Health & Exercise Forum

 HIP & KNEE REPLACEMENT UPDATES: IMPORTANT NEW OPTIONS AVAILABLE

This column is a monthly feature of “Health & Exercise Forum” in association with the students and faculty of Geisinger Commonwealth School of Medicine. 

There is good news for those in need of a hip or knee replacement today! Recent advances have ushered in a new era of joint replacement for patients in Northeastern Pennsylvania.

Recent studies conclude that hip and knee replacement surgery has had a very positive impact on lifestyle and overall health benefits for more than 7 million people in the United States that have had a hip or knee joint replaced. In view of this, it is predicted that this number will increase substantially with the aging baby boomer population.

Health & Exercise Forum will dedicate the next three weeks to the topic of “Hip and Knee Replacement Updates.” Part I will discuss hip and knee arthritis and treatment options, including knee replacement. Part II will offer a self-assessment to determine if you are ready or eligible for a new hip or knee. Part III will present the benefits and complications of a new hip or knee and will specifically discuss a new option in hip and knee replacement surgery – MAKO Robotic Assisted Joint Replacement.   

ARTHRITIS OF THE HIP OR KNEE

I have been advising my patients to exercise, keep active, and walk as long as they can in order to stay mobile and healthy. However, seniors often tell me activities that require prolonged walking are limited by hip or knee pain from arthritis. They often ask, “What is arthritis?” How does it happen? What can I do about it? I will attempt to answer these questions, however, keep in mind that having hip or knee joint arthritis is not a death sentence to an active lifestyle. 

Three Most Common Forms of Arthritis of the Hip or Knee 

• Osteoarthritis – is also known as degenerative arthritis. It is the most common form of arthritis in the hip or knee. It is usually a gradual, slow and progressive process of “wear and tear” to the cartilage in the joint which eventually wears down to the bony joint surface. It is most often found in middle-aged and older people and in weight bearing joints such as the hip, knee and ankle.
• Rheumatoid Arthritis – is a form of inflammatory arthritis in which many joints of the body can be affected. It is very destructive to the cartilage, joint and tissues surrounding the joint. It can occur at any age and often affects both legs.
• Post-Traumatic Arthritis- is a form of arthritis that can occur following a trauma or injury to the hip or knee. It is a form of osteoarthritis that is triggered years after a fracture, ligament or cartilage injury.

Symptoms of Arthritis

• Pain - usually occurs gradually. However, a sudden onset can occur, especially associated with a sudden twist or fall. Pain is often worse in the morning and improves with movement. Changes in the weather or barometric pressure can cause pain associated with arthritis.
• Swelling – can occur after increase activity at the end of the day.
• Stiffness – is more noticeable in the morning and improves with movement. 
• However, overuse can create more pain and swelling and lead to stiffness also.

• Weakness – from disuse associated with pain and can lead to occasional buckling of the hip or knee when walking or climbing steps. 
• Loss of Function- is associated with pain, swelling, weakness and stiffness which limits walking, stair climbing etc.

Diagnosis

Your family physician will examine your knee to determine if you have arthritis. In more advanced cases you may be referred to an orthopedic surgeon or rheumatologist for further examination and treatment. X-rays will show if the joint space between the bones in the joint is getting narrow from wear and tear arthritis. If rheumatoid arthritis is suspected, blood tests and an MRI may be ordered. The diagnosis will determine if your problem is mild, moderate or severe.

Treatment

In the early stages, your treatment will be a conservative, nonsurgical approach, which may include; anti-inflammatory medication, orthopedic physical therapy, exercise, activity modifications, supplements, bracing, etc. You along with your family physician, orthopedic surgeon or rheumatologist will decide which choices are best.

John J Mercuri, MD, MA; Orthopedic Surgeon at Geisinger Orthopedics and Sports Medicine in Scranton, recommends the Clinical Practice Guidelines from the American Academy of Orthopedic Surgeons (AAOS) for interventions based on the supporting literature for treatment efficacy: 

First-Line Conservative Treatment

1.  Non-Steroidal Anti-Inflammatory Drugs (NSAID’s) to reduce pain and swelling in the joint such as: ibuprofen, naproxen, diclofenac, meloxicam, celecoxib but not aspirin, which is an anti-platelet medication.
2.  Tylenol, especially for those who cannot tolerate NSAIDs
3. Physical Therapy - heat, cold, ultrasound, electrical stimulation, joint mobilization/manual therapy, range of motion exercises, strengthening exercises, partial weight bearing aerobic exercises.
4. Weight Loss – eat well and exercise. 
5. Activity Modification - doubles tennis instead of singles, sitting or lying leg exercises instead of standing, walk/bike instead of run, soft bed treadmill instead of hard surfaces, avoid squatting, kneeling, and bending.
6.  Assistive Devices (e.g., a cane)

More Aggressive Conservative Treatment

1.  Intra-articular corticosteroid injections
2.  Tramadol (pain medication)

The following interventions, while often used and may not be harmful, are NOT supported in the literature for treatment efficacy:

1.  Visco-supplementation
2.  Shoe lifts or wedges
3.  Hard or soft bracing
4.  Glucosamine and chondroitin
5.  Platelet rich plasma (However, a recent study suggests that there might be some benefit for knee arthritis)
6.  Stem cells
7.  Opiate medications
8.  Acupuncture 

Surgical Treatment

When conservative measures no longer succeed in controlling pain and deformity or improving strength and function, then more aggressive treatment may be necessary.

• Osteotomy Surgery: cuts one of the knee bones to realign the joint for less wear and tear
• Cartilage Grafting: is performed on rare occasions, usually at teaching facilities, when young healthy cartilage with minor damage needs to be repaired. 
• Total or Partial Joint Replacement: replaces severely damage joint surfaces with metal or plastic.
• NOTE: Arthroscopic Surgery for the treatment of arthritis is NOT supported in the literature according to the AAOS guidelines.

SOURCES: Rothman Institute, Philadelphia, PA;  American Academy of Orthopaedic Surgeons (AAOS), Stryker Corporation, Geisinger Orthopedics and Sports Medicine

For More Information: aaos.com; stryker.com; YouTube: “MAKO Robotic Joint Replacement.”

Medical Contributor: John J Mercuri, MD, MA; Orthopedic Surgery -  Adult Reconstruction; Geisinger Orthopaedics and Sports Medicine; Clinical Assistant Professor at Geisinger Commonwealth School of Medicine     

Visit your doctor regularly and listen to your body.      

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” Next Week: Part II of III on “Hip & Knee Replacement Updates.”  

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSOM.