Mark S. Sanders, MD FACS Special thanks to DePuy Orthopaedics, Inc.

1. Mark S. Sanders, MD FACS Special thanks to DePuy Orthopaedics, Inc. 1

2. Agenda Thigh bone(femur) Kneecap (patella) Cartilage Shin bone (tibia) • How your knee works & why it hurts • Knee replacement basics • What patients have to say • Your questions 2

3. How your knee works Anatomy of the knee • Largest joint in body • Referred to as a hinge joint because it allows the knee to flex & extend; while hinges can only bend and straighten, the knee has the ability to rotate (turn) & translate (glide) • 3 bones • Shin bone (tibia) • Thigh bone (femur) • Kneecap (patella) 3

4. What’s causing your pain? 1. Landers, S. Another reason to exercise for those with arthritis. American Medical Association website. <http://www.ama-assn.org/amednews/2005/05/02/hlsc0502.htm>, 2005. It’s estimated 70 million people in the U.S. have some form of arthritis.1 Osteoarthritis is one of the most common types. • Osteoarthritis • Wear and tear that deteriorates the “cushion” in your joints • A degenerative condition—it won’t get better and may get worse • Rheumatoid arthritis • An autoimmune disease that attacks the lining of joints, causing swelling, possibly throbbing painand deformity 4

5. What’s causing your pain? Healthy knee The end of each bone in the joint is covered with cartilage, acting as a cushion so the joint functions without pain Diseased knee (osteoarthritis) Wear and tear deteriorates natural cushion, leading to bone-on-bone contact, soreness and swelling 5

6. Assessing your pain • Does your knee hurt one or more days per week? • Does the pain interfere with your sleep? • Is it painful for you to walk more than a block? • Are pain medications no longer working? • Is knee pain limiting your participation in activities(e.g. family vacations or other functions)? • Has inactivity from knee pain caused you to gain weight? 6

7. Assessing your pain Little or no pain Excruciating, debilitating pain 1. 2007 DePuy Orthopaedics, Inc. Knee Attitudes & Usage Study. • Rate your pain on a scale of 1 to 5 • For most people, the tipping point is about 4 or 5— that’s when the pain becomes too difficult and they turn to a surgeon for relief1 7

8. Assessing your pain Bend at the hips and knees Pretend to drive: push the gas/brake Pretend to golf: swing a club Walk Check your mobility If you have difficulty performing any of the movements below, it may be time to talk to your doctor about next steps 8

9. How can your pain be treated? • Medications • Analgesics • Corticosteroids • Injections • Corticosteroids,hyaluronic acid(e.g., Orthovisc®) • Water therapy • Soaking, ice packs, hot packs • Exercise & physical therapy • Also good for weight loss 9

10. Knee replacement 1. <http://www.aaos.org/Research/stats/Knee%20Facts.pdf>, 2005. 2.The Arthritis Foundation. <http://arthitis.org/research/Bulletin/vol5no11/Printable.htm>, 2006. • Implants replace damaged surfaces • Helps relieve pain and restore mobility • More than 500,000 knee replacements are performed each year in the U.S.1 • A recent Arthritis Foundation® study shows knee replacement has a 90-95% rate of patient satisfaction2 10

11. What is knee replacement? Femoral component Tibial component A surgical procedure that removes and replaces diseased joint surfaces with implants 11

12. How does it work? Femoral component Polyethylene insert Patellar component Tibial component • Diseased areas at top of shin bone (tibia) and bottom of thigh bone (femur) are removed and reshaped • Femoral component covers the thigh bone (femur) • Tibial component covers the shin bone (tibia) • Polyethylene insert placed between femoral and tibial components • Patellar component replaces the kneecap (patella) 12

13. How does it work? Healthy knee Knee replacement 13

14. DePuy Sigma® Knees Sigma Knees come in a wide range of shapes, sizes and materials Your surgeon may be able to fit you with a Sigma Knee designed to provide a more natural feel and movement Sigma Knees can be implanted using minimally invasive surgery The Sigma Knee is a great example of a proven design that continues to evolve to meet the demands of today’s patients 14

15. Sigma® Fixed-Bearing Knees 1. IMS Health • Most widely used type of knee replacement in the U.S. today1 • Designed to enhance stability of the joint • New designs and advanced materials - Helps reduce wear 15

16. Sigma® Fixed-Bearing Knees 16

17. Sigma® Rotating Platform Knees 1. McNulty, D. et al. “In Vitro Wear Rates of Fixed-bearing and Rotating Platform Knees (Rev. 2).” 2003. 2. DePuy Multi-Center Study. 2006. Rotating Platform Knee Designed to rotate as it bends, imitating your natural knee movement • The surfaces of the knee joint roll and glide against each other as you bend. In other words, your knee naturally rotates as it bends • Designed for patients who want to remain active since it minimizes implant wear, compared to traditional knee replacements1 • A multi-center DePuy Orthopaedics study shows 97% patient satisfaction at 5 years after surgery2 17

18. Should you wait to replace your knee? • Assess your pain and ability to function • Do you feel severe pain in your knee? • Has the pain and loss of function affected your quality of life? • Do you have difficulty sleeping or performing basic functions (walking, driving, climbing stairs)? • Does medication no longer provide relief? • Consult your physician • Early diagnosis and treatment are important1 • Delaying may lower your quality of life2 • Osteoarthritis is degenerative—it won’t get better and may get worse 1. Fortin PR, et al. Outcomes of Total Hip and Knee Replacement. Arthritis & Rheumatism. 1999;42:1722-1728. 2. Fortin PR, et al. Timing of Total Joint Replacement Affects Clinical Outcomes Among Patients With Osteoarthritis of the Hip or Knee. Arthritis & Rheumatism. 2002;46:3327-3330. 18

19. Information specific to Dr. Sanders’ approach

20. Preoperative Planning • Long Standing X-rays (Orthoradiograms) • Medical, Vascular, and Cardiac clearance • Patient Education

21. Decreasing Postoperative Pain • Spinal Anesthesia decreases post op pain and thromboembolic disease • Minimally Traumatic Surgery • Minimal Use of the tourniquet averages 20 minutes • Ranawat cocktail locally injected for post op pain relief • Rapid Surgery (averages one hour) • Epidural catheter for pain relief x 2 days • Oral analgesics • Cryocuff for cold therapy

22. Decreasing the Incidence of Thromboembolism • Immediate Active Motion without CPM machine (average patient’s motion 0-120 degrees by day one) • Foot pumps placed before surgery to decrease thromboembolic disease • Ambulation with PT that afternoon TED antiembolism stockings worn for two weeks • Medications given to prevent clotting • Most patients receive only Aspirin

23. Decreasing the Infection Rate in the OR • Preoperative intravenous antibiotics • Antibiotics impregnated in bone cement • Special “Space Suits” worn by all scrubbed OR personnel

24. Post Operative Rehabilitation • Immediate active motion (no CPM machine) averages 0-120º within 24 hours • Ambulation with PT that same day • Average hospital stay from Tuesday to Friday • Most patients <70 go home • Most patients >80 go to rehab hospital • Average length of time with crutches/walker 10 days • Average time in PT ranges from 4-6 weeks

25. Wound Management/Infection Prevention • Patients shower daily with ®Hibiclens starting at 24 hours post surgery • Compression stockings worn for two weeks • No skin staples • ® Dermabond (medical grade ®Krazyglue) lasts for ten days • Intracuticular sutures (®Quill) dissolves on its own without need for suture removal

26. Important safety information. . . As with any medical treatment, individual results may vary The performance of joint replacements depends on your age, weight, activity level and other factors There are potential risks, and recovery takes time People with conditions limiting rehabilitation should not have this surgery Only an Orthopaedic surgeon can tell if knee replacement is right for you 26

27. Summary 1. Fortin, Paul R., et al. Outcomes of Total Hip and Knee Replacement. Arthritis & Rheumatism 42 (1999): 1722-1728 2. The Arthritis Foundation. <http://arthitis.org/research/Bulletin/vol5no11/Printable.htm>, 2006. The leading cause of knee pain is osteoarthritis Osteoarthritis is degenerative – it won’t get better and may get worse Early diagnosis and treatment for total knee replacement are important1 A recent Arthritis Foundation® study shows knee replacement has a 90-95% rate of patient satisfaction2 Sigma Knees come in a wide range of shapes, sizes and materials, so your surgeon may be able to fit you with a knee designed to provide a more natural feel and movement 27

28. And Never Forget: • Inform every doctor or dentist you have a knee replacement to receive antibiotics before invasive procedures

29. Thank you! To find out more about knee pain and the treatment options available, visit: www.kneereplacement.com www.aaos.org © DePuy Orthopaedics, Inc., 2010. The third party trademarks used herein are trademarks of their respective owners. 29