Articles

What’s New in Hip and Knee Arthritis

As seen in the “Be Healthy Kentuckiana” supplement of
The Courier Journal – May 26, 2004 edition.

Arthritis pain affects about 25 million Americans and its prevalence will undoubtedly grow as the “baby boomers” age and as life expectancies increase. There are two general arthritis classifications: osteoarthritis and inflammatory arthritis with the former being far more common.

Osteoarthritis is better known as “wear-and-tear” arthritis. It is more common and may either be primary (result of genetics or aging) or secondary (result of trauma, certain diseases or overuse). Strictly speaking, “arthrosis,” which infers degeneration versus inflammation (“-itis” means “inflammation”) , is the proper term for osteoarthritis but common usage permits both.

Inflammatory arthritis refers to arthritis caused by inflammatory diseases such as rheumatoid and similar arthritides. They involved different onsets, symptoms and overall management.

Arthritis of the hip and knee are common and are one of the leading causes of disability in this country in both working and retired people. There are many classical treatments and several newer ones that are emerging.

First-line treatments include non-steroidal anti-inflammatory medications which address inflammation and pain. These should be taken with food or milk to lessen the risk of gastrointestinal side effects and should be discontinued if they, or other reactions, occur. Acetominophen preparations also treat the pain of arthritic conditions but do little for inflammation and swelling. Linaments, heating pads, ice packs, elastic or neoprene braces may also provide symptomatic relief. Weight control also is helpful but will not reverse disease created by years of preceding obesity. The biomechanical force between the patella, or kneecap, is three times ones body weight ( yes, body weight) with just normal walking and it increases to 5-7 times body weight with activities such as squatting, stairs and running. The caveat is, however, that losing just 10 pounds can lessen these forces by 30-70 pounds! Moderate low-impact activities have positive effects too. Specific exercises to strengthen and balance the muscles of the hip and knee are beneficial and can be learned from handouts, online sources or from physical therapists. The use of a cane, which is a “dirty four-letter-word” in my practice, in the opposite hand can reduce joint forces by 40-60% and can help to keep people with arthritis mobile.

Patients often ask about herbal and neutriceutical treatments for arthritis. Many of these products may have side effects and should be taken judiciously. The most common formulation used for the treatment of arthritis involves glucosamine and chondroitin. Glucosamine, anyway, seems to have better-than-placebo results in some studies but it must be taken for 3-4 months to see if it works. It seems to work best in the early stages of arthritis but diabetics should discuss this with their doctors as there is glucose in glucosamine. Those with seafood or shellfish allergies should not take chondroitin.

The next tier of treatment in the knee involves injections in the joint. Intraarticular corticosteroids (“cortisone shots”) are a mainstay in controlling out of control arthritic episodes. They basically shrink swelling and inflammation and work best when these are present in the physical exam. Patients often question how many of these they can get. Basically, when the disease is fairly advanced they may be administered three or four times per year although physicians often disagree on this. The other common form of intraarticular injection therapy is viscosupplementation. This involves sequential injections (three to five) of substances thought to increase the cushioning effect of cartilage and joint fluid. Several preparations are currently available including branded Supartz, Synvisc, Hyalgan and Orthovisc. They may be repeated after six months if they are effective in a particular patient. They may delay, but not obviate, the need for joint replacements.

Arthroscopy, or the passage of a thin tube-shaped instrument with fiberoptics and video into a joint, can help some arthritic joints with mechanical defects, such as cartilage tears, but is not specifically indicated to treat arthritis alone, especially in its end stages.

Hip and knee arthroplasties, or joint replacements, are procedures that have been around for many years and they enjoy a success rate in the high ninety percent range. Most orthopedic surgeons perform these procedures and there are more than 250,000 of each performed in the United States annually. This involves “replacing” (more like substituting) the diseased hip or knee joint with bearing surfaces made of various combinations of metal alloys, plastics or ceramics. There are many choices here and there has been confusion by direct-to-consumer advertising in this arena. The best advice is to find an orthopedic surgeon that you trust and having them discuss all the treatment options, including non-surgical ones, with you.

Joint replacements are, however, big operations and involve hospitalization, often rehabilitation and therapy with extended recoveries. This can be problematic for those who do not want to be laid up for an extended period of time or for those who could benefit from surgical treatment but are still working and cannot afford time off to get it.

The hot topic in joint replacement over the last couple of years is minimally invasive hip and knee replacement. Perhaps “less invasive” is a more proper term. These procedures involve less dissection and smaller incisions (2.25-4 inches in the hip and 4-5 inches in the knee) but they are technically demanding and require training for the surgeon. Data from the initial experiences is now being presented and essentially shows little difference a year out from surgery; however, there is a quicker initial recovery from these operations. In many, but not all cases, it cuts the rehab and recovery time in half. These techniques are also showing less blood loss and therefore less risk of transfusion. This offers people who might not otherwise consider joint replacement because of time constraints the option and a chance at a significantly quicker recovery.

Since I started performing minimally invasive hip replacements almost two years ago and now knees, I have noticed my patients have required, in general, less rehab and therapy and have largely experienced quicker recoveries. It is not unusual to have them using a cane, instead of a walker, when they come in to get their staples out of their incisions about two weeks post-op. Some patients, though, still require “the normal” amount of recuperation. While one should exhaust non-operative treatment options prior to entertaining joint replacement, patients should not wait until they can barely walk prior to getting one as the joints can get very weak and stiff making recovery difficult. For additional information on arthritis and other orthopedic conditions, log on to our practice website, www.lbjs.net, where you will find links, including the American Academy of Orthopaedic Surgeons/Patient Section, that are helpful.

Stephen P. Makk, MD
Louisville Bone and Joint Specialists