Osteoarthritis and Joint Replacement Surgery: Expert Q&A

[MUSIC PLAYING] Hello and welcome to At the Forefront Live. Osteoarthritis is the most common type of arthritis, affecting millions of Americans. Most often felt in the knees, hips, lower back, and hands, osteoarthritis causes joint pain, swelling, and stiffness.

The good news, there are effective ways to minimize your risk of osteoarthritis and manage the symptoms. If your arthritis pain does not respond to nonsurgical treatments, joint replacement surgery may be an option. Sports Medicine Specialist Dr. Brendon Ross and orthopedic surgeon Dr. Sara Wallace join us to answer your questions about osteoarthritis and joint replacement surgery. That's coming up right now on At The Forefront Live.

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And we want to remind our viewers that today's program is not designed to take a place of a visit with your physician. Let's start off by having each of you introduce yourselves to our audience and tell us what you do here UChicago Medicine. And Dr. Wallace, we're going to start with you.

My name's Sara Wallace. I'm one of the joint replacement surgeons at the University. I do primarily hip and knee replacements and redo hip and knee replacements. That's really my area of expertise. And most typically, knee and hip replacements are being done for osteoarthritis.

And Dr. Ross?

Hi. Yeah. My name is Brendon Ross and I'm a Primary Care Sports Medicine Physician at University of Chicago, specializing in sports-related injuries, but then also nonoperative orthopedics, and osteoarthritis is a very prevalent condition that I oftentimes see clinically and treat clinically.

And we want to remind our viewers that our experts will answer your questions, so just type them in the comments section. We'll get to as many as possible over the next half hour. Dr. Ross, we're going to start with you. And just kind of a basic question, what is osteoarthritis?

Sure. Certainly the question of the day. So osteoarthritis is really a cumulative process of degeneration and wear and tear of cartilage, cartilage being a soft tissue structure that lives at the end of bones inside of the joints.

And the cartilage is responsible for cushioning, but then also trying to keep a healthy environment inside of a joint. And with this cumulative degenerative process and wear and tear of the cartilage, that contributes to this unhealthy environment inside of the joint that eventually leads to pain and also joint disfunction that we see in patients.

You know, I remember hearing-- I've heard this for years, Dr. Ross, that our knees aren't designed to do some of the things that we force them to do. And I don't know how accurate that is, but they do experience a lot of wear and tear, as you just mentioned. Can you comment a little bit about that, I mean, as we talk about osteoarthritis?

Sure. Yeah. There's a lot of different factors, of course, that contribute to the development of osteoarthritis and the weight bearing joints as far as the hips and the knees. Age of course, being a huge component to the development of arthritis.

As much as we want, as you kind of commented on, as much as we want our joints and our bodies to last forever, unfortunately, they don't. And again, a lot of different factors may contribute to this outside of age, including lifestyle factors, whether that be potentially sports that you may have played.

Cumulative high impact activities over many, many years or decades could potentially contribute to some of this wear and tear in the weight bearing joints, such as the hips in the knees. Also work-related wear and tear. We oftentimes see, in manual laborers, especially maybe an earlier prevalence of osteoarthritis just because of the repetitive impact activities that they may do, whether that be in the hands or, of course, the hips and the knees.

But then also excessive body weight as well can contribute to added wear and tear of the weight bearing joints. And with obesity being very prevalent in the United States, and also internationally, for that matter, this is a huge contributing factor outside of just age to the development of arthritis and arthritis-related pain.

You know, it's interesting you mentioned weight. And it's funny. Just from a personal standpoint, I know when I put on a few pounds, I can always feel it in my left knee. That's usually a pretty good indicator to me. Well, there are a few others, but that is one good indicator that I need to put the fork down and maybe eat a salad for lunch for a few days, but it does make an impact. Dr. Wallace, does joint replacement cure arthritis?

In a sense it does, for osteoarthritis, at least. In a sense, arthritis, as Dr. Ross described, is really loss of cartilage. And when we do a hip or knee replacement, we are resurfacing that area that's been lost entirely.

And if you restore the normal joint biomechanics, then the knee no longer has that inflammatory response where it produces extra joint fluid and it produces pain, and really just doesn't function well. So when we do a hip or knee replacement, we remove all of the cartilage and replace it with mechanical parts.

You know, when you talk about doing the replacement, I know technology has changed pretty dramatically over the past decade or two, particularly for joint replacements. Can you kind of explain the process and walk us through what you do with a patient? And then the second part, I guess, of my question or comment to you would be, how quickly can people get back at their regular lives after a replacement like that?

Yeah. When we see patients in the office, we want to be sure that they have failed all nonoperative management. In other words, have tried to injections, have tried physical therapy, have tried anti-inflammatory medications, bracing, and have exhausted all possibilities and really are at the final stages in dealing with their arthritis.

And when that's the case, I recommend joint replacement. Before having a hip or knee replacement, we always ask that a patient discuss the surgery with their primary care physician to ensure that they're healthy enough to undergo a surgery.

We have the patient attend a preoperative educational class that explains a bit about joint replacement. And on the day of surgery, you check in and meet with the anesthesiologists. The surgery itself is somewhere between an hour and two hours depending on exactly what we're doing.

And immediately after surgery, the patient is up and walking the same day. We have the physical therapists, oftentimes they have come to the recovery area and get patients up and moving immediately, putting full weight on their hip or knee.

And the recovery process takes, in some, somewhere between six and 12 weeks. A little quicker for hips than it is for knees. During that time, you're working with physical therapy regularly and then feeling pretty good, really, by the first follow up visit.

So the surgery itself is the easy part. I think the recovery as a little bit more challenging. Most patients that we have go home either same day or next day, though, so it's pretty quick. It's not the same surgery that we were doing a decade ago. It's come a long way in terms of utilizing more of a minimally invasive approach to both the hip and the knee, which leads to a more rapid recovery.

It's pretty amazing, really. I want to remind our viewers, you can ask our experts. Just make sure you type your questions into the comments section. We'll get to as many as possible as we can during the show.

One of our viewers, Richard, says, Dr. Wallace is the best. She performed my hip replacement surgery in May. My recovery has been phenomenal. Thank you for being so exceptional. So you have a fan there. That's awesome.

Thank you.

Here's a question from a viewer, and this is Selena. Says, sports injury here that led to an ACL and meniscus reconstruction surgery that was done by your amazing orthopedics department. So there's another nice comment.

Question. This one's actually a question. This one's from Marianne. I have osteoarthritis and had a partial knee replacement at about the age of 60. Four years later, I had a total knee revision. That was in January, 2020. My knee is now locked in a bent position. What do I do now? [INAUDIBLE], why don't you jump on that one?

It's-- I would say that that's not a normal result, obviously. That's not what we're intending from a hip or knee replacement. So if you are having any sort of mechanical block to motion like that, whether you've had a knee replacement or not, I would recommend being seen in fairly short order so we can look into what might be going on there. We expect a full recovery of range of motion and then some. So some improvement in range of motion in both hips and knees after joint replacement.

So yeah, whoever and wherever you got your treatment from, you probably need to give them a call and set up an appointment. Dr. Ross, what is the best treatment for osteoarthritis? Dr. Wallace said that we've traditionally tried to exhaust all other treatments. Can you tell us what some of those treatments would be?

Yeah, absolutely. With the treatment for osteoarthritis, at least from the nonoperative standpoint which Dr. Wallace alluded to, I really think about it in sort of three areas, if you will, nonpharmacological or nonmedication-oriented, pharmacological medications, and, of course, interventions, which include surgery.

And within the nonpharmacological area, that's probably where I spend probably the most amount of time, at least with patients, trying to optimize lifestyle modifications. So as I've alluded to, weight loss is very important in regards to the management of arthritis and arthritis-related pain, and trying to counsel the patients on achievable weight loss goals as well.

I usually use the goal of about a pound for a week. I oftentimes see patients on average about every three to four months. So a pound per week, which is an achievable goal, usually equates to about hopefully 10 to 15 pounds of weight loss by the time I see them.

And there is ample evidence that shows that as little as 10 pounds of weight loss can significantly improve pain related to arthritis outside of the course of achieving a healthy body weight is exercise. As a sports medicine physician, exercise is medicine and probably the most common thing that I prescribe, so to speak, in my clinic.

Whether that be through a home exercise program, focused physical therapy with an allied health professional, or, of course, getting them into the pool sometimes is very advantageous for the patients, especially those that can't tolerate land-based exercises because they may have more severe arthritis.

Unfortunately, with the situation of the world right now with COVID, pool-based therapy has been a little bit challenging, of course, to get patients involved in. But again, outside of exercise and achievable weight loss goals, any sort of modifiable risk factors as well I try to address.

Smoking being a huge risk factor, not necessarily for as far as an association with osteoarthritis, but there is a lot of research that shows that smokers have higher amounts of musculoskeletal pain relative to nonsmokers.

So, for instance, in the setting of maybe mild arthritis of the knee, the smoker may experience a higher level of pain relative to that nonsmoker. So really trying to get them on that train towards smoking cessation is very important in regards to the nonpharmacological components.

And also trying to address any sort of biomechanical abnormalities, whether that be through bracing to try to address any anatomical abnormalities or issues that might be contributing to some of that added wear and tear.

Within the pharmacological realm, Tylenol is usually advocated for as far as first line treatment. But oftentimes, the patient has tried this and it probably isn't cutting it as far as pain relief goes, which is why they're coming to see me or, of course, Dr. Wallace.

But I certainly don't shy away, then, from anti-inflammatories or NSAIDs, and there's a myriad of different anti-inflammatories to choose from dependent upon the patient's response, but then also other medical conditions that you have to take into account.

And I try to target the lowest dose and shortest duration possible for the anti-inflammatories just because of the long term potential side effects that have been shown, whether that be in the gastrointestinal system, the kidneys, or the heart, which has been shown in the research.

And then within that pharmacological realm are injections. So steroid injections are oftentimes first line treatments for arthritis-related pain, but there are also other injectables including hyaluronic acid or viscosupplementation. A lot of people know these as, quote unquote, "gel injections."

And hyaluronic acid has anti-inflammatory properties, hopefully to address pain. And there's more and more traction, actually, in the research for Platelet Rich Plasma, or PRP, which is where we take your own blood from your body, we spin it down utilizing a specific kit and we try to concentrate those platelets into a solution.

And platelets being you can think of as kind of the healing soldiers in your blood. And by injecting this concentrated solution into the joints, at least in the research that is surfacing, there is evidence showing that it is equal if not superior to steroids or viscosupplementation for the treatment of arthritis. So all of these are options that I pursue, again, in this pharmacological area.

And then last, of course, is the interventional area, that being potential surgery, referring to one of my great joint replacement colleagues. And there are some novel procedures, one of which my pain management colleagues perform called radiofrequency ablation, which is where they ablate or burn, basically, the nerves that receive pain signals from the knee.

And hopefully if those nerves aren't present, the patient has less pain and hopefully improved quality of life. And so this is kind of how I think about the treatment of osteoarthritis in my clinic.

You know, it's interesting. You mentioned exercise which, of course, is always important. And there are obviously patients that it's a little more difficult for them to exercise. Are there things you can do other than the water-based exercise that maybe are a little bit lower impact but can still help?

Yeah, absolutely. I oftentimes advocate for-- a stationary bike is a great sort of low impact activity that I oftentimes advocate for for patients. And then there are different types of essentially strengthening exercises that I designed for patients, either in a home exercise program that I give them or through physical therapy, one of which is called isometric exercises where there really isn't a lot of impact per se.

But we're trying to engage that muscle and keep that muscle awake. And through these isometric exercises that are very low impact, we can try to, of course, build muscle strength and stability around the joint.

So here's one that might be for you, Dr. Wallace, a question from a viewer, Patricia. Are you familiar with shoulder replacement return to function after reverse replacement? I'm not sure what reverse replacement would be if you can explain that to us as well.

Shoulder replacement is not really my area of expertise, but there are two types of shoulder replacement. There's the regular old shoulder replacement and one where we flip the ball and socket of the joints so that they're on opposite sides.

That's called a reverse total shoulder replacement. So I would recommend that you seek care if maybe from one of our shoulder experts, such as Dr. [? Contemika ?] or Dr. Shi here at the University to talk more about that.

So can you tell us what are the signs that a person needs a hip or knee replacement? What kind of things should people look for?

If no other treatments are working, if those injections don't work, if therapy doesn't work, and if your mobility is really suffering for it, then you're probably headed towards a hip or knee replacement. I always ask my patients if it's something that they think about every day.

And most of the time, by the time they're at my office, it is something that's interfering with the quality of life every day. And at that point, it's time. I mean, it's never something you'll have to do. I also tell all my patients it's never something you have to do to get your hip or knee replaced.

But it's something that can dramatically improve your quality of life both in terms of pain relief and in terms of improved function. So I am looking for patients that really are kind of at the last resort. And when that's the case, I think there's really very few reasons for most patients to hold off any longer and I would recommend moving forward at that point with hip or knee replacement.

We have another question from a viewer. This is from Mike. What are your recommendations regarding hip replacement while young, under 60, before waiting for a more advanced age that would make recovery slower and quality of life less leading up to replacement?

Goodness, I have patients in their 20s who have had hip replacements, so I think age is all relative. It really depends on the severity of the joint disease that you have and how much it's affecting your quality of life.

So historically speaking, the main concern with having a joint replacement in your younger years was the risk for part of the joint replacement, what we call the bearing or the polyethylene component, to wear out.

And over time, even going back as far as 20 years ago, we developed what's called a highly cross linked polyethylene bearing for both hip and knees that leads to lower rates of wear and lower rates of failure of the implants.

So the polyethylene that we use now in our joint replacements has been shown to have essentially no wear at 20 years. That's how long we've had it for. And so I anticipate that it lasts much longer than that, even.

So in other words, I think that age is really, to some extent, irrelevant. I think for any patient, you should try to put it off, exhaust all nonsurgical treatments, just because surgery is not without risk.

But when you are at that point where this is limiting you every day and really affecting the way you're living, I don't think there's really many reasons to hold back and I think you should move forward with joint replacement at that point.

So Dr. Ross, we've had a couple of questions on this one. Is osteoarthritis hereditary? And one of our folks that was asking the question, Tiffany, wonders because her mother-in-law has it and she's noticed potential symptoms in her husband. So she's curious to see if maybe it is hereditary.

Yeah, that's a great question. And I think the inheritance, at least, of osteoarthritis isn't still completely known. There's a lot of research that's looking into this as far as genetic factors. And time and time again, I certainly hear in my clinic that my mom, or dad, or grandparents had arthritis and I'm suffering from arthritis.

So there certainly seems to be some form of genetic or causal link that might be contributing to these degenerative changes. But there are also some hereditary conditions that can contribute to increased wear and tear of the joints, specifically dysplasia of the hip or of areas of the knee.

Dysplasia is basically the medical term for an abnormally shaped joint. So this can contribute to biomechanical, again, derangements or abnormalities, which can lead to potentially earlier degenerative changes. And then also the hypermobile individual, hypermobility being kind of more loose or lax joints that can, again, contribute to a little loss of stability around the joints, which can contribute to that wear and tear.

But there's still a lot, I think, research to be had in regards to the genetic components contributing to arthritis. But I know that that was probably a long winded answer to yes, but there's still a lot more research to be done.

Now, that was perfect because that explains it. I do have another question for you, Dr. Ross, and this is one that comes up basically every time we do one of these. And that's about CBD. People always wonder what CBD can help with and medical marijuana. Does it work with osteoarthritis?

So another great question, and I think an area that is very untapped from a research standpoint. And from the perspective of CBD versus medical marijuana, with CBD, it's thought to not have a lot of the, I suppose, cognitive euphoria and some of the side effects, at least cognitively, that medical marijuana or THC products have.

And so from my standpoint, when patients come in and tell me that they're thinking about using CBD products or utilizing them, I certainly don't tell them to stop. And more often than not, I am finding in my clinic that patients that are utilizing these CBD products, they do report some element of pain relief.

And so this is absolutely an alternative treatment option for patients. And there isn't an overwhelming amount of research yet in human populations. But at least in rodent models and other sort of baseline biochemical assays that they've done in laboratories, there is at least a lot of research and it has been shown to have pain relieving properties and also antinociceptive or basically antipain properties in Petri dishes looking at cells and other at least experimental assays.

Interesting. So Dr. Wallace, what are the risks of joint replacement surgery? I mean, it is a fairly significant surgery, I would imagine.

It is a major surgery, and that very reason is why we send patients to see their primary care doctor before surgery to make sure that your health is in the best condition that it can be in going into the surgery. And I think that's really the key to making it a safe thing to do for the majority of patients is getting ready or what we call preoperative optimization.

And that's where we focus the majority of our efforts in terms of safety and good outcomes. I think risks of joint replacement are many. Of course, infection is one risk that's common to any surgery. In particular, we worry about it with joint replacements.

And the infection can happen at any point after a joint replacement and typically requires a surgery to deal with. There are other complications as well, such as medical complications of surgeries, medical complications of anesthesia.

And I think overall, the rate of complications after joint replacement is low, certainly less than 5%. Infection is probably on the order of 1% or 2% after joint replacement. So when prepared properly, most patients can go through this process very safely.

We have another comment from a viewer. Anna says, love you guys. Best hospital in the country. We like that. We'll take that. Dr. Ross, is it possible to prevent or reverse osteoarthritis?

So I think from a prevention standpoint, I guess yes and no. But from a prevention standpoint, as I've alluded to, a lot of the factors that contribute to the wear and tear and degeneration of cartilage, especially body weight and excessive body weight, definitely be a modifiable, I suppose, risk factor to aid in the prevention of the added wear and tear of the cartilage.

From at least a stability standpoint around the joints, trying to maintain as best muscle function and strength to eliminating sort of biomechanical problems which, again, may be contributing to this wear and tear, I think can potentially prevent if not slow the progression of some of the arthritis-related changes inside of the joint.

From a reversal standpoint, once arthritis is at least present inside of the joints and that cartilage has worn down, there really isn't anything quite yet, at least from a nonoperative standpoint, to sort of reverse those changes.

Orthobiologics such as stem cells, which you may have heard about either through television or reading, this is a hot area of research to try to figure out, is there any way for us to regenerate cartilage.

There are some procedures that can be done surgically, such as a microfracture and some other cartilage-based procedures that can try to regrow certain focal areas of cartilage defects. But if it is sort of wide spread throughout the joint, unfortunately, we can't really reverse those changes. And again, joint replacement might be the best next stop for the patient.

Marianne, another viewer, asks, do you recommend platelet rich plasma treatments? And I think you touched on that a little bit earlier, Dr. Ross.

Yes, so there is a lot of traction, as I've indicated, for PRP injections in the treatment of osteoarthritis, at least primarily for knee osteoarthritis where the results seem promising, especially when comparing to steroids or viscosupplementation. It does seem to be equal in its efficacy if not potentially a little bit superior.

And with platelet rich plasma, relative to steroids or viscosupplementation, platelet rich plasma does take a little bit of time for its effects to take hold. It's not sort of an immediate property such as steroids, where patients usually experience pain relief within about the first week or so and it can generally lasts about to three months.

Platelet rich plasma, at least in the research, has been shown to have pain relieving properties potentially up to six months. So I certainly discuss this as a treatment option for patients. The caveat, at least to be open about this, is that it is not covered by insurance quite yet, much to our dismay. So it is a cash-based procedure at University of Chicago and at least most places throughout the country at the present moment.

I'm glad you said that, because it was one of the other questions from a viewer was whether or not it was covered by insurance. Dr. Wallace, this one is from a viewer named Selena. And the question is, is there a higher risk of developing osteoarthritis after knee reconstruction surgery? If yes, what can be done to help prevent it?

It depends on what you mean by knee reconstruction surgery. So I do think that hip and knee replacements should be considered somewhat of a cure to osteoarthritis in the sense that we replace the cartilage entirely, and so there's really no risk for cartilage loss down the road.

If you've had other procedures like a realignment osteotomy, like a meniscectomy, arthroscopic-type procedures, microfracture, that's just a sign that your joint may already be, at some level, at risk or potentially not entirely biomechanically sound.

And in those cases where you've had prior injuries or prior realignment procedures, oftentimes those procedures are being done to try to prevent arthritis, but you are someone that is obviously at risk if you're having to undergo those procedures for the future development of arthritis.

So we know that removing the meniscus in particular can lead to arthritis down the road. And that's not to say that it should never be done. Of course, if you're having mechanical symptoms related to a meniscus tear, for example, something needs to be done.

But it may predispose you to the future development of arthritis, again, because the mechanics of your joint aren't entirely normal at that point. Also, having had an injury before may represent injury to the cartilage as well, and cartilage damage and cartilage loss is really the hallmark of this process of arthritis.

Well, that half hour went very quickly. We're out of time. You were fantastic, shared a lot of great information with our audience. So, of course, as always, thank you very much for doing that. And thank you to our viewers because you had some really, really good questions.

Please remember check out our Facebook page for our schedule of programs coming up in the future. Also, if you want more information about UChicago Medicine, make sure you take a look at our website at uchicagomedicine.org.

If you need an appointment, you can give us a call at 888-824-0200. And remember, you can schedule your video visit by going to the website. Thanks again for being with us today. Hope everyone has a great weekend.

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