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Traditional Knee Replacement Traditional Knee Replacement Versus Versus Minimally Invasive Knee Minimally Invasive Knee Replacement in the Treatment Replacement in the Treatment of Osteoarthritis of Osteoarthritis Jeremy Waddell, PA-S Jeremy Waddell, PA-S Prof. David Fahringer, Prof. David Fahringer, Advisor Advisor 3/23/2006 3/23/2006

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Page 1: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Traditional Knee Replacement Traditional Knee Replacement

Versus Versus Minimally Invasive Knee Minimally Invasive Knee

Replacement in the Replacement in the Treatment of OsteoarthritisTreatment of Osteoarthritis

Jeremy Waddell, PA-SJeremy Waddell, PA-SProf. David Fahringer, Prof. David Fahringer, AdvisorAdvisor3/23/20063/23/2006

Page 2: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

ObjectivesObjectives

Understand the basic pathophysiology Understand the basic pathophysiology of osteoarthritis of the knee.of osteoarthritis of the knee.

Understand how osteoarthritis affects Understand how osteoarthritis affects the patient.the patient.

Know the differences between Know the differences between traditional and minimally invasive knee traditional and minimally invasive knee replacement surgery.replacement surgery.

Understand why this information is Understand why this information is important to the future PA.important to the future PA.

Page 3: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Osteoarthritis (OA)Osteoarthritis (OA)

Also known as “Degenerative Also known as “Degenerative Joint Disease”Joint Disease”

Causes intense pain which Causes intense pain which decreases the patient’s activity.decreases the patient’s activity.

Affects more than 20 million Affects more than 20 million people in the U.S. and 10% of people in the U.S. and 10% of adults over the age of 50.adults over the age of 50.

Page 4: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

A myth about OA is that it is a A myth about OA is that it is a process process of agingof aging resulting in “wear and tear” resulting in “wear and tear” of articular cartilage.of articular cartilage.

Studies show that OA is not just a Studies show that OA is not just a result of aging, but instead is a result of aging, but instead is a disease processdisease process..– Denatured type II collagen is found in Denatured type II collagen is found in

both normal and OA cartilage.both normal and OA cartilage.– Degradative enzyme activity is increased Degradative enzyme activity is increased

with OA vs. normal aging cartilage. with OA vs. normal aging cartilage.

Page 5: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Pathophysiology of OAPathophysiology of OA

The Healthy KneeThe Healthy Knee Type II collagen and Type II collagen and

proteoglycans in the proteoglycans in the matrix give cartilage matrix give cartilage cushion-like properties.cushion-like properties.

In healthy, non-arthritic In healthy, non-arthritic individuals the individuals the extracellular matrix of extracellular matrix of cartilage is slowly cartilage is slowly remodeled by remodeled by BALANCED levels of BALANCED levels of degradative and degradative and synthetic enzymes.synthetic enzymes.

Page 6: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

PathophysiologyPathophysiology

The Osteoarthritic KneeThe Osteoarthritic Knee In OA, degradative and In OA, degradative and

synthetic enzymes are synthetic enzymes are shifted OUT OF BALANCE.shifted OUT OF BALANCE.

Degradation of cartilage Degradation of cartilage occurs faster than the occurs faster than the synthesis of new synthesis of new cartilage.cartilage.

Efforts of chondrocytes to Efforts of chondrocytes to repair damaged cartilage repair damaged cartilage overmatched by overmatched by degradation process.degradation process.

Page 7: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

How does OA affect How does OA affect the patient?the patient?

Loss of cartilage leaves the joint Loss of cartilage leaves the joint without its protective cartilage.without its protective cartilage.

Patient is left with a “grinding” Patient is left with a “grinding” between the femur and tibia between the femur and tibia causing pain.causing pain.

Patients complain that they are Patients complain that they are no longer able to participate in no longer able to participate in activities they enjoy.activities they enjoy.

Page 8: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

How does OA affect How does OA affect the patient?the patient?

Patient may experience Patient may experience depression, muscle atrophy, and depression, muscle atrophy, and social withdrawal due to social withdrawal due to inactivity.inactivity.

OA can cause great amounts of OA can cause great amounts of stress to the patient and the stress to the patient and the patient’s family.patient’s family.

Page 9: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Treatments for OATreatments for OA

Many treatment modalities are Many treatment modalities are available to the patient with OA. available to the patient with OA.

TreatmentsTreatments include: analgesia, include: analgesia, supplementation, injections, supplementation, injections, strengthening exercises, physical strengthening exercises, physical therapy, and yoga.therapy, and yoga.

BUT, there is only one definitive BUT, there is only one definitive curecure for OA…joint replacement for OA…joint replacement therapy.therapy.

Page 10: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Why do patients seek Why do patients seek joint replacement?joint replacement?

When the patient is unable to When the patient is unable to participate in chosen activities, participate in chosen activities, they feel that their quality of life they feel that their quality of life is affected.is affected.

Patients who “can’t sleep, can’t Patients who “can’t sleep, can’t work, and can’t walk” are good work, and can’t walk” are good candidates for joint replacement candidates for joint replacement surgerysurgery

Page 11: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Traditional Knee Traditional Knee ReplacementReplacement Developed in the 1950sDeveloped in the 1950s Currently, performed on over 300,000 Currently, performed on over 300,000

people each yearpeople each year Large 18-20 cm incision gives surgeon Large 18-20 cm incision gives surgeon

a great view of the joint and provides a great view of the joint and provides large workspace for prosthesis large workspace for prosthesis placement.placement.

Anesthesia times average Anesthesia times average approximately 1.5 hours.approximately 1.5 hours.

Page 12: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Knee ProsthesisKnee Prosthesis

Surgery results Surgery results in resurfaced in resurfaced femoral and femoral and tibial tibial articulating articulating surfaces, surfaces, eliminating the eliminating the grinding of bone grinding of bone against boneagainst bone

Page 13: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Traditional Knee Traditional Knee ReplacementReplacement

Page 14: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Traditional Knee Traditional Knee ReplacementReplacement After reviewing 20 years of data, After reviewing 20 years of data,

the NIH found that approximately the NIH found that approximately 90% of patients who undergo 90% of patients who undergo traditional total knee replacement traditional total knee replacement experience great reductions in pain.experience great reductions in pain.

85% of knee replacement patients 85% of knee replacement patients stated that they were satisfied with stated that they were satisfied with the outcome of their procedure the outcome of their procedure

Page 15: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Study conducted by Study conducted by Peter Thadani, M.D.Peter Thadani, M.D. 10-12 year follow-up of 86 patients (49 10-12 year follow-up of 86 patients (49

women and 37 men; ages 45-89), who he had women and 37 men; ages 45-89), who he had performed a total knee replacement on performed a total knee replacement on between September 1986 and November between September 1986 and November 1988. 1988.

Average preoperative functioning score of Average preoperative functioning score of these patients’ knees was 55 on a scale of 0-these patients’ knees was 55 on a scale of 0-100.100.

These patients rated their knee function as an These patients rated their knee function as an average of 80.6 after surgery.average of 80.6 after surgery.

ROM increased 100 degrees prior to surgery ROM increased 100 degrees prior to surgery to 111 degrees 10-12 years after surgery.to 111 degrees 10-12 years after surgery.

Page 16: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Minimally Invasive Minimally Invasive Knee ReplacementKnee Replacement

Heavily developed since 1991.Heavily developed since 1991. 4-8 cm incision results in less 4-8 cm incision results in less

damage to tissue.damage to tissue. A smaller incision results in faster A smaller incision results in faster

recovery and less narcotic use for recovery and less narcotic use for patients.patients.

Anesthesia times average Anesthesia times average approximately 3 hours.approximately 3 hours.

Page 17: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Comparing Incision Comparing Incision SizesSizes

Minimally Invasive Traditional TKR

Page 18: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Study of Minimally Study of Minimally Invasive Knee Invasive Knee

Replacements (Richard Replacements (Richard Laskin)Laskin)

58 TKR were performed via minimally 58 TKR were performed via minimally invasive approach.invasive approach.

Proposed that a minimally invasive Proposed that a minimally invasive approach would limit soft tissue approach would limit soft tissue disruption, speed recovery time, diminish disruption, speed recovery time, diminish blood loss, and decrease post-operative blood loss, and decrease post-operative pain.pain.

Study was performed with a retrospective Study was performed with a retrospective control group who had traditional knee control group who had traditional knee replacement surgery replacement surgery

Page 19: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Pain was reported to be considerably Pain was reported to be considerably lower in the minimally invasive group than lower in the minimally invasive group than in the traditional knee replacement group. in the traditional knee replacement group.

Total use of morphine by the minimally Total use of morphine by the minimally invasive group was 55 mg versus 118 mg invasive group was 55 mg versus 118 mg by the traditional group.by the traditional group.

Interestingly, blood loss was greater in Interestingly, blood loss was greater in patients undergoing minimally invasive patients undergoing minimally invasive surgery at 713 mL compared to 573 mL in surgery at 713 mL compared to 573 mL in the traditional knee replacement group the traditional knee replacement group

Page 20: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

ConclusionConclusion

Patients report high satisfaction rates with Patients report high satisfaction rates with both types of total knee replacement.both types of total knee replacement.

Reduction of cost, hospitalization, post-op Reduction of cost, hospitalization, post-op pain, and a decrease in the length of pain, and a decrease in the length of rehabilitation will push further development rehabilitation will push further development of minimally invasive procedures.of minimally invasive procedures.

Longer anesthesia times and increased blood Longer anesthesia times and increased blood loss with minimally invasive procedures are a loss with minimally invasive procedures are a concern.concern.

New procedures present learning curve to New procedures present learning curve to surgeons.surgeons.

Total knee replacement can greatly improve Total knee replacement can greatly improve patients’ quality of life.patients’ quality of life.

Page 21: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

Why is this important Why is this important to the future PA?to the future PA? The “aging of America” will cause The “aging of America” will cause

osteoarthritis to be one of the most osteoarthritis to be one of the most common chief complaints of our future common chief complaints of our future patients.patients.

Cost effectiveness and a decrease in Cost effectiveness and a decrease in hospitalization time will probably hospitalization time will probably cause minimally invasive knee cause minimally invasive knee replacement to become quite popular.replacement to become quite popular.

Knee replacement can greatly improve Knee replacement can greatly improve patients’ quality of life.patients’ quality of life.

Page 22: Traditional Knee Replacement Versus Minimally Invasive Knee Replacement in the Treatment of Osteoarthritis Jeremy Waddell, PA-S Prof. David Fahringer,

-References available upon request--References available upon request-