Joint Health: Arthritis Prevention Non-operative Treatments and Replacement Surgery

Transcription

1 Joint Health: Arthritis Prevention Non-operative Treatments and Replacement Surgery John A. Abraham, MD Orthopedic Oncology Service and Arthroplasty Service, Rothman Institute Director, Jefferson Sarcoma and Bone Oncology Center Sidney Kimmel Cancer Center Associate Professor of Orthopedic Surgery and Radiation Oncology Thomas Jefferson Hospital Philadelphia, PA Images courtesy of Biomet

2 Background Info Graduate of Harvard University and Yale Medical School Surgeon at Rothman Institute and Thomas Jefferson Hospital Member of the Joint Replacement service Director of the Orthopedic Oncology Service In practice 7 years post fellowship Primary Joint replacement, revision Joint replacement, Bone and soft tissue tumors, trauma Enjoy Hiking, Mountain Biking

3 What is arthritis? Arthritis is a general term for any condition that affects the cartilage surface of the joints There are many forms of arthritis: Osteo, inflammatory, Post-Traumatic, and Secondary Number One cause of disability in the United States 23 million people affected by osteoarthritis annually in the United States Cartilage Images courtesy of Biomet

4 Types of arthritis Osteoarthritis is wear and tear of the joint surfaces Post-traumatic arthritis is damage to the joints related to a prior injury Inflammatory arthritis is joint destruction related to a disease process, examples are rheumatoid arthritis, or Lyme disease Secondary arthritis occurs subsequent to another intra-articular condition, such as a neoplasm such as PVNS or synovial chondromatosis Images courtesy of Biomet

5 Joint Anatomy Joints are made up of two bones that meet, and the surfaces are covered with cartilage The joint surface is coated with articular cartilage Healthy articular cartilage contains chondrocytes, water, collagen, chondroitin sulfate, and other important components Images courtesy of Biomet

6 Joint anatomy In order to work properly and deal with mechanical loads, the two bones of any joint must mate together perfectly Smooth motion occurs between the cartilage surfaces that match perfectly Weight must be distributed evenly across a joint surface, so that no one particular area of cartilage is being overloaded with weight. Images courtesy of Biomet

7 Arthritis causes loss of important components of articular cartilage: water, hyaluronic acid, chondrocytes, chondroitin sulfate Cracking, fissuring, delamination of the cartilage follows, loose bodies may occur Eventual loss of all cartilage from joint surface: bone on bone Change in bone shape causes reactive bone formation (bone spurs) and acceleration of the process Arthritis Images courtesy of Biomet

8 Symptoms of arthritis Pain (aching, burning, soreness) Stiffness, decreased range of motion Swelling and effusion (swelling inside the joint) Mechanical symptoms (locking, clicking, catching, crackling sounds) Muscle symptoms (Weakness, soreness, atrophy) Images courtesy of Biomet

9 Who gets osteoarthritis? Anyone can get osteoarthritis! Not related to age alone Being overweight contributes significantly to arthritis Tends to run in families Exercise does not cause arthritis, but it may help prevent or delay it! Changes is hormone levels in women after menopause may increase arthritis Traumatic and Inflammatory arthritis have their own causes, but ultimately lead to the same problem: destroyed cartilage surfaces. Images courtesy of Biomet

10 Getting a Proper Diagnosis See your physician Medical history Symptoms Health Activity Exam of affected joint Range of motion tests Joint-line tenderness Joint deformities X-rays Images courtesy of Biomet

11 Osteoarthritis Normal Hip X-ray Arthritic Hip X-ray Images courtesy of Biomet

12 Osteoarthritis Healthy Knee X-ray Arthritic Knee X-ray Images courtesy of Biomet

13 Treatment of arthritis Initial management of arthritis does NOT involve surgery Take preventative steps toward decreasing pain and improving cartilage health: Lifestyle modifications Weight loss Nonoperative Measures: Medicines, Injections In many cases these treatments will allow a person to delay or even avoid the need for surgery Last choice: Joint Replacement Surgery

14 Prevention Lifestyle Modifications Exercise Weight Loss Medicaitons

15 Lifestyle modifications Incorporate daily physical exercise Do this gradually Check with your doctor first Physical Therapy centers can give you guidance on how to incorporate exercise Improve diet and habits Avoid heavy weight, high impact activities Increase muscle strength Slide courtesy of Biomet

16 Walking Swimming Bicycling Water aerobics Work with physical therapist Types of Exercise Low impact activities are better Slide courtesy of Biomet

17 Modifying Activities of Daily Living Posture Lift correctly Rest Balanced Diet Slide courtesy of Biomet

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

19 Weight Loss This is the single most important thing most Americans can do to improve arthritis symptoms Use the help of weight loss programs, but make sure that the changes you make are changes that will last, not a quick diet It takes discipline and dedication but it will make you feel better! Journal of Bone and Joint Surgery Study: Most people who complained that their arthritis was what prevented them from doing a daily exercise routine DID NOT maintain an exercise routine once their joints were replaced.

20 Medication: prevention Ca ++ supplementation and Vit D as directed by AAOS guidelines Supplements, like glucosamine, chondrotin, generally have shown no real benefit in large scale population studies, However, smaller cohort studies have shown some suggestion of benefit Okay to try these medications for a few months but if they don t help, stop them

21 Vitamins/Minerals Some studies indicate higher incidence of arthritis in people with low Vitamin C and D intake Too much calcium does not cause arthritis Too little calcium can cause osteoporosis Arthritis patients should take vitamins regularly if recommended by physician Slide courtesy of Biomet

22 Treatment: Nonoperative Medications Injections Physical Therapy

23 Medications Medicines can help control flare-ups of arthritis, but should not be used as the sole method of symptom relief Acetaminophen, NSAIDS are useful to control symptoms. Narcotic medicines should be avoided

24 Over The Counter Medications Acetaminophen Aspirin Naproxen Ibuprofen

25 Nonsteroidal anti-inflammatory drugs (NSAIDs) Effective in reducing swelling Stomach and blood side-effects Always ask physician before taking Slide courtesy of Biomet

26 Injections Intra articular injections of steroids can help decrease the inflammation, and as a result the symptoms of arthritis temporarily Generally considered unsafe to get more than three injections, and these are spaced at least three months apart Accumulation of steroid can be a problem Lidocaine Chondrolysis may be a problem

27 Viscosupplementation Hyaluronic Acid injection (Synvisc, Orthovisc, Monovisc) Lubrciates joint and replaces lost hyaluronic acid. No proven benefit in large scale studies May benefit some 1,3,5 injection series 6 months apart

28 What s next? Do I need a joint replacement? Am I too young or too old? Will it help my pain? Will it help my motion and activity level? My knee is not bad enough or is too bad to replace. I m going to wait as long as I can before I get my knee replaced.

29 Surgical Management Partial Joint replacement Total Joint Replacement

30 When to Consider Joint Replacement Conservative treatments fail to provide relief Diminished quality of life After discussing with your orthopedic surgeon After deciding what is best for you Slide courtesy of Biomet

31 Goal of Joint Replacement To improve quality of life by reducing joint pain Improving mobility decreasing need for medication restoring function 3 Slide courtesy of Biomet

32 Dollar Value of Joint Replacement Total joint replacement can save an individual as much as $68,000 (total knee replacement) to $180,000 (total hip replacement) in medical costs over the life of the average total joint recipient as compared to non surgical treatment. 4,5 Slide courtesy of Biomet

33 Success of Total Joint Replacement Every year, over 1,000,000 people in the United States have joint replacement Joint replacement treats debilitating pain from various forms of arthritis Joint Replacement is considered one of the most successful procedures known to modern medicine Slide courtesy of Biomet

34 Primary Hip Components Shell Liner Head Stem Slide courtesy of Biomet

35 Primary Knee Components Femoral Component Polyethylene Bearing Tibial Tray Slide courtesy of Biomet

36 Post Operative X Rays Total Knee Replacement

37 Rehabilitation In most cases, you will be allowed to put full weight on your new joint immediately That doesn t mean you will feel like it! About 3-6 months recovery time Plan ahead for the fastest recovery Joint replacement classes can be informational and helpful

38 Minimizing Potential Complications See your primary-care physician Make sure dental work is up to date Prepare home to assist recovery Follow your surgeon s postoperative instructions Slide courtesy of Biomet

39 Follow-Up Visits with Your Surgeon Surgeon will advise when you can return to low-impact, daily activities May occur every three months during the first year Occasional visits after first year Regular check-ups may help in preventing complications and monitor wear Slide courtesy of Biomet

40 58 yo M Inflammatory Synovitis Gout history Recent pulmonary infection Cases

41 Post op

42 Post Traumatic arthritis 50 yo F Morbidly obese s/p MVA, traumatic hip dislocation

43 Post traumatic Arthritis

44 Osteoarthritis 68 yo F, no major comorbidities, R knee pain failed multiple conservative measures

45 Synovial neoplasm 66yo M with history of PVNS, now with recurrence and knee pain

46 PVNS TKA Postop

47 Avascular necrosis 67 yo F prior alcoholism now with R hip Pain, no L hip pain

48 Where to find help Numerous organizations to help you live better: Rothman Institute The Arthritis Foundation The American Association of Orthopaedic Surgeons Biomet Orthopedics Slide courtesy of Biomet

49 Images courtesy of Biomet Thank you!

50 References 1. Centers for Disease Control and Prevention 2. The Arthritis Foundation 3. Vanguard Complete Knee System Package Insert 4. Chang RW, Pellissier, JM, Hazen GB, A Cost effective Analysis of Total Hip Arthroplasty for Osteoarthritis of the Hip, Journal of the American Medical Association (JAMA), Vol. 275, No.11, 1996, pp Figures apply to average 60 year old patient and adjusted for inflation. 5. Gottlob C., AAOS Presentation #114, Figures apply to average 70 year old patient and adjusted for inflation. Slide courtesy of Biomet