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

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

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

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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

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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

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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.

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Arthritis • 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

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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)

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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.

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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

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Osteoarthritis

Normal Hip X-ray

Arthritic Hip X-ray

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Osteoarthritis

Arthritic Knee X-ray

Healthy Knee X-ray

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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

Prevention

• Lifestyle Modifications

• Exercise

• Weight Loss

• Medicaitons

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

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Types of Exercise

• Walking

• Swimming

• Bicycling

• Water aerobics

• Work with physical

therapist

• Low impact activities

are better

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Modifying Activities of Daily

Living

• Posture

• Lift correctly

• Rest

• Balanced Diet

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Weight Control (Being Overweight…)

• Places extra stress on your joints1

– 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

destruction2

• Makes it harder to exercise

properly before and after surgery2

1. Harrington, I. J. (1976): A bioengineering analysis of force actions at the knee in normal and pathological gait. Biomed. Eng.,

11:167–172.

2. Felson, D. T.: “Weight and osteoarthritis.” J. Reumatol, 43: 7–9, 1995.

Slide courtesy of Biomet

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.

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

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

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Treatment: Nonoperative

• Medications

• Injections

• Physical Therapy

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

Over The Counter Medications

• Acetaminophen

• Aspirin

• Naproxen

• Ibuprofen

Nonsteroidal anti-inflammatory

drugs (NSAIDs)

• Effective in reducing swelling

• Stomach and blood side-effects

• Always ask physician before taking

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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

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

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.

Surgical Management

• Partial Joint replacement

• Total Joint Replacement

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

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Goal of Joint Replacement

• To improve quality of

life by

– reducing joint pain

– Improving mobility

– decreasing need for

medication

– restoring function3

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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

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Success of Total 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

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Every year, over 1,000,000

people in the United States

have joint replacement

Primary Hip Components

Shell

Liner

Head

Stem

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Primary Knee Components

Polyethylene Bearing

Tibial Tray

Femoral Component

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Post Operative X Rays

Total Knee Replacement

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

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

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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

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Cases 58 yo M

Inflammatory Synovitis

Gout history

Recent pulmonary infection

Post op

Post Traumatic arthritis

50 yo F Morbidly obese s/p MVA, traumatic hip dislocation

Post traumatic Arthritis

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

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

PVNS TKA Postop

Avascular necrosis

67 yo F prior alcoholism now with R hip

Pain, no L hip pain

Where to find help

• Numerous organizations to help you live better:

Rothman Institute www.rothmaninstitute.com

The Arthritis Foundation www.arthritis.org 800-283-7800

The American Association of Orthopaedic Surgeons www.aaos.org

Biomet Orthopedics www.biomet.com

Slide courtesy of Biomet

Thank you!

Images courtesy of Biomet

References

1. Centers for Disease Control and Prevention

http://www.cdc.gov/chronicdisease/resources/publications/AAG/arthritis.htm

2. The Arthritis Foundation http://www.arthritis.org/rheumatoid-arthritis.php

3. Vanguard Complete Knee System Package Insert

http://www.biomet.com/orthopedics/getFile.cfm?id=2171&rt=inline

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. 858‐865. Figures

apply to average 60 year old patient and adjusted for inflation.

5. Gottlob C., AAOS Presentation #114, 1996. Figures apply to average 70 year old patient and adjusted for

inflation.

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