Knee Arthritis: A Primer

March 21, 2017 By Stefan D. Tarlow MD Leave a Comment

Facts About Arthritis of the Knee

A 15 year study of middled aged (avg 53 years) of normal body weight (BMI avg 25) from the United Kingdom provides insight on the incidence and severity of symptomatic Knee OsteoArthritis.

These data are gender specific and since this is a normal weight population can not be extrapolated to the obese population. The annual rate at which middle-age women develop knee osteoarthritis (OA) is fairly low, but progression is common when x-ray changes in the joint are already present, a community-based cohort study found.
During 15 years of follow-up there is a 49% lifetime risk of developing symptomatic (not necessarily severe OA of the knee). 51% of normal weight women never develop knee arthritis.

Among the entire cohort, 561 had undergone knee radiography at baseline and then at years 5, 10, and 15.
High body mass index also was associated with an increased incidence, with a nearly 20% greater incidence by year 10 among obese women.

At 15 year followup nearly 30 % of those women with knee arthritis had the disease in both knees. 70 % had symptomatic arthritis in only one knee.
The rate of total knee replacement by year 15 was about 10 %.
The also know risk factors in order of significance are genetics, obesity, female gender, serious knee injury (bone or ligament or meniscus).

Knee Osteoarthritis Treatment Options – AUC from AAOS A Guide

AUC (appropriate use criteria) are meant to augment—not supersede—clinician expertise and experience or patient preference. The scope of this AUC includes nonpharmacologic and pharmacologic interventions for symptomatic OA of the knee as well as surgical procedures less invasive than total or partial knee replacement.

The new appropriate use criteria (AUC) on nonarthroplasty treatment of patients with OA of the knee covers 10 different treatment options and more than 500 patient scenarios.
A web-based application (www.aaos.org/aucapp) enables clinicians to submit a patient profile based on specific clinical findings and receive feedback on the appropriateness of various treatment options.
Although the AUC addresses the most common clinical scenarios, it does not include all of the possible indications, and is not meant to supersede clinician expertise and experience or patient preference.

The full AUC can be found on the website of the American Academy of Orthopedic Surgeons. Try it yourself.

Open the AUC. Enter the patient specific information detailing knee pain, knee range of motion, knee stability, knee xray findings, knee aligment (bow legged or knock kneed), meniscal symptoms and patient age. Enter submit and treatment options categorized as appropriate, may be appropriate and rarely appropriate will be shown. These options now provide a basis for an intelligent conversation between the patient and the orthopedic surgeon with respect to non surgical and surgical treatment options.

Viscosupplementation for Knee Arthritis

Dr. Tarlow’s opinion – About half of my patients with mild to moderate osteoarthritis of the knee Visco injections report less pain and better function for 6-12 months following a series 3 weekly injections – brand of Visco does not matter in outcome. Patients with severe OA rarely benefit from type of injection.

OA is the death of the articular cartilage cells that cover the bone.

Here is a summary of the recent literature review:

Hyaluronic acid has little effect on pain, none on function, new review states

Tuesday, June 12, 2012

If the first series of injections help then it is likely a repeat series will be successful. Not all insurers reimburse for this medication – so many patients pay out of pocket for the drug and come to the office for the doctor to inject the drug into their knee.

Another unknown is how and why this medication decreases pain – the mechanism is not clear at this time.

escribe injections of hyaluronic acid, also called viscosupplementation.

There is no evidence to suggest that viscosupplementation results in any relevant reduction in symptoms in patients with knee osteoarthritis, said study co-author Dr. Peter Juni, professor of clinical epidemiology at the University of Bern in Switzerland.

The U.S. Food and Drug Administration in 1997 approved the injections, which are commercially available from several companies and much more costly than pain relievers.

For the study, Juni’s team reviewed 89 studies that compared injections with either a placebo treatment or no treatment. In all, the studies involved more than 12,000 adults aged 50 to 72.

The effect on pain was minimal, and the injections had no effect on functioning, the researchers found.

In some of the studies, the injections reached peak effectiveness at eight weeks, then declined.

“Viscosupplementation therapy for the knee appears to have some transient improvement in a relatively small number of patients for variable periods of time — most often six to 12 months,”

Look at the pros and cons from a patient’s perspective. Many turn to the injections to avoid surgery or medications, which can have their own harmful side effects, he said.

“Some patients, however — particularly patients with earlier stage arthritis — benefitted from viscosupplementation for periods of time sufficient to continue the use of this therapy,” he said.

Diet + Exercise Effective

Report in JAMA September 25, 2013 (Journal of the American Medical Association) concludes Diet and Exercise is Effective in Improving quality of life (diminishing symptoms of pain, improving function/mobility) compared to exercise alone in overweight and obese patients with Osteoarthritis of the knee. Weight loss was greater in the Diet/Exercise group (11 %) compared to Exercise group (2%).

Details: According to a study published in the Sept. 25 issue of JAMA, diet and exercise may improve quality of life more than exercise alone for overweight and obese adults with knee osteoarthritis (OA). The authors conducted a randomized, single-blind trial of 399 patients who were allocated to one of three groups: diet, exercise, and diet plus exercise. At 18-month follow-up, the authors found that mean weight loss was 11.4 percent for participants in the diet plus exercise cohort, 9.5 percent in the diet group, and 2.0 percent in the exercise group. In addition, knee compressive forces were lower in diet participants compared with exercise participants, and concentrations of IL-6 were lower in diet plus exercise and diet participants compared against exercise participants. Finally, patients in the diet plus exercise group had less pain and better function than those in the diet group or the exercise group, and the diet plus exercise group had better physical health-related quality of life scores than those in the exercise group.

Link to Abstract – https://jama.jamanetwork.com/article.aspx?articleid=1741824.

Dr. T Speaks —– Hello People. There are simple measure that are dramatically effective in helping you treat yourself with medications, injections, or surgery. Make the effort to convert America into a healthier place. This is an easy way to treat a common problem that is effective and will lower health care costs. Take ownership of your own well being.

Physical Activity

Research suggesting that physical activity could help prevent Knee Osteoarthritis has been presented this week at the AVS 62nd International Symposium and Exhibition, in San Jose, CA.

Researchers including Dr. Burris at the University of Delaware found that as the sliding speed increased toward typical walking speeds cartilage thinning was reversed. At slow sliding speeds (less than would occur in a joint at typical walking speeds) cartilage thinning and an increase in friction occurred over time. This may explain why walking or cycling can mitigate knee pain in patients with osteoarthritis of the knee.
A healthy joint surface is composed of 80 % synovial fluid (water and proteins). To investigate whether hydrodynamic pressurization could refill deflated cartilage, the researchers placed larger-than-average cartilage samples against a glass flat to ensure that there would be a wedge. Pressure forced fluid back into the articular cartilage stopping the joint surface from deflating. If movement occurs faster than the fluid can diffuse then continuous knee movement could prevent deflation.
Articular Cartilage is a firm, porous, rubbery material covering the ends of the bones in the knee joint. It reduces friction in the joint and acts as a “shock absorber.” Loss of synovial fluid occurs when articular cartilage is damaged or diseased. Osteoarthritis is a degenerative disease resulting from a reduction in the articular cartilage thickness, leading to an increase in friction, inflammation, pain and deformity of legs.

When cartilage becomes damaged or deteriorates, it limits the knee’s normal movement and can cause significant pain, and eventually the need for knee replacement surgery.

Surface damage to articular cartilage in a knee

Knee Braces

Non Operative Treatment of Knee Pain/Arthritis with BracingAdvanced Knee Care offers a custom bracing service to patients. This service includes a brief physician visit to confirm the diagnosis and need for the brace, a confirmatory x-ray of the knee and a detailed visit with our bracing specialist, Megan. The charge for this screening visit is $50 (insurance will be billed, if applicable).

The concept for this service is that there are many people that can be treated without surgery. A knee brace may be just what is needed to keep one active for years—no surgery required. This treatment is for people with Knee Pain and Knee Arthritis (either in the main joint or in the patellofemoral joint) that do not want a complex or expensive work up by the doctor, have already tried the myriad of other options for knee arthritis (pills, injections, Physical Therapy, Arthroscopic Surgery) and want a streamlined way to purchase a knee brace to help improve their knee function, help them be more active, and help them exercise to stay fit. There are also good bracing applications for runners with knee pain.

Treat Depression

A Korean study published in March, 2011 concludes that depression is linked to knee arthritis symptoms. The authors evaluated 660 patients aged 65 years or older; severity of knee OA was assessed based on radiographs and symptoms and depression was assessed based on interviews and patient questionnaires. The presence of a depressive disorder was associated with increased risk of symptomatic knee OA among patients with a radiographic severity of minimal to moderate OA.

Mental well being and a positive outlook help people cope with and tolerate symptoms of disease. In this study, a person with minimal to moderate Knee Osteoarthritis was more likely to have moderate to severe symptoms, and the reason for the increased dysfunction was thought to be due to poor mental health, not poor physical health.

This is a good lesson for both patients and doctors. Always consider a person’s overall health when formulating treatment plans. In some cases treatment should be directed at the cause of symptoms (treat depression, not knee arthritis) for the best outcome.

Improving Total Knee Replacement Surgery Results: Optimize Risk Factors PreOp

March 20, 2017 By Stefan D. Tarlow MD Leave a Comment

One way of improving the results of Total Knee Replacement Surgery is to optimize the risk factors. The common patient risk factors include the following: uncontrolled diabetes (Blood Sugar >150, HbA1C>8), Smoking, Obesity (BMI > 40), Opioid use, and Kidney disease. All these risk factors should be corrected prior to having the surgery.

There are treatments available to reverse these risk factors. Uncorrected, the above listed factors increase the chance a patient will suffer an prosthetic joint infection, a return to the operating room for another knee procedure, wound healing problems, revision knee surgery or an unsatisfactory surgical result.

Knee Replacement Surgery Risks

Like any other surgery, total knee replacement carries some risks. However, the occurrence of these risks is quite low: infection, nerve damage, stroke or blood clot. The aforementioned risks are those that might occur during or after the surgery. What we are going to focus on are the factors that might affect the outcome of the surgery. Such factors or risks must be corrected before the surgery is conducted. They include the following: uncontrolled diabetes, smoking, obesity, opioid use and kidney disease.

Uncontrolled Diabetes

The Risks

According to a number of studies, people with diabetes face a higher risk of postsurgical complications. The possible complications that a patient may experience if he/she undergoes a surgery such as total knee replacement with uncontrolled diabetes are the following: joint loosening, fracture around the implant, blood clot, stroke and wound infection.

The Treatment

Diabetes is an important consideration before a patient undergoes a surgical procedure. The research suggests that patients need to control their diabetes before undergoing a major surgery such as total knee replacement. While your blood sugar will be tightly monitored right before and after surgery, it’s up to you to make the long-term lifestyle changes necessary to ensure you get the best outcome. This is an important conversation to have with both your surgeon and the physician or provider who helps you manage your diabetes. Eating well and exercising (if appropriate and with approval from your providers) can help you get your body ready for surgery.

Smoking

The Risks

Research shows that there is a correlation between smoking and the success of knee surgery. Some studies put the chance of redoing the surgery at a rate ten times higher in smokers than in non-smokers. Smokers also show higher rate of surgical complications which include blood clots, kidney problems, urinary tract infections, and abnormal or irregular heartbeats. This is because nicotine constricts the blood vessels, which interfere with and affect the healing process.

The Treatment

The best way to get rid of the risks is to quit smoking. You may have tried to do so in the past and not found success, but if you’re going to have total knee replacement surgery, let this be the big push you need to finally quit. In addition to the possibility of increased post-surgical complications, just imagine trying to find a place to smoke while you’re recuperating. Talk with your primary care provider about available techniques and support.

Obesity

The Risks

Obesity is the root of various health conditions and diseases like type 2 diabetes, obstructive sleep apnea, cardiovascular diseases, hypertension and metabolic syndrome. All these conditions increase the risk of knee replacement surgery. Aside from these, patients with obesity are also more at risk to experience the following postsurgical risks: blood clots, difficulty breathing, poor and slow wound healing, infection and pulmonary embolism.

The Treatment

To lower the risks and to promote a better result, patients with obesity are advised to lose some weight. It is important that the patient is in good health and weight prior the surgery. Try hard to lose some weight and eat healthy before the scheduled surgery. Your immediate post-surgical health will improve—and along with your new knee, being in better shape will give you a new lease on life.

Opioid Use

The Risks

One of the total knee replacement precautions a patient must know concerns opioid use. One study showed chronic opioid use before a total knee arthroplasty led to worse outcomes for patients, including “longer hospital stays, more postoperative pain, and higher complication rates… [patients] were also more likely to need additional procedures, require referrals for pain management, suffer from unexplained pain or stiffness, and have lower function and less motion in the replaced knee.”

The Treatment

The FDA suggests that patients undergoing knee replacement surgery should decrease the duration and amount of opioid use. There are many other pain management treatments available besides opioids, and you should explore them with your pain management physician—not just because of your surgery, but because chronic opioid use itself brings a whole host of problems you don’t want.

Kidney Disease

The Risks

Patients with kidney disease, particularly chronic renal disease, have increased risk for readmission after the surgery. The success of knee replacement surgery is also low and the occurrence of common complications is high among patients with kidney problems.

The Treatment

If you have kidney disease and need to have surgery—any kind of surgery—you and the doctor managing your disease, as well as the surgeon, need to work closely together to assess your risk and make sure surgery is the right course for you. If you and your providers move ahead, techniques like post-operative dialysis, substituting or changing the normal dose of medications like antibiotics given before and during surgery and avoiding pain medications that are known to cause problems are all good strategies to keep you healthy.

Reducing Total Knee Replacement Complications

We, the patient and the doctor, both want something in common. That is, the best outcome possible of the surgery. Knowing how to reduce the complications is powerful information. It is very important that you follow the tips mentioned in this article and control the risks mentioned to improve the results of your total knee replacement surgery.

If you’re contemplating knee replacement, schedule an appointment to see me and the rest of the team here at Advanced Knee Care. Assessing your needs and the appropriate treatment for you is our top priority.

Gender and Race in Knees and Joint Replacement

March 8, 2017 By Stefan D. Tarlow MD Leave a Comment

Male and Female Differences in Knee Injuries and Disease

Gender variances exist due to anatomic differences, hormones, and genetic factors.

ACL knee injuries occur at a higher frequency in female athletes – on the order of 3:1 vs age and sport matched males.

Osteoarthritis in the knee develops more frequently in women. One explanation is that women lose healthy joint surface cells (articular cartilage) at 4 times the rate as men. Obesity afflicts women more than men and this is one link to the greater incidence of knee OA. Estrogen may play a role.

Replacing Knees Sooner in Women May Enhance Outcome

Conventional Orthopedic Surgical wisdom is to delay joint replacement until the patient is seriously impaired by their symptoms, even though on x-ray the patient’s knee joint is destroyed by arthritis. This means delaying surgery for serious knee arthritis until patients can not walk more than a block or two, can only ascend and descend stairs one at a time, patients are limping and patients have sleep disturbance from arthritis pain. Additionally, conventional wisdom recommends trials of NSAIDS (ibuprofen like meds), physical therapy, bracing, steroid injections or Hyaluronic Acid injections (synvisc and the like).

The lead article in the November, 2007 Journal of Bone and Joint surgery challenges this precept and presents strong scientific evidence to support the conclusion to operate sooner on women with serious knee arthritis that have measured functional deficits. The article is entitled Disease-Specific Gender Differences Among Total Knee Arthroplasty Candidates and was done at the University of Delaware.

Arthritis of the knee has a greater effect on knee function and strength in women, reflecting a gender difference in the disease impact. This larger impact on knee function in women is manifest by lower quadriceps muscle strength ( large muscle group in the front of the thigh), longer timed up and go standing test, longer timed stair climb, and shorter 6 minute walk distance compared to men with knee arthritis.

The logical and yet revolutionary conclusion is that strength and functional decline should be closely monitored (this functional testing could be documented by a Physical Therapist) in women with knee arthritis and when worsening is observed, joint replacement should be carried out. In some cases this may mean joint replacement is done sooner (compared to using traditional standards for deciding on the timing of surgery).

Closing the Gender Gap in Joint Replacement

It has been observed that there is an under use of Total Joint Replacement among willing and appropriate women who suffer from severe hip or knee arthritis. Even though women are as likely as men to seek treatment physicians are less likely to refer and recommend joint replacement surgery for women. Now that recognition of gender and cultural differences have been made, the focus is on more training for physicians in culturally competent patient care and shared decision making so that there will be a reduction in this disparity. Changes need to occur at the primary care level for referral to an orthopedic surgeon, better communication by all care providers so as to fully understand the severity of symptoms, the patient perceiving how severely debilitating their symptoms actually are, and dealing with issues related to surgery ( risks, interference with caregiver role, perceived burden on others during recovery process).

Improving Your Knee Replacement Results

February 24, 2017 By Stefan D. Tarlow MD 1 Comment

How to Improve Total Knee Replacement (TKR) Results

Here are five “fun facts” about Total Knee Replacement.

1. Have the same surgical team for every case (Surgeon, Assistant Surgeon, Circulating Nurse, Scrub Tech, Second assistant, and anesthesia). 30 day readmission rates due to complications are lower when consistent teams are used.

2. Use Saphenous Nerve blocks (adductor canal blocks). This provides better post op pain relief and shorter hospital stays or allows for same day Total Knee surgery.

3. Emphasize the importance of post op rehabilitation. Stronger quadriceps muscles are correlated with increased patient satisfaction after TKR.

4. Unexplained knee pain 6 months after TKR surgery predicts a poor functional outcome at 2 years post op.

5. Total Joint clinics see a higher percentage of obese people than are present in the total population. Obesity is a modifiable risk factor for hip and knee osteoarthritis.

Research suggests spinal and epidural anesthesia, peripheral nerve blocks safe to use

Released: 2/14/2014 4:00 PM EST
Source Newsroom: American Society of Anesthesiologists (ASA

Citations Anesthesiology

Newswise — Two types of regional anesthesia do not make patients more prone to falls in the first days after having knee replacement surgery as some have previously suggested, according to a study based on nearly 200,000 patient records in the March issue of Anesthesiology.

Regional forms of anesthesia – spinal or epidural (neuraxial) anesthesia and peripheral nerve blocks (PNB) – which only numb the area of the body that requires surgery, provide better pain control and faster rehabilitation and fewer complications than general anesthesia, research shows. But some surgeons avoid using them due to concerns regional anesthesia may cause motor weakness, making patients more likely to fall when they are walking in the first days after knee replacement surgery.

“We found that not only do these types of anesthesia not increase the risk of falls, but also spinal or epidural anesthesia may even decrease the risk compared to general anesthesia,” said Stavros G. Memtsoudis, M.D., Ph.D., professor of anesthesiology and public health and director of critical care services, Hospital for Special Surgery, New York, and lead author. “This work suggests that fear of in-hospital falls is not a reason to avoid regional anesthesia for orthopedic surgery.”

Researchers analyzed the types of anesthesia used in 191,570 knee replacement surgeries in the Premier Perspective database: 76.2 percent of patients had general anesthesia, 10.9 percent had spinal or epidural anesthesia, and 12.9 percent had a combination of neuraxial and general anesthesia. In addition, 12.1 percent of all patients had PNB. Researchers then analyzed the type of anesthesia used for those who suffered a fall in the hospital. Of patients who had general anesthesia, 1.62 percent fell, compared to 1.3 percent of those who had neuraxial anesthesia and 1.5 percent who had general and neuraxial anesthesia. Patients who also received a PNB had a fall rate of 1.58 percent.

When patients fall during recovery, they are more likely to have worse outcomes, including more heart and lung problems and higher rates of death within 30 days of surgery. Spinal or epidural anesthesia and PNB are used far less often than general anesthesia because of concern that regional forms of anesthesia – particularly PNB – may increase muscle weakness and make patients more prone to falls. However, there has never been a large study based on real-world practices to determine if that is true.

“In this study using data from a wide range of hospital settings we found this concern seems unfounded, especially because hospitals and physicians performing these procedures use fall-prevention programs and are able to reduce the impact of other factors shown to increase fall risk, such as higher narcotic use,” said Dr. Memtsoudis.

How to Get Back on Your Feet Quickly After Knee Surgery

February 24, 2017 By Stefan D. Tarlow MD Leave a Comment

Predictors for Returning to Work After Total Knee Replacement

A study from Cleveland identified factors that are important in estimating a patients return to work following Total Knee Replacement surgery. Average time to return for all patients is 9 weeks.

An accelerated group returning to work in 4-5 weeks had some of these qualities: had a sense of urgency to return, were female, were self employed, had high mental health scores, had higher physical function scores, and had good overall health.

Patients with some of these qualities were likely to return to work 9 or more weeks after Knee Replacement surgery: a physically demanding job, were receiving Workman’s Compensation or had less pre operative pain.

In my practice – Advanced Knee Care – most patients return to work 4-12 weeks after Knee Replacement (a few return sooner, a few return later).

The report concluded that although the physical demands of a patients job has a moderate influence on the ability to return to work, individual characteristics including physical and mental well being and motivation are the most predictive factors for estimating return to work after Total Knee Replacement surgery.

Lifestyle Modification Key to Great Outcomes Following Knee Replacement Surgery

After recovering from knee replacement surgery, patients’ physical activity levels with their new joint were varied.

Total knee replacement is primarily for pain relief, it’s not a lifestyle intervention. After surgery patients need to change their lifestyle in order to attain expected improvement in Function and Mobility and Exercise Tolerance.

Most people who have the surgery are pleased with the results in terms of having less pain and gaining more day-to-day function. These people are not always pleased with their ability to participate in recreational activities, such as participating in sports, yoga or gardening.

At the time of surgery, study participants reported spending about two hours a week being active, mostly doing moderate-intensity activities such as yard work, strength training and walking.

After surgery patients spent about 11 hours a week being physically active, according to findings published in The Journal of Arthroplasty.

Commitment to a lifestyle change including eating healthy, exercising regularly and avoiding harmful behaviors will go a long way towards improving a patients outcome from Total Knee Replacement surgery.

Internet Based Outpatient Physical Therapy

After recovering from knee replacement surgery, patients’ physical activity levels with their new joint were varied.

At the time of surgery, study participants reported spending about two hours a week being active, mostly doing moderate-intensity activities such as yard work, strength training and walking.

After surgery patients spent about 11 hours a week being physically active, according to findings published in The Journal of Arthroplasty.

Is Makoplasty Partial Knee Replacement Right for You?

February 13, 2017 By Stefan D. Tarlow MD Leave a Comment

Makoplasty Robotic Partial Knee Replacement Best for One Compartment Disease

While Makoplasty parts can be combined in several different configurations, by far the most common is to resurface only one compartment. The one compartment most commonly resurfaced is the medial compartment of the knee.

Medial knee is the time tested application with predictably great outcomes. This procedure has been dramatically improved upon using Robotic Technology.

In my opinion, lateral uni compartmental application works well when your surgeon is able to incorporate accurate implant placement using Makoplasty Robotics and Computer Balancing and CT mapping technology.

Xray of Medial Mako (most common construct)

Bicompartmental Mako Components for Tibial Resurfacing

Bicompartmental Mako components (No patellar button shown and 2 options for tibial resurfacing shown)

Bicompartmental Mako with no patellar button

Cartoon of Bicompartmental Mako (no patellar button)

Bicompartmental Knee Resurfacing:

In my hands, bicompartmental use is a less desirable construct. If two or more compartments are arthritic Dr. T. will usually recommend Total Knee Replacement. Another bicompartmental construct is to resurface the medial and lateral compartments, leaving healthy patella. This is rarely done and no xray image was able to be found on line to even demonstrate the appearance of this.

Xray of Bicompartmental Mako (patellofemoral + medial uni)

Makoplasty Unicompartmental Knee Mimics Natural Knee

Dr. Tarlow attended a course titled “Update on Unicondylar Knee Replacement” this past week at the annual meeting of the American Academy of Orthopedic Surgeons.

The best surgical outcomes are in unicompartmental knee patients. Uni patients have a higher satisfaction score, lower chance of infection, stroke, heart attack, blood transfusion, blood clot and death rate compared to total knee replacement patients.

The appeal of the unicompartmental or partial knee replacement also known as Makoplasty can be summarized in the following thoughts.

Makoplasty replaced knees compared to Total Knee Replacement:

Retain more normal knee tissue – including the ACL and PCL ligaments
There is less bone resection
Smaller incisions
Less pain/quicker recovery
improved, often times normal knee motion
Less expensive

2014 study from Germany showed unicompartmental knee closely preserves natural knee kinematics in vitro.

2015 study from New York showed Unicompartmental knee arthroplasty is an economically attractive alternative in patients sixty-five years of age or older, and modest improvements in implant survivorship could make it a cost-effective alternative in younger patients.

Most studies comparing unicompartmental knee replacement versus total knee replacement find a slight preference in favor of unicompartmental knee.

Makoplasty Partial Knee Resurfacing Shown To Be Best Surgical Method

Study finds MAKOplasty® Partial Knee Resurfacing Offers Lower Post-Op Pain, Improved Knee Function

The content for this blog post comes from the work by Blyth MJ, Smith J, Jones B, MacLean III AB, Anthony, Rose P entillted Does robotic surgical assistance improve the accuracy of implant placement in unicompartmental knee arthroplasty?

Comments from Dr. Tarlow: Common sense would lead me to conclude that precise implant placement will result in the best patient outcomes from partial knee replacement surgery. Makoplasty allows the surgeon to optimize implant size, knee alignment, implant tracking and limp alignment. My observation is that many patients return to close to normal knee function after this procedure. Scientific research is lacking to validate my observation. This is the first in hopefully many studies that corroborate my clinical observations.

Summary of Study: Results of an ongoing study on partial knee replacement surgery provide early clinical evidence that robotic arm assisted MAKOplasty Partial Knee Resurfacing results in improved knee function and less pain when compared to manual procedures using Oxford® implants.1 The study, which started in October 2010, is being conducted in Scotland and will be ongoing for ten years. The initial results looked at early outcomes of 100 partial knee replacement procedures – 50 robotic arm assisted MAKOplasty procedures and 50 manual procedures performed with Oxford® implants. All surgeries were unicompartmental knee arthroplasty (UKA) procedures, which involve only one compartment of the knee.

The researchers found that when compared with conventional procedures MAKOplasty resulted in:

Lower post-operative pain from day one up to 8 weeks after surgery
More accurate implant placement
Twice as many patients with improved knee functionality (57% vs. 26%) based on American Knee Society Scores

This study was presented at the 2013 Annual Meeting of the American Academy of Orthopaedic Surgeons.

Makoplasty Knee Surgery and Home In One Day-Outpatient Partial Knee Replacement

Makoplasty knee surgery with Dr. Stefan Tarlow and his team

Dr. Tarlow team performing Makoplasty

Stefan D. Tarlow, M.D., Knee Surgeon with Advanced Knee Care, P.C. has posted a new video with an overview showing how Makoplasty, a partial knee replacement procedure using robotic technology can be performed as an outpatient. Click here to watch the 4 minute video.

Makoplasty – Partial Knee Replacement – Home the Same Day

Scottsdale Healthcare Thompson Peak acquired a Mako RIO system in Janaury, 2011. Since that time Dr. Stefan Tarlow has performed over 180 procedures, more than any other orthopedic surgeon in Arizona. Dr. Tarlow is Arizona’a most practiced and well-versed Makoplasty surgeon. Not content with status quo, he and his team continue to innovate and improve on the technique.Our team of Surgeons, Nurses and Anesthesiologists have continued to refine our delivery of care for our surgical patients. This is particularly evident in the patients undergoing partial knee replacement using the robotic technology known as Makoplasty.

Today’s standard delivery of care has evolved to outpatient day surgery
due to improved surgical efficiency, saphenous nerve block (little to no motor weakness compared to femoral nerve block), and recovery room pain management with short acting opiods (Fentanyl). Together these modifications allow many patients to go home directly from recovery room.

Makoplasty Specialist Brian Fighting Irish

Everything You Need to Know About Minimally Invasive Surgery

February 13, 2017 By Stefan D. Tarlow MD Leave a Comment

Who is a Candidate for Minimally Invasive Surgery?

Here in the Phoenix – Scottsdale, Arizona area I am frequently asked by patients “Can you perform Minimally Invasive (MIS) Total Knee Replacement (TKR) on my knee?”

My answer is I can perform Minimally Invasive Total Knee Replacement on most any patient but I choose to use the technique on the large subset of patients that benefit most from the technique. It is a surgical procedure that is more technically demanding and more time consuming than traditional Total Knee Replacement so I am somewhat selective on choosing patients for this method. By analogy, I would not buy a new Basketball for my 90 year old mother in law but I would for my teenage son who is on the high school basketball team. She would never use the basketball and he would use it frequently.

I always perform Minimally Invasive Surgery on the healthy, motivated, energetic patients who will recover fast because of their good health and motivation to get well fast. I rarely perform Minimally Invasive Surgery on unhealthy patients with multiple co morbidities (Diabetes combined with cardiac or respiratory disease combined with high Body Mass Index is a typical patient profile that comes to mind). The first example patient would take full advantage of having had this technique by discharging from the hospital in 1-2 days, be walking freely without a walker in 5-10 days, be driving in 10 days -3 weeks, be back to work in 2-4 weeks and be golfing or hiking in the beautiful Arizona desert in 4-8 weeks. The second example patient would recover but take 1-3 months to reach similar milestones.

Body mass index is sometimes a factor since some patients with high BMI have low energy. BMI alone is not a reason not to perform MIS Total Knee surgery.

A normal BMI is under 30 and defined as a six foot tall man weighing 215 pounds or less or a five foot six inch woman weighing 182 pounds or less.
Obesity (BMI 30-40) is the six foot man between 215 and 285 pounds or the five foot six woman between 182 and 240 pounds. Morbid obesity (BMI above 40) is above 285 pounds for the six foot man and above 240 pounds for the five foot six inch woman. (BMI tables are available online to calculate your own BMI). Minimally Invasive Surgery can be performed on the higher BMI patients. It always requires a skin incision 2-4 times longer than the incision in under 30 BMI patients. The longer skin incision allows the surgeon to “convert” the high BMI patient into a low BMI patient by retracting away the “extra” skin and subcutaneous tissue. However, the definition of Minimally Invasive Surgery Knee Replacement and the key factor allowing for faster recovery is not the size of the skin incision but the size of the deep or Capsular incision that allows the surgeon into the knee joint proper. Therefore high BMI patient can have Minimally Invasive Total Knee Replacement Surgery and enjoy the benefits of a faster recovery.

Returning to the question posed at the beginning of this post: Who is a candidate for Minimally Invasive Total Knee Replacement Surgery? The answer is that most people are good candidates for MIS TKR as long as they are healthy, have a good energy level and are motivated to recover quickly.

Minimally Invasive Knee Replacement is Safe/Better: Refuting the Wall Street Journal

The October 14, 2008 edition of the Wall Street Journal published an article entitled “New Doubts About Popular Joint Surgery”. The following excerpt from the WSJ raises issues concerning Minimally Invasive Joint Replacement surgery (MIS).

“But patients aren’t always told that minimally invasive surgery is more difficult to perform than a traditional operation. Because of the smaller incision, surgeons have a harder time seeing what they are doing. And because minimally invasive surgery has grown so fast, many doctors don’t have extensive experience performing the complicated procedure.”

As an experienced MIS Knee Replacement Surgeon I completely agree with the above quoted comments. However, the other side to the story is that experienced surgeons using computer surgical navigation have patients with consistently excellent outcomes and complication rates as low or lower than traditional joint replacement surgeons.

I would like to address the three issue raised. First, “minimally invasive surgery is more difficult that a tradition joint replacement”. There is a known “learning curve” of approximately 25 cases, after which most surgeons will have mastered the MIS technique. I have been performing MIS Total Knee Replacement since 2004 and to date have over 500 cases experience. The transition to MIS replacement will occur with time and can be compared to the transition in sports medicine from open “traditional” knee and shoulder surgery in the past to current arthroscopic treatment for most knee and shoulder injuries.

Secondly, “because of the smaller incision, surgeons have a harder time seeing what they are doing”. Using Computer surgical navigation intraoperatively or computer generated surgical cutting blocks preoperatively provides the Minimally Invasive Joint surgeon with the information needed to accurately place the new hip or knee joint using the smaller incision. Computer technology more than overcomes the exposure issue raised in this second point. I personally do not perform MIS Total Knee Replacement unless I have computer navigation or computer generated cutting blocks.

Third, “because minimally invasive surgery has grown so fast, many doctors don’t have extensive experience performing the complicated procedure”. Every major city and some smaller towns have compentent, experienced minimally invasive joint replacement surgeons. As a patient, do your research and find the well trained, experienced minimally invasive joint replacement surgeon and you will often times be rewarded by a faster recovery and a less painful experience while getting all the long term benefits of traditional total joint replacement.

Minimally Invasive Total Knee Replacement Facilitates Recovery

An article appeared in the July, 2007 Journal of Bone and Joint Surgery entitled “Minimally Invasive Total Knee Arthroplasty Compared With Traditional Total Knee Arthroplasty“. The main author is Seth S. Leupold, M.D. from the Department of Orthopedic Surgery at the University of Washington in Seattle.

The conclusion of the article is that minimally invasive Total Knee Replacement seems to facilitate recovery after this operative procedure. The patients who had the minimally invasive approach demonstrated significantly better clinical outcomes with respect to shorter length of hospital stay, higher percentage of patients discharged to home instead of inpatient rehabilitation facility, less narcotic use at 2 and 6 weeks post-operatively and less need for assistive devices to walk at two weeks after surgery.

The Journal of Bone and Joint Surgery is one of the most respected and credible orthopedic surgery publications. The journal was founded in 1903 and is the official journal of the American Association of Orthopedic Surgery. The guiding principle of the JBJS is excellence through peer review. There are high standards, professional review and rigid criteria that have to be met before an article is accepted for publication. This is one of the first unbiased articles to appear in a prestigious orthopedic journal confirming the benefits of minimally invasive Total Knee Replacement. Therefore I believe the appearance of this article in the JBJS is highly significant.

Like the author of this article, I began performing MIS Total Knee Replacement in 2004. And just as the author discusses in the quoted article there is a learning curve of at least 25 cases to become more familiar with the technique. Like the author I perform a number of these operations on a monthly basis so that I got the over the learning process in a 3 month period. Over the last 3 years I have performed Minimally Invasive Knee Replacement on most of the patients I treat surgically for knee arthritis.

The components that are implanted are the same for MIS and Traditional Knee Replacement. I always use Surgical Computer Navigation as I believe this improves the accuracy in component position.

In my experience 1 in 4 patients are discharged home after one night in the hospital and most of the remaining patients go home after 2 nights. It is less common for a patient to be hospitalized 3 nights or to be discharged to an inpatient rehab facility. Similarly 25 % of patients are walking without assist in a week and the 70 % are walking without assist at 2 weeks. Most patients are driving in 2-3 weeks.

The results with respect to mobility, knee motion, pain relief and function for activities of daily life after MIS and Traditional Knee Replacement seem to merge around 3-12 months after surgery, however the return of quadriceps strength seems to occur sooner in MIS patients.

In conclusion I found the publication of the article highly significant and supportive of the beliefs of my colleagues who are currently performing minimally invasive Knee Replacement. Surgeons using minimally invasive techniques for Joint Replacement do so because of the greater patient benefits with this procedure.

3 Reasons Computer-Assisted Knee Replacement Is Better Than Traditional Surgery

February 8, 2017 By Stefan D. Tarlow MD 2 Comments

Computer Assistance Increases Precision of Component Placement in Total Knee Arthroplasty with Articular Deformity

Computer Navigation is a valuable tool that surgeons use to accurately position components for Knee and Hip replacement surgery. Computer navigation is embraced by patients – it is common sense that technology is helping medicine to evolve and improve. However, there continues to be push back to the adoption of this technology. Not surprisingly, health insurance companies continue to deny payment to surgeons who believe this valuable technology improves joint replacement surgery. Traditional “old guard” joint surgeons refuse to adopt emerging technologies. Insurance claim payment for navigation is denied is based on ” experimental or not necessary” reasoning. However, a large body of medical literature supports the use of computer navigation to aid joint replacement surgeons.

The next wave of technology will combine navigation with robotics which will further revolutionize joint replacement surgery. Look for this technology to be minimized and deprecated by health insurance companies and old guard surgeons.

This is the abstract of a scientific paper demonstrating the value of computer navigation in total knee replacement surgery.

The accuracy of computer navigation applied to total knee arthroplasty (TKA) in knees with severe deformity has not been studied.

Questions/purposes

The purpose of this study was to compare the radiographic alignment achieved in total knee replacements performed with and without navigation and to search for differences in the final alignment of two groups of patients (with and without previous joint deformities) using the same system of surgical navigation.

Methods

The first series comprised 40 arthroplasties with minimal preoperative deformity. In 20 of them, surgical navigation was used, whereas the other 20 were performed with conventional jig-based technique. We compared the femoral angle, tibial angle, and femorotibial angle (FTA) by performing a post-TKA CT of the entire limb. In the second series, 40 additional TKAs were studied; in this case, however, they presented preoperative deformities greater than 10º in the frontal plane.

Results

The positioning of the femoral and tibial component was more accurate in the group treated with surgical navigation and FTA improvement was statistically significant. When comparing the results of both series, FTA precision was always higher when using computer-assisted surgery. As for optimal FTA, data showed the use of surgical navigation improved the results both in the group with preoperative deformity greater than 10° in the frontal plane and in the group with minimal preoperative knee deformity.

Conclusions

Surgical navigation obtains better radiographic results in the positioning of the femoral and tibial components and in the final axis of the limb in arthroplasties performed on both deformed and more normally aligned knees.

Level of evidence

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

This study belongs to a project promoted by the Health Research Institute (Carlos III Health Institute) of the Spanish National Healthcare System.

Computer-Assisted Surgery More Accurate for Total Knee Replacement

Medical articles on new technologies are often times conflicting. The the old guard designs research protocols to verify that time tested procedures are the standard. The forward thinking innovators design studies supporting the benefits new technologies represent. Computer Navigated Knee (and Hip) replacement surgery is in the middle of a technological revolution and this is being carried out in the press, the medical literature and in operating rooms across the world. Here is a compelling study citing both the effectiveness and safety of computer assisted Knee Replacement Surgery.According to data presented at the AAOS 2010 Annual Meeting, total knee arthroplasty (TKA) conducted with computer assistance is more accurate than conventional surgery. The authors based their data on the results of 1,000 computer-assisted TKAs conducted at a single center between February 2005 and January 2010. They found that alignment within 3 degrees was achieved in 100 percent of the patients, with an average final, post-surgical alignment of 0.8 degrees. In addition, none of the knees failed early or have required revision secondary to misalignment, instability, or aseptic loosening. In other words, a study of 1,000 consecutive Computer-Assisted Robotic Total Knee Replacements performed over a five year period at Mercy Medical Center in Rockville Centre, NY demonstrates that the computer-assisted procedures result in far better leg alignment, much less likelihood of complicating infection, and a far lower early failure rate than surgeries performed using conventional techniques.

Scientific Article Questions Routine Use of Computer Navigation for Knee Replacement Surgery

A Mayo Clinic 15 year study confirms accurate placement of Total Knee Components does not improve long term results.

One long-held tenet of total knee arthroplasty is that implant durability is maximized when postoperative limb alignment is corrected to 0° ± 3° relative to the mechanical axis. Recently, substantial health-care resources have been devoted to computer navigation systems that allow surgeons to more often achieve that alignment. Better long-term survival of total knee arthroplasty in accurately aligned implants was similar to the group of alignment outliers. 398 Knees were studied.

Results At the time of the latest follow-up, forty-five (15.4%) of the 292 implants in the mechanically aligned group had been revised for any reason, compared with fourteen (13%) of the 106 implants in the outlier group. Revision for specific reasons thought to be related to initial position showed the following: seventeen (5.8%) of the 292 implants in the mechanically aligned group had been revised because of aseptic loosening, mechanical failure, or wear, compared with four (3.8%) of the 106 implants in the outlier group (p = 0.49).

Conclusions A postoperative mechanical axis of 0° ± 3° did not improve the fifteen-year implant survival rate following these 398 modern total knee arthroplasties. We believe that describing alignment as a dichotomous variable (aligned versus malaligned) on the basis of a mechanical axis goal of 0° ± 3° is of little practical value for predicting the durability of modern total knee arthroplasty implants.

This report suggests that for traditional knee replacement surgery with standard instrumentation aligns the knee well enough for an 85 % good result rate fifteen years after surgery. This report suggests that “perfect axial alignment” is not an important variable toward improving the long term result after total knee replacement. The author’s initial bias was to discount the benefit of accurate alignment using the current technology of computer navigation, which the data confirms. Computer navigation use to prevent implant alignment errors in minimally invasive surgery or in the case of unusual leg deformities as a result of trauma or congenital variation is still considered valuable in my opinion. Also, the combination of computer assisted surgery with robotics might be the next “great” advancement in joint replacement surgery. More on robotics and computers later.