What VICRYL Plus Means to Ethicon

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Contemporary Solutions for Arthritis of the Knee
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Arthritis affects over 70 million Americans
2nd only to heart disease in causing
disability 1 million new patients diagnosed each
year Affects 50 of people 65yrs or older
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Osteoarthritis is most common form of Arthritis

• Rheumatoid arthritis
• Post-traumatic arthritis
• Inflammatory arthritis
• Septic arthritis
• All result in loss of joint cartilage

Healthy
Diseased
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Factors that influence the onset of arthritis

• Heredity / Family history
• Age
• Weight
• Gender
• Trauma / Repetitive stress
• High impact sports
• Other illnesses

Diseased compartment
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The Knee is the 1 Joint Affected by Arthritis

• Large weight bearing joint
• Complex motion pattern
• Common site of injury
• Ligaments, meniscus

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Presenting symptoms of Knee Arthritis

• Stiffness
• Swelling
• Deformity
• (knocked-knee/ bow-legged)
• Crepitus (clicking, crunching, grinding)
• PAIN
• Start-up
• Activity limiting
• Nighttime

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Diagnostic Studies

• Weight-bearing Radiographs
• A/P, Lateral, Notch view
• Fairbanks Changes (subtle)
• Joint space narrowing
• Squaring of the condyles
• Osteophytes
• Sclerosis
• MRI
• Most helpful for ligaments and meniscal injury
• Mechanical symptoms
• Symptoms dont seem to fit

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Initial Conservative Treatments

• Tylenol
• NSAIDs
• (non-steroidal anti-inflammatory drugs)

• Physical Therapy
• Activity Modification
• Weight Loss
• Nutritional Supplements

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The first level of invasivenessTherapeutic
Injections

• Corticosteroid
• Inter-articular anti-inflammatory agent
• Short term symptomatic relief
• Viscoelastic Series
• Hyaluronic Acid injections 3-5 shots
• Attempts to augment normal joint lubrication
  properties
• Potential for more long lasting relief (6mos-1yr)

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The Orthopaedic Specialist

• When conservative treatments no longer resolve
  activity limiting pain caused by osteoarthritis
  then . . .
• Surgical and reconstructive treatments may be
  appropriate

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Surgical Options for Knee Arthritis

• Arthroscopy
• Debridement
• Meniscectomy
• Chondroplasty
• Osteotomy
• Bone cut and re-aligned onto remaining good
  cartilage
• Arthroplasty (Joint Replacement)
• Uni-compartmental knee replacement (partial knee
  replacement)
• Tri-compartmental knee replacement (total knee
  replacement)

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Arthroscopic Debridementclean out or scrape
bone

• Somewhat unpredictable results
• 50 to 66 percent get relief for some period of
  time
• Best for patients with mechanical symptoms
  (catching, locking and giving out)

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Knee OsteotomyRe-align weight-bearing axis
through good cartilage

• Most popular before success of contemporary knee
  replacement
• Useful for patients too young, heavy or active
  for knee implants
• Early results acceptable, questionable durability

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End-Stage Osteoarthritis ? Knee Replacement

• Uni-compartmental Knee Replacement
• Uni, partial replacement or UKR
• Tri-compartmental Knee Replacement
• total replacement or TKR

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Minimally Invasive Knee Replacement

• Same implants as traditional knee replacements
• Components
• Femoral
• Tibial
• Patellar

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Minimally Invasive Knee Replacement

• Potential Benefits
• Less trauma to the knee
• Less bleeding
• Less pain
• Cosmetically appealing (smaller scar)
• Shorter hospital stay
• Quicker recovery than traditional total knee
  replacement
• Potential Complications and Risks
• Factors that effect risks
• Skill of the surgeon
• Age, weight and health of the patient
• Patient compliance

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Total Knee Replacement

• Most common joint replaced
• First performed in 1968
• Nearly 400,000 TKRs performed per year in US

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Total Knee Replacement

• Patient satisfaction typically 85-90
• Relieves pain
• Restores mobility
• Durability well documented at 90 survivorship
  _at_10yrs
• Improvements in materials and techniques continue
  to increase effectiveness

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TKR Whos a candidate?

• Many patients that could be helped by knee
  replacement dont know about it or do not seek
  care
• Lack of knowledge
• Misconceptions
• Fear

How long do patients wait before they see their
surgeon?
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Important Patient Demographic Trends

• Over 65yr group is the most rapidly expanding
  segment of our population
• Increasing individual longevity will result in a
  greater number of individuals living long enough
  to be diagnosed with arthritis

(Average age of todays total knee replacement
patient is 67yrs)
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Important Patient Demographic Trends

• 36 of TKR patients are between ages 40-64
• This group of younger patients requiring TKR is
  increasing
• Those individuals requiring treatment for their
  arthritis will need solutions with even greater
  durability

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Common Misconceptions Delaying TKR Surgery

• Too YoungComponents will wear out and have to
  be revised
• Too ActiveComponents will wear out prematurely
  and have to be revised
• Too HeavyStresses on components will cause them
  to wear out or break

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Kinematics of a traditional (fixed-bearing) TKR

• Normal knee motion is a complex combination
• Flexion/extension
• Anterior/posterior translation
• Internal/external rotation
• Varus/valgus lift off

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Leading Causes of TKR Failures

• Component loosens
• Surgical technique
• Infections
• Polyethylene component wears out
• What causes this wear?
• What can we do about it?

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Addressing Polyethylene Wear

• Wear is affected by
• Implant design
• Implant materials
• Implant alignment (surgical technique)

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Polyethylene Wear

• One of the leading causes of implant failure over
  time
• Osteolysis
• Early Revision
• Negative Effect/Perception of patient
• Decreased Range of Indications
• Implant design and materials chosen are two of
  the most significant things that can be done to
  minimize (or virtually eliminate) the effect

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Implant Design Materials
Stress Load/Area
Area
Stress
Area
Stress
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Implant Design Materials continued
Contact Stress Patches

• Overall applied stress (force)
• Surface contact area
• Limitation in contact area results in relatively
  high level of Polyethylene stress (wear)
• Sheer

Fixed Bearing System
Rotating Platform System
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If Contact Stress is not Optimized
Results in relatively high level of Polyethylene
stress (wear)
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If alignment is not optimized
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Predisposes to accelerated polyethylene wear
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Todays Implants

• The Goal of a TKR Implant
• Restore normal function of the knee
• Last as long as possible
• Solutions
• Fixed Bearing TKR System
• A Mobile Bearing/ Rotating Platform TKR System

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Fixed Bearing TKR Systems

• Good clinical results
• Designs of Fixed Bearing systems may not optimize
  wear reduction
• Does not mimic all range of motion of the natural
  knee

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The Rotating Platform Solution Congruity with
Mobility

• Constraint forces minimized by allowing bearing
  rotation
• Articulates like the natural knee
• Full and normal range of motion
• Increased contact area results in reduced
  polyethylene stresses (wear)
• 94 reduction over Fixed Bearing Systems
• Shear forces at implant-bone interface minimized
• Could minimize loosening
• Outstanding clinical results for over 25 years

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Advantages of a Rotating Platform Knee
ReplacementShow me the Data
94 wear reduction with Rotating Platform vs
Fixed bearing
Fig. 1 Average Wear Rate per Million Cycles
McNulty, ASTM,2002
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Implant Alignment

• Self Aligning Q-Angle
• Less Stress on Quadriceps
• Reduced Lateral Release rate
• Reduced Bleeding
• Reduced Pain
• Improved Recovery
• Maximize Tibial Placement and Alignment
• Extensor Mechanism Aligns w/ the Trochlear Groove
• Promotes Patellar Tracking

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Advantages of a Rotating Platform Knee
ReplacementShow me the Data

• Twenty year evaluation of rotating platform
  mobile bearing knee replacements
• Survivorship 97.7 at 16-20yr
  Buechel et al Clin Ortho
  2001
• Cemented rotating-platform total knee
  replacements 9-12yr follow-up
• 119 TKAs, Survivorship 100 at 10yrs
  Callahan et al JBJS 2000

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Contemporary Solutions for Arthritis of the Knee
Summary

• The number of patients suffering from arthritis
  of the knee is steadily growing
• Of the patients suffering from knee arthritis
  nearly half may not seek treatment due to poor
  information or fear
• Patients seeking care are younger, more active
  and more demanding
• Total knee replacement is a reproducible,
  reliable and durable solution to end-stage knee
  arthritis

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