The Role of Surgery in the Treatment of Arthritis

General overview with examples

by Dr. Arno Smit Orthopaedic Surgeon White Rock, BC

Please Note: The information contained in this presentation was most accurate in 2004. Orthopaedic technology and practice changes over time. Always consult your doctor to ensure the information applies to your case.

  1. Role of Surgery in Arthritis Treatment
    1. Pain Relief Only
    2. Ankle
      1. Pre-Op
      2. 1 Year Post Fusion
  2. Prosthetic Replacement
    1. Current Trends
    2. Shoulder Replacement
      1. X-ray: Before Surgery, RA
      2. X-ray: Rotator Cuff Deficient - Stem, RA
      3. X-ray: Rotator Cuff Deficient - Copeland, RA
      4. X-ray: Rotator Cuff Intact - Copeland, Osteo-Arthritis
    3. Hip Replacement
      1. Stemmed Hip Replacement
      2. Bearing Surfaces - Wear Rates
      3. Implants
      4. Bone Preserving Hip Replacement
        1. X-ray: Before Surgery- Osteo-arthritic Hip
        2. X-ray: Birmingham Hip
        3. X-ray: Birmingham Hip
        4. Why or why not Bone Preserving?
        5. Comparison of Survival
        6. Technology & History
      5. Conclusions
    4. Knee Replacement Surgery
      1. Implants
      2. Total Knee Replacement
      3. Partial Knee Replacement (Unicompartmental Knee Replacement
        1. Types of Partial Knee Replacment
        2. Prerequisites for surgery
        3. X-ray: Standing
        4. X-ray: Stress Views
        5. X-ray: Partial Knee Replacement
        6. X-ray: Partial Knee Replacement
        7. X-ray: Partial Knee Replacement
        8. X-ray: Partial Knee Replacement
  3. Conclusion
  4. Thank You!

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 Before Surgery

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

If entire knee 'worn out'-->
Total knee replacement is by far the best solution

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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