects 50 percent of people 65 years of age people 65 years of age and olderand older

• Population of older Population of older adults with arthritis will adults with arthritis will nearly double by 2030 nearly double by 2030

Arthritis affects 70 million AmericansArthritis affects 70 million Americans

The Knee and OsteoarthritisThe Knee and Osteoarthritis

• Most common joint affected by Most common joint affected by osteoarthritisosteoarthritis

• Large weight-bearing jointLarge weight-bearing joint

• Complex motion patternComplex motion pattern

• Common site of injuryCommon site of injury

Osteoarthritis is the most common Osteoarthritis is the most common form of arthritisform of arthritis

• Rheumatoid arthritisRheumatoid arthritis• Post-traumatic Post-traumatic

arthritisarthritis• Inflammatory arthritisInflammatory arthritis• Septic arthritisSeptic arthritis

All result in loss of All result in loss of joint cartilagejoint cartilage

Presenting Symptoms of ArthritisPresenting Symptoms of Arthritis

• StiffnessStiffness

• Swelling Swelling

• Long limb deformityLong limb deformity

– (“knock-knee”/ “bow-leg”)(“knock-knee”/ “bow-leg”)

• CrepitusCrepitus

• Activity limiting Activity limiting PAINPAIN!!

Initial Conservative TreatmentsInitial Conservative Treatments

• TylenolTylenol®®

• NSAIDsNSAIDs

• Nutritional Nutritional supplementssupplements

• Physical therapyPhysical therapy

• Activity modificationActivity modification

• Weight lossWeight loss

Therapeutic InjectionsTherapeutic Injections

• Corticosteroid Corticosteroid – Inter-articular anti-Inter-articular anti-

inflammatory agentinflammatory agent

• Viscoelastic SeriesViscoelastic Series– Augment normal joint Augment normal joint

lubricationlubrication

– Hyaluronic Acid (HA)Hyaluronic Acid (HA)

©MMG 2001

The Most Common Complications

• Cortisone Injections – Allergic reaction, joint swelling and pain several hours after

injection and infection

• Hyaluronic Acid (HA) Injections – Temporary pain, swelling, and/or fluid accumulation in the

injected knee

These procedures are not for everyone. Results vary in patients.

The Orthopaedic SpecialistThe Orthopaedic Specialist

• When conservative treatments When conservative treatments nono longer resolve activity longer resolve activity limiting pain caused by limiting pain caused by osteoarthritis then . . . osteoarthritis then . . .

• Surgical and reconstructive Surgical and reconstructive treatments may be appropriatetreatments may be appropriate

Surgical Options for Knee ArthritisSurgical Options for Knee Arthritis

• ArthroscopyArthroscopy– debridement, debridement,

meniscectomy, meniscectomy, chondroplastychondroplasty

• OsteotomyOsteotomy– bone re-alignmentbone re-alignment

• ArthroplastyArthroplasty– joint replacementjoint replacement

Arthroscopic DebridementArthroscopic Debridement“clean out” or “scrape bone”“clean out” or “scrape bone”

• Somewhat unpredictable Somewhat unpredictable resultsresults

• 50 to 66 percent get relief for 50 to 66 percent get relief for somesome period of time period of time

• Best for patients with Best for patients with mechanical symptoms mechanical symptoms (catching, locking and giving (catching, locking and giving out)out)

Knee OsteotomyKnee OsteotomyRe-align weight-bearing axis through “good” cartilageRe-align weight-bearing axis through “good” cartilage

• Most popular before success of Most popular before success of contemporary knee replacementcontemporary knee replacement

• Useful for patients too young, Useful for patients too young, heavy or active for knee implantsheavy or active for knee implants

• Early results acceptable, Early results acceptable, questionable durabilityquestionable durability

The Most Common Complications

• Arthroscopy– Bleeding, infection and blood clots

• Osteotomy – Insufficient pain relief, nonunion/malunion, intra-articular

fracture, DVT, infection and neurovascular injury

These procedures are not for everyone. Results vary in patients.

End-Stage Osteoarthritis End-Stage Osteoarthritis Knee ReplacementKnee Replacement

“Gold Standard of Care”“Gold Standard of Care”

• UUni-compartmental ni-compartmental KKnee nee RReplacementeplacement– ““Uni,” “partial replacement” or UKRUni,” “partial replacement” or UKR

• TTri-compartmental ri-compartmental KKnee nee RReplacementeplacement– ““total replacement” or TKRtotal replacement” or TKR

The Knee: 3 CompartmentsThe Knee: 3 Compartments

MedialMedialLateralLateral

Patella-Patella-FemoralFemoral

Osteoarthritis in 1 of 3 Compartments:Osteoarthritis in 1 of 3 Compartments:Treatment = UKRTreatment = UKR

Uni-compartmental Knee Uni-compartmental Knee Replacement (UKR)Replacement (UKR)

• 20+ year clinical history20+ year clinical history

• Less commonly performedLess commonly performed

– Growing interest utilizing Growing interest utilizing minimally invasive techniquesminimally invasive techniques

Osteoarthritis in 2 of 3 Compartments:Osteoarthritis in 2 of 3 Compartments:Treatment = TKRTreatment = TKR

Total Knee Replacement (TKR)Total Knee Replacement (TKR)

• 30+ year clinical history30+ year clinical history

• >95 percent of all knee >95 percent of all knee replacements performedreplacements performed

Uni-compartmental Knee ReplacementUni-compartmental Knee Replacement(Early Results)

• Aglietti & Insall – 30 percent revised at 5 to 7 year Aglietti & Insall – 30 percent revised at 5 to 7 year follow-up follow-up (Aglietti, Paulo, MD and John Insall, MD. “A Five to Seven Year Follow-up of Unicondylar Arthroplasty.” Journal of Bone and Joint Surgery Dec. 1980: 1329-1337.)

• Marmor – 65 percent survivorship at 11 year Marmor – 65 percent survivorship at 11 year follow-up follow-up (Marmor, Leonard, MD. “Unicompartmental Knee Arthroplasty Ten- to 13-Year Follow-up Study.” CORR Jan. 1988: 14-20.)

• Scott, et al. – 85 percent survivorship at 10 year Scott, et al. – 85 percent survivorship at 10 year follow-up follow-up (Scott, R.D., MD, et al. “Unicompartmental Knee Arthroplasty Eight- to 12- Year Follow-up Evaluation With Survivorship Analysis.” CORR Oct. 1991: 96-100.)

Uni-compartmental Knee ReplacementUni-compartmental Knee Replacement((Early Challenges)

• TechniquesTechniques

• ImplantsImplants

• InstrumentsInstruments

Trusted InnovationTrusted Innovation

Mobile-bearingMobile-bearing

LCSLCS Heritage Heritage

Fixed-bearingFixed-bearing

P.F.C.P.F.C. Sigma Heritage Sigma Heritage

1982 1983

Uni-compartmental Knee ReplacementUni-compartmental Knee Replacementlong-term results long-term results (fixed-bearing)(fixed-bearing)

10 Year Survival Rates

96% 90% 98%91%85%

70%

0%

20%

40%

60%

80%

100%

120%

Marmor, MD1988

(n=228)

Scott, MD1991

(n=100)

Heck, MD1993

(n=294)

Ansari, MD1997

(n=461)

Squire, MD1999

(n=140)

Berger, MD1999 (n=62)

Uni-compartmental Knee ReplacementUni-compartmental Knee Replacementlong-term results long-term results (mobile-bearing)(mobile-bearing)

10 Year Survival Rates

98% 95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Murray, MD (1998), 144 UKAs Svaard, MD (1999), 124 UKAs

Potential Patient Benefits with a Potential Patient Benefits with a UKR ProcedureUKR Procedure

• Higher patient satisfactionHigher patient satisfaction

• Quicker recoveryQuicker recovery

• Better range of motionBetter range of motion

• Less blood lossLess blood loss

• Less chance of infectionLess chance of infection

• Cost savingsCost savings

Uni-compartmental Knee ReplacementUni-compartmental Knee Replacement“Show Me the Data”“Show Me the Data”

• UKR versus TKR – 23 patients with bothUKR versus TKR – 23 patients with both– Average ROM UKR=123 degrees, TKR=110 degreesAverage ROM UKR=123 degrees, TKR=110 degrees

– 44 percent preferred UKR side, 12 percent preferred 44 percent preferred UKR side, 12 percent preferred TKRTKR

(Laurencin, C.T., MD, et al. “Unicompartmental Versus Total Knee Arthroplasty in the Same Patient.” CORR Dec. 1991: 151-156.)

• 81 UKRs versus 120 TKRs81 UKRs versus 120 TKRs – Blood Tx 1 percent with UKRs versus 67 percent with Blood Tx 1 percent with UKRs versus 67 percent with

TKRTKR

(Rougraff, MD, et al. “A Comparison of Tricompartmental and Unicompartmental Arthroplasty for the Treatment of Gonarthrosis.” CORR Dec. 1991: 157-164.)

Uni-compartmental Knee ReplacementUni-compartmental Knee Replacement“Show Me the Data”“Show Me the Data”

• 50 UKRs versus 52 TKRs50 UKRs versus 52 TKRs – UKR = shorter hospitalizationUKR = shorter hospitalization– UKR = better knee flexion, 69 percent >120 UKR = better knee flexion, 69 percent >120

degrees versus 17 percent TKRsdegrees versus 17 percent TKRs(Newman, MD, et al. “Unicompartmental or Total Knee Replacement? Five-Year Results of a Prospective, Randomised Trial of 102 Osteoarthritic Knees With Unicompartmental Arthritis.” Journal of Bone and Joint Surgery Br. Sept. 1998: 862-865. )

• Swedish Knee RegistrySwedish Knee Registry

– Risk of infection 0.8 percent for UKR versus 2 Risk of infection 0.8 percent for UKR versus 2 percent for TKR percent for TKR

(Knutson, MD, et al. “Revision of Unicompartmental Knee Arthroplasty: Outcome in 1,135 Cases From the Swedish Knee Arthroplasty Study.” Acta Orthop Scand 1998: 469-474.)

The Most Common Complications

• Knee Arthroplasty

Loosening, deformation or wear of one or more of the components, osteolysis, infection, DVT and fracture of the components or bone.

This procedure is not for everyone. As with any surgery, there are risks. Recovery takes time and hard work. The life of a joint replacement depends on weight, activity level, age and other factors. Each patient responds differently.

UKR TodayUKR TodayMinimally Invasive Technique!Minimally Invasive Technique!

• 6 to 8 in. incision reduced 6 to 8 in. incision reduced to 3 to 4 in.to 3 to 4 in.

• Minimal muscle traumaMinimal muscle trauma

• Extensor mechanism left Extensor mechanism left intactintact

• Conservative bone Conservative bone resectionsresections

• Minimal blood lossMinimal blood loss

• Shorter hospital staysShorter hospital stays

UKR TodayUKR Today Minimally Invasive Technique!Minimally Invasive Technique!

Postoperative RecoveryPostoperative Recovery

• 24 to 48 hour hospitalization 24 to 48 hour hospitalization (outpatient?)(outpatient?)

• Weight-bearing as toleratedWeight-bearing as tolerated

• Improved range of motionImproved range of motion

• Quicker return to activityQuicker return to activity

UKR TodayUKR TodayMinimally Invasive Technique!Minimally Invasive Technique!

3 weeks postoperative

A Modern Implant System Designed forA Modern Implant System Designed for Minimally Invasive SurgeryMinimally Invasive Surgery

Implants

Instruments

GVF-UHMWPE

• Elderly patientElderly patient

• Isolated (uni-compartmental) Isolated (uni-compartmental) osteoarthritisosteoarthritis

• <250 lbs<250 lbs

• Good ROM, minimal deformityGood ROM, minimal deformity

• Relatively sedentary activity levelRelatively sedentary activity level

*Deshmukh, R.V., MD and R.D. Scott, MD, “Unicompartmental Knee Arthroplasty: Long Term Results”, CORR - No. 392 (pgs 272-278), 2001.

Minimally Invasive UKRMinimally Invasive UKRWho is a (traditional*) candidate?Who is a (traditional*) candidate?

Minimally Invasive UKRMinimally Invasive UKRWho is a (relative*) candidate?Who is a (relative*) candidate?

• Younger patients (<65 yrs)Younger patients (<65 yrs)

• >250 lbs>250 lbs

• Higher activity expectations Higher activity expectations (relative)(relative)

• Patella-femoral compartment Patella-femoral compartment arthritisarthritis

*Experience of surgeons currently conducting UKR.

• Younger patients with end-stage uni-compartmental Younger patients with end-stage uni-compartmental arthritis as a good conservative option that minimizes arthritis as a good conservative option that minimizes bone removal and preserves additional options for bone removal and preserves additional options for future surgery (UKR future surgery (UKR TKR) TKR)

• Elderly patients with end-stage uni-compartmental Elderly patients with end-stage uni-compartmental arthritis that would benefit from less surgery, less arthritis that would benefit from less surgery, less down time and less rigorous recoverydown time and less rigorous recovery

*Experience of surgeons currently conducting UKR.

Minimally Invasive UKRMinimally Invasive UKRWho is a (good*) candidate?Who is a (good*) candidate?

Thank youThank you

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