You can now watch the online webinars given by the Physicians of Proliance Orthopaedics & Sports Medicine when it’s convenient for you! We’ve recorded our live webinar, and now you can watch them on-demand.
WEBINAR: A Pain in the Knee – Is Joint Replacement Right for You
PRESENTER: Dr. Trevor Scott
Simply sign in using this link: https://events.genndi.com/register/818182175026332712/7dbdf5a620 and you’ll be able to view the webinar in its entirety at your convenience.
The transcript from the webinar is below:
Moderator: Welcome everyone. Thank you for coming to our webinar today. A Pain in the Knee – Is Joint Replacement Right for You? Our presenter tonight is Dr. Trevor Scott with Proliance Orthopedics & Sports Medicine. He’s going to address common symptoms, concerns, and treatments for knee pain including knee replacement surgery. You can type your questions into the chat bar on the side and we will do our best to try and address them towards the end of the webinar. If we don’t get to your questions, we will try and follow up with you sometime in the near future. And with that, I’m going to hand the floor over to Dr. Scott.
Dr. Scott: All right. Hi guys. My name’s Trevor Scott. I’m a specialist in hip and knee adult reconstruction. Basically a fancy way of saying hip and knee replacements. So we’re going to be talking today about knee pain and treatment for that pain up to and including surgery, like Jessica mentioned. So let’s get started. One sec. There we go. So just a little bit about myself. I trained UCLA and then at the hospital for special surgery, which is the highest volume center for hip and knee replacements in the country. Now we practice here on the East side of Seattle. And with that, let’s, get into it. So a good place to start is the anatomy of the knee. Now on the left of the screen, you’re going to see an X-Ray. And Jess, are you able to see my mouse? Does that come up on the screen for them on the webinar?
Dr. Scott: All right. Here we go. Okay, so that is an x-ray of the knee that’s looking at a right knee from the front and we sort of marked out all the key anatomy there. And then over here on this side, this is a model and this is something we have in the office to show patients, which is actually a pretty accurate model. Again looking at a right knee from the front and what we look at here is this is the thighbone technically called the femur. And where it meets the tibia, or shinbone, which is what I’m marketing right now. That’s the knee. Now as knee surgeons, we think of the knee as being made up of three compartments.
Dr. Scott: The medial compartment here, which is on the inside or groin side of the knee, where the thighbone and the shinbone meet. And then the lateral compartment here, which is on the outside aspect of the leg again, where the thighbone and shinbone meet. And this is a normal x-ray essentially. So this patient has no arthritis. They’ve got good joint space and we’ll talk about what that means more in a second. And you can again see this anatomy shown here on the model.
Dr. Scott: This is the medial compartment that we were discussing and the lateral compartment there. And you can see that there are both cartilages, which is this nice smooth structure on the ends of the bones, on both the thigh bone and shin bone. And the knee between the thigh bone and shin bone is another type of cartilage known as the meniscus, which I suspect many people who are listening to this are familiar with secondary slight of pain that could be externally associated with arthritis.
Dr. Scott: So the main cause of knee pain in aging patients is arthritis. We’re going to talk a little bit here about just sort of the basics of arthritis, what it is and its destruction of the joint resulting in loss of cartilage. Cartilage is a smooth caps on the ends of the bones that allow them to glide past one another. And cartilage, when it’s destroyed or dies off or wears out, is gone. Our bodies don’t have the ability to make more cartilage, which is why arthritis is generally a problem for people. And this affects about almost 50 million people in the United States. These numbers are a little bit old, so probably at this point, it is 50 million. And there are generally three main types of arthritis that we think about, although the treatment for them is quite similar.
Dr. Scott: The most common type, and the type we’re going to focus on primarily on this talk is osteoarthritis, which is essentially arthritis associated with the typical wear and tear of aging and sort of just the mechanical wear and tear of certainly being alive and aging. The second type of arthritis, that’s known as inflammatory arthritis. And that’s a little bit of a different idea. It’s essentially when the immune system turns its attention to the joints and attacks the joints causing destruction to the cartilage, and that’s things like rheumatoid arthritis, psoriatic arthritis, lupus [inaudible 00:05:16] is a little bit different, but we consider gout inflammatory arthropathy, which is a fancy term for joint pain. And then a third common cause of arthritis is post-traumatic. Cartilage can be damaged if someone’s in a bad accident. You will frequently see patients who are in car accidents in their 30’s or 40’s and maybe broke a bone, but you can heal bones, you can’t heal cartilage.
Dr. Scott: And so often those patients may develop arthritis in their knee down the line. And probably a lot of patients have a mix of these three things. When I was in training my chairman had to have both his hips replaced and he swore up and down that the right hip was replaced because he was tackled too hard playing rugby by a general surgeon in the 70’s and he could pinpoint the guys who complain about it all the time. So probably most are osteoarthritis, but long story short, we treat all of those really pretty similar from a surgical perspective. The end result being cartilage destruction is essentially the same once you’re kind of in the surgeon’s office. Although there were some medical treatments for inflammatory arthritis, which will hopefully help prevent it from progressing if you catch that early.
Dr. Scott: So really going to focus this talking on osteoarthritis and it’s sort of presentation and treatment options. But this is like I said, pretty germane for the other types of arthritis we’re discussing. And osteoarthritis is essentially a result of normal wear and tear and aging. And with aging, the water content in cartilage decreases and the proteins which make up the cartilage can begin to degenerate and break down. And the cartilage itself then begins to degenerate and break down and over years, this can cause irritation and inflammation in the bones. And if you lose enough of the cartilage where you get to what’s known as a bone on bone arthritis can often become quite painful for patients and at least pain and also stiffness as the main symptom.
Dr. Scott: So this is just a cartoon image of a normal knee on the left of the screen there, and then arthritic knee on the right of the screen. And forgive me if I reversed my left or right. I’m used to looking at x-rays, which are backward. So you might have to bear with me. This is a normal knee x-ray and so this is just a little cartoon, excuse me, a cartoon, but see nice kind of smooth white cartilage and we’ll have some slides at the end which will show what that actually looks like. And it really is kind of an aesthetically pleasing smooth surface when it’s healthy. This is the thigh bone again.
Dr. Scott: And here on this view we can see degenerative arthritis where it’s worn through and there are bone spurs, which are areas where the patient’s body has formed bone to try to protect itself from the arthritis, since it can’t form cartilage and fortunately that’s counterproductive. It actually makes the arthritis worse and kind of cracked and fissured and probably quite painful for this imaginary person.
Dr. Scott: Arthritis affects probably about 10 million Americans in the knee joints, one of the most commonly affected is the most commonly affected joint after the finger joints. And we’re doing probably pretty close to a million knee replacements a year for this now in this country. So it’s very, very prevalent. And signs of arthritis, so symptoms that the patient may have that suggest to us that arthritis of the knee is probably the source include pain, persistent swelling in the joint, joint deformity so being very bow legged or knock-kneed, and not having that be correctable overtime when these kind of become stiff in that position with arthritis. Along those lines loss of motion is a very common finding with arthritis, increasing pain with activity. Patients will say typically that the knees often don’t bother them too much when they’re at rest, but it can become very painful when they’re walking on them, especially with things like going up and downstairs, and stiffness, which is really just another way of saying loss of motion.
Dr. Scott: If you’re experiencing those and you come to see us in the office to sort of figure out what’s going on, we diagnose arthritis with a couple of different things. One and probably one of the two or three most important things are getting the story from you. Where does it hurt? What type of things make it hurt? Does it bother you at rest? Are you having night pain? Does it bother you going up and downstairs and things of that nature? And we’ll try to pair that with the physical exam. We want to make sure that the places that you’re having pain are in the joint. Because there are other things in the knee, the soft tissue around the knee can be sore. And so sometimes patients will think they have arthritis, but in fact, they have something as simple as tendonitis in the patellar tendon, which is jumpers tendon.
Dr. Scott: And we can often figure that out by palpating around the knee and sort of pushing to see where it hurts you and putting you through various range of motion tests. And then sort of the hallmark for us is x-rays. Almost all cases of arthritis, not all, but almost all, can be diagnosed simply on x-rays. And we’ll kind of go through a few of those in a second here. And rarely if we suspect arthritis, but your X rays are normal or close to normal, we might consider getting an MRI or even more realistic thing like a bone scan. But this is pretty atypical. It’s not something typically having to do for arthritis. Sometimes if we think someone has a little bit of arthritis and maybe a meniscus tear that’s really causing them some issues, we’ll get an MRI to assess that as well.
Dr. Scott: So like we discuss, patient history and exam. So what I’m looking for when I suspect arthritis I still want to hear the patients have joint pain and swelling and stiffness, both before and after activity, decreasing range of motion, the deformities we talked about being bow-legged or knock-kneed essentially. A sensation of grinding or catching in the knee. And some complaints we really kind of key in on are whether you have the pain was stairs, especially going downstairs. Going downstairs is about five to seven times body weight force across the knees and is often the one thing that’ll really generate pain for patients. It’s probably the most force across the knee of any normal day to day activity. Similarly, pain getting out a chair, which is also potentially up to five times body weight will often cause pain and pain sometimes sitting. If you have pain sitting in a chair for a long time that can indicate arthritis behind your knee cap, which we’ll talk about in a second.
Dr. Scott: So those are the things that I’m looking for and listening for from a patient to try to sort out if arthritis is the problem for them. So here are some images, some x-rays of arthritis and these are what are called AP views, which is a fancy way of saying we’re looking directly at the patient. So in the center here is a normal x-ray. And this is a left knee. Bear in mind, all x-rays are essentially reversed so it’s as if the patient is standing and facing us. And so this is a nice normal knee. They’ve got a normal femur and more importantly, they’ve got a nice smooth joint space with good space between the bones.
Dr. Scott: So again, if you remember back from the earlier slides, arthritis is loss of cartilage and cartilage isn’t visible on x-ray. But we can almost always tell if a patient has cartilage or not based on how far apart and how smooth the bones are. So this patient his vision is very nice, smooth bones without any bone spurring, good space between [inaudible 00:13:09] This view here is a view of a patient with medial compartment arthritis. In this case, you’ll notice where the knee looks a little different. This is the right knee. But if you look here, you’ll see that there’s no space between the thigh bone and the shin bone here. This patient has bone on bone arthritis in this compartment. Now they also probably have reduced space here in the lateral compartments. This patient has arthritis through their knee, but it’s much worse on this medial side or coined side of the knee.
Dr. Scott: This is the most common pattern of arthritis. These patients tend to be somewhat bow-legged and this tends to be quite painful for people. Conversely over here, this patient has primarily lateral compartment arthritis. If you look here, you’ll see that the joint space loss is on the other side of the knee, what we call the lateral or outside aspect of the knee. And again they probably have decreased joint space here, probably has some arthritis in the medial compartment, but not as affected. Patients do tend to tolerate this type of arthritis a little bit better for longer. Although eventually, those two will typically become quite painful for people. And both really generally present with similar symptoms. It just depends on where it’s hurting the patient the most.
Dr. Scott: And this is a patient with very severe arthritis throughout the knee. This is the same AP view. We’re looking at the knee from the front here. And you can see very little space between the bones. Now these a quite an old x-ray [inaudible 00:14:42] guy and got off the internet here, but it was really significant destruction throughout the joints. This is what’s called a lateral view. Now haven’t seen this yet, but this is looking at the knee from the side as if we’re standing beside the patient and you can see here significant arthritis also behind the knee cap where it meets the thigh bone in the groove in which it runs. This patient was most likely in quite significant amount of pain. It’s rare, but not unheard of, of course, to see patients with arthritis this severe. Most patients end up coming into the office before it gets to this point, but we certainly see things like this, not uncommonly.
Dr. Scott: So I should’ve warned you guys, sorry. This is a picture from a surgery. And this is a picture of the knee as we’re approaching that he needs to do a knee replacement. And what you can see here is this patient has significant wear or arthritis or cartilage loss, all of which are really used interchangeably as terms, in the medial compartment of the knee here. This is that groin side of the knee we were talking about. Sort of the most common arthritis pattern. And you can see they have this very shiny hard looking almost ivory-like bone compared to the nice, more normal cartilage kind of up in this.
Dr. Scott: This area of the knee here. This is the knee cap that has been flipped out of the way. This was a very good indication for a knee replacement of this patient has quite severe arthritis in a large area of their knee. and presumably has not done well with non-operative treatment. So we’re going to go to the next slide. So treatment options for arthritis. There are a variety of treatment options from least aggressive to most aggressive. We’re going to start always with less aggressive treatment of course. And those include things like activity modification, weight loss, medications, specifically anti-inflammatory medication, formal physical therapy, bracing, sometimes is an option. We’ll talk about that. And then injections.
Dr. Scott: So probably really the most effective treatment for patients is activity modification. We want patients to stay active. We know that one of the things it really does help them is keeping the joints moving and the muscles around the joint strong. What we recommend is lower impact activity and that’s things like walking on a flat surface. Obviously like we talked about going up or downstairs or a hill can be painful. Cycling is very good. Swimming and lightweights and then probably my favorite activity, which I suggest to almost all my patients, although many of them don’t do it because I don’t have access to a pool, is walking in a waist-deep pool of water.
Dr. Scott: And those are things that help really strengthen the quad muscle and the hamstring muscles. Keep the muscles around the knee functioning well, but are easy on the joint itself. Won’t inflame an arthritic joint. Higher impact activities are okay. It’s not dangerous to do higher impact activities, but it can be painful. So when I have a patient comes in and they have severe arthritis in their hips or knees, these patients love things like skiing, I’ll say, “Well you know you can ski. I think it’s probably going to hurt you quite a bit, but it’s not dangerous to do it. You’re going to need to blow it up. I don’t leave her ibuprofen, but it is an option for you.” Now, traditionally for a long time, we thought that things like running actually caused arthritis.
Dr. Scott: It actually turns out probably if anything, things like this, just running, are protective against arthritis. But once you have arthritis, it’s a bit of a different story. If you have arthritis and try to run, it’s likely your knee is going to hurt you again. Its probably not dangerous. Might lead to increased wear. But, once you have wear, you have wear. So like I said, I usually tell patients, “And this is what you want to do. You have to be ready for it to hurt, but it’s okay to proceed with it.”
Dr. Scott: Similar to activity modification is weight loss. So we know that this is another thing that is definitively helpful for patients that they can do, but it’s very hard to do. Obviously it’s difficult to lose weight when your knees hurt from watch that you can’t exercise. And like we talked about, and these take up to four times your body weight or through most day to day activities, it can take up to seven times body weight upstairs. So even a weight loss of five, 10, 20 pounds can really be a significant force difference across a patient’s needs.
Dr. Scott: And in some cases, we’ll even recommend patients see a bariatric surgeon before surgery to see if, or at least a consult with a bariatric team, to see if we can help them lose weight to help them. Now if you have severe arthritis and you lose weight, probably your knees will still hurt, but often that the pain improves. And also, and we’ve talked about, we’ll talk about this when it gets to surgery, it makes the surgery safer. It’s dangerous to do or more dangerous to do these surgeries in patients who are significantly overweight for a variety of reasons.
Dr. Scott: Medication wise, the most effective medications by far are anti-inflammatory meds. So things like Ibuprofen, Aspirin, Neproxin, Mobic, Celebrex, and then a topical version called Voltaren, which is a gel version, which is often nice for needs so that can be more expensive in United States. And what these do is they essentially calm down the inflammation in the joint that the arthritis has been causing. So the arthritis causes pain in and of itself. It also causes inflammation, which causes pain. And by decreasing inflammation, often we can help that pain.
Dr. Scott: But like all things, there’s a trade-off. Side effects include potential kidney and liver damage over long periods of time, a potential GI bleed with most of them that can certainly cause ulceration if you use alone, increased blood pressure that can cause fluid retention. So generally these are medications which ideally don’t want you on for long, long periods of time. Now healthy patients often we’ll suggest, “Look, take them regularly for a week or two to calm down the inflammation if you have an arthritis flare.” When you have an arthritic joint that’s becoming acutely more painful, which they will do from time to time. But again, we have to be cognizant of the risks associated with this. So we don’t want you at high doses of these medications forever, although they tend to be the most effective medications.
Dr. Scott: If I can go back for a second, what I would add is medications we really try to avoid are things like narcotics. The data’s very clear that those are not good long-term solutions for arthritic pain. Patients can tolerate two of them, they continue to hurt and it just makes it harder to control a patient’s pain after surgery, if and when they ever get to surgery. So that’s something we try to avoid if we can.
Dr. Scott: Bracing. So arthritis, we’ve alluded to this a few times where arthritis changes or can change the alignment of a leg. So on this patient, this was called a leg line standing view. This is an x-ray of a patient standing in front of us. And this patient’s left leg here is normal. A line is drawn from the center of their hip to the SAR ankle that’s just right through the center of the knee. This patient’s in what’s called neutral Lyman and you’ll see the left knee if you look carefully, really doesn’t. However, the right knee is different. You’ll see that same line drawn from the center of the hip to the center of the ankle passes well to the inside of this knee.
Dr. Scott: So this patient has medial compartment arthritis and they’re bow-legged, which is what we see. Bowlegged patients have worn out their medial compartments. And one option for treatment, if the knee is flexible enough, is we can give you what’s called an unloader brace, which will push this knee back into more neutral Lyman. It takes some of the force across painful and arthritic medial aspect of the knee. Now the truth is with those braces tend to be quite uncomfortable. So this is a picture of it. It’s exerting force across the knee in three points. 12 three-point molder bent in order to try to push the knee into more neutral alignment to take the force off that painful medial compartment.
Dr. Scott: These can be helpful and they do work often for patients with arthritis in just one compartment, but they are very uncomfortable to wear and quite frankly most of the time when I prescribed these to a patient, they eventually come back and tell me that that’s sitting in the bottom of their closet because it hurts them too much to be in it. So it’s an option, but it’s not an option most patients elect to proceed with certainly for very long.
Dr. Scott: That brings us to injections, which is typically the next line of treatment. Now there’s a variety of injections that are available and we’ll run through these. The two main ones or two ones traditionally used ones are corticosteroid injection and what’s known as viscosupplementation. So corticosteroid injections is an injection of cortisone or when it’s driven as what’s known as a steroid injection. And the goal of this injection is to decrease the inflammation in the joint. And that can lead to temporary relief from the inflammatory pain in the joint.
Dr. Scott: Now this doesn’t affect the underlying arthritis. You still have that. This isn’t a treatment for that. It’s purely symptomatic. And while it can give you temporary relief, we typically advise against multiple injections in the setting because we think it will lead to further wear in the cartilage of the joint, which is something we want to avoid. Most surgeons think that one or two of these is probably okay and potentially you can have up to three or four a year, but if you came back for four in a year, I’d really have a serious talk with you that I’m worried A is going to make arthritis worse [inaudible 00:24:15] and B, is probably not working that well.
Dr. Scott: Typically they’re a little bit unpredictable how long they last. We see on average three months, but there’s wide variability. And it tends to be less and less effective every injection you get. Often when we talk to patients was using this for a special occasion. I’ll have patients come and ask for one because their grandson is getting married and they want to be able to dance at the wedding or they’ve got a big trip, a cruise or a trip to Europe or something or they want to, then they know that they want to go off and we’ll walk around. And I think it’s reasonable for that. And alternative injections with someone’s Viscosupplementation. So there are a variety of these on the market and they’re marketed to patients as if they go in and coat the knee and sort of lubricate the joint.
Dr. Scott: We really can’t prove that they’re terribly effective. And so a lot of insurance companies don’t cover the same wear, but we do know based on biologic data that some patients do respond to this. It’s just a little bit unclear who it is. It tends to be patients with less severe arthritis. And it’s a reasonable option to try. It’s not dangerous. And typically it’s done as a series of three other depends on the specific brand. It does not, I should add, lubricate the joint or replace the warrant cartilage. It works probably as an anti-inflammatory in the patients in which it works, which is really how all of these work. And it’s not really usually very effective for very advanced arthritis.
Dr. Scott: Now the two other types of injections, which I don’t think are on the slide, they’re not, that we get asked about are PRP stands for platelet-rich plasma. That’s when we take your blood from the patient, spin it down for the growth factors that are in it, inject it back to them. Those devised for treatment for tendinitis type issues in athletes. There are some early data that it’s effective in young patients with relatively mild arthritis in their 40’s and 50’s. It seems to have an anti-inflammatory effect. And that data is in small series, but it’s probably reasonable to presume that that may be accurate. And so for patients in that age range, that can be a reasonable thing to try. It doesn’t really have a lot of downside to it other than the cost.
Dr. Scott: The third or fourth type of injection people ask about are STEM cells. Now I’m biased because my specialty is replacing hips and knees, but I don’t really believe in STEM cells. I don’t think the science behind them is good. I really don’t think there’s evidence to support that they regrow cartilage in any way. Patients who get STEM cell injections do often feel better. But that’s because, in my opinion, like all the injections on this list, the STEM cell injections probably act as an anti-inflammatory, decreasing the inflammation in the joint, they do not, in my opinion, regrow cartilage. And they tend to be very expensive and not covered by insurance.
Dr. Scott: PRP is usually $400, $500. STEM cells are $300, $400 or $500, sometimes $10,000 typically out of pocket. So I usually personally steer patients away from them. But that being said, they’re safe. It’s not a crazy thing to try if you’re really looking to try. The last non-operative treatment that I don’t have on the slide here is a something called cryoablation. This is a newer idea, but I think it’s pretty well supported in the literature and our scientific data. And that is numbing up the nerves around the knee, freezing them temporarily, which can provide some pretty reasonable pain relief for at least a period of time.
Dr. Scott: It’s not perfect, it doesn’t numb up all the pain in the knee. And eventually the nerves wake back up. That’s a temporizing measure. And that’s something I’ve been doing a little bit more personally in patients who have very bad arthritis and don’t have a lot of options short of surgery that I think will be helpful, but maybe aren’t ready for surgery because they really don’t want it or they’re very medically ill or very overweight or very elderly and we just don’t think it’s safe to do it. So that’s a newer treatment that I think is supportive. I think that’s a reasonable thing to try.
Dr. Scott: So that kind of concludes the part on non-operative treatment, which brings us to surgical treatment options for the knee. So we’ll go through these from the sort of, again, the least aggressive to most aggressive. So one option, although arthritis usually not a great option, is arthroscopy. Arthroscopy is what we often call this getting a knee scoped. This is when we make two or three keyhole size incisions in your knee and use instruments inside the knee to do the surgery. This does not really work for arthritis. There’s no way to repair cartilage-like we talked about in the past. So this really isn’t a treatment for a significantly arthritic knee. However, in some limited indications, it’s sometimes helpful for patients who have relatively mild arthritis, but have a large and painful meniscus tear will sometimes consider going in and cleaning up the tear quote-unquote, which basically means cutting out the torn part.
Dr. Scott: Patients who have large floating pieces of loose bone in the knee sometimes do this to take that out because that can cause pain and further damage to the knee. We’ll sometimes try to trim that down. Now that can be temporarily helpful for patients, but again, this is no longterm, really fix for arthritic pain. So the reason people want it is it’s a straightforward procedure. It takes us as the surgeon 20 or 40 minutes, you’re in and out same day, you recover pretty quickly using the two to six weeks. But in general and when a patient has arthritis and this is the treatment, it’s no more effective than a placebo. Now on the right of my screen here, you’ll see a normal knee.
Dr. Scott: This is, like we talked about briefly, this is normal cartilage on the tibia, nice and smooth. This is a normal healthy meniscus here. And then above that is normal cartilage on the femur. Nice and smooth and white. So this is healthy. And again the same image you’ll see here. This is that normal healthy knee. On this side, see evidence of a patient with a big torn meniscus. The meniscus is that cushion between the thigh bone and shin bone that can tear in arthritic knees and we caught ground between here between the arthritic shin bone and that caused these flap tears, which almost act like a hangnail on the knee. They get caught and pinched and become painful.
Dr. Scott: And then younger patients will consider often trying to repair that and the arthritis. Often if we think that this is the problem and usually we want you to try conservative measures, therapy, and injection. But if we continue to think that this meniscus tear is really the problem, we might offer to go in and clean that up and see if that’s helpful. As long as the patient understands that this is not a way we can treat the arthritis or the loss of cartilage on the thigh bone and shin bone and that’ll probably continue to be an issue for the patient.
Dr. Scott: And you can see that here in the last few views. This is a picture of a patient with arthritis throughout the knee. So there’s a shaver here, which was used to clean everything up and you can see this cartilage is very frayed, you can see the raw bone underneath here. This is a thigh bone obviously. And this patient has a big area of missing bone, very bad meniscus tear, very bad wear on the tibia. This is a pretty degenerative knee on the knee scope. [inaudible 00:31:47] This is like this patient’s going [inaudible 00:31:48] to feel a lot better after this procedure, unfortunately. And probably is heading towards a knee replacement, at least that’s their option surgically.
Dr. Scott: So next possible treatment is what’s called an osteotomy. So this is the same x-ray as you’ll remember from the picture we talked about for bracing. And another option besides bracing is doing what’s called an osteotomy. That involves fracturing the bones. Depending on the pattern of arthritis, it’s either the tibia or femur that we break to realign the joint. Now as you may suspect, that’s a pretty big surgery and can be quite a challenging recovery. Something we typically use for arthritis in very young, very active patients who have arthritis and only one compartment of their knee. And we know that they’re going to need a knee replacement, but maybe they’re in their 20’s or 30’s and we’re trying to get them another 10 or 15 years before they need it. And that is a reasonable option in that patient population. Although generally, we don’t do an enormous number of these. There’s not a ton of patients, at least not in my practice, who are great candidates for this. But certainly, if you are a good candidate can be an excellent surgery for you.
Dr. Scott: So this is a picture of that osteotomy. You can see in this patient that they have arthritis in that compartment. And so his knee with broken here and then fixed back with this plate into different alignments so that now the mechanical access of many. That line is right through the center and the knee they’re not wearing out that compartment as much anymore. Now they still have arthritis in that area and eventually, I suspect this patient, most of these patients do get a knee replacement, but often it can be put off for a long time, which is helpful.
Dr. Scott: So that brings us to the actual joint replacement options here. And there are two types of knee replacements, partial knee replacement, also technically known as a unicompartmental knee replacement and a total knee replacement, which we’ll get to shortly. So in this image here, this patient has arthritis again in the medial compartment of the knee. See they’re missing all that cartilage there. They’ve got bone on bone arthritis in that part of it. If the rest of the knee is pristine, if they don’t have arthritis in the rest of the knee, then a good option for them is potentially just replacing that medial compartment, which has been down here. You can see that the rest of the knee is normal, nothing’s been done to it. And this is a picture of it within surgery here.
Dr. Scott: One, the recovery is easier typically than a total knee replacement. Usually, patients have less pain and are feeling better earlier than a total knee replacement, which while a very effective surgery does have a long and somewhat challenging recovery period. Secondly, when they’re done correctly on the right patients, patients generally are very happy with them. The knee feels very normal, the patient, as they stated, feels like their knee typically has a very high score and what’s known as the forgotten joint test, which is a test, those of us who do a lot of hip and knee replacements, use to judge sort of effectiveness of treatment. In other words, once you’ve recovered from the surgery, did you forget that you even had it? And partial knee replacements do quite well and I think it’s somewhere around two thirds to three-quarters of patients saying that they don’t even remember that they had the surgery on a day to day basis.
Dr. Scott: I mean they know that there are some things like the knee is sore, but in other words, the knee feels quite good and natural to them. The downside to the surgery or the issue of the surgery is that the risks are higher, the failure rate is significantly higher than a total knee. The data suggests that 20% of partial knee replacements have had to be revised at 10 years. And that’s compared to only 5% of total knee replacements. So they fail at a higher rate. And there are probably two main reasons for that. And the big one is generally patient selection.
Dr. Scott: There’s a variety of opinions on who to do this on, but we know that if we do this type of surgery on someone and they have arthritis in the lateral aspect of the knee or behind the knee cap, which we really can’t see on these x-rays, probably not going to be that happy because we didn’t replace the other arthritic areas of the joint. And so those patients typically aren’t thrilled. Also, patients can then proceed to develop arthritis in the rest of the knee and that can be problematic. But they can pick an early on behalf [inaudible 00:36:15] with a surgeon that over time it can fail them as the rest of the knee degenerates and they can end up needing to be converted to a total knee replacement or sometimes what’s known as a revision total knee replacement.
Dr. Scott: Along those lines, the other issue with the knee replacements [inaudible 00:36:29] cause they’re essentially technically somewhat more demanding I suppose I would think. As surgeons, we don’t have the tools we have in a total knee replacement to reorient the knee the same way we can do. So we’re somewhat limited in our tool bag. So this is a surgery that more of us these days are doing, not all, but a lot of us are doing robotically, which is not something personally I do all that often otherwise. But I think this as a surgeon, it’s very finicky and it’s really reliant on very, very, very precise component or knee replacement part positioning. And so it’s a nice indication for a robot and that seems at least early with our kind of two to five-year data to be helping improve outcomes from this type of surgery. But again, it’s very dependent on correct patient selection for this.
Dr. Scott: So this is kind of just reviewing what I said. It’s an effective treatment with the arthritis is isolated to one compartment of the knee, but it’s has a higher failure rate. So we have to be careful with who we select it on. Traditionally this was done mostly for arthritis in that medial compartment we talked about. Now with the robot, it’s being done a little bit more on the lateral compartment as well. That data is starting to come out and it looks like it’s probably an effective treatment for isolated lateral compartment arthritis.
Dr. Scott: It’s also been done for isolated arthritis behind the knee cap. And that has had mixed outcomes over the years old. Again, that appears to be improving as we kind of get a little bit better with patient selection in surgical technique probably. So that brings us to the final surgical option and this is what’s known as a total knee replacement. It’s when we replace all three compartments of the knee that we talked about, medial, patellofemoral, and the patella. And this is the most reliable surgery, as we’ve talked about it earlier. It’s got 95% success rate of 20 years. We do this using metal and plastic implants and we’ll go through that in a little bit more detail here in a second. That really technically this isn’t a replacement, it’s a resurfacing.
Dr. Scott: We’re converting the surface of the femur, which is the thigh bone, the tibia, which is the shin bone, and the patella to prosthetic components, metal or plastic components. So this is an image of a total knee replacement model. Right here is an x-ray. I have a knee after it’s had a knee replacement and you can see that there’s a metal, what we call metal baseplate here in the shin bone. And then another one up here on the femur. And between those two, which is invisible on x-rays, is a plastic liner, which technically is what’s called highly cross-linked polyethylene. And you can see that here on this model. So here there’s a tibial baseplate, the plastic liner, which you can now see on this one, and we’ll call the thermal component. And then again here is a picture of the same thing.
Dr. Scott: So in this knee, you can see that the whole knee from the front has been replaced and we’ll show you a view from the side here in a second. So this is looking at you from the side. This is an arthritic knee. Femur, patella or kneecap, and then tibia or shinbone. And this is the x-ray of it having been replaced. And you can see this is what we call the tibial baseplate, that plastic liner that’s invisible on x-ray. You can see a little bit of an outline of it though, that black shadow. And then the thermal component here. And this patient is actually not had their patella resurfaced, and that’s an option. Sometimes we’ll leave the patient’s knee cap totally alone. That’s what’s called surgeon preference. In the United States, about 80% of surgeons resurface the patella at all surgeries, some 20% don’t. But internationally it’s somewhat less common.
Dr. Scott: I have a good friend and quite a brilliant surgeon who is an Irish surgeon. They think we’re crazy for resurfacing this. That’s a little bit of surgeon choice. And you can see this model here is an example of how it fits on the bone. It really matches the, when done correctly, it really matches the thigh bone and the Shinbone very well. And then you’ve got this plastic liner in here. So we can go to the next slide. Let’s talk a little bit about the logistics of the surgery.
Dr. Scott: So prior to surgery, we want you to get a pre-operative workup, usually medical clearance, labs, make sure you’re healthy enough to have the surgery. And we always want you to go to one of the joint education classes that the hospitals have. So you’re ready for you and hopefully the person who’s helping you kind of during your recovery period already for what to expect. And those classes are very helpful. Day of surgery, we don’t usually want you eating anything after midnight. We’re starting to have you have a sugary drink a few hours before surgery, but definitely don’t want you to have any food. We have, you arrive a few hours before the surgery where you meet the anesthetist who’s going to put to sleep.
Dr. Scott: You’ll get your pre-operative antibiotics. You’ll always see your surgeon before surgery, you certainly should. I come in and talk to you and sign your leg and sign the consent and then you’ll be wheeled back to the operating room, given anesthesia, and you’ll have surgery, which usually takes, as far as operating time for the surgeon, usually about 60 to 90 minutes. You’re in the room somewhat longer, typically about two and a half hours or so between everything that happens in there.
Dr. Scott: So let’s talk a little bit about anesthesia choices. Our preference based on what we know patients on average do best with is a spinal with light sedation. And then typically we’ll often then set you up with a nerve block or catheter into one of the nerves in the front of the knee called the saphenous nerve and that has been quite effective, that really helps patients a lot. We like this because patients wake up quickly, they’re able to work with physical therapy rapidly, it reduces nausea, and pain. Generally, patients do very well with this. Sometimes patients have had spine surgery or for a variety of the reasons they’re on hydros blood thinners or something along those lines. They can’t have a spinal on a nerve block, in which case we’ll do a little bit more traditional general anesthesia and that’s fine.
Dr. Scott: That works as well, is typically our second choice, but it’s certainly an effective option and that’s when you’re, in general anesthesia it usually means essentially you’re really put to sleep, you’re intubated. After surgery we want to get you up in a PT right away, immediately begin working on range of motion and make sure that we got your pain control dialed in because like we’ve discussed, the surgery is pretty tough and post-operative we can keep you comfortable. We do need to sometimes get the exact right medications for you and that sometimes takes a little bit of trial error on our part. And often if you’re doing well, we’ll want to get you a home the same day, next day at the latest is usually a goal. We don’t want you in the hospital for too long. That’s not a great place to be. Patients really do better at home.
Dr. Scott: So like we talked about, we’re going to get out kind of same day or next day for partial and really for full knee replacements. Most patients, a couple of the things we’ve talked about, some patients come in and they have arthritis in both knees. Now if you’re perfectly healthy and you have arthritis in both knees, it is maybe an option to do both knees at the same time. We usually avoid this in people because frankly, it makes the recovery quite challenging. And in addition, it’s medically riskier. There’s increased bleeding, increased risk of transfusion, increased risk of blood clots, kidney failure, things like that. So it’s an option, but really only for the healthiest patients. Most patients opt to, even if they have arthritis in both joints or both knees will often opt to stage them, to do one and then the other a few months later. Because the recovery, frankly with both is very tough.
Dr. Scott: But it is an option for healthy patients if they really want it. As you can see on the slide, the goal is really to get you home. This is a good time to call in a favor from your friends and family. My mother tells me this is why you have daughters, for what that’s worth. So we really would prefer you not to go to the SNF. The data’s very clear. The patient’s do better if they go to their home environment instead of to a SNF, but if you have to go to SNF, we will certainly coordinate that for you. We’re going to want you to do home exercises and then want you to do an outpatient physical therapy and that’s really important. If you don’t do these things, the knees will absolutely get stiff and not function well for you. So it’s very important that you’re able to do that stuff.
Dr. Scott: So a couple of reasons we would consider or not want to do a total knee. BMI, which stands for body mass index over 40. This is a marker for obesity. If your BMI is over 40 we know that the risk of a surgery goes up fairly significantly. Now, this is a little bit of surgeon preference. I am a little bit more liberal with this than some surgeons. Even if your BMI is over 40 if you try to get it down, give an honest effort, you can’t do it. We can talk about potentially going for the surgery anyway, but patients have to understand that they’re definitely an increased risk for complications, especially infection, which is quite a devastating complication. We really want to avoid any. So ideally we want your BMI below 40. We know that patients do better in that situation.
Dr. Scott: Chronic narcotic use pre-operatively. That’s something we would try to avoid in patients because it frankly makes it very hard to control pain after the surgery. So we understand some patients are going to be on narcotics a little bit before surgery, that’s not unheard of. But the goal is ideally for you to not be on those because it’s hard to control your pain afterward. Uncontrolled diabetes. This is a big one because this really does increase infection risk significantly. Now we don’t know exactly where the cutoff is. It’s somewhere between an A1C of seven or eight. A1C is a marker of longterm diabetes control essentially. But certainly, nothing over eight and I’m very strict to that. You have an A1C over eight I will absolutely not do the surgery until you get that under control. That’s because that’s a fixable problem.
Dr. Scott: That’s something that correct diabetes regimen with insulin and other medications really is correctable and we can make that safer for you. I don’t want to do a surgery that if it can be done safely, we don’t want to do it unsafely for you. Other issues include being medically unstable and that is rare, but when patients were very sick, this just may not be an option for you. Unfortunately, we have I, and I think most surgeons have, some patients in their late 80’s and 90’s where they’re just not healthy enough. Their heart just isn’t, their cardiologists tell us. The heart’s not going to be able to go through with it. But that being said, age in and of itself is not a reason not to do the surgery. Now again, if you’re in your 90’s I usually steer patients away from knee replacement unless they’re exceptionally healthy nine year old because the recovery is challenging, but age is not a reason not to [inaudible 00:47:41] Poor health is
Dr. Scott: All right, so here are some pictures from the operating room. All of the blue things you see, these are all sterile. And in this OR, you can see those number of tables and trays. These are with the implants we’re using, they’re all set up. All our retractors are on sterile table. We wear these space suits, which most surgeons, not all surgeons like these, we think that they probably make the room a little bit more sterile for you. And in the room there’s a number of people. There’s a scrub tech who is basically an assistant who helps hand us the instruments, have the instruments ready for us as we asked for them. We’ll usually have sometimes another surgeon or certainly a physician assistant in the room to hold the retractors and position the leg for us. It’s really not a surgery you can do without another set of hands.
Dr. Scott: There’s an anesthesiologist. And then actually representative of the company who’s implant, who’s knee replacement we’re putting in is always in the room. They don’t touch you or do anything like that, but they’re there to help the staff set the implants up and they provide us some background information. Sometimes I may say, “Hey, this knee replacement, thought it was going to be a size five. Looks like it’s going to be size six. Remind me, is that two millimeters bigger, three millimeters bigger,” things like that. And they help bring that stuff in. So we’re going to go to the next slide here. Part of the surgery is we will plan your surgery out typically on a computer ahead of time. And so we’ll kind of have a good idea of what size we want to do, where we want to make the cut, the angles that we use those cuts at, and then we try to replicate that plant so you can see that this patient’s had a templating here and then it’s actually a different knee, but that the knee is now nice and lined up and much more straight.
Dr. Scott: After surgery, you’re almost certainly going to be able to put full weight on it right away. You’re going to be on some type of blood thinner usually about four to six weeks. Typically in healthy patients who aren’t on another blood thinner already we just use aspirin. And these days many of us are just using baby aspirin. Most surgeons want to see you back in the clinic either with them or with their physician assistant at two weeks, six weeks, 12 weeks after surgery and that’s to follow your progress, make sure you’re getting your range of motion back, get some basically an x-ray, generally make sure you’re doing well.
Dr. Scott: It does take a year to fully recover from this surgery. It’s important that patients understand that. This is not a surgery you wake up from and say, “Oh man, I feel great.” You have to do the therapy. It takes a year to totally recover. As far as driving goes, that’s a common question. For the left knee it’s about two weeks as long as you’re not on narcotics. It’s probably six to eight weeks on the right knee and that’s based on how long it takes for your reaction time to come back to normal after the surgery, as far as being able to hit the brake.
Dr. Scott: So possible complications of the surgery. If the surgery is something you’re considering, these complications all go for both partial and total knee replacements. These are things you have to be aware of. Now, the biggest risk is infection. Statistically, nationwide, that risk is somewhere between one and probably 3%. At our hospital it’s lower, 0.25 to 0.5% in healthy patients, but that’s not zero and an infection, and we’ll talk about that in a second is really that’s the big thing we worry about. That’s what we want to avoid as much as possible. And so you’ll get antibiotics before surgery, you’ll get antibiotics after surgery. We wash things up very thoroughly. During surgery. A lot of stuff drinks [inaudible 00:51:03] minimize this risk and that’s because if knee gets affected, typically what we have to do is go in and take the knee replacement out, put in a temporary device called a spacer, which is something that’s shaped like a knee replacement with Nino to antibiotics [inaudible 00:51:16] Does not feel very good.
Dr. Scott: It’s not comfortable. Usually can’t put full weight on it. That’s typically in for both three months and then we try to go in and redo the surgery with a new knee replacement. So it’s quite a process for people that happens. Second risk instability. As we do the knee replacement, it just kind of feels loosey goosey to people. It doesn’t feel right. And that’s a little bit of the artists are [inaudible 00:51:39] getting more called knee balancing from a surgeon’s perspective to find how tight or loose do we want the knee in that.
Dr. Scott: That is matched to you a little bit and kind of to what the surgeon feels. And so that’s an issue we see in knee replacement sometimes. And when these are unstable for patients, they’ll start to develop pain in a lot of the muscles and tendons around the knee and often have recurrent swelling in the knee, pain. And so often to diagnose it because we need a tricky diagnosis. We may put you in a knee brace and see if that makes you feel better. If that patient’s had a knee replacement, have a problem, then we’re trying to figure out what’s going on.
Dr. Scott: The converse is possible, stiffness is possible. And in other words he looses range of motion after the surgery. That’s one of the reasons we want to see it at two weeks and six weeks, make sure that you’re getting that range of motion back. Because if you’re not, we sometimes have to take you between 10 and 12 weeks after surgery and do what’s called a manipulation under anesthesia where we put you asleep and bend and straighten the knee for you to get your motion back. Now that is effective, but it’s much easier for patients if they do it on their own. It’s not a super fun thing to have done. But that being said, it happens for sure and it is an effective treatment if we need to do it. But it’s definitely not a reason to avoid PT. Patella or kneecap tracking issues. This is statistically one of the more common complications with this. Patients will sometimes, even after the rest of the knee replacements doing well have some issues with the knee cap not tracking exactly correctly.
Dr. Scott: That’s a lot of what we try to do during surgery is to make sure that that tracks correctly. Because if it doesn’t, it can bang against the knee replacement essentially cause some discomfort. Fortunately, it’s relatively rare. Nerve or artery damage, very unlikely. The main nerves and arteries of the leg are in the posterior behind me essentially. We operate through the front. Very, very uncommon. That’d be said, most patients will have a numb spot on the front of the knee near where the incision is, but that is not a numb spot that causes any other issues and typically slowly goes away over time. Some of the things patients say is they say they have a mechanical feeling. The majority of patients have knee replacement are quite happy with the procedure, but most of them do say, “I know it’s not my knee. It still aches a little bit. It still hurts a little bit sometimes with weather changes. It clicks and just feels not like my knee.”
Dr. Scott: And I think it’s important the patient understand this. There is not a surgery really where we’re going to give you back the knee you had when you’re 18. This is a knee where we give you a better knee than what you have, but it’s usually not a knee that, for most patients, feels 100 natural to them. Although it is usually significantly, significantly better than what they had in it. And then longterm where. Eventually typically the plastic liner in the knee replacement, that was technical Holocaust, [inaudible 00:54:14] st Paul, I will start to wear out and we think that’s around 15 or 20 years. Now we’re thinking it might be a bit longer. The plastic liners we’re using for the last 15 years appear to be blasting somewhat better we think, but we want to see every year to check to make sure that that’s not wearing out.
Dr. Scott: Because if that happens eventually you get enough plastic debris in the knee that the immune system is going to be activated to clean it up. And this is a bit of an oversimplification, but essentially that your immune system can’t tell the difference between the plastic debris that might be generated down the line and the knee replacement itself and start to chew up the bone around the knee replacement. That’s again, no [inaudible 00:54:50] The upshot is the whole system can get loose from the bone and lose its fixation and become increasingly painful and problematic for people. Sometimes we have to take it all out and start over again. Now I do a lot of that, but if you’re having the surgery we try to get you to avoid it by coming back and seeing us regular so we can nip that in the bud if it’s going to happen, which again is usually decades in the future from the surgery.
Dr. Scott: So a little bit about infection. This is when patients are having … there’s a big part of my practice is what’s called revision your class. [inaudible 00:55:23] So I’ll see knee replacements, the patients that have had an issue with him, it’s discipline inefficient, the most common. [inaudible 00:55:29] So if we’re working up, we’ll get your history and exam. Might probably take some fluid out of the knee and send it to the labs, we’ll get some blood work to send that for labs, that x-rays and then talk about options, which most commonly is what’s called a Tuesday’s revision down here. That’s when we take the knee replacement out, put the antibiotic spacer that we discussed in and then come back later when we do the knee.
Dr. Scott: Sometimes if it’s an infection only been in there a little bit, just a couple of days and it’s a treatable bacteria, we’ll take the knee replacement out and put a new one in at the same surgery. That’s a little bit more popular in Europe, but it’s an option depending on what’s going on occasionally. And then occasionally very sick patients, we might just try to clean the knee up and put you on antibiotics, that’s not an ideal solution. It’s usually not super effective unless the infection is very brand new, in which case it can work.
Dr. Scott: There’s a picture of those antibiotic spacers. You can see that it’s shaped somewhat like a knee replacement, but looks different. And what you’re seeing here is what’s known as bone cement loaded with antibiotics and that provides a high dose of local antibiotics to help clear the infection from the area. This is a picture of it inside a knee that’s had it placed, and this is really what it looks like. You can see it’s got sort of a shiny greenish tint.
Dr. Scott: And that’s essentially it. So if anyone has any questions, I’m happy to answer.
Moderator: All right. I’m not seeing any questions come through and that’s okay. If you guys find that you have some later, please feel free to go ahead and send them over to us. And with that, that’ll conclude our session today. Thank you for joining us. And if you’re interested in scheduling an appointment or you want to learn more, check us out at possum.com. We’re Proliance Orthopedics and Sports Medicine. You can request an appointment online, or you can call our office at 425-392-3030. Thanks, everybody.