2. Disclosure
• no financial relationship with
any of the company implants or
products mentioned in this talk
• Exparel (liposomal bupivacaine)
– received compensation in the
past for being one of the
consultants
3. Articular cartilage and joint anatomy
• Joint is made up of two or more bones
• Articular cartilage at the end of bones.
Up to 4 mm thick in larger joints
• Joint fluid – contains hyaluronic acid
• Smooth surfaces with viscous joint
fluid in between makes it smooth
movements comparable to ice-on-ice
• Changes in articular cartilage with
osteoarthritis
- Increase in water content
- Decrease stiffness
- Chondrocytes (cartilage cells) clumps up
in cluster
- Decrease GAG (joint vitamins like keratan
sulfate and glucosamine)
- Collagen fibers gets disorganized
5. Osteoarthritis
•Osteoarthritis - wear & tear type
- loss of articular cartilage
•It is non inflammatory disease
but inflammation can set up in
later stage of the disease
•most common type of arthritis
after the age of 50
•used to be known as “crippling
disease” - not anymore
6. Risk factors for osteoarthritis
• Age: increasing age with
wear and tear
• Genetics: hereditary
• Obesity: increase stress to
weight bearing joints like
knee and hip
• Injury: previous injury with
damage to cartilage or
change in alignment
7. Risk factors for osteoarthritis
• Leg mal-alignment or
deformity
(congenital/trauma): wear
in one side of joint
- bow legs or knock knee
• Occupation: increase stress
on certain joints
- mechanics, sports
professionals, surgeons
• Persistent wrong posture or
wrong foot ware
8. Symptoms of osteoarthritis
• Pain
- Dull aching
- Good days and bad days
- Cold weather
• Stiffness – in the morning, after period of
inactivity
• Loss of range of motion
- Prevents full extension, loss of flexion
10. Commonly involved joints and associated symptoms
• Knee
• hip
• Spine
- Lower back (lumbar)
- Neck (cervical spine)
• basal joint of the
thumb
• shoulder
• big toe MTP joint
• joints of fingers
11. Commonly involved joints: Knee-symptoms
- Hinge joint
- Three bones…
- most common joint to develop OA
- Diffuse or localized pain
- Worse after prolonged inactivity or
overactivity
- Stairs, getting in & out of chair
- Giving out of knee (instability)
- Popping
- Deformity (knock knee/bow legs)
12. Commonly involved joints: Hip-symptoms
- Ball and socket joint
- Pain in groin and front of the thigh
- Knee pain (sometimes only knee
pain)
- Difficulty in raising from toilet,
getting in and out of car
- Difficulty in wearing sox & shoe
- Shortening of the leg in extreme
arthritis is bone destruction.
13. Commonly involved joints: lumbar spine - symptoms
- Degeneration of disc
- Facet joint degeneration
- Spondylolisthesis
• Lower Back pain
• Spasm kind of pain
• Radiating pain in legs –
pinch nerve in lumbar
spine - Sciatica
• tingling and/or
numbness
• Muscle weakness in
extreme cases
14. Commonly involved joints: cervical spine - symptoms
- Degeneration of disc
- Facet joint degeneration
- Spondylolisthesis
• Neck pain
• Spasm kind of pain
• Crepitus with neck
movement
• Radiating pain in arms to
fingers
• tingling and/or numbness
• Muscle weakness in
extreme cases
15. Commonly involved joints: basal joint of thumb-symptoms
- Trapezium (carpal) metacarpal joint
- Pain at the base of the thumb
- Difficulty in turning the door knob
- Difficulty in opening the jar
- Deformity in severe cases
16. Commonly involved joints – symptoms
• Shoulder
- Ball and socket joint
- Pain around shoulder
- Radiating to arm
- Difficulty in overhead work or
reaching the back
- Crepitus
• Great toe MTP joint
- pain at the base of the toe
- Pain with walking
- Pain in certain shoe
- Bunion deformity in severe
cases
17. Commonly involved joints: finger joints - symptoms
• Interphalangeal joints
• Metacarpo-phalangeal
joint
- Nodules (spur)
- Swelling of finger joints
- Difficulty in fine activities
- Deformity - lesser amount
compared to rheumatoid
arthritis
18. Diagnosis
• Medical history - symptoms
- slowly worsening pain
- pain with certain movements
- stiffness after inactivity
• Physical exam - joint specific
• x-rays - most important
• other diagnosis - usually don't
require advanced imaging like CT
scan or MRI except for spine
23. How to prevent or slow down osteoarthritis?
• Activity modification
- Prevent activities which make joint hurt
more (avoid stress on joint)
- Knee: avoid squatting, pounding of joint
(running, jumping), prolonged sitting.
- Hip: use elevated toilet seat, use cane,
install grab bar in bathroom
- Hand/fingers: avoid repeated activities.
Use door knob extension and key
turners. Use of electric can openers or
jar openers
- Spine: avoid weight lifting, avoid bad
posture
25. How to prevent or slow down osteoarthritis?
• Weight reduction
- Each pound of weight loss decreases 4 pound of stress
from knee joint
• Muscle strengthening exercises
- Strong muscles and ligaments around the joint will take
some load/stress off of the joint – decreases the pain
and slows wearing of the cartilage
• Joint vitamins
- Vit D and Calcium: soft subchondral bone (bone
underneath the cartilage) leads to early arthritis.
- Glucosamine and chondroitin sulfate (?): questionable
role. Studies suggested no added benefits in treatment
or prevention of osteoarthritis
27. Treatment - activity modification
Limit activities which causes/aggravate the pain
- Knee: avoid squatting, limit stair, avaoid prolonged sitting with flexed
knees.
- Hip: use elevated toilet seat, use cane, install grab bar in bathroom
- Hand/fingers: avoid repeated activities. Use door knob extension and
key turners. Use of electric can openers or jar openers
- Spine: avoid weight lifting, avoid bad posture
28. Treatment - exercise or physical therapy
- Helps strengthening of muscles around
joint
- decrease stress on joint
- keeps joint mobile, avoid stiffness
• knee - quad sets, balance
• hip - hip girdle muscles
- water therapy can help with joint
arthritis pain
• spine - back and core strengthening
- Physical therapy - key for long term
pain relief of back pain due to arthritis
29. spine - exercise or physical therapy
• back and core strengthening exercises
• have to do it regularly
30. Treatment – weight reduction
• Each pound of weight loss decreases 4 pound
of stress from knee joint
• Peri-operative risks for complications increases
in obese patients (infection, wound healing
problems, blood clot, loosening of implants)
• VA hospitals denied knee or hip replacement
surgery to patients with BMI above 35
• Medicare and Medicaid also asks for
explanation if joint replacement planned in
patient above BMI 40
• Diet, joint protective exercises , bariatric
surgery for morbid obesity
31. Treatment - cane, heel wedges
• Walking aid and support help
reducing stress on joint
• Cane should be used in opposite
hand
• shoe insert or wedges - for knock
knees (valgus) and bow legs (varus)
32. Treatment - Brace
• Unloader brace for bow legs or
knock knee
• Thumb brace
• Lumbar support brace
• Soft cervical collar
• Ankle brace
- shouldn’t use regularly, weakens
muscles.
33. Treatment - topical cream
- relieves pain with less side effects
- Work as counter-irritants, local anti-
inflammatory or local anesthetic
• Capsaicin – derived from cayenne peppers
• Bengay – Methyl salicylate or menthol
• Voltaren gel – Diclofenac (need Rx –
insurance)
• Lidocaine patch
• Aspercreme (Trolamine)
• Icy hot
• Biofreeze
34. Treatment - oral pain meds
• Acetaminophen (Tylenol)
• NSAID (Aleve, Ibuprofen - Motrin, Advil) -
stomach burn, kidney problem
• Combining Tylenol with Aleve/ibuprofen –
synergistic effect (less side effects than
taking one type of medicine in excess)
• COX-2 inhibitor (Celebrex)- less stomach
burn
• Cymbalta (Duloxetine) – off label use
• opioid medications - should be avoided for
arthritis pain
35. Treatment – Intra-articular injections
Cortisone (steroid) Injection
- Mixture of depo-medrol (steroid) and numbing
medicine
- Acts within hours, lasts 6 weeks to 3 months
depending on severity of arthritis
- Commonly used for knee, shoulder and thumb
arthritis – can be done in office/clinic
- Hip and back/neck injections needs
fluoroscopic/x-ray guidance
- Can be repeated every 3 – 4 months but decrease
efficacy with subsequent injections
- Multiple injections can damage remaining cartilage
- Tolerable (does it hurt?)
36. Treatment – Intra-articular injections
Hyluronic acid (gel) injection
- synthetic joint fluid
- Joint lubrication
- Does not regrow the worn cartilage but
possibly slow down further degenration
- Works in only 50% of patients
- Acts slow, lasts longer if works
- Series of 3 injections
- Insurance denial (AAOS has no positive
recommendation)
Platelet rich plasma (PRP) injection
- Largest study published in 2013 suggests it
decrease pain by 3 to 6 months
- Insurance payment issue due to cost and
questionable long term efficacy
37. Surgical treatment
• Surgical advancement - no longer have
to “live” with arthritis
• Consider surgical treatment once non
operative treatment exhausted
• In my practice, patient makes the
decision when they are ready for the
surgery
• Joint preservative versus joint
replacement surgery
• Sophisticated joint replacement started
in early 70s in USA, it has advanced
significantly now
• No longer crippling disease
1969
38. Surgical options for hip osteoarthritis
• Arthroscopic surgery rarely work for
hip osteoarthritis
• Fusion is almost obsolete
• Hip replacement
- Partial hip replacement is mostly for
fracture only
- Total hip replacement (arthroplasty)
- Surface replacement arthroplasty
(metal-on-metal) – found to have
metal toxicity - failed
39. Total hip replacement (arthroplasty)
• Replace socket and head ball
• Medicare/federal health have
announced it as second most
successful surgery in restoring quality
of life next to the cataract surgery.
• Types or bearing surfaces options
- Metal or ceramic on plastic
(polyethylene) – best option in current
time
- Ceramic on ceramic – less wear but
squeaking and fracture
- Metal on metal – failed due to metal
ions release and causing severe soft
tissue reaction.
40. Total hip replacement (arthroplasty)
• Different approaches
- Posterior (back)
- Direct anterior (front)
- Lateral/antero-lateral (side)
Posterior approach (traditional hip
replacement)
- Time tested, used for years
- More dislocation - precautions
- Have to cut and reattach muscles –
longer recovery
- Implant position may not be
consistently accurate
41. Total hip replacement (arthroplasty)
• Direct anterior approach
- no need to cut muscles –
faster recovery
- Less dislocation
- Done under x-ray, so more
accurate implants placement
and restoration of leg length
- Difficult to do surgery -
Learning curve for surgeon,
more complications during
learning curve
42. Surgical options for knee osteoarthritis
• Knee arthroscopic surgery
- temporary pain relief, helps more in
mild to moderate OA
- AAOS doesn’t have strong
recommendation for it
- Speeds up process of osteoarthritis
• Osteotomy
- High tibial osteotomy for bow legs
- Distal femoral osteotomy for knock
knees
- For one compartment arthritis only
in younger patients
44. Surgical options for knee – total knee replacement
• 500,000 knee replacement per year in
USA
• Scarifies ACL and sometimes PCL
• Good pain relief – 95% happy patients
depending on their expectation
• VCU CMH joint replacement program
45. Surgical treatment of thumb osteoarthritis
• Arthroscopic surgery
• Excisional arthroplasty with
tendon interposition
• Arthrodesis (fusion)
• Joint replacement
46. Surgical treatment of shoulder osteoarthritis
• Arthroscopic surgery – minimum role in osteoarthritis
• Hemiarthroplasty (partial shoulder replacement)
• Total shoulder replacement
• Reverse total shoulder replacement
47. Surgical treatment of toe MTP joint osteoarthritis
• Fusion (arthrodesis)
• Joint replacement
48. Treatment for spine (back and neck) arthritis
• Regular back and core
strengthening exercises
• Heat pad
• Pain meds
• Steroid (prednisone) for acute pain
• Muscle relaxer
• Brace (for short duration)
• Epidural steroid injection
• surgery
49. Treatment for spine (back and neck) arthritis
• Regular back and core strengthening
exercises
• Heat pad
• Pain meds
• Steroid (prednisone) for acute pain
• Muscle relaxer
• Brace (for short duration)
• Epidural steroid injection
• Surgery
- Nerve decompression
(Laminectomy/discectomy) + fusion
- Disc replacement surgery
50. Surgical treatment of hand joints osteoarthritis
• Bone spur removal
• Joint replacement
