Boomeritis Arthritis of the hip and knee joint - Duke Raleigh Hospital

BoomeritisArthritis of the hip and knee jointHardy Singh, M.D.

Background…Hardy Singh, M.D.Medical School, Punjab, IndiaOrthopaedic Training, IndiaResearch, Duke University Medical CenterResidency Duke University Medical Center6 month Fellowship, Joint replacement

Joint Efforts• Putting the springback in your steps….• Or..• Charting your courseto a more normallifestyle….

Choosing an orthopaedic surgeon…• How are orthopaedicsurgeons trained?• What is BoardCertification?• What is a fellowship?

Topics..• Arthritis• Joint Anatomy• Treatment options

The Arthritis Foundation“Half of Americans diagnosed witharthritis don’t think anything canbe done to help them.”

The Arthritis Foundation• Arthritis is the number one cause ofdisability in the U.S. *• Over 16 million adults say that arthritislimits their usual activities in some way. *• 8.2 million working aged U.S. adults(about 1 in 20) report work limitations dueto arthritis or joint symptoms.

Anatomy• Ligaments– Connect bone to bone• Tendons– Connect muscle to bone• Cartilage– Lubricates and cushionsmovement

• Covers bone ends inevery joint• White, slippery tissue• One-quarter inch thick• Can be damagedCartilage = Tires

What is Arthritis..?• Defined as inflammation of the joint• More than 100 different types• Affects 43 million Americans each year• Pain, swelling, and loss of motion• Most common cause of disability in US—1 in 6 affected• Two primary types– Osteoarthritis– Rheumatoid arthritis• Source—Centers for Disease Control and Prevention

Rheumatoid Arthritis• Inflammatory arthritis• Often affects many joints at once• Can occur at any age, even children• Excess synovial fluid

Osteoarthritis (continued)• Begins as small area• Eventually results in bone-on-bone contact• Results in swollen, painful and stiff joints

OsteoarthritisHealthy knee x-rayArthritic knee x-ray

OsteoarthritisNormalhipXrayArthriticHipX-ray

Symptoms of Arthritis• Joints warm to the touch• Joints swelling• Joint pain and immobility• Joint stiffness• Joint weakness (buckling)• Decreased activity• Impaired lifestyle• Joint deformities

Osteoarthritis vs. NormalAging• Osteoarthritis causeschanges in the bone belowcartilage• Osteoarthritis occursprimarily in weight-bearingjoints• With osteoarthritis, thewater content increasesearly in the diseaseprocess

Exercise Nourishes Cartilage• Extremely beneficial.• Keeps bones strong.• Keeps joints limber.• Strengthens muscles.– Good muscle tone decreasesstress to the articular surface ofthe joint.• Helps prolong life of joints.

Types of Exercise• Walking• Swimming• Bicycling• Water aerobics• Work with physicaltherapist.• Posture– Lift correctly– Rest– ADL’s

Modifying Activities of DailyLiving• Posture• Lift correctly• Rest

Weight Control(Being Overweight…)• Places extra stress on your joints 1– 3 pounds of pressure for every 1 pound ofbody weight– 150 pound person can place up to 450pounds of pressure across each joint• Accelerates rate of cartilage destruction 2• Makes it harder to exercise properlybefore and after surgery 2 .• Harrington, I. J. (1976): A bioengineering analysis of force actions at the knee in normal and pathological gait.Biomed. Eng., 11:167–172.• Felson, D. T.: “Weight and osteoarthritis.” J. Reumatol, 43: 7–9, 1995.

Too much to handle..

Ice….is nice• Decreases localcirculation• Decreases swelling• Acts as a local antiinflammatory• Decreases pain• Improves exercisetolerance

Heat… is nice• Increases local circulation• Promotes relaxation• Helps muscles and joints stretch• Decreases joint and muscle aches

Braces and Self-HelpDevices• Back/Hip/Knee– Abdominal supports to reduce stresson the back– Long-handled reachers and grabbersto reduce bending– Sock sliders• Knee– Bracing the knee reduces painfulinstability– Unloader braces are special kneebraces to reduce stress on the kneejoint.

Orthotics• Properly fitting footwear is essential toalign legs• Heel wedges or orthotics help align thelegs, relieving pressure on knees• Rubber shoe inserts may reduce some ofthe impact loading that your knees or hipsexperience.• Canes (in opposite hand).• Walkers

Glucosamine/Chondroitinsulfate• Building block of cartilage• May be useful in strengtheningcartilage, preventing breakdown.• Can be extracted from shells ofcrabs and shrimp• Not a cure. Does not rebuildcartilage.• May help with keeping cartilagespongy.• Some anti-inflammatory properties.

Vitamins/ Minerals• Some studies indicate higher incidence ofarthritis in people with low Vitamin C andD intake• Too much calcium does not cause arthritis– Too little calcium can cause osteoporosis• Arthritis patients should take vitaminsregularly

Medications/NSAID’s• Acetaminophen, Aspirin, Naproxen,Ibuprofen, Celebrex.• Host of NSAID’s (as needed best)• Effective in reducing swelling• Stomach and blood side-effects.• Topical Creams: Capsaicin, zostrix (fromred peppers)– Helps block pain.

Hyaluronate• Naturally occurring substance in cartilage• Relieves pain• Restores function• Provides lubrication to cartilage• Relief may last from 6 to12 months.• Hyalgan, Supartz, Synvisc, etc..• Few side effects..pseudosepsisWang CT, Lin J, Chang CJ, Lin YT, Hou SM. Therapeutic effects of hyaluronic acid on osteoarthritis ofthe knee. A meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2004; 86:538-545

Cortisone• Naturally Occurring Hormone.• Anti-inflammatory• Short term pain relief• Reduce swelling• Relief is variable• Long-term use may injure cartilage.Leopold SS, Redd BB, Warme WJ, Wehrle PA, Pettis PD, Shott S. Corticosteroid compared with hyaluronic acid injectionsfor the treatment of osteoarthritis of the knee. A prospective, randomized trial. J Bone Joint Surg Am. 2003; 85:1197-1203.

Is Surgery for You?• This should be acooperative onebetween you, yourfamily, your familyphysician and yourorthopaedicsurgeon.

The OrthopaedicEvaluation• Medical historyincluding:– Previous injuries andsurgeries– Current medications– Lifestyle issues anddemands• Physical examination• X-rays• Occasionally bloodtests, MRI or bonescan

SurgeryChondroplasty, RF ablationOATS, microfractureCarticelOsteotomiesPartial joint replacementOrthoglide spacerTotal joint replacement

Arthroscopy• Controversial for Degenerative knee• Mechanical symptoms= success.– Relieves pain from torn meniscus, Loosebodies, pathologic plica, osteophytes, notchstenosis• Severity of arthritis= failure• Less successful with malalignment/ Gaitissues.• Arthroscopy=sham for arthritis.

Osteotomy

“Minimally Invasive”Surgery• Traditional jointreplacement surgery isperformed through an 8 -10 inch incision• Some patients mayqualify for a “minimal”incision, only 4 inches to6 inches long• Your surgeon will selectthe best approach foryour unique situation.

Total knee/Hip replacement• Primary ComponentsFemoral componentPlastic linerTibial trayShellLinerHeadStem

Preparing for Total JointReplacement• Donate some of yourown blood• Stop taking certaindrugs before surgery• Begin exercises tospeed your recoveryafter surgery• Plan for home therapyand rehabilitation aftersurgery

Total joint replacementRealistic expectations90 percent of individuals who undergo totaljoint replacement experience a dramaticreduction of pain and a significantimprovement in the ability to performcommon activities of daily living.• Survivorship:– 90%@10 yrs– 80%@15 yrs– 75%@20 yrs.

Possible Complications• Most are successfully treatable• Types of possible complications:– Loosening– Infection– Wear– Blood clots– Dislocation– Nerve Injury

The Recovery Process• Use your "new" jointshortly after youroperation• Begin walking shortlyafter surgery• Initially, you will walkwith a walker,crutches or a cane.

Home Planning• Safety bars• Secure handrails• Stable chair• Toilet seat riser• Remove all loosecarpets and cords• Same floor livingspace

The Recovery Process• There will betemporary pain in thereplaced joint• The muscles are weakfrom inactivity• The tissues arehealing• Pain will end in a fewweeks or months

A few weeks later..

New Implant- FDA• ORTHOGLIDEapproved 2006

What type of patient is thisfor??• A patient who is havingpersistent pain mainly frominside part of the knee• A patient who’s received allother non-surgical therapiesand is still having pain• A patient who’s surgeon hastold them their next step is aUniarthroplasty or TKR

How it works• Reduces the forces placed on the painful middlepart of the knee by redistributing them to theother less painful half• Increase the contact area of the moving parts inthe knee, thus reducing painful point forces• Decrease the bone-on-bone friction by providinga smooth glide path for the femur to move on

The OrthoGlideAdvantages…• Provides pain relief without compromising the kneeanatomy• No bone cuts• 2-3 inches long, combined with arthroscopy• Total procedure time: 45-60 min.• Does not “Burn any Bridges”• Easy conversion to other surgical options (i.e. Uni, TKR)• Home next day, no Physical Therapy• Weight bearing as tolerated.

Current Patient Results100OrthoGlide Results90WOMAC Score8070605040PainFunction3020Pre-op3 Monthn=486 Monthn=481 Yearn=1

Future of arthritis• By the year 2030, an estimated onequarter of the projected total adultpopulation, or 64.9 million adults aged 18years and older, will have doctordiagnosedarthritis, compared to the 42.7million adults in 2002. *• These estimates may be conservative asthey do not account for current trends inobesity.

Closing• Education of various options• We can/must successfully treat arthritis• Surgery is a last resort• Returning patients to activity andemployment is critical• We must work together.

Future• Identifying high risk patients.• Genetic basis• Disease prevention through– Health– Lifestyle &– Disease modifications.

Thank youHardy Singh, M.D.