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

Your Joint Pain and Treatment Options

Steven L. Drayer M.D.Private Practice-Lansing/Sparrow Hospital

Joint Pain and Treatment Options

About My Practice

1) Trained at Henry Ford Hospital in Detroit, Michigan.

2) Have been in private practice for 20 years

3) Have been performing joint replacements for 24 years

4) 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.


5) I also perform revision surgery for worn out, loose or

painful joint replacements.

6) I update my knowledge on joint replacement surgery

twice a year at educational courses.

7) 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?

1) 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.)

2) It is not to be confused with osteoporosis which is the loss of bone mass.

3) The loss of this surface, whether partial or complete, results in variable pain, stiffness, swelling, weakness and loss of motion.

4) With progression over time it results in the destruction of the underlying bone and adjacent ligaments.


How does it present?

1) It can either present in a slow gradual fashion or have a sudden appearance after a minor injury.

2) You can have “good and bad” days. Pain will be low level aching to intense pain that won’t allow walking on the leg.

3) You can be stiff and achy in the morning, comfortable during the day, then painful at the days end.

4) Oft time the pain will lessen with mild to moderate activities.

5) You may experience popping, locking or catching.


6) Prolonged positions will cause increase symptoms, ie. Standing in line, long car rides or sitting for a movie.

7) You avoid, or have difficulty doing, activities like kneeling, squatting, stair climbing, getting out of cars/chairs or even tying your shoes.

8) You have trouble finding a comfortable position while resting at home with a book or watching t.v.

9) You have trouble with waking up at night due to joint pain.


Diagnosis

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

Physical Examination


Diagnosis

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

Additional Tests


Nonsurgical Options

Diet and Exercise

Rest and Joint Care

Cane / Walker

Medications

Cortisone

Glucosamine

Visco-supplementation

Braces


Treatment OptionsRest

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– Extra pressure on some joints may aggravate your arthritis

Stay healthy


Range of Motion ExercisesStretching

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

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.

Walking, Biking


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 TherapyThe 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.


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– 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

Injection

Effective

Temporary


Injections / Visco-supplementation

Hyaluronic Acid (Cock’s Comb)

Injection

Effective (5-13 wks)

Does Not Prevent Progression


Hyaluronic Acid

Natural substance that lubricates the joint

Injection – Lubricates the joint

– 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

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

Preoperative


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


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

1) My goal as a joint surgeon is to meet the activity demands of my patients.

2) We now have a more active “older” population.

3) 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.)

4) 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® CeramicSteven L. Drayer M.D.Private Practice-Lansing/Sparrow Hospital



Realistic Expectations

Age

Weight

Activity level

Bone strength

Longevity of Hip Replacement

New Technologies are Meeting the Needs of the More Active

Patient

New Technology for Active PatientsTrident Ceramic


Hip Implant OptionsConventional Hip Implants Ceramic Hip Implants

Metal femoral head

Femoral stem

Plastic insert

Acetabular shell

Ceramic femoral head

Ceramic insert

Acetabular shell


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


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

1) In the 50 year old and greater age group 95% of the replaced joints are functioning well at over 20 years.

2) In the younger than 50 year old group 70% are functioning well at 10-15 years after placement.

3) This data does not include the data on the new ceramic and metal on metal hip replacements.

4) Finally, all joint replacements are now modular. Should a singular part wear out, it can be replaced with a simpler, less involved surgery.

Minimally InvasiveTotal 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?

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

You're Not Alone!



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?

1) Talk to your orthopedic surgeon.

2) Find out the best joint treatment option for you.

3) Visit the website of your surgeon, AAOS or joint manufacturer.

4) Ask questions!


517.371.3407

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