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
Images courtesy of Biomet
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
Images courtesy of Biomet
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
Images courtesy of Biomet
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.
Images courtesy of Biomet
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
Images courtesy of Biomet
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)
Images courtesy of Biomet
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.
Images courtesy of Biomet
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
Images courtesy of Biomet
Osteoarthritis
Normal Hip X-ray
Arthritic Hip X-ray
Images courtesy of Biomet
Osteoarthritis
Arthritic Knee X-ray
Healthy Knee X-ray
Images courtesy of Biomet
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
Slide courtesy of Biomet
Types of Exercise
• Walking
• Swimming
• Bicycling
• Water aerobics
• Work with physical
therapist
• Low impact activities
are better
Slide courtesy of Biomet
Modifying Activities of Daily
Living
• Posture
• Lift correctly
• Rest
• Balanced Diet
Slide courtesy of Biomet
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
Slide courtesy of Biomet
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
Slide courtesy of Biomet
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
Slide courtesy of Biomet
Goal of Joint Replacement
• To improve quality of
life by
– reducing joint pain
– Improving mobility
– decreasing need for
medication
– restoring function3
Slide courtesy of Biomet
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
Slide courtesy of Biomet
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
Slide courtesy of Biomet
Every year, over 1,000,000
people in the United States
have joint replacement
Primary Hip Components
Shell
Liner
Head
Stem
Slide courtesy of Biomet
Primary Knee Components
Polyethylene Bearing
Tibial Tray
Femoral Component
Slide courtesy of Biomet
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
Slide courtesy of Biomet
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
Slide courtesy of Biomet
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.
Slide courtesy of Biomet