Introduction

Role of surgery in arthritis

General overview with examples

Dr. Arno Smit
Orthopaedic Surgeon
White Rock, BC

Role of surgery in arthritis:

Prevention: create normal joint surface

• after trauma
• for certain developmental joint abnormalities

Modulation: slow down the progression

• unloading surgery

Restoration:

• biological
• prosthetic replacement

Pain relief only:

• excision
• fusion

Surgery for pain relief only

Excise painful joint

• Usually poor control of joint motion (flail)

Eliminate pain through elimination of motion

• Fusion surgery
  • Commonly used in smaller joints
  • Now rarely used in large joints
  • Main option in spine, ankle, foot, wrist, hand

End-stage Osteo-Arthritis ankle, pre-op

End-stage O.A. ankle, 1 year post ankle fusion

Prosthetic Replacment Surgery

1. Eliminate arthritic pain by providing smooth gliding joint surface.
2. Optimize range of motion and functional capacity

Prosthetic replacement surgery

Current trends:

• implants more 'bone-and-joint' friendly
  • 'don't burn the bridges'
• better bearing surfaces
  • 'will last longer'
• less-invasive surgery
  • 'recover faster and better'

Shoulder replacement

Ball and 'shallow socket' joint

• 'Socket' replacement controversial
• 'Ball' replacement well established
• Traditional stemmed design
• More recent: bone-preserving design

Shoulder replacement, Rheumatoid Arthritis

Shoulder Replacement, Rheumatoid Arthritis
rotator cuff deficient, stem

Shoulder Replacement Rheumatoid Arthritis
rotator cuff deficient, Copeland

Shoulder Replacement Osteo-Arthritis
rotator cuff intact, Copeland

Hip replacement

Ball and 'deep socket'

Both are replaced

1. Traditional stemmed design
2. More recent bone-preserving design

Stemmed hip replacement

Well-proven technology

Recent improvements:

• better bearings
• less-invasive surgery

Hip replacement -bearing surfaces

Hip replacement: implants

Hip replacement: bone preserving

For the 'young and vigorous'

Resurfacing of femoral head

Metal-on-metal bearing

Allows higher activity level

Requires full traditional exposure

Unknown: possibility of toxicity of metal in long run

Osteo-arthritis left hip, 52 y old woman

Osteo-arthritis left hip Birmingham hip

Osteo-arthrosis left hip Birmingham hip

Hip replacement: bone preserving

Why?

Will last longer

More options for revision after failure

But: upfront costs are higher-->
difficulty with funding

Hip replacement: bone preserving

Cobalt Chrome Alloys

Peter Ring 1960's

Hip replacement

So:

1/ older and more sedentary-->
refine standard hip replacement

2/ younger and more vigorous-->
refine standard hip replacement

OR

consider metal-on-metal resurfacing

Knee replacement

Total knee replacement:

• well established
• big operation

Newer trend:

• if possible, consider less invasive partial knee replacement

Knee replacement: implants

Knee replacement: total

Knee replacement: partial

If only part of the knee 'worn out'-->
Partial knee replacement.

Less invasive
Faster and better recovery
'Don't burn bridges'

Knee replacement: partial

• Mobile bearing

vs.

• Fixed bearing

Knee replacement: partial

Step 1: Must demonstrate intact opposite compartment

Step 2: Must demonstrate ACL integrity for mobile bearing knee

Knee replacement: partial, Standing

Knee replacement: partial, Stress views

Knee replacement: partial

Knee replacement: partial

Knee replacement: partial

Knee replacement: partial

Conclusion

• Surgery will remain an important tool to deal with end-stage, disabling arthritis
• Improvements in materials, design and surgical technique continue to be refined
• Biological solutions for end-stage arthritis are NOT imminent
• The main issue today is ACCESS.

Thank You !!!

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