How many of you do arthroplasty? Yeah. I was thinking about this, and I'm coming to an arthroscopy meeting to talk about arthroplasty. How ironic. But 20 years ago, we would do joint preservation at the arthroplasty meeting. So I'm Bill Bugbee, and I do, for every one joint preservation procedure, I do 10 total knees, probably. So that's where I'm at. But I've done a lot of arthroplasty. My disclosure is in the Academy website as well. I've thought about this often, ever since I was a resident, watching my first osteochondroallograft in the early 1980s and being mesmerized by the concept that you could do something for these joints without doing an arthroplasty. And because I have an arthroplasty population, I've studied the difference between the two, and I'll show you that at the end. So I've been 25 years practicing, and a lot of data. And I was taught by my residency director and chairman that the decision is way more important than the incision. So that's been my mantra throughout my career. Decide what the right thing to do is before you start cutting on people. In this world, it's hard to interpret published studies because it's such an individualized thing. Each patient is so uniquely different, not just what their x-ray shows or their quantification of their cartilage loss or extent of OA, but what they feel about themselves and what they perceive as, I'm too young for arthroplasty, or I don't want, it's hard to interpret what the data says. But in the end, after 25, 30 years of this, I'm way more careful with my joint preservation, particularly in the older group, 40 and over, but I'm gonna take chances in the younger group. You know the definition, I just wanted to put this out there. Joint preservation is about avoiding joint replacement. That's what the definition is, which is kind of ironic. But we're talking about when is there agreement on when it's appropriate, experimental, controversial, or ill-advised. We still see a lot of ill-advised joint preservation. And I think of joint preservation as a journey because patients are with you forever and you're reoperating, and arthroplasty is a destination, final common pathway of the degenerative knee. And this is a perfect example of a successful joint preservation. This gal, she started her journey at age 14, now she's 36, 37, and a lot of us in the joint preservation field have had a crack at her, but this is, I would call this a success. She's 36, 37 years old, she's active, she can live a normal life, be a mom, sports, recreation, no eye impact, and this is her knees. And she's on her journey still, but she's probably had three or four operations in each knee, but that's a successful joint preservation operation. So, the question when you think about arthroplasty in these patients, and I'll make a point, I think of OA, it's hard to name the metric, degenerative chondralesions, that's one basket I think about, and what is OA? I don't know, there's not a quantitative metric for that, so again, it's nuanced. Is arthroplasty really that bad? Are young people poor candidates? Are they impaired after total knee? These are all the common ideas that we share, or have shared ever since we trained, right? And is wear, loosening, and failure really that common, and how often do implants last? So, we're all afraid of the failed joint replacement, of course. Functional impairment is real. This is a famous study from 20 years ago now, showing that people with total knees are impaired compared to control, so that's what we think about. What can we give these people that's higher functioning? So, this is a situation where the tail wags the dog. This person, a 46-year-old professional motocross rider, he gets an arthroplasty, and I didn't show all the x-rays, but post-minusectomy lateral compartment arthritis. The irony of this is that I saw his agent, 55-year-old guy, ACL, five surgeries for a total knee, and we got to talking, and I found out what he did. He said, oh, so-and-so sent me to you because it's frickin' amazing how good he is. He's riding, he's doing things he didn't do since he was 20 years old on the motorcycle, and that makes you think that these high-functioning people can remain high-functioning. So, hopefully, I'll be retired before he needs his revision, but anyway. So, this gal's another one. She eventually got an arthroplasty, but I started on the journey when she was in her 30s. If we sat in a room, she's got a three-by-two medial femoral cartilage lesion, intact meniscus, da-da-da-da-da. We'd all probably do cartilage repair on her, right, if you talk about that? And it took me 10, 12, 14 years to get her to arthroplasty in her mid-40s, and this speaks of the natural history. We haven't talked about this, but all these injured knees have a natural history you're trying to come to terms with. And remember, nothing we do has been proven to really change the natural history, so we're treating their current symptoms. So, these people, if they have OA, or clinical signs of OA in their 30s and 40s, the future of their knee is bleak. And I hate to say that, but I call it the beginning of the end. So, you wanna be real careful about trying to identify which people you think are gonna slide downhill quicker than others, and I don't know how to tell you any more than that. And then, the reality is we haven't done that great with cartilage repair in OA. This is my data, and OA at 41% failure rate over 10 or 15 years. Now, that may be good, like this gal I showed you, 15 years without a joint replacement if you're 35 years old may be a success, but it's clearly not as good as our cartilage repair and the perfect candidate. So, this other thing about delaying an arthroplasty, I just mentioned, is that an important metric? You know, I don't know. Maybe, it really depends on the people. So, survivorship of total joints, and modern total joints is quite good, actually. 75% of people that have had their joint replacement 25 years ago, or their knee, still have their knee intact. Now, does that mean they're high-functioning? Maybe not, but 75% 25-year survivorship for total knee arthroplasty. And that's knees done 25 years ago. And even in younger people, survivorship of arthroplasty is better than cartilage repair. So, just remember that concept. But really, what about function? How does joint replacement, knee replacement, compare to joint preservation in similar young patients? So, I did a study last year. I was really interested in this, and I presented it, the arthroplasty group, the knee society presented the cartilage repair, and it's interesting to see what people thought about it. So, here's the question. I do all these operations. Which one's better? Which one is more powerful? Which one has a better functional outcome in the patient's perspective? Not a long follow-up, and remember, this is not randomized. This is shared decision-making, so they're not equal patients, but I had 300 patients with the various operations that met criteria. No multiple operations, isolated treatment with one of these five operations. And if you know the coups, many of you know the coups, but if you don't, and you do knee surgery, and you want to collect your own data, I would just collect this. It's the simplest, easiest thing to do, and your practice, you don't have to see the patient. They fill out the five scales, and it's a wonderful tool to compare, you can compare a meniscectomy to joint replacement. It's validated across all these. So, we use this, and first thing I'll tell you on this slide is every one of those operations works great. These are tremendous, important improvements in patients all across the board with every operation, so that's the first thing. None of them were bad operations for these people, but if you added up all the improvements, the winner was total knee arthroplasty, and these people under 50, and Seth is looking at me like, really? Now, the allograft was the lowest chain score, but had the highest end score, so that's why these aren't same, same patients, but the treatment effect was better for arthroplasty than it was. The reoperation rate, much lower for arthroplasty. And satisfaction, pretty good across the board, but I always make this point. Allograft, 80% satisfaction, 40% reoperation rate, what goes there? This is a bias. That's just demonstrating bias. These people come, again, they came for joint preservation. They're bought in. They want that. They don't want an arthroplasty. They'll accept a reoperation so that they can avoid an arthroplasty, and this is part of the psyche that it's hard to explain to you, but when you see these patients, you understand that. Yeah, I had to have another operation, but I'm happy I chose joint preservation over arthroplasty. So why is arthroplasty the right choice? Theoretically, we haven't had time to go into the nuance and details, but those of you that do arthroplasty, you know materials are better. Implants are better. I love the medial congruent knee stability function. You know, you can personalize alignment and total knee replacement now with robots and navigation that you couldn't do before, so you feel like you're being a more personalized surgeon rather than blopping in the joint. These arthroplasties may last a lifetime in someone under 50. I don't know. They always ask me, but it's not, oh, 10 years and it's going to need to be revised. High satisfaction, as I told you, low reoperation rate. So if I look at my own results, it helps me make decisions. I will still take risks in young people, you know, the 18-year-old, the 25-year-old. Okay, we're going to try this. The classic is the post-meniscectomy lateral compartment arthritis in the 18-year-old gal, but I use arthroplasty more and more in my patients in that 35, 40, 45, particularly patellofemoral. I'm a big fan of patellofemoral arthroplasty for degenerative conditions in the patellofemoral joint rather than doing a lot of, because these people aren't that resilient in the end and they've had multiple operations. I want to get them done and they're generally happy. So thank you for attention. Questions? Come on, arthroplasty people. Is there any role for combining UKA and osteotomy? Ooh, no. I don't, never done. Yes, no. There is a couple studies. There's actually the Oxford people did a study and they found, because Oxford requires an intact ACL or, and after osteotomy, I've only done one or two, UK and osteotomy. I think that's a bridge too far because if you need to correct that much alignment problem, a UKA isn't designed to correct malalignment. That puts you in a world of kinematic conflict with a UKA, so it's not a great idea. But ACL and UKA, there's reasonable data, but that's a rare bird. What's your take on conversion to any arthroplasty after osteotomy? I invoke the multiply operated knee rule. You count up how many operations and when they come in and they've had six, four, five, six, you know they're gonna have more arthrofibrosis, more chance of poor range of motion and generally more pain. And that's one of the things I think about when I start doing joint preservation. Oh, I'm gonna do a DFO when I have to get to the total knee, but it doesn't impact me as much as you think in my decision-making. Most studies on arthroplasty after osteotomy done well and not creating deformity, particularly opening wedge. It's good, it's pretty good. You just get some weird ligament balances that you got a nuance and that's where the robot and stuff comes in. You can do an opening wedge and then you go back and you have to cut more medial tibia. You get a more lax in the medial side and you may not like that arthroplasty if you haven't prepared for things like that. Good question. It depends on the hardware removal. If it's a big tibial plateau fracture plate thing, usually I'll try to take out a screw or two, leave the hardware. But the outcome of arthroplasty with hardware removal, typically the ACL screw, it's a lot worse. Even the simple one, oh, just the screw here. By the way, I take it out from the top, not from the bottom. You just cut the tibia and you find it and pull it out. So it is a risky business. Doug Dennis in Denver did a big study on this and higher infection rate and everything else. So that's a danger. One more. What are your thoughts on arthroplasty in those patients that don't have almost bone on bone? So their MRI and their scope pictures far outweigh their x-rays, which is a huge population for me. I send them to my partners, they send them right back. Is that the right strategy? Great question, because this is that nuance about what do you do with the person that doesn't have the classic arthroplasty x-ray but is too far gone for you to think of a joint preservation procedure. A joint preservation procedure, normal alignment, multifocal disease, resiliency, and all the other things about that patient. And I see one of these every month or week and say, gosh, he really hurts, but they don't really have a bad x-ray. There must be one of these, you know. And then you get the MRI and it's all over the place and then you judge them for their resiliency. But as you all know, the data on arthroplasty in people without complete joint space loss is not great. A lot of residual pain. This is that 20% that don't like their arthroplasty. But if it's multifocal and you get it, so what I do is seeing how much synovitis they have. Some of these people, their x-rays are okay, but they got this inflammatory OA, and you know the difference. There's non-inflammatory and inflammatory. So if they got a big inflammatory OA, synovitis throughout, that's an arthroplasty patient. But if they have a quiet knee with lots of focal defects, I'm not sure. Excellent. Thank you.

arthroplasty

joint preservation

total knees

surgery decision

functional outcomes