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
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. Diagnosis Physical Examination 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

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 Options Rest
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 steps/day
Reduces stress on weight-bearing joints

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

13. Range of Motion Exercises Stretching
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. Helps keep you balanced so you don’t hurt other joints.
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 Short-term side effects include
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
Effective
Temporary

30. Injections / Visco-supplementation
Hyaluronic Acid (Cock’s Comb)
Injection
Effective (5-13 wks)
Does Not Prevent Progression
Contraindication only if known allergy. Caution with avian proteins, feathers, eggs.

31. Hyaluronic Acid Natural substance that lubricates the joint Injection
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 *

32. Knee Braces
Simple Braces
“Unloader” 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. Normal hip joint, showing healthy articular cartilage
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. What Causes Hip Joint Pain?
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
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 Technologies are Meeting the Needs of the More Active Patient
New Technology for Active Patients
Trident Ceramic
New Technologies are Meeting the Needs of the More Active Patient

51. Conventional Hip Implants
Hip Implant Options
Conventional Hip Implants
Ceramic Hip Implants
Acetabular shell
Acetabular shell
Plastic insert
Ceramic insert
Metal femoral head
Ceramic femoral head
Femoral stem

52. Ceramic in Hip Replacement
Superior wear performance in laboratory testing compared to metal-plastic bearings*
Excellent biocompatibility
Long clinical history
Provides smooth surface with low friction
Extremely hard material
*Taylor, SK, Serekian P, Manley, M, Wear Performance of a Contemporary Alumina:Alumina Bearing Couple Under Hip Joint Simulation, Trans. 44th Ann. Mtg. ORS, 51, 1998.

53. Experience with Ceramics
Ceramic is used in aeronautics, bullet proof vests and golf clubs
Ceramics in hip replacement have evolved over the past 30 years
Early use in the US revealed limitations

54. Trident® Ceramic System
Improvements in material strength, quality and design
Advanced processing, testing and quality control produces stable, extremely strong ceramic implants

55. U.S. Clinical Study
The first US clinical study of contemporary ceramic-on-ceramic hip replacements began in 1996
Over 1,300 hip surgeries
16 centers in the United States
FDA approved Trident® Ceramic for sale in the US in February 2003
The US Clinical began in 1996 with Stryker’s first generation ceramic design, called ABC. Trident was added as part of the Study in Over 1,300 ceramic surgeries were done in the study and “Continued Access” – all prior to FDA approval. Including the control group (metal-poly), over 1500 surgeries were done.

56. Alumina Ceramics in Hip Replacement
Alumina ceramic-on-ceramic components demonstrate significantly lower wear versus conventional metal-on-plastic components in laboratory testing.
Taylor, SK, Serekian P, Manley, M, Wear Performance of a Contemporary Alumina:Alumina Bearing Couple Under Hip Joint Simulation, Trans. 44th Ann. Mtg. ORS, 51, 1998.

57. Range of motion (ROM) of the Trident® Ceramic System
Although there are many factors that will influence your range of motion, the Trident® Ceramic System is designed to accommodate the range of motion as in a normal, healthy hip joint
An increased ROM may help minimize the risk of hip dislocation

58. Trident® Ceramic System
Biocompatible
Reduces friction
Extremely hard
Superior wear properties to other bearings available on the market today*
*Taylor, SK, Serekian P, Manley, M, Wear Performance of a Contemporary Alumina:Alumina Bearing Couple Under Hip Joint Simulation, Trans. 44th Ann. Mtg. ORS, 51, 1998.

59. Ceramic-on-Ceramic Hip Replacement
Additional information about ceramic hip replacement is available to you:
Call STRYKER or
visit
Individual results may vary. There are potential risks and recovery takes time. The life of any joint replacement will depend on your weight, age, activity level and other factors. Only an orthopaedic surgeon can tell if surgery is right for you.

60. Joint Replacement Survival
In the 50 year old and greater age group 95% of the replaced joints are functioning well at over 20 years.
In the younger than 50 year old group 70% are functioning well at years after placement.
This data does not include the data on the new ceramic and metal on metal hip replacements.
Finally, all joint replacements are now modular. Should a singular part wear out, it can be replaced with a simpler, less involved surgery.

61. Minimally Invasive Total Hip Replacement
Steven L. Drayer M.D.
Private Practice-Lansing/Sparrow Hospital

62. Topics What is hip arthritis?
What is conventional hip replacement surgery?
What is MIS hip replacement surgery?

63. Ready to Consider Hip Replacement?
You're Not Alone!
Today, more than 300,000 Americans a year have hip replacement surgery
First performed in 1960, this procedure is considered one of the most important surgical advances of the past 100 years

65. Replaced Hip X-ray

66. What is ‘Minimally Invasive Surgery’?
MIS is a general term used to describe a surgical procedure that often utilizes a smaller incision(s) than conventional surgery. In these cases ‘MIS’ more accurately describes “Mini Incision Surgery”
Other MIS procedures reduce the amount of soft tissue (muscles and tendons, etc) that are disrupted during surgery. In these cases ‘MIS’ more accurately describes “Minimally Invasive Surgery”

67. What are the potential benefits of MIS Hip Surgery?
Less soft tissue disruption
Faster discharge from the hospital
Quicker rehab and recovery
Less blood loss
Reduced pain
Smaller scar
Source: Keggi, Kristaps J., Total Hip Arthroplasty Through A Minimally Invasive Anterior Surgical Approach JBJS, Vol. 85-A.

68. What are the potential risks?
Results may vary from patient to patient
Surgery time may be extended
Risk factors relating to anatomy, weight, and prior joint replacements
Risks which are normally encountered in conventional THA remain

69. Is MIS Total Hip Arthroplasty for everyone?
No, patient limitations include:
Obese, high BMI
Muscular males
Pre-existing conditions

70. Stryker Implant Technology
Accolade® TMZF® is an MIS-friendly implant
Compatible with ceramic-on-ceramic technology for long-term results

71. What Do I Do? Talk to your orthopedic surgeon.
Find out the best joint treatment option for you.
Visit the website of your surgeon, AAOS or joint manufacturer.
Ask questions!