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Partial Joint Replacements
Evan Argintar, MD, discusses the varying types of knee replacement surgeries, including total, partial, and a new hybrid surgical approach that combines arthroplasty with cartilage restoration techniques. Advancements such as this provide the opportunity for faster recovery and maximized function.
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Learn more about Evan Argintar, MD
Evan H. Argintar, MD
Evan Argintar, MD, is a member of the MedStar Orthopaedic Institute at MedStar Washington Hospital Center, where he performs surgery. Dr. Argintar also serves as the Assistant Director of Sports Medicine at MedStar Washington Hospital Center.Learn more about Evan Argintar, MD
Transcription:
Partial Joint Replacements
Melanie Cole (Host): Uni-compartmental knee arthroplasty has had varying degrees of acceptance since its introduction approximately thirty years ago. However, with the introduction of more minimally invasive technologies this procedure has seen an increased interest. My guest today is Dr. Evan Argintar. He's an orthopedic surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Argintar. For people who've had knee pain and require surgery, what's typically been done in terms of joint replacement?
Dr. Evan Argintar (Guest): I always like to start off by saying that joint replacement is the last option, but the unfortunate reality of arthritis is that it's a condition that's not curable. Cartilage doesn't have blood flow and for that reason, it can't heal. So, when non-operative management fails and that's traditionally activity modification, anti-inflammatory medication, bracing, physical therapy. When that fails, in general, the only predictable outcome that improves clinical measures would be joint replacement. Traditionally, people favor doing a total joint replacement or total knee replacement. However, that's a big surgery and that replaces all three compartments of the knee, the medial, the lateral, and the anterior or the patellofemoral joint. Because some individuals have worse disease in one or two out of the three compartments of their joint, this created the need for another alternative which is also known as “partial knee replacement”. Today in 2017, partial and total knee arthroplasty are the mainstays of surgical treatment for the arthritic knee.
Melanie: Dr. Argintar, what are some of the radical advantages of the procedure as it stands now?
Dr. Argintar: Whenever I'm discussing the pros and cons of partial and total knee replacement, the first thing I make clear to them is that both are good operations for the right person. The problem with total knee replacement is that unlike a hip, which is a true joint replacement, meaning everything that is removed surgically is replaced, knee placement is a little bit different. I say that for two reasons, one, in general, when you do a knee replacement you have to sacrifice ACL and usually you sacrifice the PCL. These are two ligaments that provide the knee with rotational stability on the inside of the knee and they also have proprioceptive fibers which allow your brain to, in a sense, know where your knee is. It helps with the kinematics normal function of the knee. Additionally, with a total knee replacement you change the orientation of the joint line and this, in general, creates a new knee, what I usually call a replaced knee but not exactly what you are starting with. So, patients with a total knee return a little bit slower and have some restriction that perhaps someone with a partial knee does not have. That would be one difference. Now, again, if all three of your compartments are bad, then a total knee replacement is a great option but if you're someone who has horrible medial knee arthritis and your other two compartments aren't quite as bad, then sometimes the partial knee is a better option. Conversely, with a partial knee, you keep most of your stuff. By stuff, I mean the compartments that aren't diseased or are not advanced diseased. This means that you have more normal function, faster recovery, and you maintain the ligaments on the inside of your knee.
Melanie: Dr. Argintar, what is the current thinking for you? What are you doing that's a little bit unique and combined with a partial knee replacement?
Dr. Argintar: That's a great question. People who don't subscribe to the partial knee replacement would say, well, if you have one bad compartment and you have another one that is where the writing is on the wall, you might as well just bite the bullet, call a spade a spade and replace the whole thing because really that is the downside of partial knee replacement. The very upside to it, which is preservation of the rest of your knee, well, that can get worse. So, in five years, in ten years, in twenty years or forty years, you might find that you have to convert that over to a full knee replacement. Really, the million dollar question is how much time of activity preservation with a partial knee would make that surgery a surgical value to someone if even they knew it had to be converted to a full knee replacement. Most experts believe that that number is somewhere around a decade and that's been my results. The interesting thing that I'm doing is combining elements of the sports world, sports orthopedic surgery, specifically cartilage restoration with arthroplasty. I believe this has giving me a hybrid surgical option that is somewhere in between partial knee replacement and full knee replacement. What I've been doing is in very unique situations when people have advanced arthritic disease in one portion of their knee and perhaps some mild disease in the other of the three compartments, is that I do the partial knee replacement. Then, I do some element of cartilage restoration. Cartilage restoration means doing something to stimulate the knee to heal and create a fiber cartilage which is better than nothing. Not quite as good as what you're born with and this can be accomplished in lots of different ways. You can transfer plugs of cartilage from part of the knee to the arthritic knee and, in fact, when you're doing a partial knee replacement you resect the arthritic component of the knee and oftentimes there are little pockets of cartilage that you remove that are actually quite normal and before I remove these I take them and just simply transfer them over to the other side of the knee where it needs some help. There are other options called “micro-fracture”. That's a traditional surgery where you poke holes in arthritic areas that are deficient of cartilage and you can help to stimulate a fiber cartilage growth, which is something in 2017 we have ways of making this better. Now I use a proprietary substance called bio-cartilage which is minced up juvenile cartilage which we think has the ability to help stimulate the production of even better cartilage, something similar to a fiber cartilage. The long and short of it is that not all knees can be treated the same. It's not just a partial, it's not just the total. There might be this whole area in between which maximizes function and minimizes the restrictions inherent with the full knee replacement.
Melanie: Are there certain indications for patient eligibility? Younger patients might be candidates for this. Are older patients exempt from this type of cross procedure?
Dr. Argintar: That's a very interesting question. The original literature that guided orthopedic surgeons for partial knee replacement was actually found in the geriatric population. The population that was a little bit more sedentary but had more focal arthritic injury because the results of knee replacement are a little bit unpredictable, a uni-arthroplasty was then applied to a younger active population. For me, when I'm doing a partial knee replacement, a total knee replacement, or this hybrid what I call a bio-plasty, I don't really allow age to factor into the discussion. Really,, I look at people more based on what is the condition of their knee and also, more importantly, what are their goals, what are their activities, what will they be happy with, what restrictions they can deal with. That being said, I think my most successful clinical outcomes with this type of bio-plasty hybrid surgical approach are in the younger patients who have come to me for second or third opinions, are not excited about a full knee replacement and are excited about doing something else which preserves functions, preserves their youth, and preserves their level of activity.
Melanie: After surgery while the joint surface is protected while that cartilage heals, what do you tell patients about living with this new knee the way that it is now? Are there any limitations for them?
Dr. Argintar: The answer is not really. A true statement is that the more you work, or run, or jump on these arthroplasties, the quicker they do run out. That being said, the person that I'm offering those bio-plasty to is someone who I want to be active, who I want to not modify their activities, so they can maintain their youth and their active lifestyle. So, I don't give them any restrictions. I do find that the recovery is faster and so far I have been very happy with the subset of patients who have been a good candidate for this surgery.
Melanie: Wrap it up for us, Dr. Argintar, with what you want other physicians to know about using that world of sports medicine and combining it with orthopedic surgery, why that's so unique and what you want them to know about it.
Dr. Argintar: It's a unique approach and I think in 2017, we have to be open to new things but we have to approach new things guarded. There are many excellent examples of exciting innovations in orthopedic surgery that simply didn't work out. What I find so attractive about this type of hybrid surgical approach is that each of these surgical options, that being arthroplasty and cartilage restoration, have independently been validated within the spectrum of their own specialty. What's unique about my approach is that I do a lot of arthroplasty and a lot of sports medicine and I've fused these two well-established, evidence-based medicine approaches together in the hope of finding a solution that is not, shall I say, the norm or currently offered. I would ask clinicians as they have their youthful, young, active patients who are perhaps slowly getting arthritic disease to be aware that there are other options available for their patients and they should seek out providers who are comfortable in describing and implementing these types of approaches.
Melanie: It's great information. Thank you so much for being with us today. You're listening to Medical Intel with Med Star Washington Hospital Center. For more information you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Partial Joint Replacements
Melanie Cole (Host): Uni-compartmental knee arthroplasty has had varying degrees of acceptance since its introduction approximately thirty years ago. However, with the introduction of more minimally invasive technologies this procedure has seen an increased interest. My guest today is Dr. Evan Argintar. He's an orthopedic surgeon with MedStar Orthopedic Institute at MedStar Washington Hospital Center. Welcome to the show, Dr. Argintar. For people who've had knee pain and require surgery, what's typically been done in terms of joint replacement?
Dr. Evan Argintar (Guest): I always like to start off by saying that joint replacement is the last option, but the unfortunate reality of arthritis is that it's a condition that's not curable. Cartilage doesn't have blood flow and for that reason, it can't heal. So, when non-operative management fails and that's traditionally activity modification, anti-inflammatory medication, bracing, physical therapy. When that fails, in general, the only predictable outcome that improves clinical measures would be joint replacement. Traditionally, people favor doing a total joint replacement or total knee replacement. However, that's a big surgery and that replaces all three compartments of the knee, the medial, the lateral, and the anterior or the patellofemoral joint. Because some individuals have worse disease in one or two out of the three compartments of their joint, this created the need for another alternative which is also known as “partial knee replacement”. Today in 2017, partial and total knee arthroplasty are the mainstays of surgical treatment for the arthritic knee.
Melanie: Dr. Argintar, what are some of the radical advantages of the procedure as it stands now?
Dr. Argintar: Whenever I'm discussing the pros and cons of partial and total knee replacement, the first thing I make clear to them is that both are good operations for the right person. The problem with total knee replacement is that unlike a hip, which is a true joint replacement, meaning everything that is removed surgically is replaced, knee placement is a little bit different. I say that for two reasons, one, in general, when you do a knee replacement you have to sacrifice ACL and usually you sacrifice the PCL. These are two ligaments that provide the knee with rotational stability on the inside of the knee and they also have proprioceptive fibers which allow your brain to, in a sense, know where your knee is. It helps with the kinematics normal function of the knee. Additionally, with a total knee replacement you change the orientation of the joint line and this, in general, creates a new knee, what I usually call a replaced knee but not exactly what you are starting with. So, patients with a total knee return a little bit slower and have some restriction that perhaps someone with a partial knee does not have. That would be one difference. Now, again, if all three of your compartments are bad, then a total knee replacement is a great option but if you're someone who has horrible medial knee arthritis and your other two compartments aren't quite as bad, then sometimes the partial knee is a better option. Conversely, with a partial knee, you keep most of your stuff. By stuff, I mean the compartments that aren't diseased or are not advanced diseased. This means that you have more normal function, faster recovery, and you maintain the ligaments on the inside of your knee.
Melanie: Dr. Argintar, what is the current thinking for you? What are you doing that's a little bit unique and combined with a partial knee replacement?
Dr. Argintar: That's a great question. People who don't subscribe to the partial knee replacement would say, well, if you have one bad compartment and you have another one that is where the writing is on the wall, you might as well just bite the bullet, call a spade a spade and replace the whole thing because really that is the downside of partial knee replacement. The very upside to it, which is preservation of the rest of your knee, well, that can get worse. So, in five years, in ten years, in twenty years or forty years, you might find that you have to convert that over to a full knee replacement. Really, the million dollar question is how much time of activity preservation with a partial knee would make that surgery a surgical value to someone if even they knew it had to be converted to a full knee replacement. Most experts believe that that number is somewhere around a decade and that's been my results. The interesting thing that I'm doing is combining elements of the sports world, sports orthopedic surgery, specifically cartilage restoration with arthroplasty. I believe this has giving me a hybrid surgical option that is somewhere in between partial knee replacement and full knee replacement. What I've been doing is in very unique situations when people have advanced arthritic disease in one portion of their knee and perhaps some mild disease in the other of the three compartments, is that I do the partial knee replacement. Then, I do some element of cartilage restoration. Cartilage restoration means doing something to stimulate the knee to heal and create a fiber cartilage which is better than nothing. Not quite as good as what you're born with and this can be accomplished in lots of different ways. You can transfer plugs of cartilage from part of the knee to the arthritic knee and, in fact, when you're doing a partial knee replacement you resect the arthritic component of the knee and oftentimes there are little pockets of cartilage that you remove that are actually quite normal and before I remove these I take them and just simply transfer them over to the other side of the knee where it needs some help. There are other options called “micro-fracture”. That's a traditional surgery where you poke holes in arthritic areas that are deficient of cartilage and you can help to stimulate a fiber cartilage growth, which is something in 2017 we have ways of making this better. Now I use a proprietary substance called bio-cartilage which is minced up juvenile cartilage which we think has the ability to help stimulate the production of even better cartilage, something similar to a fiber cartilage. The long and short of it is that not all knees can be treated the same. It's not just a partial, it's not just the total. There might be this whole area in between which maximizes function and minimizes the restrictions inherent with the full knee replacement.
Melanie: Are there certain indications for patient eligibility? Younger patients might be candidates for this. Are older patients exempt from this type of cross procedure?
Dr. Argintar: That's a very interesting question. The original literature that guided orthopedic surgeons for partial knee replacement was actually found in the geriatric population. The population that was a little bit more sedentary but had more focal arthritic injury because the results of knee replacement are a little bit unpredictable, a uni-arthroplasty was then applied to a younger active population. For me, when I'm doing a partial knee replacement, a total knee replacement, or this hybrid what I call a bio-plasty, I don't really allow age to factor into the discussion. Really,, I look at people more based on what is the condition of their knee and also, more importantly, what are their goals, what are their activities, what will they be happy with, what restrictions they can deal with. That being said, I think my most successful clinical outcomes with this type of bio-plasty hybrid surgical approach are in the younger patients who have come to me for second or third opinions, are not excited about a full knee replacement and are excited about doing something else which preserves functions, preserves their youth, and preserves their level of activity.
Melanie: After surgery while the joint surface is protected while that cartilage heals, what do you tell patients about living with this new knee the way that it is now? Are there any limitations for them?
Dr. Argintar: The answer is not really. A true statement is that the more you work, or run, or jump on these arthroplasties, the quicker they do run out. That being said, the person that I'm offering those bio-plasty to is someone who I want to be active, who I want to not modify their activities, so they can maintain their youth and their active lifestyle. So, I don't give them any restrictions. I do find that the recovery is faster and so far I have been very happy with the subset of patients who have been a good candidate for this surgery.
Melanie: Wrap it up for us, Dr. Argintar, with what you want other physicians to know about using that world of sports medicine and combining it with orthopedic surgery, why that's so unique and what you want them to know about it.
Dr. Argintar: It's a unique approach and I think in 2017, we have to be open to new things but we have to approach new things guarded. There are many excellent examples of exciting innovations in orthopedic surgery that simply didn't work out. What I find so attractive about this type of hybrid surgical approach is that each of these surgical options, that being arthroplasty and cartilage restoration, have independently been validated within the spectrum of their own specialty. What's unique about my approach is that I do a lot of arthroplasty and a lot of sports medicine and I've fused these two well-established, evidence-based medicine approaches together in the hope of finding a solution that is not, shall I say, the norm or currently offered. I would ask clinicians as they have their youthful, young, active patients who are perhaps slowly getting arthritic disease to be aware that there are other options available for their patients and they should seek out providers who are comfortable in describing and implementing these types of approaches.
Melanie: It's great information. Thank you so much for being with us today. You're listening to Medical Intel with Med Star Washington Hospital Center. For more information you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.