North Carolina Orthopaedic Clinic

1

JOINT DISEASE

HIP AND KNEE

Scott Kelley MD

North Carolina Orthopaedic Clinic

919-471-9622

(updated May 19, 2006)

INTRODUCTION

JOINT ANATOMY

JOINT PATHOLOGY

SPINE

PAIN

NONSURGICAL TREATMENT OF ARTHRITIS

SURGICAL TREATMENT: HIP

SURGICAL TREATMENT: KNEE

PRE-ADMISSION INFORMATION

HOSPITAL OVERVIEW:

GOING HOME AND RECOVERY (FIRST 6 WEEKS)

ACTIVITIES (AFTER RECOVERY)

RESULTS AND COMPLICATIONS

MEDICAL MANAGEMENT

EXERCISES

INTRODUCTION

The purpose of this educational video is to provide you with basic information about our approach to joint replacement. Our approach is based on the background and training of my team.

I am a third generation surgeon, born and raised in Iowa. My grandfather and father both attended medical school at Northwestern in Chicago. My grandfather graduated from there in 1907 and practiced General Surgery at IowaMethodistHospital in Des Moines. My father returned to Des Moines after serving as a medic in World War II and completing his training in Orthopaedic Surgery at the Mayo Clinic.

I grew up with Medicine and Surgery. Even before I started high school, my father would take me with him on the weekends, to a small county hospital outside of Des Moines. Helping manage Orthopaedic cases was a service he provided these small communities. One such hospital, in MadisonCounty allowed me to watch him in surgical cases. In high school, I worked as an orderly in the operating room, performing jobs ranging from scrubbing floors to helping position patients for surgery. Both my father and I were born and worked in this same hospital, IowaMethodistHospital.

After graduating high school, I attended the University of Iowa for both undergraduate and medical school. I did my surgical internship and Orthopaedic residency at the State University of New York, UpstateMedicalCenter in Syracuse. I was recruited to this residency by Dr. David Murray, who was a former president of the AmericanAcademy of Orthopaedic Surgeons and one of only two Orthopaedic Surgeons to serve as President of the AmericanCollege of Surgeons. He was a founding member of the knee society and inventor/developer of a knee replacement prosthesis call the Variable Axis Total Knee Replacement.

Following my general Orthopaedic Training, I did an adult hip and knee reconstructive fellowship at the Mayo Clinic. After my fellowship, I returned to Des Moines, just as my father was retiring from Surgery. I joined a partnership with Dick Johnston called Joint Replacement Surgeons. Dick was one of the founding members and past president of the Hip Society.

One of the highlights of my time back home was the opportunity to operate on many of the same patients that both my grandfather and father had performed surgery. One such patient was Don Gardner, whose life my grandfather had saved at age 16. In 1932, my Grandfather performed an emergency appendectomy on Don. Years later, my father performed a left hip replacement and in 1988, I performed a right total hip replacement on Don. This story was picked up by the Des Moines Register and Tribune – the only paper with statewide distribution.

Shortly before Dick Johnston retired from Surgery, I joined the faculty of the University of North Carolina at Chapel Hill.

I was recruited by Frank Wilson. Dr. Wilson was the past president of the American Orthopaedic Association and a founding member of the Knee Society. During my eleven years at the University of North Carolina, I saw the transition from a division of surgery to a Department of Orthopaedic Surgery, where I served as Vice Chairman for the remaining five years of my tenure.

In 2003, I joined with a group of four other academic physicians and formed the North Carolina Orthopaedic Clinic. Our reasons for the change were simple; we needed more control of our practice in order to deliver a higher quality of medicine.

Dr Joe Minchew is our spine surgeon, Dr. Louis Almekinders is our Sports Medicine Surgeon, Dr David Thompson is our Hand/Upper Extremity/Foot Surgeon, and Dr. Paul Tawney is our Physical Medicine and Rehabilitation Physician.

Many of the North Carolina Orthopaedic Clinic patients are from outside the Research Triangle, often from out of state and sometimes from outside the United States. Almost 50% of my patients live outside the four counties that make up the Triangle (Durham, Wake, Orange, and Chatham). While managing patients from a distance has its difficulties, we have over time adapted our system to accommodate the situation.

As we review our surgical results later in this program, it should become clear that our high rate of success (and low complications) should significantly reduce your chance of having more than one operation per joint in a lifetime. Unquestionably, the surgery I later describe can be performed very successfully in many hospitals throughout the country, but the key question is, “what are their published results?”

I cannot guarantee that you will get a good result in my hands. I cannot guarantee that you will not suffer complications… but I can tell you what the odds are.

The key to our success is the word “our”. Your care will be delivered by a team approach. What that means, is that I will be involved with every aspect of your care, either visibly or behind the scenes. My focus will be on your actual surgery and the identification and management of any adverse outcomes. Specifically this means - I personally will be doing your surgery.

I will not be primarily responsible for the majority of the communication between you and our team. In order for me to maintain my focus, I have organized a team to “field” your questions and concerns. While this approach may give you the impression I am not involved, it allows me to give more attention to the key elements of your care, including the technical aspects of your surgical management. The key is that you trust our team concept by trusting the members of my team to handle their assigned jobs and alert me when appropriate.

This team approach will be most apparent during your postoperative management. I will see you, during this period, but my visits will be direct and system orientated. I will leave my team to gather and present your concerns.

I feel strongly, it is only by such a team approach, such a system, that I am able to almost eliminate your chance for failure.

As the patient, you are also a member of the team managing your care. We will need your help, not only in following the treatment plans but in and helping make the plans.

My ten year data for knee replacement and our publication of the 20 year results from the Iowa Hip experience will be reviewed. The data I will present for both hips and knees is as good as, or better than, any previously (or subsequently) published results in the Orthopaedic literature. My success is based on a team approach focused toward reducing your chances for future surgery on the same joint. Or simply worded - My primary goal is to do only one operation on your joint.

The rest of this DVD will review all aspects of lower extremity disease, including anatomy, pathology, nonsurgical and surgical treatment modalities, risks and complications and finally recommended exercises.

JOINT ANATOMY

INTRODUCTION

Wherever two bones meet, it is called a joint – the significance of this relationship is highlighted by the name of the most important orthopaedic journal, “The Journal of Bone and Joint Surgery” with a worldwide distribution of over a 130 countries.

The normal anatomy of a joint includes:

HARD TISSUE: bone, cartilage, and

SOFT TISSUE which includes

• meniscus & labrum,
• the ligaments & associated capsule,
• synovium & bursa and
• lastly, muscles & tendons.

HIP AND KNEE

The Hip Joint is made up of two bones: the pelvic bone AND THE femur (also known as thigh bone). The hip is often described as being a ball and socket joint. Let’s take a closer look at the hip joint by removing the capsule and dislocating the hip. The socket (also known as cup or acetabulum) is a part of the pelvic bone and the ball (also known as the femoral head) is a part of the femur (thigh bone).

The bones of the knee joint include the lower end of the thigh bone (femur), the top end of the calf bones (tibia and fibula), and the knee cap (patella).

The knee joint is really two joints:

The Femoral-Tibial Joint (which consists of two distinct compartments: one on the inner and one on the outer half of the knee) and the

Patello-Femoral Joint: which is the weight bearing joint with climbing stairs.

CARTILAGE:

Cartilage is the key structure within the joint. Cartilage is the bluish-white shiny material you see on the end of a chicken bone, when you break it open at the joint. Cartilage does not have any nerves in it.

Pictured on the left is the blood supply to a normal hip and on the right is a close up of the cartilage and its relationship to the blood supply.

All of the nutrition to the cartilage comes from the joint fluid, as cartilage does not have a blood supply.

MENISCUS/LABRUM:

In addition to cartilage covering the bones, there are soft tissue fillers, called the meniscus and Labrum. In the hip, there is only one labrum…

and in the knee, there are two menisci. To some degree, they function as shock absorbers, but they also increase the surface area of the joint.

LIGAMENTS & JOINT CAPSULE:

Ligaments hold the bones together in the same way that a hinge holds a door to the door frame.

The knee relies heavily on its ligaments for stability. There are four main ligaments in the knee: collateral ligaments on each side of the knee, and posterior and anterior cruciate ligaments, which are inside the joint.

The collateral ligaments stabilize the knee with side-to-side stress. The anterior cruciate ligament prevents the tibia from moving forward on the distal thigh bone or femur and the Posterior Cruciate ligament prevents the tibia from moving backward in relationship to the distal femur or thigh bone. Ligaments are confluent with the joint capsule and in some cases; the ligament is just a thickened portion of the capsule.

SYNOVIAL LINING (Joints and Bursa):

The inside of the joint capsule is coated with synovial tissue, which secretes fluid to lubricate and give nutrition to the cartilage. To illustrate this, a picture of the hip and its capsule are shown. With only the capsule removed, the synovial lining is now shown in blue. Outside the joint is another structure lined with synovial tissue, called Bursa. Bursa help lubricate the edges (or corners) of bone, so that the soft tissue can glide over the bone as you move your joints.

In the hip joint, bursa is located around the part of the thigh bone called the Greater Trochanter. The knee joint has many more bursa. The bursa are located around the patellar tendon, the patella, and the hamstring tendons – in particular a bursa called the pes anserine bursa.

MUSCLES & TENDONS:

The muscles cross the joints and attach to bone by tendons, as seen here in the diagram of a musculotendon unit. The muscles pull on tendons and provide what is called “active” motion – they power joint movement.

In the hip there are multiple muscle groups that function in an extremely complex fashion – the most important muscle group are the abductors. The abductor muscle performs two important functions: 1) keep your body level when standing on only one leg (by pulling the body in the direction of the arrows and 2) they lift or move the leg outward sideways

There are two main groups of muscles about the knee.

The Hamstrings flex the knee from the back side of the joint. The quadriceps extend (or straighten) the knee on the front side.

The quadriceps muscles are attached into the top of the kneecap or patella. The patella is then attached to the tibia by the patella tendon. As mentioned earlier, the patella is part of the patello-femoral joint.

PATELLA FUNCTION

What is the function of this joint? The quadriceps (and its tendon) travel around the end of the femur and attaches to the tibia by the patellar tendon. When the Quadriceps contracts, it pulls on the tibia to straighten the knee.

If you ran a rope around a corner and pulled back and forth from both ends, it would abrade over time. By running the rope around a pulley, function is improved. The patello-femoral joint acts as part of a pulley system for your quadriceps muscle. Just as a rope sits in the groove of a pulley, the patella (or kneecap) sits in the groove of the femur. While this pulley, improves the mechanical function of your quadriceps, enormous forces are transferred to this small joint.

The forces are greatest when climbing stairs or sitting. The forces are so great at times; the question should be “why doesn’t everyone’s knees hurt?”

JOINT PATHOLOGY

We will divide our discussion of Hip and Knee Disease into Hard Tissue Disease (Bone and Cartilage) and Soft Tissue Disease (Meniscus, Ligaments, Muscle and Synovium).

HARD TISSUE

BONE Abnormalities and Disease:

There are many problems that occur in bones. … The two most frequent problems in the knee and hip are fractures and avascular necrosis (otherwise know as osteonecrosis). Fractures or breaks involving bones need little explanation. Osteonecrosis is less frequently encountered. ….. Osteonecrosis is death of the bone and results from a reduction in the blood supply to the bone. This condition may lead to a painful collapse of the dead segment of bone and subsequently the cartilage, which it supports. When this process occurs, arthritis usually follows.

CARTILAGE & ARTHRITIS:

As previously discussed, cartilage does not have any nerves in it, so you can move bone against bone without feeling any pain (when you have normal cartilage).

If you have a hole or defect in the cartilage, then bone (which has nerves) can rub against bone and you will have pain. A fracture hurts for similar reasons: there are two bones rubbing against each other without any protective surface in between. Nerves are similar throughout the body. If you had a hole in your tooth down to the nerve, it would hurt in a similar fashion. The pain might vary during the course of the day, throbbing at night, sharp pain when biting, or radiating pain throughout the jaw.

There are three main categories of arthritis. The first is Degenerative Arthritis, which is also known as Osteoarthritis or “wear-and-tear” arthritis.

The second category of joint arthritis is caused by inflammatory disease. The most common disease in this category is rheumatoid arthritis. This is a systemic (throughout the body) disease. The basic problem in rheumatoid arthritis is that the body’s immune system begins to attack normal joints causing inflammation and eventual destruction of the joint. Other forms of inflammatory arthritis are associated with Lupus (SLE), psoriasis, inflammatory bowel disease, ankylosing spondylitis, Reiters and Gout (to name a few). One of the more severe forms of destructive inflammatory arthritis is the result of joint infection.

When cartilage damage is caused by (or is secondary to) structural changes of the joint; we call this ‘Secondary Arthritis. Causes of secondary arthritis include:

• congenital (birth) abnormalities such as joint dysplasia,
• childhood disease (such as Blount’s, slipped epiphysis or Perthes) or from
• trauma (joint fractures, meniscal / labral injuries or ligament injuries).

We diagnose the loss of cartilage by your history of progressive pain with activity, by your exam – often showing swelling, warmth, loss of motion and deformity AND FINALLY, by x-ray.

X-rays help diagnose arthritis – but we do not operate on x-rays, we operate on people and their symptoms – no matter how bad the x-rays look – whether any surgery is recommended or not is determined by your pain and your level of function.

SOFT TISSUE DAMAGE/DISEASE AND INJURY

Soft tissue damage can occur in two basic forms: NonSurgical and Surgical. NonSurgical Soft Tissue damage occurs with either minimal or no trauma, often overuse type syndrome from repetitive activities. The damage is often similar to a deep blister and is characterized by local inflammation.

Surgical Soft Tissue Damage usually occurs with significant trauma and when the soft tissue tear is completely through and through; only surgery will bring the tissue together so that it can heal.

The different types of soft tissue involved are listed (Meniscus, Ligaments, Muscle and Synovium). Some have such poor blood supply, that inflammation does not occur and healing is unlikely – such as meniscal tears.

When soft tissue is irritated or inflamed, it has the suffix “-it is” attached. While the meniscus does not have enough blood supply to become inflamed, the other tissue types are all susceptible and are given such terms as capsulitis, tendonitis, synovitis and bursitis.