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The Painful Arthritic Joint: Williamsburg Hometown Care Daniel R. Cavazos Hampton Roads Orthopaedics and Sports Medicine “Experience Matters”
The Painful Arthritic Joint: Williamsburg Hometown Care
Daniel R. CavazosHampton Roads Orthopaedics and
Sports Medicine
“Experience Matters”
Osteoarthritis
Osteoarthritis is the gradual wear of the cartilage that covers the ends of the bony surfaces over the course of decades of time.
There is a genetic component to the development of osteoarthritis.
The Normal Knee Joint
The width of the dark interval between the bony surfaces represents the amount of cartilage between them. Cartilage does not have a nerve supply and is NOT a source of pain.
The Arthritic Knee
Notice the complete erosion of the cartilage in the medial compartment of the knee…. Bonehas nerve endings, therefore it is a source of pain.
The Arthritic Hip Joint
Notice the cysts (erosion) in the head of the femur and the dense (scar) bone formation in the acetabulum (cup).
The Characteristics of OA Pain
Do you have stiffness in the morning/ pain after prolonged activities or pain with weight bearing activities?
These characteristics represent the arthritis pain from the pressure on the exposed nerve endings of the bone in the joint interval (hard tissue pain).
The Characteristics of OA Pain
• Does the joint cause night time pain or increased pain at the end of the day?
• This discomfort represents synovitis or (soft tissue pain)
• Synovium is the tissue in a joint which produces the lubricant and removes debris
The Characteristics of OA Pain
Do you have to use the handrail to negotiate stairs?
The use of the handrail often indicates weakness of the leg muscles, in particular the quadricepsmuscles.
These muscles are used to power the hip and knee into extension (make the joints go straight).
The Characteristics of OA Pain
Is it difficult to get into and out of a car because of hip or knee pain? Can you easily don socks?
The loss of this these routine function(s)usually suggests that the hip or knee joint has a loss of motion.
The Characteristics of OA Pain
How far can you walk without pain?
The inability to ambulate is the loss of a basic activity of life and usually represents a lack of endurance.
The Characteristics of OA Pain
The aforementioned characteristics of OA pain can be combined in any manner.
Usually patients will present with both soft and hard tissue pains… the night time pain is often a life changer.. “Cannot get comfortable”
Treatment of OA of the Knee/Hip
Recommend that patients with symptomatic OA of the hip/knee who are overweight (BMI>25) should lose weight.
Weight loss has a definite improvement on the function of the joints.
Weight is a definite contributing factor to OA pain.
Treatment of OA of the Hip/Knee
Patients should participate in low impact aerobic activities (e.g. walking, cycling) as much as possible.
Quadriceps strengthening is suggested.
Range of motion/flexibility exercises provide NObenefit.
Braces are NOT recommended. They offer NOstability.
Treatment of OA of the Knee/Hip
Glucosamine +/- chondroitin sulfate NOT be prescribed.
Acetaminophen(Tylenol) or NSAIDs are recommended for pain relief.
Patients with increased GI risk should use Celebrex, topical NSAIDs or Tylenol( <4 g/day)
Treatment of OA of the Knee/Hip
Intra-articular corticosteriods (cortisone) can provide short term relief (usu. < 1 week duration). Treats the soft tissue pain.
Intra-articular hyaluronic acid (Supartz,Eufflexa)injections may be effective. Treats the hard tissue pain.
These two forms of injection can be combined to effectively “buy some time and delay surgical treatment”.
Treatment of OA of the Knee/Hip
Arthroscopic surgery (clean-up) is NOT recommended in the symptomatic OA patient.. It will only make the pain WORSE.!!!
On the other hand, an arthroscopic partial menisectomy is an option for those OA patients who have mechanical symptoms of a meniscal tear…painful clicking/popping
Platelet Rich Plasma (PRP)
• The healing growth factors reside on the human platelet and are the necessary for the coordination of a healing response.
• A sample of blood is centrifuged to concentrate the platelets in the plasma which is injected into the injured site.. “fertilizer and water”
• PRP growth signals do not recruit stem cells.. they stimulate local healing potential.
Mesenchymal Stem Cells (MSC)
• MSC are isolated from bone marrow aspirates and are thought to be multipotent cells.
• MSCs can differentiate into bone, cartilage, fat tendon and muscle tissues.
• Think of this treatment as “planting seeds into the damaged tissue”.. Blood supply remains a major obstacle to clinical application
Safe Surgery in Modern TKA/THA
“Safe surgery” in a dedicated effort to avoid INFECTIONS and blood transfusions..TWO RED LINES
Sufficient blood volume to minimize the possibility of a transfusion (Hgb > 10). For bilateral knees,(HgB>13)
In all patients, strict control of serum blood sugars (< 120 mg/dl) … measurement of the HgbA1C (<7.0) in diabetics.. Lower risk for infection
Safe Surgery
• The red line of a BMI of less than 40 has become a reality.
Blood Preservation
The most common complication from a blood transfusion is not disease transmission rather, it is getting the wrong blood type.
Tranexamic acid reduces post-operative blood loss and decreases the need for a transfusion.
No use of drains.. Infection risk and increase blood loss.
Safe Surgery in Modern TKA/THA
Betadine swab the nares at the hospital before surgery… 100% EXCEPT ALLERGIC PATIENTS
Pre-surgical scrubs are mandatory.
Safe Surgery in Modern TKA/THA
The “philosophical age”- 75 years of age. This is the age group which is at higher risk for complications.
It is published that patients who are > 75 years of age need a more comprehensive pre-operative evaluation (esp. cardiac).
Surgery is very successful in the mature patient. These patients may require close monitoring.
Total Knee Replacement
The femoral nerve which transmits pain from the anterior thigh and knee is “put to sleep” for approximately 8-10 hours by a adductor nerve block.
Concurrently, the patient receives a multi-modal form of medications to decrease the inflammation which decreases pain and the incised tissues are injected w/ EXPAREL
-- a marked decrease in the level of post-op pain--decrease the use of narcotics with less nausea/vomiting --allows for more rapid early progression of ambulation and recovery of knee range of motion.
Exparel
New technology (Depofoam)..50 million spheres of an analgesic drug which are time released over 8 hours and extends the immediate pain relief from a TKA to about 48 hours:
Hybrid Plasma Scalpel
• Deploys an argon gas blade with a depth of injury of .2 mm vs. 4 mm for the conventional electrocautery..better tissue healing.
• Marked decrease in bleeding… less blood loss and lower transfusion rate.
• No use of tourniquet.. Less post-op swelling and less quadriceps pain.
Incision Care
• No staples to repair incision.
• “Skin glue” to seal the incision.
• No drains.
• 10 day “no touch” dressing.
• Shower on the second day after surgery.
• Text a picture of the incision to our team for further instructions.
Kinematic Conflict: Working Against the Body
Kinematic Alignment: Working with the Body
Single Radius Triathlon (The Get Around Knee): Allows for Stability. Easier to obtain extension.
What is the 0o Mechanical Axis of the Femur?
– A line extending from the center of the femoral head, bisecting the tibial plateau and ankle joint.
– This is the alignment that joint replacement surgeons strive to achieve during TKR.
The Mechanical Axis
Establishing the mechanical axis of the leg maximizes the potential for the knee implants to survive 20 years...
The use of image guidance can readily establish the mechanical axis.. Allows for minimal soft tissue dissection with resultant less scar tissue.. Less pain
MAKOPLASTY
A robotic method of performing total knee replacement and assist in hip replacement.
the precision of a saw.
Improvement on computer guidance?
Hard Bearing Surfaces
• The 1990’s focused on bearing surfaces with a wear rate of less than .1mm/year.
• The development of hard-bearing surfaces-metal on metal , and ceramic on ceramic progressed… not commonly used
• Highly cross linked polyethylene components were refined…lasts for decades
“Small Incision Surgery”
• Dr. Joel Matta popularized the direct anterior (DA) approach.
• Beginning in 2000, patients began to demand surgery through smaller incisions..3” to 4” vs. 8” to 12 “.
• Cut no muscle, ligament, tendon.. Straight to the hip joint which is closest to the skin from the front.
OREF Study
• Again, psychology overcame science in the minds of the public.
• A study funded by the Orthopaedic Research and Education Foundation discovered that 95% of patients wanted MIS/THA for cosmetic reasons, 93% less violation of the body and 89% because of muscle sparing.
Direct Anterior (DA) Approach
• Our team adopted the direct anterior approach for total hip arthroplastypopularized by Dr. John Keggi 14 years ago.
• Our anecdotal results (14 years) are similar to those seen on a national level.
Dr. John Keggi Report
THA Through A Minimally Invasive Anterior Surgical Approach; JBJS, Kennon & Keggi,2003
Reported on 2132 Direct Anterior THAs with the following results:
18 clinically relevant thromboembolic events or .8% 7 infections or .03%
28 dislocations or .13%
The authors attributed these results to the minimal exposure/positioning of the patient
Rapid Recovery with DA Approach
The empirical evidence strongly suggests that DA/THA patients mobilize much quicker and with virtually no restrictions on their activities---
--- 12-24 hour hospital dismissal possible
--- no hip precautions
--- immediate weight bearing
--- bilateral hip surgery
The Jiffy Hip (Direct Anterior)
The red line seen over the hip joint represents the skin incision noted above.. 8cm (approx. 4 inches)long
Intra-operative radiograph of measured leg length using anatomical reference points in a simultaneous bilateral DA/THA patient.
MDMTM X3®Modular Dual MobilityTM Acetabular System
Physical Therapy
• The best inpatient PT in the region based upon my experience. Group therapy is well received and stimulates encouragement
• The TKA patients routinely achieve 90-100 degrees of motion prior to discharge.. 1 day
• The THA patients walk approx. 300 ft. w/in 24 hours after surgery.
Skilled Nursing Facilities (SNF)
• The total joint arthroplasty patient is being discharged to home 94 % of the time.
• The discharge to home rate is a closely measured national metric.
• Most readmissions originate from a SNF.
Recent Trends
“Pre-hab” program to initiate the learning process to make patients as aware of total joint arthroplasty as possible.
Aggressive rehabilitation of all ages of patient.
Moving toward outpatient total joint arthroplasty
Enhanced Response to Surgery (ERAS)
• Clear liquids up to 2 hours before surgery
• Eliminate the use of narcotics pre-op and in the recovery room by giving a combination of special drugs to decrease inflammation, nausea/vomiting and post-op opiod use.
• No IV narcotics post-operative.
Complication/Problem
In our present patient population, the most common complication/problem related to total joint arthroplasty surgery is:
CONSTIPATION
Advancing towards a single two week prescription for narcotics..based on surveys.
EXPECTATIONS
• Our respect for your valuable time and array of anticipated goals of surgery demands we make a maximum effort to educate our patients in the process of arthroplasty and advise them on how to return to their anticipated level of performance as rapidly as possible.. NO SURPRISES.
Most RecentTrends
• Length of stay to Same DaySurgery…Medicare has taken the TKA/THA off the “inpatient list only”.
• Direct to outpatient physical therapy.
• Minimal admissions to a skilled nursing
facility…<1% … coach contract.
Summary
* Osteoarthritis is a painful progressive disease.
* Non-operative options treat early OA.
* Safe surgery to prevent complications of TJA
*Exparel, tranexamic acid, plasma scalpel
*TKA with image guidance with a uniquely designed implant can last 20 years.
* Direct anterior hip replacement (DA Hip) allows for a very rapid recovery.
