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

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.

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.

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.

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.

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.

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

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

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

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.

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

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

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

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.

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.

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

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

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.

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.

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

Medications: NSAIDs Traditional Aspirin Ibuprofen Naproxen New Cox II

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.

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

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.

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.

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

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.

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

Injections: Corticosteroids Effective Temporary

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.

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 *http://uconnsportsmed.uchc.edu/patientinfo/whathurts/treatment/hyaluronic_acid.html

Knee Braces Simple Braces “Unloader” Braces

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.

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.

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

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

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

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

Total Hip Replacement

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

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.

Total Knee Replacement

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

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.

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

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

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

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

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.

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

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

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 1999. 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.

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.

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

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.

Ceramic-on-Ceramic Hip Replacement Additional information about ceramic hip replacement is available to you: Call 1-888-STRYKER or visit www.aboutstryker.com 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.

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 10-15 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.

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

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

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

Replaced Hip X-ray

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”

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.

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

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

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

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!

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