Modern concepts in Joint Modern concepts in Joint replacement surgeryreplacement surgery

Dr. K. N. Srikanth,Dr. K. N. Srikanth,Consultant Knee and Hip surgeonConsultant Knee and Hip surgeon

MBBS, AFRCS, MSc (T & O, MBBS, AFRCS, MSc (T & O, WrightingtonWrightington), FRCS (Eng) ), FRCS (Eng) Trauma & OrthTrauma & Orth

Formerly Consultant in Trauma and Joint replacement Formerly Consultant in Trauma and Joint replacement surgery, UKsurgery, UK

MD Sarathi Super specialty Knee & Hip centre, MD Sarathi Super specialty Knee & Hip centre, Gavipuram, BangaloreGavipuram, Bangalore

Consultant in Sagar/Manipal/Sparsh/Apollo/MSRS Consultant in Sagar/Manipal/Sparsh/Apollo/MSRS group of hospitals, Bangaloregroup of hospitals, Bangalore

Website: Www.Srikanthkn.comWebsite: Www.Srikanthkn.com

Before I start!Before I start!

• Happy Krishna Happy Krishna janmastamijanmastami

• Thank you for your Thank you for your valuable timevaluable time

• Thank Medilab & Thank Medilab & Lucid team for this Lucid team for this meetmeet

Dr. K. N. SrikanthDr. K. N. Srikanth• Trained in UK, in all aspects of Orthopaedics and Trained in UK, in all aspects of Orthopaedics and

TraumaTrauma• Specialist interest in Computer assisted knee Specialist interest in Computer assisted knee

surgery/PSI (GMC recognised Fellowship at surgery/PSI (GMC recognised Fellowship at Plymouth/Exeter teaching Hospitals)Plymouth/Exeter teaching Hospitals)

• Specialist interest in Hip and Knee sports & Revision Specialist interest in Hip and Knee sports & Revision surgery(Avon Orthopaedic Centre, Bristol Fellowship)surgery(Avon Orthopaedic Centre, Bristol Fellowship)

• Septic revision (Fellowship in Germany)Septic revision (Fellowship in Germany)• UG & PG from Bangalore Medical college, BangaloreUG & PG from Bangalore Medical college, Bangalore• National Merit Scholar through outNational Merit Scholar through out• Bring experience of more than 10,000 Joint Bring experience of more than 10,000 Joint

replacements over 14 years in UKreplacements over 14 years in UK

Bangalore Medical college Bangalore Medical college and research institute, and research institute, Bangalore, India-Where it all Bangalore, India-Where it all started!started!

General Medical Council(UK) General Medical Council(UK) recognised fellowship in Knee/Hip recognised fellowship in Knee/Hip replacement(Plymouth)replacement(Plymouth)

Presentation of Fellowship-Presentation of Fellowship-By Dr. Jon Keenan-DirectorBy Dr. Jon Keenan-Director

Recognition of excellence in Recognition of excellence in Knee replacement surgeryKnee replacement surgery

Revision(re-do) Knee and Revision(re-do) Knee and Hip fellowship-Avon Hip fellowship-Avon Orthopaedic Centre, Bristol, Orthopaedic Centre, Bristol, UKUK• Dr. Evert smith, UK Dr. Evert smith, UK

head of European head of European Hip societyHip society

• Mr. Antony Ward, Mr. Antony Ward, Director of Director of Acetabular & Pelvic Acetabular & Pelvic reconstruction, UKreconstruction, UK

At Endo-klinic with Prof At Endo-klinic with Prof GerkheGerkhe• Septic revision Septic revision

fellowship at Endo-fellowship at Endo-Klinic Hamburg, Klinic Hamburg, Germany-One of Germany-One of few single stage few single stage septic revision septic revision surgeons for the surgeons for the world.world.

Arthritis a Common Arthritis a Common Orthopaedic conditionsOrthopaedic conditions• Arthritis-14 million Knee OA pts in IndiaArthritis-14 million Knee OA pts in India• Knee and Hip OA> 20 million ptsKnee and Hip OA> 20 million pts• Increased life expectancy in last 10 Increased life expectancy in last 10

years-increase in the prevalence of OAyears-increase in the prevalence of OA• (Big skill shortage- Every trained and (Big skill shortage- Every trained and

untrained surgeon at Knee/Hip untrained surgeon at Knee/Hip replacement- Garbage in-Garbage out)replacement- Garbage in-Garbage out)

The Knee Arthritis- a The Knee Arthritis- a complex 3D hingecomplex 3D hingeWhat is causing the What is causing the

knee pain? knee pain? • How old is the patient? How old is the patient? • Was there a traumatic Was there a traumatic

event? event? • Where is the pain Where is the pain

located? located? • Did the symptoms Did the symptoms

develop immediately develop immediately or over time? or over time?

• Once these questions Once these questions are answered, can are answered, can begin to investigate begin to investigate the symptoms. the symptoms.

• Putting the symptoms Putting the symptoms together with the together with the examination often examination often leads to a diagnosis.leads to a diagnosis.

Site of painSite of pain• Front of the knee : Front of the knee : Pain over the front of the knee is Pain over the front of the knee is

most commonly related to the most commonly related to the knee cap. knee cap.

• Inside of the knee : Inside of the knee : Pain on the inside, or medial Pain on the inside, or medial

aspect, of the knee is aspect, of the knee is commonly caused by medial commonly caused by medial meniscus tears, medial meniscus tears, medial collateral ligament injuries, collateral ligament injuries, and arthritis of the joint.and arthritis of the joint.

• Outside of the knee : Outside of the knee : Pain on the outside of the knee, Pain on the outside of the knee,

or lateral aspect of the knee or lateral aspect of the knee joint, is commonly caused by joint, is commonly caused by lateral meniscus tears, lateral lateral meniscus tears, lateral collateral ligament injuries, IT collateral ligament injuries, IT band tendonitis, and arthritis band tendonitis, and arthritis of the joint. of the joint.

• Pain in the back of the knee :Pain in the back of the knee : Baker's Cyst, in the back of the Baker's Cyst, in the back of the

knee joint due to OA. knee joint due to OA. kneecap pain to be felt in the kneecap pain to be felt in the

back of the kneeback of the knee

Take home pointsTake home points• Pain while walking down steps is very commonly Pain while walking down steps is very commonly

associated with knee cap problems, such as associated with knee cap problems, such as chondromalacia/PF OA.chondromalacia/PF OA.

• Morning pain : Pain after first waking in the Morning pain : Pain after first waking in the morning that resolves with gentle activity is morning that resolves with gentle activity is typical of early arthritis. typical of early arthritis.

• Sharp pain with clicking, locking of knee is due to Sharp pain with clicking, locking of knee is due to meniscal pathology, PF problem or a loose meniscal pathology, PF problem or a loose fragment in Kneefragment in Knee

• Pop associated with swelling and knee giving way Pop associated with swelling and knee giving way is due to cruciate ligament injuryis due to cruciate ligament injury

Arthritis of KneeArthritis of Knee• Any of the rheumatic diseases may Any of the rheumatic diseases may

commence in the form of isolated commence in the form of isolated arthritis of the kneearthritis of the knee

InvestigationsInvestigations• FBC/U & E/Clotting/Gp & FBC/U & E/Clotting/Gp &

Save/ECG/CXRSave/ECG/CXR• Weight bearing Weight bearing

AP/Lateral/Sky line-X AP/Lateral/Sky line-X raysrays

• Indication for whole leg Indication for whole leg filmsfilms

-bowing/previous -bowing/previous fractures/tall/short fractures/tall/short patients/Osteotomiespatients/Osteotomies

• Measurements:Valgus Measurements:Valgus cut angle/MATcut angle/MAT

Types of non replacement Types of non replacement surgeriessurgeries• Diagnostic ARTHROSCOPYDiagnostic ARTHROSCOPY• ARTROSCOPIC MENISCAL TRIMMING/ ARTROSCOPIC MENISCAL TRIMMING/

REPAIRREPAIR• Arthroscopic micro-fractureArthroscopic micro-fracture• Arthroscopic OATS grafting(Not MRI!)Arthroscopic OATS grafting(Not MRI!)• Arthroscopic ACI/MACIArthroscopic ACI/MACI• ACL/PCL/PLC knee surgery –ACL/PCL/PLC knee surgery –

Replacement of damaged structures.Replacement of damaged structures.

Indications for knee Indications for knee replacement surgeryreplacement surgery• Osteoarthritis-96%Osteoarthritis-96%• Inflammatory arthritis-3%Inflammatory arthritis-3%• Post traumatic ArthritisPost traumatic Arthritis• Avg age-67(38-96)(UK data, No Avg age-67(38-96)(UK data, No

Indian data!)Indian data!)• F>MF>M

Types of Knee replacement Types of Knee replacement surgerysurgery• Partial knee replacement surgery- Medial, Partial knee replacement surgery- Medial,

lateral uni or PF replacementlateral uni or PF replacement• Total knee replacementTotal knee replacement• Modern concepts: Computer navigated Modern concepts: Computer navigated

surgery-predictable accuracy, makes surgery-predictable accuracy, makes surgery safe and recordable and prepares surgery safe and recordable and prepares better surgeons of tomorrow(Transparency better surgeons of tomorrow(Transparency & accountability)& accountability)

• Patient specific implants(All Knees are not Patient specific implants(All Knees are not same!)same!)

KNEE REPLACEMENTSKNEE REPLACEMENTS• Definition: Neuropathic spacer to Definition: Neuropathic spacer to

relieve pain from an arthritic relieve pain from an arthritic joint.joint.

• Types:Types: -Uni compartmental (Oxford/MG)-Uni compartmental (Oxford/MG) -Patello-femoral( Avon/ Lubinus)-Patello-femoral( Avon/ Lubinus) -Total Knee Replacement -Total Knee Replacement 1. Unconstrained-CR/PS1. Unconstrained-CR/PS 2. Constrained non hinged2. Constrained non hinged 3. Constrained Hinged3. Constrained Hinged -Minimal access TKR-5%-Minimal access TKR-5%

Common myths and Common myths and (mal?)practice(mal?)practiceMyths 1Myths 1• Eyeballing better than computer Eyeballing better than computer

navigation!navigation!• One size fits all!(Truth- Every Knee is One size fits all!(Truth- Every Knee is

unique)unique)• Bilateral knee and hip replacements are Bilateral knee and hip replacements are

better than staged procedures (better than staged procedures (Restrepo C, Parvizi J, Restrepo C, Parvizi J,

JBJS America, 2007, meta-analysisJBJS America, 2007, meta-analysis))• Claiming greatness (TKR) with a 2D solution Claiming greatness (TKR) with a 2D solution

to a 3D problem!to a 3D problem!

Common myths in India!Common myths in India!Myths 2Myths 2

• Any body can do Any body can do a Knee and hip a Knee and hip replacement!replacement!

• UK trainee UK trainee survey-My survey-My registrar in UK registrar in UK also thought so!also thought so!

John Insall-Father of Knee John Insall-Father of Knee replacement surgeryreplacement surgery• Knee Knee

replacement is a replacement is a soft tissue soft tissue operation with operation with some bony cutssome bony cuts

Role of ligaments in the Role of ligaments in the knee!knee!• Primary restraint to Ant Primary restraint to Ant

translation in flex/ext-ACL, translation in flex/ext-ACL, 2ndry=ITB(20%),Med/lat 2ndry=ITB(20%),Med/lat capsule-20%, MCL=LCL(10%)capsule-20%, MCL=LCL(10%)

• Posterior restraint-Posterior restraint-PCL(90%),2ndry-PLC,MCLPCL(90%),2ndry-PLC,MCL

• IR: Primary restraint-ACL, IR: Primary restraint-ACL, 2ndry-POL,PMC2ndry-POL,PMC

• ER: Primary restraint-Fibulo-ER: Primary restraint-Fibulo-pop lig, PLC inc LCL at 30 deg pop lig, PLC inc LCL at 30 deg & PCL at 90 deg(basis of dial & PCL at 90 deg(basis of dial test). MCL at all angles!test). MCL at all angles!

• Valgus: Sup MCL at 30 Valgus: Sup MCL at 30 deg(Full extn=PMC) 2ndry-deg(Full extn=PMC) 2ndry-ACLACL

• Varus: Primary=LCL max at Varus: Primary=LCL max at 30 deg, 2ndry-ACL30 deg, 2ndry-ACL

6 Degrees of Freedom-Knee a 6 Degrees of Freedom-Knee a Complex 3D HingeComplex 3D Hinge

Real answer to common Real answer to common myth in India!myth in India!

• So, Have answered if So, Have answered if Any body can do a Knee Any body can do a Knee and hip replacement!and hip replacement!

• A clear ‘NO’, if you have A clear ‘NO’, if you have the patient interest at the patient interest at your heart! -Primum Non your heart! -Primum Non NocereNocere

• Proper training and Proper training and experience a MUSTexperience a MUST

• So the modern concepts, So the modern concepts, Why Navigation /PSI?Why Navigation /PSI?

You Know why he is the You Know why he is the best in the world-You can best in the world-You can measure what he has done.measure what he has done.

Limitation of human eyeLimitation of human eye• Eyeballing can’t differentiate less than 10 Eyeballing can’t differentiate less than 10

degrees of change in the angulationdegrees of change in the angulation• More than 6 degrees change in Varus/ valgus More than 6 degrees change in Varus/ valgus

alignment leads to catastrophic failure of TKR!alignment leads to catastrophic failure of TKR!(Ref 4,6)(Ref 4,6)

• You don’t want a bad day at office to effect the You don’t want a bad day at office to effect the outcome of your patient surgeryoutcome of your patient surgery

• You want to minimise surgeon error when so You want to minimise surgeon error when so many factors are at play(some known and many many factors are at play(some known and many unknown)!unknown)!

So the need for a patient specific Implant/ So the need for a patient specific Implant/ computer navigation in Knee surgerycomputer navigation in Knee surgery

Variety: PSIVariety: PSIShape matching/Tru Shape matching/Tru matching/prophecy (Wright), matching/prophecy (Wright), visionaries(S-N)- type of patient visionaries(S-N)- type of patient specific TKR.specific TKR.Navigation:Navigation:1. ASM/Precision/Ortho-Pilot1. ASM/Precision/Ortho-Pilot

Why Change?Why Change?• Historical MythsHistorical Myths1. A 2 D hinge1. A 2 D hinge2. J curve kinematics2. J curve kinematics3. TEA defines rotation-Now the 3. TEA defines rotation-Now the

Trans-cylindrical axis!Trans-cylindrical axis!

Trans-Cylindrical axis(TCA)Trans-Cylindrical axis(TCA)

Arthritic ModelInternal geometry of the jigs

Planning ModelAlignment of the

Implants

What is Shape What is Shape Matching?Matching?

Two 3D Models are ProducedTwo 3D Models are Produced

Custom made femoral and tibial cutting guides are Custom made femoral and tibial cutting guides are machined to match the virtual plan of the knee and to machined to match the virtual plan of the knee and to position the femoral and tibial components in all 6 position the femoral and tibial components in all 6 degrees of freedom.degrees of freedom.

OtisMedOtisMed®® ShapeMatch ShapeMatch® ®

TechnologyTechnology

Hospital

6. Surgery performed with guide

4. (Surgeon validates planning via web)

2. Acquire CT / MRI Scan

1. Surgeon creates order via web.

3. Semi-automatic planning

5. Template production

Send MRI\CT scan via web

Send templatewith surgery plan

Stryker

OtisMed® ShapeMatch® Technology

Post Op X- raysPost Op X- rays

Patient specific implant (Shape Patient specific implant (Shape matching)matching)• Advantage:Advantage:1. Reduced op time by 20 minutes/case1. Reduced op time by 20 minutes/case2. Reduced bleeding and trays to 2 form 8.2. Reduced bleeding and trays to 2 form 8.3. ?Reduced cost- 200£+300£(MRI)=500£3. ?Reduced cost- 200£+300£(MRI)=500£4. MIS surgery4. MIS surgery5. Patient specific knee5. Patient specific knee6. Better function and ‘forgotten knee’- Holy 6. Better function and ‘forgotten knee’- Holy

grail!!!grail!!!

Patient specific Hip Patient specific Hip ReplacementReplacement

• In 50% of modern THR In 50% of modern THR the exact center of hip the exact center of hip rotation is not achieved.rotation is not achieved.(Ref 7)(Ref 7)

• Hence need for a Hence need for a navigation/PSI particularly navigation/PSI particularly in younger patientsin younger patients

• Choice of ProsthesisChoice of Prosthesis- resurfacing- resurfacing- un-cemented- un-cemented

• Choice of BearingsChoice of Bearings- ceramic,X3 on Ceramic- ceramic,X3 on Ceramic

3D CT Planning with Hip 3D CT Planning with Hip PlanPlan

Symbios Total Hip Symbios Total Hip ReplacementReplacement

• Pre op 3D CT Pre op 3D CT • Exact fit Anatomic Exact fit Anatomic

THRTHR• Better Functional Better Functional

resultresult• Longer life(95% Longer life(95%

stem survival at 15 stem survival at 15 years in less than 50 years in less than 50 year old pts)(ref 7)year old pts)(ref 7)

Modern concepts of TJR: Navigation & Modern concepts of TJR: Navigation & Patient specific implant (Summary)Patient specific implant (Summary)

• Advantage:Advantage:1. Customize the implant to the patient for better outcome 1. Customize the implant to the patient for better outcome

& longevity.& longevity.2. Reduced op time by 20 minutes/case.2. Reduced op time by 20 minutes/case.2. Reduced bleeding and trays to 2 from 8.2. Reduced bleeding and trays to 2 from 8.3. ?Reduced cost- by reduction of revision burden-As 3. ?Reduced cost- by reduction of revision burden-As

doctors we should not contribute to this.doctors we should not contribute to this.4. MIS surgery.4. MIS surgery.5. And achieve ‘forgotten knee/hip’- Holy grail!!!5. And achieve ‘forgotten knee/hip’- Holy grail!!!

Questions?Questions?• Seeking possibilities where others Seeking possibilities where others

see a full stop- ‘A die hard attitude’see a full stop- ‘A die hard attitude’

Take Home message-to Take Home message-to PatientsPatients• Choose the surgeon carefully(eg: Choose the surgeon carefully(eg:

time for Op, tall claims)time for Op, tall claims)• Check if he is fellowship trained in Check if he is fellowship trained in

joint replacement surgery & where?joint replacement surgery & where?• Ask him about his results and Ask him about his results and

complications & not literaturecomplications & not literature

The proof of the pudding!The proof of the pudding!

Thank youThank youWe are what we repeatedly We are what we repeatedly

do. Excellence is therefore not do. Excellence is therefore not an act but a habitan act but a habit

Help me to serve our patients Help me to serve our patients better-a win-win approach for better-a win-win approach for

all!all!

ReferencesReferences1. Robert B. Bourne, Bert M, Chesworth M: Patient Satisfaction after Total Knee Arthroplasty, Who is Satisfied and Who is Not? 1. Robert B. Bourne, Bert M, Chesworth M: Patient Satisfaction after Total Knee Arthroplasty, Who is Satisfied and Who is Not? Clinc Orthop Relat Res (2010) 468:57–63(Canada)Clinc Orthop Relat Res (2010) 468:57–63(Canada)2. Janse AJ, Gemke RJ, Uiterwaal CS, van der Tweel I, Kimpen JL, Quality of life: patients and doctors don’t always agree: a 2. Janse AJ, Gemke RJ, Uiterwaal CS, van der Tweel I, Kimpen JL, Quality of life: patients and doctors don’t always agree: a meta-analysis. J Clin Epidemiol. 2004;57:653–661.meta-analysis. J Clin Epidemiol. 2004;57:653–661.3. Eckhoff DG, Bach JM, Spitzer VM, Reinig KD, Bagur MM, BaldiniTH, Flannery NM. Three-dimensional mechanics, kinematics, 3. Eckhoff DG, Bach JM, Spitzer VM, Reinig KD, Bagur MM, BaldiniTH, Flannery NM. Three-dimensional mechanics, kinematics, andandmorphology of the knee viewed in virtual reality. J Bone Joint Surg Am. 2005;87(suppl 2):71–80.morphology of the knee viewed in virtual reality. J Bone Joint Surg Am. 2005;87(suppl 2):71–80.4. Archibeck MJ, White RE Jr. What’s new in adult reconstructive knee surgery.J Bone Joint Surg Am. 2002;84:1719-26.4. Archibeck MJ, White RE Jr. What’s new in adult reconstructive knee surgery.J Bone Joint Surg Am. 2002;84:1719-26.(malalignment leads to increased failure)(malalignment leads to increased failure)5. Eckhoff DG, Dwyer TF, Bach JM, Spitzer VM, Reinig KD. Three-dimensional morphology of the distal part of the femur viewed 5. Eckhoff DG, Dwyer TF, Bach JM, Spitzer VM, Reinig KD. Three-dimensional morphology of the distal part of the femur viewed in virtual reality. J Bone Joint Surg Am. 2001;83 Suppl 2(Pt 1):43-50.(Trans cylindrical axis is true fle-ext axis and its is in post in virtual reality. J Bone Joint Surg Am. 2001;83 Suppl 2(Pt 1):43-50.(Trans cylindrical axis is true fle-ext axis and its is in post condyle of femur)condyle of femur)6. Guettler JH, Glisson RR, Stubbs AJ, Jurist KA, Higgins LD. The triad of varus malalignment, meniscectomy, and chondral 6. Guettler JH, Glisson RR, Stubbs AJ, Jurist KA, Higgins LD. The triad of varus malalignment, meniscectomy, and chondral damage: a biomechanical explanation for joint degeneration based on pressure and force distribution within the medial knee. damage: a biomechanical explanation for joint degeneration based on pressure and force distribution within the medial knee. American Orthopaedic Society of Sports Medicine; 2002 June(>3 deg varus/valgus leads to doubling of loading and 68% rise American Orthopaedic Society of Sports Medicine; 2002 June(>3 deg varus/valgus leads to doubling of loading and 68% rise in poly peek contact stress) in poly peek contact stress) 7. Fletcher X, Paratte S: Custom cement less stem improves hip function in young patients at 15-year follow up. Clinical 7. Fletcher X, Paratte S: Custom cement less stem improves hip function in young patients at 15-year follow up. Clinical Orthopaedics and Related Research 2009; 468(3):747-55. Orthopaedics and Related Research 2009; 468(3):747-55.

THANK YOUTHANK YOUTel: 9686 752732PRO:9741993366

Website: www.Srikanthkn.comE-mail: sarathi.clinic@gmail.com

Time: Monday-Saturday: 5-8.30 PMMon, Tue, Fri- 10 AM-1 PM

Sarathi Super Specialty Ortho CentreWed,Thur,Sat- 10 AM-1 PM, SHRC,Jayanagar

Camp Running:3D Knee/Hip replacement camp 5th 5th Sep-5th Dec 2015

Camp ending: TKR for needy(1.6L) with Imported implant.

The Sarathi Knee and Hip CentreThe Sarathi Knee and Hip Centre

Where Excellence is a habit!Where Excellence is a habit!