HHC: Treatments for Arthritis Pain
Hello, I’m Dr. John Irving from Connecticut Orthopaedics. Thank you for joining me today for this discussion on hip and knee arthritis. I’m an orthopaedic surgeon specializing in total joint replacement. Today we’re going to cover different aspects of arthritis, including what arthritis is and how to manage, what to do when you need to consider surgery and where you should consider having a total hip and knee replacement.
Hip and knee arthritis affects millions of Americans. It is characterized by pain and loss of joint motion and with this there can be a loss of work activities, activities of daily living and lifestyle and the ability for one to care for themselves. It requires extensive and sometimes expensive medical and surgical management.
The most common type of arthritis is osteoarthritis or wear and tear arthritis, which is losing the surface coating on a bone, at a joint. It’s very similar as shown by the picture on the right, to losing a tread on a tire or potholes in the road.
Specifically for knee arthritis a progressive osteoarthritis with potholes in the road or the surface coating this can cause pain and stiffness. Patients will realize swelling, stiffness, achiness, difficulty getting in and out of a car chair and toilet and up and down stairs. They may notice that their legs are becoming more bow-legged or even knock-kneed depending on where the erosive process is located. The x-ray below shows the progression of arthritis in a knee from left to right with loss of the surface coating and joint space with the knee becoming progressively more bow-legged.
Hip arthritis is similar to the knee, there is erosion of the joint surfaces and the development of bone spurs is illustrated by the slide on the right. The patient can experience similar symptoms as with the knee but located in the groin, on the outside of the hip, the buttock and even radiating down to the knee. The x-ray below shows a normal hip joint on the left with a normal joint space in the arthritic process, on the right with loss of joint space and bone spurs.
I’d like to go into some detail and talk about non-surgical management of hip and knee arthritis. I’m going to touch base on personal responsibility for health optimization, exercises and physical therapy, the use of a cane, braces, medications and injectables. If you have arthritis, one of the most important factors is optimizing your personal health. This includes stabilizing all chronic medical conditions, maintaining a healthy body weight (preferably with a BMI less than 30 or even lower), if your diabetic, maintaining a hemoglobin A1c under 7 and nutritionally making sure you’re getting enough protein so that when we have to measure your albumin before surgery, the level is greater than 3.5.
Your body weight is one of the most significant factors in controlling pain and disability and progression of hip or knee arthritis. As you can see by the slide below, the forces across the knee joint or pressure are significant depending on the activity level you are doing whether it is running, squatting, climbing stairs or walking. The forces can be anywhere from two and a half to seven or eight times bodyweight. What this translates to, is that a 10-pound weight loss can take 25 to 70 lb of pressure or force off of the hip and knee joint, which will improve pain, it will improve function and your quality of life. We do recommend that you continue physical activity, low-impact activities such as: swimming, biking, and elliptical machines at the gym. If you are doing exercises, we do recommend that you do high repetition and low load exercises with 25-30 repetitions per set. We also may recommend that you use a cane. If this is used in the opposite hand from the affected hip or knee it can effectively reduce the forces across the bad joint by 25%. For certain indications we may recommend the use of a brace for the knee. We typically recommend an off loader brace, which will shift the pressure off of the affected side of the knee to the unaffected side, decreasing your pain and increasing your function to allow you to continue activities.
It is important for you to consider pain relief with different medications that are available without a prescription. Medications that are available are mildly anti-inflammatory pain relievers or both. There’s Motrin and Advil which is ibuprofen. There is Aleve, which is naproxen and acetaminophen which is Tylenol. Some patients find supplements helpful including, turmeric, glucosamine and chondroitin sulfate and MSN, which is available in different formulations at the pharmacy. If over the counter medications do not help you we can help with a prescription. The NSAIDs or non-steroidal anti-inflammatories that we would prescribe are ibuprofen, naproxen or diclofenac. Sometimes we will consider the use of a cox-2 inhibitor which is a different class of anti-inflammatory and includes Meloxicam and Celebrex. The American Academy of Orthopaedic Surgeons also recommends for pure pain relief, a medication called Tramadol, which may or may not be mixed with acetaminophen or Tylenol.
If medications, physical activity modifications and physical therapy are not healthful, we may recommend injectables. These include steroids which are anti-inflammatory medicines that temporarily decrease inflammation and swelling and can be used on both the hip and the knee. Many of my patients asked me about the chicken comb gel and this is viscosupplementation. The classic one is made from biological sources including chicken or rooster combs, and it is a medication that is injected to help lubricate the knee joint and decrease inflammation. Patients also talked about platelet-rich plasma, which is still an experimental process. We can collect a tube of your blood, spin it down and collect that pellet of platelets and inject it back into the knee.
Lastly, I would like to touch base about stem cell injections. Scientifically we are not there yet and many of the processes available only inject fat cells that are harvested from your body back into the knee joint and have not been shown to have any effect on arthritis pain or deterioration. Any of the above treatments including steroids, viscosupplementations and PRP are only temporary symptom reducing treatments. None of them have been shown to halt the progression of the arthritis.
Now we’ve talked about many of the non-surgical interventions and if despite all these treatments you continue to have severe pain and disability it may be time to consider surgery. You have to take into consideration whether this pain and disability affects your lifestyle, your activities of daily living, your safety and your independence.
Pain and disability is the most important factor in considering surgery. Is the pain chronic? Is it moderate-to-severe? Is it emotionally draining? Does the pain and disability compromise your activities of daily living, such as putting your shoes and socks on, dressing, bathing, climbing stairs, getting in and out of a car and on and off a toilet? Does the pain and disability compromise your lifestyle activities including, decrease socialization, your ability to cook for yourself, your hobbies and recreation? Most importantly is your safety compromised? Do you find that you’re tripping, stumbling? Have you fallen? These may all be related to pain, stiffness, muscle spasms and loss of motion at the joint. Lastly, is your independence threatened? Are you no longer able to take care of yourself or your home? Is your ability to go to work threatened? Are you able to drive yourself around? There may be a loss of personal dignity which again, is your ability to take care of yourself such as, dressing, bathing and toileting.
If you’re ready to consider surgery, a total hip and knee replacement is a wonderful operation that has been changing people’s lives for the better for the past 40 years. Last year in the United States there were over 750,000 total knees and over 500,000 total hip replacements preformed. It’s a durable operation, and with the current parts one would expect a 20 year history before there is consideration of a revision for a plastic part that is wearing out. Total hip replacement or total knee is a very important consideration for maintenance of your lifestyle, your independence and your activities of daily living.
For total joint replacement the most significant advancement in the last 5 years has been pain reduction during and after the operation from less invasive techniques and improved anesthesia. Our goal is improve patient comfort and improved early function with reduction of opioid narcotic use.
Today’s total joint patient is much more active, expects faster rehabilitation with proven reliable devices. The age range has expanded from their 20s into their 90s, with the most common being patients from 50-80. Patients will expect a comfortable technologically-advanced and patient-centered local facility.
If you are considering total joint replacement, please consider the Hartford HealthCare Orthopaedic Center at St. Vincent’s Medical Center in Bridgeport. We are happy to announce that since October of 2019 Hartford HealthCare is now in Fairfield County at St. Vincent’s Medical Center offering surgery for hips, spine and shoulder and knees. The Orthopaedic Center at St. Vincent’s is a collaborative effort between Hartford HealthCare and private practices. We will have total joint replacement and spine surgery with orthopaedic surgeons and neurosurgeons.
The Orthopaedic Center at St. Vincent’s continues the tradition of being designed by doctors and inspired by patients expectations for the highest quality hospital care and results from their surgery. It was a team effort to put together this center. It’s a total hospital experience built from a joint effort of the entire medical staff including: housekeeping, nursing, physical and occupational therapy, anesthesia, orthopaedic and neurosurgery with consultation from our medical colleagues. We will offer a seamless experience from booking surgery to post-discharge care. The orthopaedic navigators will work closely with doctors offices and patients to anticipate and plan for all their needs.
Patients and families can expect an outstanding experience coming to St. Vincent’s, with concierge parking, family and patient lounges and dedicated kitchens. We’ve redesigned the hospital to accommodate the needs of our special orthopaedic patients and have built a hospital within a hospital including, check in family waiting areas and patient rooms. The illustration on this slide shows an exceptional waiting room environment with state-of-the-art lighting, seating and noise reduction and all the amenities for family comfort.
It all starts with extensive patient-oriented preoperative education classes and booklets. The more you know what to expect, the better you will do. We recommend and encourage family participation. Our surgeons have been chosen for their experience and expertise with the latest technology including robotic hip and knee surgery, 3D implant printing and custom patient matched surgical tools to optimize implant positioning. Patients will also benefit from an orthopaedic specific enhanced recovery after surgery or ERAS protocol which has been developed by our anesthesiologist and orthopaedic surgeons and nursing to minimize surgical pain and therefore decrease opioid use postoperatively.
Our goal is to shorten hospital stay significantly lower than the national average with nearly all patients being discharged home. We will set you up for success and you will be safe, comfortable and confident to go directly home the next day or even the same day in some cases.
Thank you very much for your attention today with this online session. If you have any questions about hip and knee arthritis please do not hesitate to contact me. And if you are considering surgery, please consider The Orthopaedic Center at St. Vincent’s Medical Center.