2016: osteoarthritis and total joint replacement-meyer
TRANSCRIPT
OFFICE TREATMENT OF ORTHOPAEDIC INFECTIONS
OSTEOARTHRITIS AND TOTAL JOINT REPLACEMENTR. Scott Meyer, M.D. Section Chief, Orthopaedic SurgeryVA San Diego Healthcare SystemClinical ProfessorDepartment of Orthopaedic SurgeryUC San Diego Health System3rd Annual Clinical Geriatrics Interprofessional SymposiumDecember 3, 2016
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DisclosuresNone
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Overview of Osteoarthritis27 million Americans with osteoarthritis1/3 adults >age 60 have knee OAKnee > hip (3x)Women > men
1985 - 35 million 1990 - 37.9 million 1998 - nearly 43 million (1 in 6 people) 2005 66 million (nearly 1 in 3 adults) -- 42.7 million have doctor-diagnosed arthritis and 23.2 million people live with chronic joint symptoms, but have not been diagnosed by a doctor Arthritis is one of the most prevalent chronic health problems and the nations leading cause of disability among Americans over age 15. Arthritis is second only to heart disease as a cause of work disability. Arthritis limits everyday activities such as walking, dressing and bathing for more than 7 million Americans. Arthritis results in 39 million physician visits and more than a half million hospitalizations. Costs to the U.S. economy totals more than $86.2 billion annually. Arthritis affects people in all age groups including nearly 300,000 children. Baby boomers are now at prime risk. More than half those affected are under age 65. Half of those Americans with arthritis dont think anything can be done to help them. Arthritis refers to more than 100 different diseases that affect areas in or around joints. Arthritis strikes women more often than men.
Cost approx direct (medical care), indirect ie. Lost wagesPage #
Overview of Osteoarthritis22% of all ambulatory care visits$128 billion to US economyMedical careLost wages/productivity
1985 - 35 million 1990 - 37.9 million 1998 - nearly 43 million (1 in 6 people) 2005 66 million (nearly 1 in 3 adults) -- 42.7 million have doctor-diagnosed arthritis and 23.2 million people live with chronic joint symptoms, but have not been diagnosed by a doctor Arthritis is one of the most prevalent chronic health problems and the nations leading cause of disability among Americans over age 15. Arthritis is second only to heart disease as a cause of work disability. Arthritis limits everyday activities such as walking, dressing and bathing for more than 7 million Americans. Arthritis results in 39 million physician visits and more than a half million hospitalizations. Costs to the U.S. economy totals more than $86.2 billion annually. Arthritis affects people in all age groups including nearly 300,000 children. Baby boomers are now at prime risk. More than half those affected are under age 65. Half of those Americans with arthritis dont think anything can be done to help them. Arthritis refers to more than 100 different diseases that affect areas in or around joints. Arthritis strikes women more often than men.
Cost approx direct (medical care), indirect ie. Lost wagesPage #
Overview of OsteoarthritisLimits activities of daily living #1 cause of disabilityExcess mortality compared with general population
1985 - 35 million 1990 - 37.9 million 1998 - nearly 43 million (1 in 6 people) 2005 66 million (nearly 1 in 3 adults) -- 42.7 million have doctor-diagnosed arthritis and 23.2 million people live with chronic joint symptoms, but have not been diagnosed by a doctor Arthritis is one of the most prevalent chronic health problems and the nations leading cause of disability among Americans over age 15. Arthritis is second only to heart disease as a cause of work disability. Arthritis limits everyday activities such as walking, dressing and bathing for more than 7 million Americans. Arthritis results in 39 million physician visits and more than a half million hospitalizations. Costs to the U.S. economy totals more than $86.2 billion annually. Arthritis affects people in all age groups including nearly 300,000 children. Baby boomers are now at prime risk. More than half those affected are under age 65. Half of those Americans with arthritis dont think anything can be done to help them. Arthritis refers to more than 100 different diseases that affect areas in or around joints. Arthritis strikes women more often than men.
Cost approx direct (medical care), indirect ie. Lost wagesPage #
Overview of OsteoarthritisOA is a disease with NO cureNo disease modifying drugsTreatment for early OA Prevent disease progressionLate disease is NOT just a cartilage problemDeformityLigamentsBone lossStiffness
1985 - 35 million 1990 - 37.9 million 1998 - nearly 43 million (1 in 6 people) 2005 66 million (nearly 1 in 3 adults) -- 42.7 million have doctor-diagnosed arthritis and 23.2 million people live with chronic joint symptoms, but have not been diagnosed by a doctor Arthritis is one of the most prevalent chronic health problems and the nations leading cause of disability among Americans over age 15. Arthritis is second only to heart disease as a cause of work disability. Arthritis limits everyday activities such as walking, dressing and bathing for more than 7 million Americans. Arthritis results in 39 million physician visits and more than a half million hospitalizations. Costs to the U.S. economy totals more than $86.2 billion annually. Arthritis affects people in all age groups including nearly 300,000 children. Baby boomers are now at prime risk. More than half those affected are under age 65. Half of those Americans with arthritis dont think anything can be done to help them. Arthritis refers to more than 100 different diseases that affect areas in or around joints. Arthritis strikes women more often than men.
Cost approx direct (medical care), indirect ie. Lost wagesPage #
Overview of OsteoarthritisCausesHereditary (genetic predisposition)OBESITYPost-traumaticAging
1985 - 35 million 1990 - 37.9 million 1998 - nearly 43 million (1 in 6 people) 2005 66 million (nearly 1 in 3 adults) -- 42.7 million have doctor-diagnosed arthritis and 23.2 million people live with chronic joint symptoms, but have not been diagnosed by a doctor Arthritis is one of the most prevalent chronic health problems and the nations leading cause of disability among Americans over age 15. Arthritis is second only to heart disease as a cause of work disability. Arthritis limits everyday activities such as walking, dressing and bathing for more than 7 million Americans. Arthritis results in 39 million physician visits and more than a half million hospitalizations. Costs to the U.S. economy totals more than $86.2 billion annually. Arthritis affects people in all age groups including nearly 300,000 children. Baby boomers are now at prime risk. More than half those affected are under age 65. Half of those Americans with arthritis dont think anything can be done to help them. Arthritis refers to more than 100 different diseases that affect areas in or around joints. Arthritis strikes women more often than men.
Cost approx direct (medical care), indirect ie. Lost wagesPage #
WorkupPlain xraysKneeSTANDING AP!!!!!LateralMerchant/SunriseConsider Rosenberg view
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WorkupPlain xraysHipAP pelvisAP/Lateral hipNot typically weight bearing
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Weight-Bearing Xrays
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Weight-Bearing Xrays
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Merchant View
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Rosenberg View
30 deg
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Rosenberg View
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WorkupMRI is NOT indicated in moderate/severe OAMRI is RARELY indicated in mild OASymptomatic meniscus tearDifficult to distinguish clinicallyCommon, incidental findingEven if meniscal tear is diagnosis still require standing plain xrays of knee
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MRI reportACL tearMacerated, complex tear of the medial meniscusComplex tear of the lateral meniscusSignal change in the MCL consistent with partial tearSubchondral bone edema and cystsGanglion cyst adjacent to the PCLLarge popliteal cystMultiple intra-articular bodiesLarge joint effusionDiffuse synovial hypertrophySEVERE OSTEOARTHRITIS OF THE KNEE
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Management of OA
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Management of OAOARSINon-pharmacologicPatient education self help, patient drivenP.T. HEP, strength trainingAerobic exercise JUST LIKE LBP!!Aqua exerciseWeight lossBracing/Sleeves/Shoe insertsCaneTensAcupuncture
AppropriateAppropriateAppropriateAppropriateAppropriateAppropriateAppropriateUncertainUncertain
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Management of OAOARSIPharmacologicAcetaminophenNSAIDSTopical NSAIDSIA steroid injectionsIA hyaluronate injectionsGlucosamine/CSWeak opioidsOnly if non-opioids failedStronger opioids only in exceptional circumstances
AppropriateAppropriateAppropriateAppropriateUncertainUncertainUncertain
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Management of OA
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Management of OAAAOS GuidelinesSORSelf-management educational programStrongWeight lossModerateAgainst use of acupuncture/tens/manualStrongBracingInconcl.NO lateral heel wedgeModerateNo glucosamine/CSStrong7a. NSAIDS or TramadolStrong7b. Tylenol, opioids, pain patchesInconcl.8. Intra-articular steroidsInconcl.
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Management of OAAAOS GuidelinesSOR9. No HA injectionsStrong PRP or growth factor injectionsInconcl. No needle lavageModerate No arthroscopy for debridementStrong Arthroscopic meniscectomyInconcl. OsteotomyLimited No uni-spacerConsensus
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Management of OAHA injectionsAAOS recommends againstOlder supportive studies flawed publication biasMCII (minimum clinically important improvement) Recommendation controversial, criticizedWorks for my patients!Many studies show efficacy10 CPG: 30% yes, 30% no, 40% inconcl.Better studies neededStill used widely by surgeons and others
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Management of OAPRP/MSC injectionsMeheux et al. Systematic Review (Arthroscopy 2016;32(3):495)Efficacy up to 12 monthsBetter than HAExpensive, not covered by insuranceWhat are they doing??
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Management of OAObesity and OADirect link, particularly with knee OAForces across knee 3X BW with walking, 6X BW with stairsMal-alignment magnifies the problemNOT JUST MECHANICAL
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Management of OAObesity and OASystemic componentFat is an endocrine organPro-inflammatory cytokines (adipokines)Elevated crp, IL-6, etc.. MES (obesity, HTN, IR, dyslipidemia now add OA)Obesity linked with PAINTendons, fascia, FM
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Management of OAWeight lossFor 1 lb weight loss, 4 lb reduction knee loadMessier et al. Arth & Rheum 2005Losing 11 lbs can reduce your risk of OA by 50%Felson et al. Ann Int Med 1992Losing 15 lbs can reduce pain by 50%Bartlett et al. Arth & Rheum 2004
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Management of OAWeight lossObesity is associated with other co-morbidities which increase surgical riskDM, CAD, etc..Obesity increases perioperative risk ofInfectionWound healingDVT/PEMost patients GAIN WEIGHT after surgery
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Management of OAOpioid therapyOARSI - uncertainAAOS - InconclusiveCochrane Review da Costa et. al. 2009The small mean benefit of non-tramadol opioids are contrasted by significant increases in the risk of adverse events.For the pain outcome in particular, observed effects were of questionable clinical relevance No MCID.
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Management of OAOpioid therapySurgery recommended in most cases of severe OAVERY difficult postoperative careMany significant side effectsNegative prognostic indicator for outcomeDetox prior to surgery recommended
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Management of OA
Role for arthroscopy of the knee?Loose bodyIntra-articular bodies are incidentalNOT for meniscus tears if significant OA
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Management of OANo benefit to arthroscopy compared to P.T. and medical therapy
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Management of OAMensicus tears COMMON in OA of the knee81% of surgical patients had debridement of meniscus
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Management of OAAttributing pain to meniscus tear is difficult52% had catching/locking88% joint line pain
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Management of OANo difference at 6 months30% cross-overBottom line try physical therapy first
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Management of OATotal Joint Arthroplasty
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Overview of Total Joint Replacement650,000 TKA per year (2010)290,000 THA per year (2010)Kurtz et. al. JBJS AM 2014;96:624-630.Very high success rate (>90%)Significant positive impact on quality of life
1985 - 35 million 1990 - 37.9 million 1998 - nearly 43 million (1 in 6 people) 2005 66 million (nearly 1 in 3 adults) -- 42.7 million have doctor-diagnosed arthritis and 23.2 million people live with chronic joint symptoms, but have not been diagnosed by a doctor Arthritis is one of the most prevalent chronic health problems and the nations leading cause of disability among Americans over age 15. Arthritis is second only to heart disease as a cause of work disability. Arthritis limits everyday activities such as walking, dressing and bathing for more than 7 million Americans. Arthritis results in 39 million physician visits and more than a half million hospitalizations. Costs to the U.S. economy totals more than $86.2 billion annually. Arthritis affects people in all age groups including nearly 300,000 children. Baby boomers are now at prime risk. More than half those affected are under age 65. Half of those Americans with arthritis dont think anything can be done to help them. Arthritis refers to more than 100 different diseases that affect areas in or around joints. Arthritis strikes women more often than men.
Cost approx direct (medical care), indirect ie. Lost wagesPage #
Overview of Total Joint ReplacementLow major complication rate (1%)Only 10% of patients will require revision surgery10% of 1 million is 100,000 revisionsRevisions are expensive and less predictable outcome and more complications
Revision burden double for THA, mainly because more patients alive with THA than with TKA likely due to so many TKA put in elderly patients that they die before revision so at any given point in time, even though more TKA done that THA, there are more patients alive with THA than TKA. Page #
Overview of Total Joint ReplacementFuture demand?By 2020:1.4 million TKA500,000 THA200,000 revisionsBy 2030:4.5 million total joints!
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Total Joint ArthroplastyWidely successfulRapid improvement in pain/function (90%)Durable
1985 - 35 million 1990 - 37.9 million 1998 - nearly 43 million (1 in 6 people) 2005 66 million (nearly 1 in 3 adults) -- 42.7 million have doctor-diagnosed arthritis and 23.2 million people live with chronic joint symptoms, but have not been diagnosed by a doctor Arthritis is one of the most prevalent chronic health problems and the nations leading cause of disability among Americans over age 15. Arthritis is second only to heart disease as a cause of work disability. Arthritis limits everyday activities such as walking, dressing and bathing for more than 7 million Americans. Arthritis results in 39 million physician visits and more than a half million hospitalizations. Costs to the U.S. economy totals more than $86.2 billion annually. Arthritis affects people in all age groups including nearly 300,000 children. Baby boomers are now at prime risk. More than half those affected are under age 65. Half of those Americans with arthritis dont think anything can be done to help them. Arthritis refers to more than 100 different diseases that affect areas in or around joints. Arthritis strikes women more often than men.
Cost approx direct (medical care), indirect ie. Lost wagesPage #
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68 yo male
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2 weeks postop
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Overview of Total Joint ReplacementThe Perfect Operation?
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How long do they last?
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How long do they last?
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How long do they last?
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How long do they last?In general total hips and knees fail about 0.5% to 1% per year (durable!)
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Why do they fail?KneeInfection 25%Implant loosening/breakage 20%HipDislocation 22%Implant loosening 20%Infection 15%
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Ficat and Arlet in Europe and Hungerford in USPage #
Ficat and Arlet in Europe and Hungerford in USPage #
Ficat and Arlet in Europe and Hungerford in USPage #
Ficat and Arlet in Europe and Hungerford in USPage #
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Are patients happy?Outcomes THA90% patient satisfaction95% would undergo same operation againOutcomes TKA80% patient satisfaction90% would undergo same operation again
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TKA OutcomesPatient satisfaction why not everyone?
ExpectationsPersistent pain
From: Scott et al. JBJS(B) 2010;92(9):1253-58Bourne et al. CORR 2010;468:57-63
Edinburgh UKProspectiveSent questionaires94% response (1213/1290)Page #
Overview of Total Joint ReplacementPatients must be properly indicatedNot for everyoneStill have not solved long term failures and need for revisionsProsthetic joint infectionRevisions are complicatedRevisions have poorer outcomesRisks uncommon but can be devastating
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THA/TKA Referral Criteria Significant OA (complete JS loss)BMI