B W ll L Be Well Lecture Series: t S i Cutting-edge Joint - - PowerPoint PPT Presentation

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B W ll L Be Well Lecture Series: t S i Cutting-edge Joint - - PowerPoint PPT Presentation

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B W ll L Be Well Lecture Series: t S i Cutting-edge Joint Replacement Cutting edge Joint Replacement Technologies and Advances in Functional Outcomes for Arthritis Patients Patients D David C. Ayers MD id C A MD Patricia Franklin MD,

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B W ll L t S i Be Well Lecture Series: Cutting-edge Joint Replacement Cutting edge Joint Replacement Technologies and Advances in Functional Outcomes for Arthritis Patients Patients

D id C A MD David C. Ayers MD Patricia Franklin MD, MPH, MBA

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SLIDE 2

David C. Ayers, M.D.

The Arthur M Pappas Professor & Chair The Arthur M. Pappas Professor & Chair Department of Orthopedics Rehabilitation Director MSK Center of Excellence Director MSK Center of Excellence UMass Memorial Healthcare System Worcester MA Worcester, MA

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SLIDE 3

TJR OUTCOME STUDIES TJR OUTCOME STUDIES SHOW

  • Successful surgical

d

T K R

procedure

  • Sustained pain relief

T K R

t o f c h

  • i c e

t a t i n g

  • Improved physical function
  • Best QUALY analysis for
  • d

/ e x c e l l e n t l l o w

  • u

p

ANY surgical procedure

  • Miracle of modern

medicine

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Be Well Lecture Series: 6-16-10 Be Well Lecture Series: 6 16 10 Joint Replacement Surgery

  • Introduction
  • History of total joint replacement
  • History of total joint replacement
  • Modern THR; Fixation to skeleton

Biologic fixation with porousm Improved UHMWPE; RSA Analysis

  • Modern TKR

High Flexion TKR High Flexion TKR Gender specific TKR

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TJR Surgery

  • “cost effective, reliable

treatment for the pain and treatment for the pain and disability of advanced knee and hip arthritis” NIH Consensus Panel 2001

  • >600,000 TKR and

>375,000 THR in US each year I th i l l t

  • Is the single largest

expenditure of the federal Medicare budget Medicare budget

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SLIDE 6

Total Joint Replacement Total Joint Replacement

  • Prevalence growing in

ll l ith th i parallel with the aging ,

  • verweight adult US

l ti population

  • 50% over age 65 have

diagnosis of arthritis

  • 60% of women; making

it the leading chronic condition among women

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SLIDE 7

TJR

  • Projected growth; more than 600% increase

Projected growth; more than 600% increase by the year 2030 F l d b i f th l ti

  • Fueled by aging of the population
  • Desire to remain physically active later in

p y y life

  • 35% TJR patients under the age of 65 and
  • 35% TJR patients under the age of 65 and

part of the work force

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SLIDE 8

Knee Surgery Most Common Knee Surgery Most Common Surgery in USA

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Total Joint Replacement Total Joint Replacement

  • Common operation

Common operation for patients with severe arthritis severe arthritis

  • Severe Pain
  • Decreased Physical

Function Function

  • All non-operative

treatments failed

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SLIDE 10
  • Sir. John Charnley
  • Sir. John Charnley
  • Wrightington UK
  • Developed modern

Developed modern THR; 1965 M l F l H d

  • Metal Femoral Head
  • Teflon, UHMWPE

e o , U W Socket PMMA B C t

  • PMMA: Bone Cement

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Cemented Charnley THR Cemented Charnley THR

  • Stainless steel

femur

  • UHMWPE socket

PMMA fi i

  • PMMA fixation

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SLIDE 12

M l h f

  • Metal change from

stainless steel to Chrome-cobalt alloy

  • Modification of

Modification of femoral design to increase rotational increase rotational stability M d l h d k

  • Modular head-neck

junction to tension soft tissue/ adjust leg length

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Implant Geometry: Implant Geometry: Finite Element Analysis

  • Important

contribution to longevity of fixation

  • Minor design
  • Minor design

changes can greatly effect interface stresses and clinical results

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SLIDE 14
  • Evaluate stresses at

Bone Implant or Bone-Implant or Stem-Cement i f interface

  • Cement mantle

stresses particularly important for important for survival of the i l t implant

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Surface Finish of Femur Surface Finish of Femur Does it affect fixation?

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  • Figure 3:

Reflected light micro-graph of a 'grit' stem illustrating a well

  • bonded region
  • f stem/cement

interface adjacent to a stem/cement gap.

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Loosening of Cemented Stems: Effect of Cement Type Effect of Cement Type

(Cox regression with adjustment for gender age systemic 18 (Cox regression with adjustment for gender, age, systemic antibiotics, operating theatre, prosthesis design, operative approach…Data from Norwegian Registry 2005.)

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TJR: Fixation to the Skeleton

  • Replace

PMMA PMMA; Cemented TJR d

  • Uncemented

Biologic fi ti fixation

  • Bone in-

th i t growth into porous metal surfaces surfaces

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  • C. McCollister Evarts, MD
  • C. McCollister Evarts, MD
  • Pioneering work in
  • Pioneering work in

Tapered Cementless stems

  • University of Rochester
  • Early to mid 1980’s
  • Early to mid 1980 s

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Biologic Fixation in THR Biologic Fixation in THR

  • Has been successfully

accomplished in p

  • Acetabular Components
  • Femoral Components

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SLIDE 22

Biologic Fixation Biologic Fixation

  • Intimate contact between

host bone and the porous p coating

  • Immediate stability

achieved at the time of surgery

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Biologic Fixation Biologic Fixation

  • Porous surface of

appropriate microstructure pp p

  • Made from biocompatible

material

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SLIDE 26

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Bi l i Fi ti Biologic Fixation Ti Prostheses Ti Prostheses

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Tapered Cementless Stem Tapered Cementless Stem

  • Based on sound design

principles p p

  • >15 Years of outstanding

clinical results

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Neck Geometry

Reduced neck geometry allows for greater ROM

M/L Taper

  • vs. Stryker Accolade

M/L Taper

  • vs. Biomet Taperloc Stem

g y g

M/L Taper

  • vs. DePuy Tri-Lock
  • vs. Stryker Accolade

Stem

  • vs. Biomet Taperloc Stem
  • vs. DePuy Tri Lock

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Trabecular Ti Beaded Metal (Material) (Coating) (Material)

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30% void space 80%

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Bone Ingrowth at 6 months Densification and Sealing of Bone at Cortical Rim

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Trabecular Metal Trabecular Metal Bone Polyethylene Bone in-growth up to poly within TM

6 months in-vivo

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RSA RSA

  • Requires each

segment of interest to g be defined by a minimum of three minimum of three and preferably up to i t t l nine tantalum markers

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RSA Examination RSA Examination

  • Two x-ray tubes are

positioned at 40° p angle to each other

  • Simultaneous x ray
  • Simultaneous x-ray

exposures are

  • btained that include

a calibration cage g and the THR

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SLIDE 35

RSA – Femoral Head Penetration RSA Femoral Head Penetration

  • Center of femoral head

determined by edge detection

  • 3D motion of this point

p can be calculated relative to a rigid body segment g y g

  • Several software

packages developed to packages developed to facilitate this analysis

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Highly Cross-Linked UHMWPE Highly Cross Linked UHMWPE in THR

  • Improved UHMWPE
  • RSA studies here at UMASS show wear

reduced significantly reduced significantly

  • Allows THR in younger and more active

i patient

  • Improve longevity of THR

Improve longevity of THR

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SLIDE 37

UMASS Excellence in TKR UMASS Excellence in TKR

  • Gender TKR;

made specifically p y for women

  • High Flexion
  • High Flexion

TKR

  • Ranawat Award

from the Knee from the Knee Society

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SLIDE 38

HIGH HIGH-

  • FLEXION

FLEXION ON ON TKR TKR TKR TKR

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Traditional TKA vs. High Flex TKA g

  • Designed to safely

accommodate fl i t 125 –Designed to safely d t flexion up to 125

  • Global cultural and

accommodate flexion up to 155 religious activities < 125 155 –Global, cultural d li i and religious activities to 155

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Keys to high flexion Keys to high flexion

  • Patient selection
  • Surgical technique
  • Surgical technique
  • Implant design

p g

  • Rehabilitation

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SLIDE 41

Patient selection Patient selection

  • Activity level

– Ability and desire for high y g flexion

  • Best indicator of post op
  • Best indicator of post-op

flexion is pre-op flexion

  • Compliance with

rehabilitation program p g

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SLIDE 42

ANATOMY: Cartilage N O : Ca age

CARTILAGE

ARTICULAR CARTILAGE LATERAL MEDIAL MENISCUS ARTICULAR MENISCUS ARTICULAR CARTILAGE

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SLIDE 43

Arthroscopic Knee Surgery Arthroscopic Knee Surgery

  • Out-patient
  • Small portals

Small portals

  • Correction of

i meniscus tears, loose bodies

  • Does not

change arthritis change arthritis

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MENISCAL TEAR

ARTHROSCOPIC VIEW MENISCUS MENISCAL Normal Meniscus MENISCAL TEAR

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Treatment of Degenerative MENISCAL TEARS MENISCAL TEARS

TEAR TORN SEGMENT REMOVED REMOVED

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Unicompartmental Unicompartmental Knee Replacement Knee Replacement

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Younger Patients Younger Patients

  • More reasonable to do joint replacement with

current options available p

  • Now an option for patients in 50’s

A i i fl h i i

  • Any age in inflammatory arthritis
  • Patients should limit their activities to

at e ts s ou d t t e act v t es to maximize the life-span of their replacement

no high impact activities – no high impact activities

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SLIDE 56

The “New Patient” The New Patient

Y

  • Younger
  • More active
  • More educated
  • More
  • More

informed H i

  • Heavier
  • More #’s

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SLIDE 57

THANK YOU! THANK YOU!

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