Your Joint Pain and Treatment Options

1. Your Joint Pain and Treatment Options Steven L. Drayer M.D. Private Practice-Lansing/Sparrow Hospital

2. About My Practice • Trained at Henry Ford Hospital in Detroit, Michigan. • Have been in private practice for 20 years • Have been performing joint replacements for 24 years • I perform approximately 150 replacements/year, not including those done for broken hips. These are knee and hip primarily, but also shoulder and, rarely, elbow.

3. I also perform revision surgery for worn out, loose or painful joint replacements. • I update my knowledge on joint replacement surgery twice a year at educational courses. • I’m well trained and experienced in alternative treatments for arthritis. These include medications, P.T., exercise, dieting, bracing, injection therapy, arthroscopic surgery, cartilage transplant and partial joint replacements.

4. What is arthritis? • It is the loss of joint surface that covers the bone. This special surface allows the bones to glide effortlessly, smoothly and pain-free. (This is the white, pearly substance on the end of the chicken bone.) • It is not to be confused with osteoporosis which is the loss of bone mass. • The loss of this surface, whether partial or complete, results in variable pain, stiffness, swelling, weakness and loss of motion. • With progression over time it results in the destruction of the underlying bone and adjacent ligaments.

5. How does it present? • It can either present in a slow gradual fashion or have a sudden appearance after a minor injury. • You can have “good and bad” days. Pain will be low level aching to intense pain that won’t allow walking on the leg. • You can be stiff and achy in the morning, comfortable during the day, then painful at the days end. • Oft time the pain will lessen with mild to moderate activities. • You may experience popping, locking or catching.

6. Prolonged positions will cause increase symptoms, ie. Standing in line, long car rides or sitting for a movie. • You avoid, or have difficulty doing, activities like kneeling, squatting, stair climbing, getting out of cars/chairs or even tying your shoes. • You have trouble finding a comfortable position while resting at home with a book or watching t.v. • You have trouble with waking up at night due to joint pain.

7. Tenderness to the touch Weakness in the muscles Loss of passive and active range of motion Spurs that can be felt along the bone edges Grinding, popping or other joint noises that can be felt or heard Fluid on the knee Catching or locking Diagnosis Physical Examination

8. Diagnosis Additional Tests • X-Rays (needs to be done with one view in the standing position)

9. Nonsurgical Options • Diet and Exercise • Rest and Joint Care • Cane / Walker • Medications • Cortisone • Glucosamine • Visco-supplementation • Braces

10. Treatment OptionsRest • Short-term bed rest helps reduce both joint inflammation and pain, and is especially useful when multiple joints are affected and fatigue is a major problem. • Individual joint rest is most helpful when arthritis involves one or only a few joints.

11. Weight Loss • Average American is 20–40 lbs. overweight • Average person takes 5000-7000 steps/day • Reduces stress on weight-bearing joints

12. Balanced Diet • Helps manage weight • Extra pressure on some joints may aggravate your arthritis • Stay healthy

13. Range of Motion ExercisesStretching • Maintains normal joint movement • Increases flexibility • Relieves stiffness • Increases the ease of surgery, thus allowing better outcomes.

14. Strengthening Exercises • Increasing muscle strength helps support and protect joints affected by arthritis. • Exercise is an important part of arthritis treatment that is most effective when done properly and routinely. • Allows easier recovery and shorter rehabilitation after surgery.

15. Aerobic Exercises Walking, Biking • Improve cardiovascular fitness • Helps control weight • May help reduce inflammation in joints • For those worried about advancement of arthritis, a Swedish study showed no progression of arthritis with moderate exercise.

16. Heat and Cold Therapies • Reduce pain and inflammation • Heat Therapy • Increases blood flow, tolerance for pain, flexibility • Cold Therapy • Cold packs, ice massage, OTC sprays and ointments • Reduces pain by numbing the nerves around the joint

17. Physical Therapy • The goal is to get you back to the point where you can perform normal, everyday activities without difficulty. • Preserving good range of motion is key to maintaining the ability to perform daily activities. • Physical therapists provide exercises designed to preserve the strength and use of your joints. • Show you the best way to move from one position to another • Teach you how to use walking aids

18. Assistive Devices • Make activities easier and less stressful for the joints and muscles. • Splint or brace when recommended by a doctor or therapist • Walking aides • Orthotics • Bath stool for use in the shower or tub • Sock grippers • Other devices are available to assist with everyday activities.

19. Walking Aides Cane Walker Helps keep you balanced so you don’t hurt other joints.

20. Medications: Analgesics • Analgesics, pain relievers, may provide temporary relief of arthritis pain.

21. Medications: NSAIDs • Traditional • Aspirin • Ibuprofen • Naproxen • New • Cox II

22. Medications: Topical Pain Relievers • Over-the-counter patches, rubs and ointments can provide quick pain relief for people with arthritis that is in just a few joints − such as a hand − or whose pain isn't severe.

23. Nutritional Supplements • Glucosamine and Chondroitin may relieve joint pain. • Occur in the body naturally; vital to normal cartilage function. • Researchers are also studying chondroitin for use in making medicines more effective and helping to prevent blood clots (anticoagulant). Not FDA approved • Warrant further in-depth studies on their safety and effectiveness, according to the Arthritis Foundation. Source: Arthritis.org website, Aug. 2006

24. May help osteoarthritis pain and improve function.1, 2 • Some studies indicate that glucosamine may help as much as ibuprofen in relieving symptoms of osteoarthritis, particularly in the knee, with fewer side effects • 1. Dieppe P, et al. (2002). Osteoarthritis. Clinical Evidence (7): 1071–1090. • 2. McAlindon TE, et al. (2000). Glucosamine and chondroitin for treatment of osteoarthritis. A systematic quality assessment and meta-analysis. JAMA, 283(11): 1469–1475. • 3. Update on glucosamine for osteoarthritis (2001). Medical Letter on Drugs and Therapeutics, 43(1120): 111–112.

25. Side Effects of Glucosamine and Chondroitin These arthritis supplements are generally well tolerated. However, side effects can occur. The most commonly reported side effects are: • Nausea • Diarrhea or constipation • Heartburn • Increased intestinal gas • See your doctor for complete information.

26. Glucosamine and Chondroitin • People with osteoarthritis who have diabetes should talk with a doctor before they take glucosamine because it may influence blood sugar (glucose). • Do not take glucosamine if you are allergic to shellfish. • Glucosamine is made from shellfish covering Source: WebMD

27. Dietary Supplements • Other than in vitamins and minerals, the long-term effects of most dietary supplements are not known. • Talk to your doctor before taking supplements.

28. Corticosteroids • Decrease inflammation • Oral • Cream (topical) • Short-term side effects include • Swelling, increased appetite • Long-term side effects include • Stretch marks, excessive hair growth, osteoporosis, high blood pressure, infections and high blood sugar

29. Injections: Corticosteroids • Injection • Effective • Temporary

30. Injections / Visco-supplementation • Hyaluronic Acid (Cock’s Comb) • Injection • Effective (5-13 wks) • Does Not Prevent Progression

31. Natural substance that lubricates the joint Injection Lubricates the joint Provides temporary relief of pain and movement 80 to 85% of individuals who are treated with this series of injections have some amount of pain relief which lasts anywhere from nine to 12 months.* Approved for knee osteoarthritis Hyaluronic Acid *http://uconnsportsmed.uchc.edu/patientinfo/whathurts/treatment/hyaluronic_acid.html

32. Simple Braces “Unloader” Braces Knee Braces

33. When to have a Joint Replacement • Joint replacement may be a treatment option when: • Pain is chronic or more recent and disabling • Pain interferes with desired activities • Pain interferes with daily activities, recreational or work activities • Significant loss of motion (this will become permanent) occurs.

34. When to have a Joint Replacement • When rest pain becomes prominent. • When you have joint pain that wakes you up at night. • When there has been a failure of medical treatment to relieve pain. • When there is severe bony deformity on x-ray.

37. Joint Replacement Preoperative • Preparing for a joint replacement procedure begins weeks before the actual day of surgery. • In general, patients may need: • Routine blood tests • Urinalysis • Physical examination • Exercise • Quit smoking • Stop certain medications • Donate blood

38. Total Joint Replacement • Goals of total joint replacement are to help: • Relieve pain • Restore motion • Improve function • Improve fitness and health • Restore quality of life

39. Your Hip Joint • A joint is formed by the ends of 2 or more bones.The hip must bear the full force of your weight and consists of two main parts: • A ball (femoral head) at the top of your thigh bone (femur) • A rounded socket (acetabulum) in your pelvis Normal hip joint, showing healthy articular cartilage

40. One of the most common causes of joint pain is arthritis. The most common types of arthritis are: Osteoarthritis (OA) Rheumatoid Arthritis (RA) Post-traumatic Arthritis Avascular Necrosis What Causes Hip Joint Pain? Diseased hip joint, showing worn cartilage

41. Total Hip Replacement

42. Your Knee Joint • Femur – thigh bone • Cartilage – tissue between bones that provides cushioning • Patella – knee cap • Tibia – shin bone • Synovium – tissue that provides lubricating fluid to joint • Ligament – flexible tissue that holds knee joint together

43. Total Knee Joint Replacement • End surface of femur replaced with metal • End surface of tibia replaced with metal • Plastic liner is inserted between femur and tibia • Patella is resurfaced with plastic • The entire knee is not removed as myth and lore would have it. • This is a resurfacing procedure.

44. Total Knee Replacement

45. Limitations After Surgery • Athletic activities that place excessive stress on the joint replacement will need to be avoided. Examples of these activities include: • Skiing (snow or water) • Basketball • Baseball • Contact sports • Running • Frequent jumping

46. Enhanced Performance After Surgery • My goal as a joint surgeon is to meet the activity demands of my patients. • We now have a more active “older” population. • The newer materials now available are more durable and longer lasting to meet these demands. (ceramics, high density polyethylene, HA coated components, metal-on metal.) • There are certainly higher risk activities for joint patients, yet many on the previous slide can be undertaken by experienced individuals.

47. Technology for Active Patients Trident® Ceramic Steven L. Drayer M.D. Private Practice-Lansing/Sparrow Hospital

49. Realistic Expectations Longevity of Hip Replacement • Age • Weight • Activity level • Bone strength

50. New Technology for Active Patients Trident Ceramic New Technologies are Meeting the Needs of the More Active Patient