Session 19: The New Arthritic Patient and Non- Arthroplasty Treatment Options

Transcription

1 : The New Arthritic Patient and Non- Arthroplasty Treatment Options Learning Objectives Upon completion of this activity, participants should be able to: 1. Detail a treatment algorithm combining both non-operative and operative treatments in managing arthritic patients. 2. Describe non-arthroplasty surgical techniques in the management of the arthritic patient. Moderator Michael A. Kelly, MD Chairman Department of Orthopedic Surgery and Sports Medicine Hackensack University Medical Center Hackensack, New Jersey Director Insall Scott Kelly Institute New York, New York Demographics of the New Patient David Dalury, MD Chief, Adult Reconstruction St Joseph Hospital Towson, Maryland Assistant Professor of Orthopedic Surgery Johns Hopkins School of Medicine Baltimore, Maryland Background: The patient of the future who will be seeking arthroplasties of the hip and knee will be markedly different from those of the last few decades. First of all, there will be many more of them. They will also tend to be younger, heavier, more active, and better informed. For instance, it will no longer be sufficient to provide a total knee replacement (TKR) that is relatively pain-free. The new patient will expect a betterperforming knee that is less painful, bends more, and lasts 30 years. All this, and done via a less traumatic and painful surgical procedure. The new patient will arrive with many more questions and in general be more, if not better, informed via the Internet, marketing, or other research. The trend of heavier and younger patients requesting total joint replacement (TJR) will continue. The higher expectations of the new patient will require enhanced surgical and rehab techniques, improved implants and better education from the

2 surgeon. This talk will highlight the changing face of the TJR patient of the future and offer commentary on how to manage their expectations and needs. Arthroscopic Procedures May Be Temporizing Michael Kelly, MD It was a natural transition to utilize arthroscopic techniques in the management of the mild-to-moderate osteoarthritic knee. As the literature has reviewed clinical results utilizing these procedures, favorable prognostic indicators began to emerge. These included short duration or a mechanical nature to the symptoms, less severe radiographic degenerative joint disease and deformity, and younger-aged patients. The addition of cartilage-resurfacing techniques, such as abrasion arthroplasty and drilling, does not appear to add any benefit. Microfracture remains controversial in this setting. The 2002 Moseley et al study, including a sham surgical procedure in selected patients, did not demonstrate any clinical difference in the arthroscopic procedures and the sham or placebo procedure. 1 While there have been multiple criticisms of this paper, a more recent study from London, Ontario, was published in the New England Journal of Medicine in September This was a prospective, randomized controlled study comparing arthroscopic debridement, optimized medical and physical therapy with optimized medical and physical therapy alone using several validated scoring systems. At 2 years follow-up, they demonstrated no significant differences between the 2 groups. 2 Arthroscopic procedures in the arthritic knee may have a temporizing role, but it is difficult to identify the correct patient. These procedures have a much more limited role in my own practice than 5 years ago. 1. Moseley JB, O Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002:347(2): Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Eng J Med. 2008; 359(11): Kelly MA. Role of arthroscopic debridement in the arthritic knee. J Arthroplasty. 2006;21(4 Suppl): Matsusue Y, Thomson NL. Arthroscopic partial medial meniscectomy in patients over 40 years old: a 5- to 11-year follow-up study. Arthroscopy. 1996;12(1): Livesley PJ, Doherty M, Needoff M, et al. Arthroscopic lavage of osteoarthritic knees. J Bone Joint Surg Br. 1991;73(6): Stuart MJ, Lubowitz JH. What, if any, are the indications for arthroscopic debridement of the osteoarthritic knee? Arthroscopy. 2006;22(3):

3 Tibial Osteotomies: Indications, Techniques, Outcomes Raymond Kim, MD Orthopaedic Surgeon Colorado Joint Replacement Denver, Colorado Tibial osteotomy remains a reasonable treatment for knee arthritis to provide pain relief and functional improvement in young patients with medial compartment degenerative arthritis associated with malalignment, or a necessity to alter the mechanical axis in conjunction with ligamentous reconstruction, meniscal transplantation, or cartilage transplantation. Contraindications for proximal tibial osteotomy include patellofemoral pain, previous meniscectomy or arthrosis in the lateral compartment, and inflammatory disease. Preoperative evaluation should include careful physical examination to assess alignment, range of motion, and the presence of patellofemoral, ligamentous, or lateral compartment pathology. Radiographic evaluation should also be performed with a weight-bearing hipto-ankle film to determine the mechanical axis and to template the osteotomy. Patients should be counseled regarding postoperative recovery, potential complications, and expected clinical results. Proximal tibial osteotomy can be performed with either a medial opening wedge or a lateral closing wedge. Advantages of opening wedge tibial osteotomy include avoidance of the proximal tibiofibular joint, avoidance of the peroneal nerve, and better control of multiplanar deformity correction. Closing wedge provides the advantages of allowing accelerated weightbearing postoperatively and no required bone grafting. Disadvantages include violation of the tibiofibular joint and alteration of patellar height. Properly performed proximal tibial osteotomy yields satisfactory clinical results with appropriate patient selection. 1. Aglietti P, Buzzi R, Vena LM, et al. High tibial valgus osteotomy for medial gonarthrosis: a 10- to 21-year study. J Knee Surg. 2003; 16(1): Berman AT, Bosacco SJ, Kirshner S, et al. Factors influencing long-term results in high tibial osteotomy. Clin Orthop Relat Res. 1991;(272): Billings A, Scott DF, Camargo MP, et al. High tibial osteotomy with a calibrated osteotomy guide, rigid internal fixation, and early motion. Long-term follow-up. J Bone Joint Surg Am. 2000;82(1): Cass JR, Bryan RS. High tibial osteotomy. Clin Orthop Relat Res. 1988;(230): Coventry MB, Ilstrup DM, Wallrichs SL. Proximal tibial osteotomy. A critical long-term study of eighty-seven cases. J Bone Joint Surg Am. 1993;75(2):

4 6. Majima T, Yasuda K, Katsuragi R, et al. Progression of joint arthrosis 10 to 15 years after high tibial osteotomy. Clin Orthop Relat Res. 2000;(381): Naudie D, Bourne RB, Rorabeck CH, et al. The Install Award. Survivorship of the high tibial valgus osteotomy. A 10- to 22-year followup study. Clin Orthop Relat Res. 1999;(367): Ritter MA, Fechtman RA. Proximal tibial osteotomy. A survivorship analysis. J Arthroplasty. 1988;3(4): Rudan JF, Simurda MA. Valgus high tibial osteotomy. A long-term follow-up study. Clin Orthop Relat Res. 1991;(268): Sprenger TR, Doerzbacher JF. Tibial osteotomy for the treatment of varus gonarthrosis. Survival and failure analysis to twenty-two years. J Bone Joint Surg Am. 2003;85-A(3): Femoral Osteotomy: Indications, Technique, Outcomes David Backstein, MD Assistant Professor, Department of Surgery University of Toronto Surgical Skills Centre at Mount Sinai Hospital Toronto, Ontario Osteotomies around the knee for the purpose of deformity correction and unloading of unicompartmental arthritis remain a viable treatment modality in active, physiologically youthful patients. While varus deformity is commonly corrected through the proximal tibia, it is advisable to correct valgus deformity through distal femoral varus osteotomies (DFVOs) due to the frequently associated superolateral slope of the joint line. Such osteotomies can be conducted via medial closing wedge or lateral opening wedge techniques. A recent report studied 40 medial closing wedge DFVOs with a mean followup of 123 months. At most recent follow-up, 24 knees had good or excellent results (60%), 3 were fair (7.5%), and 3 were poor (7.5%). Four of the fair/poor group were awaiting total knee arthroplasty (TKA). Eight knees (20%) had been converted to TKA. Mean Knee Society objective score improved from 18 (range: 0-74) to 87.2 (range: ). Mean Knee Society function score improved from 54 (range: 0-100) to 85.6 (range: ). Ten-year survival rate of the DFVO was 82% (95% confidence interval [CI]: 75%-89%), and the 15-year survival rate was 45% (95% CI: 33%-57%). 1 There is relatively little data in the literature pertaining to the long-term results of DFVO for the treatment of isolated lateral compartment knee arthritis with associated valgus deformity. Survivorship at 10 years has been reported to be in the range of 71% to 82%. 2 Our institution has previously reported 7 of 21 knees (33%) were converted to a total knee replacement at an average of 133 months after distal femoral osteotomy. 3 Recently, Wang et al published series of 30 knees treated with DFVO and reported a satisfactory Hospital for Special Surgery (HSS) score in 83% at a mean of follow-up of 99 months. 4 In summary, DFVO remains a viable alternative for the treatment of unicompartmental

5 arthritis of the knee, particularly in young and active patients. Ten-year survivorship data demonstrate reliable outcomes which may assist in delaying the inevitable need for TKA. 1. Backstein D, Morag G, Hanna S, et al. Long-term follow-up of distal femoral varus osteotomy of the knee. J Arthroplasty. 2007;22(4 Suppl 1): Edgerton BC, Mariani EM, Morrey BF. Distal femoral varus osteotomy for painful genu valgum. A five-to-11-year follow-up study. Clin Orthop Relat Res. 1993;(288): Finkelstein JA, Gross AE, Davis A. Varus osteotomy of the distal part of the femur. A survivorship analysis. J Bone Joint Surg Am. 1996;78(9): Wang JW, Hsu CC. Distal femoral varus osteotomy for osteoarthritis of the knee. J. Bone Joint Surg Am. 2005;87(1): Case Presentations and Discussion David Backstein, MD; Henry D. Clarke; David Dalury, MD; Michael A. Kelly, MD; Raymond Kim, MD