Jul 24, 2018
Partial knee replacements can provide relief from arthritis pain without the long recovery of a total knee replacement. Orthopedic Surgeon Dr. Evan Argintar explains the benefits and who might qualify for the procedure.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
Host: Thanks for joining us today. We’re talking to Dr. Evan Argintar an orthopedic surgeon and assistant director of sports medicine at Medstar Orthopedic Institute at Medstar Washington Hospital Center. Today we’re discussing an advancement in joint replacement surgery called bioplasty. These procedures preserve as much of the normal joint anatomy as possible. Dr. Argintar, what’s the goal of this advancement?
Dr. Evan Argintar: So traditionally the treatment of arthritis has been a big issue and as the Baby Boomers age, we’re actually finding that there are not enough orthopedic surgeons to treat the amount of arthritis that is developing in our country. And as people get older the good news is that people want to maintain the quality of their life, the level of activity and the problem traditionally has been that the definitive treatment for arthritis specifically in the knee has been somewhat limited. We used to do knee arthroscopy but appropriately this has come under criticism because it doesn’t give a very sustained relief and then the only thing you can do definitively is some element of a knee replacement. There are three parts of the knee. The inside the outside and underneath the kneecap, and a full total knee replacement or total knee arthroplasty replaces all three types. That is a very good procedure that’s a fantastic procedure if all three portions of your knee are diseased or arthritic. Because sometimes patients have an isolated medial or lateral portion of their knee which is far worse than the rest we have developed as orthopedic surgeons partial knee replacement, and so the indication for that is very specific and not all patients are candidates for it.
The problem arises when patients have one out of the three compartments extremely arthritic, one completely normal, and one kind of average, and this puts people in a bit of a grey area. Do you do a partial knee replacement and accept that some of that cartilage in the remaining portion of the knee is diseased and potentially pain generating? Maybe. Or do you do a full knee replacement, replace all the bad stuff with all the good stuff? Maybe. The problem with doing the full knee replacement is that in 2017 you have to sacrifice the ligaments on the inside of the knee and you usually have to change the joint line and what that translates to is really a bit of an artificial feeling knee, and one that does have some intrinsic limitations for activity. Certainly, you can walk and move and have pain relief, but the ability to have a sport and to be active and to pursue professions where you need to have that level of comfort and that sense of a normal knee can somewhat be limited or altered. What I’ve done here at MedStar Washington Hospital Center is incorporate technologies of both partial knee replacement with some of the treatments I’ve done in isolation in the sports world, cartilage restoration, ligament reconstruction. So once upon a time, for example, if you had medial isolated arthritis on the inside part of your knee without an ACL, you had no option without a knee replacement. Now you can do a partial knee replacement with an ACL reconstruction, and this allows people to maintain their youth and maintain their activity and avoid some of the limitations inherent with a bigger surgery.
Host: What other types of bioplasty surgeries are available?
Dr. Argintar: Another example would be a partial knee replacement on one side of the knee with a transfer of cartilage to the other side of the knee. If you have a pothole in the middle of a normal road, you can do sporty cartilage restoration surgeries to make that pothole complete. Arthritis is the opposite. That’s a street that has no more pavement, and that’s when you have to repave it with the knee replacement. But again, now as we’re fusing the sports medicine with joint reconstruction, we’re coming up with novel solutions for people who don’t want the inherent limitations with full knee replacement. Patients are not all good candidates for this. We’re finding that patients are coming in seeking to see if they are good candidates for this.
Host: Who is a good candidate for a bioplasty surgery?
Dr. Argintar: Candidates are both people who have a combination of the desire to maintain young and youthful coupled with the right type of need. Unfortunately, sometimes I find people who want to maintain their anatomy but at such advanced tricompartment arthritis that my advice to them is let’s consider the full knee replacement. However, a lot of times people come in and we find that they are in fact candidates for this novel approach to joint reconstruction. Knee replacement is a great surgery and it has been done historically successfully, but like in all surgeries, we’re trying to identify patients who might not be as successful as others and so I would incorporate others to be aware that other surgical interventions exist, and although you might not be a great fit for it, it’s worth pursuing and we’re happy to have those consultations and oftentimes we recommend that the first opinion is dead on accurate and other times we are able to give different operative options.
Host: Could you talk a little bit about how the prep and the procedure for that vary from the partial knee replacement and some of these other fusion type surgeries?
Dr. Argintar: Well, it’s interesting. Even in my training you know 10 years ago, we would do knee arthroscopy with a hope that you could quote unquote clean up the arthritic knee. Everyone with arthritis has a meniscal tear, and the meniscal tear is an easy target. And I spend many hours all day long convincing people that a knee scope to treat a degenerative meniscal tear will not solve their problems. And, unfortunately, I see a lot of unhappy customers coming from other areas around us that do that surgery knee scope with the thought they can clean it up and they come out very unhappy with a lot of pain, and those are often patients who I find are good candidates for a potential partial knee reconstruction or replacement in combination with some other cartilage restorative procedure. There has been some good well known, well publicized articles and major publications—The New York Times—showing that knee arthroscopy may be overused in the setting of arthritis and I would agree with that 100 percent. It’s just so very unpredictable, and very often not sustainable, and so although they may have some relief for weeks to months, it doesn’t change the quality of their life for any meaningful period. So, I shy away from knee arthroscopy in the setting of arthritis.
Host: If surgeons have practiced the same way for so long, why was there a need to develop something different?
Dr. Argintar: The evolution of my practice was based on a lack of satisfaction for both me seeing patients coming from other places in the area that had unsuccessful knee arthroscopy outcomes coupled with some of my younger patients who although got pain relief from a full knee replacement, never felt great with it, always had some limitations with it, and so I challenged myself, and this is the challenge that has been brought on the shoulders of some of my other colleagues, you know, regionally and throughout the country, to create a solution that is a middle ground between the minimally invasive knee scope and the maximally invasive full knee replacement and I think that we have found something that is relatively unique and novel here.
Host: Do you have any shining patient success stories you could share?
Dr. Argintar: Sure. So, a perfect example of someone who has done quite well is a lady of mine who is quite young. She had a full knee meniscectomy, removal of the knee the meniscus 15 years earlier. We know that after a course of that is full blown arthritis eventually, and she was a victim to that, only 45 very active, working, running around, young children. She was not excited to sacrifice two-thirds of her knee because she had a degenerative medial joint with an ACL tear. So, in this situation, I was able to do an ACL reconstruction, which allowed me to do a successful partial knee replacement. She’s been beyond happy, back to work, back to activity, back to being a mom, well she never left being a mom, but she’s doing it more comfortably, and she hasn’t looked back. You know doing a full knee replacement sometimes you have to do that in the 30s, the 40s. The problem aside from the artificial feeling of it is that twenty years later you have to do another one. Partial knee replacements also don’t last forever, but it gives people potentially a long window of feeling more normal when they’re younger in their life and wanting to do more activity recreationally, professionally whatever that may be.
Host: How long is recovery for a bioplasty procedure compared to a traditional knee replacement?
Dr. Argintar: I usually tell my patients that a full knee replacement will take about six months whereas a partial knee replacement is more of a four-month recovery. Everyone walks and stands immediately, but because you’re doing less surgery, there’s less inflammation, less pain, easier to move it, so it’s a little bit of an easier recovery
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