Hip and Knee Arthritis On Demand Seminar

Hip and Knee Arthritis On Demand Seminar


(upbeat funky music) – As I mentioned again, I’m Dr. Williams, and I’m in the division
of orthopedic surgery here at Coordinated Health. Let’s talk about arthritis a little bit. Arthritis technically, if we’re trying to be exactly correct, is
inflammation of a joint. Usually arthritis results in accelerated wear and tear of that joint. There are many causes of arthritis. It can be the result of
an injury earlier in life. It can be the result of activity, for instance, if you had a job where you stood on your feet for
40 or 50 years on concrete. It can be the result of
something you’re born with. Not that you’re born with arthritis, but you’re born with deformity of a joint which later on goes on
to develop arthritis. That big word, “autoimmune,”
that’s a way of saying either psoriatic arthritis, which you’ve seen Phil
Mickelson advertise on TV, or rheumatoid arthritis. And infection at an earlier
time can cause the joint to decay and become arthritic. The most common kind of arthritis
is called osteoarthritis, and it’s a degenerative,
or wear-and-tear arthritis. Here are some X-rays of a hip. Now, the X-ray on the right is a normal, or relatively normal, hip. You see you’ve got a nice dark area here. That’s the joint space. Actually, this patient is starting to get a little arthritis. You can see a little bit of whiteness here and a little spurring. But then that goes on to our picture here. You can see you’ve lost
that nice round dark space, and the white area has
become more pronounced. That’s wear-and-tear arthritis of the hip. If we look at the knee, this is a nice X-ray of a normal knee. Nice smooth surfaces,
nice big wide open space. And obviously you can see here, the wide open space is no longer there, and that nice smooth surface? Well, that’s not so smooth anymore. Osteoarthritis and osteoporosis
are not the same thing. I have many patients get that confused, and they ask me, “Well,
I have osteoporosis. “Does that mean I have osteoarthritis?” They’re really not even related at all, except they’re both found in what I’m going to call the
more mature individual, translate older, and both words begin
with the word “osteo,” which is a Greek word that means “bone.” OK, so they both involve the bone, but other than that,
they’re not at all related. So we’re gonna talk about
osteoarthritis tonight. How much of a problem is arthritis? Well, 46 million Americans suffer from arthritis. That results in 44 million
doctor visits a year, and in about one million
hospital admissions per year, so we’re not talking about,
“Oh, it’s not a big deal.” We’re talking about a big problem. Arthritis has a low mortality rate, which means it’s probably
not gonna kill you, but it has a high morbidity. Morbidity is a quality of life thing, meaning you have pain, you
don’t want to do things, you can’t walk, you can’t
go up and down stairs. That’s morbidity. So I guess it doesn’t kill you, but it sometimes makes
you kind of wish it would. What are the symptoms of arthritis? Well, if we remember the
movie The Wizard of Oz and the Tin Man, he
was stiff, he had pain. And again, the symptoms are
pain, worse with weight bearing, meaning worse with
walking, putting weight, getting up and down out of a chair, arising from a seated position. Many patients with arthritis
can have pain at night. Why do you have pain at night? I tell patients it’s
because during the daytime, your brain’s concentrating
on all the stuff you have to do during the day, whereas at nighttime, it
doesn’t have anything to do except let you fall asleep, and now all these things start. “This hurts, that hurts.” We can get swelling with arthritis. Now, if you have arthritis of the hip, you’re probably not gonna see swelling, but if you have arthritis of the knee, you probably will see swelling. Stiffness. That feeling of, “OK, it’s morning, and now
I gotta get out of bed. “Well, let’s move. OK,
that moves OK. All right. “Oh, this one, not quite so good.” That’s stiffness. Grinding in the joint. The joint actually can make noise, which sometimes sounds
like somebody stepping on crackers or marbles in the joint. Medically, we call that crepitation. But that’s grinding of the joint. Who is the typical patient with arthritis? The typical patient with arthritis, particularly the wear-and-tear arthritis, is an older patient. We’re all there, unfortunately. A female patient. Why a female patient? Because the women outlive the men. There’s more women around
who are in their eighties than there are men. And, unfortunately for all of us, usually the patient with arthritis is at least somewhat overweight, and that’s both for the men and the women, so I can’t point the finger at any of you folks, that’s for sure. So here you see, you
have a picture of a man. You can’t see if he’s overweight or not, but he’s obviously older
and he’s using a walker, which probably makes you think he’s got some pain in his legs. What are the multiple
treatments for arthritis? We can do activity modification. And I’m gonna go through
each one of these in detail. Activity modification, weight loss, physical therapy, bracing, pain medication, which I’m going to call non anti-inflammatory medication. Then there’s the
anti-inflammatory medication, which we call nonsteroidal because it doesn’t have cortisone in it. Steroid injections, another type of injection, big long word, viscosupplementation, and
then sometimes surgery. But notice, where is surgery in this list? It’s all the way at the bottom, after you’ve tried many of
the other things, hopefully. Let’s talk about activity
modification. What do we mean? Well, you take it easy a little bit. Maybe you don’t use the
stairs quite so much. You pace yourself. My dad is 89 years old, and before he sold his
house a couple years ago, he would say, “Gee, you know, “I used to be able to trim the hedges “and do X, Y, and Z, and
do it all in one day, “and now I have to break it up “and take two days or three days.” That’s pacing yourself. Exercise. There’s weightbearing
exercise, things like walking, and non weightbearing exercise, more things like lifting weights or swimming. One can use an assistive device. That can range anywhere from a
cane to crutches to a walker. Most of my older patients
don’t use crutches very well, so by the time we get into that age group, usually it’s either a cane or a walker. When you use the cane, you have to use it on the opposite side, so please
do not imitate Dr. House, because he had a bad whichever leg it was, and he used the cane on the same side, and I once had about a 15-minute
discussion with a patient about why that was wrong, and
she still didn’t believe me because Dr. House used it on that side. And I guess he’s smart. Weight loss. OK. We can
all do it, let me tell you. However, every pound gained or lost is a gain or loss of four pounds of force on the knee or hip. I had a patient, came in one time, I was getting ready to do
bilateral knees on him, and he said, “Doc,” he said, “I’m gonna go get my
gastric bypass first.” I said, “Great. Good idea.” So he got his gastric bypass. He came back to me six months later. He looked terrible, but he
had lost like 150 pounds, and he said, “Doc, my
knees don’t hurt anymore.” I said, “OK, well, then you
don’t need your knees replaced.” I mean, his X-rays looked terrible, but he doesn’t have pain,
because he basically took 600 pounds of force off his
knees by losing the 150 pounds. Unfortunately, it’s kind
of hard to lose weight because if your knees or your hips hurt, you can’t exercise to lose the weight. However, this caveat here, consuming food with either Diet Coke or Pepsi, or, in some cases, light beer, negates any calories
associated with that food. So you can have a big plate of pasta, have a little Diet Coke,
and there’s no calories. Please do not believe that one. Physical therapy. How does
physical therapy help? The therapist can teach
you how to use that cane that we’ve really been
wanting you to use properly. There’s exercises which can help strengthen the muscles
that go around the joint to help the joint run more efficiently. The physical therapist
can help you evaluate. Maybe you’re already
on an exercise program, and the therapist can kind of say, “Look, this is good exercise.
This is not good exercise.” Therapists can use
modalities like heat or ice to help make the joint feel better, and a good therapist is very motivational. Sort of like this fellow down here. We hope that he is not
your physical therapist. Bracing. You can’t really brace the hip,
but you can brace the knee. Bracing can range
anywhere from an Ace wrap, which is just a little support and a little warmth for the knee, up to a neoprene sleeve,
which is a little more support and a little easier to put on. Then sometimes we use a
knee sleeve with hinges, because the hinges help
support the knee a little bit. And then, if we’re really gonna brace, there’s something called
an unloader brace, which helps to transfer the weight to other parts of the leg. The only problem with the unloader brace is it’s very large, it’s
very cumbersome to put on, and they don’t always fit the best. So we spend a lot of money on the brace and then the patient,
after a couple weeks, says, “Ah, forget it,
Doc. Not gonna use it.” Now let’s talk about medication. We’re gonna talk first of
all about what I would call non anti-inflammatory medicine. This is just medicine for pain. The most common is Tylenol, or acetaminophen. Extra strength Tylenol
is the 500 milligrams. You can do two of those
up to three times a day. Tylenol Arthritis is
simply an extended release where you take two pills and
supposedly it lasts all day. Doesn’t always work that way. Unfortunately, it seems like
for the makers of Tylenol, a lot of the drug stores
and the pharmacies and the food stores are not
getting the branded Tylenol. They get the store brand,
which is really just as good. There are other types of
medications we call topicals, which is something applied to the skin. A common example is Bengay.
How does Bengay work? Bengay makes the knee, or
whatever you rub it on, feel warmer, and it sort of
confuses the pain fibers, and so sometimes Bengay helps. The only problem is Bengay smells. There’s another pain
medicine called Tramadol, which is by prescription only. It’s a non-narcotic pain
medicine. Works pretty well. The only caution is in older patients, sometimes they get a little confused. Then, in some cases, we
move on to the narcotics, hydrocodone, the brand name is Vicodin, oxycodone, the brand name is Percocet. Try to use that very sparingly,
because they are addictive. There are long-acting narcotics. Durgesic is a patch, OxyContin is a pill. OxyContin’s sort of got a bad rap because the drug dealers like it, but, you know, in small
doses and used regularly in patients who sort of have chronic pain, it works. Then there’s also nutritional supplements. The most common one is
glucosamine and chondroitin. A common brand name is Osteo Bi-Flex. I tell my patients, if
you’re gonna use this stuff, go to the drugstore,
find the Osteo Bi-Flex. Right next to it is the
generic. Buy the generic. The glucosamine and
chondroitin seems to help about half the people who take it. There are no side effects. You have to take it at least a month to see if it’s gonna help,
but definitely worth a try. Now the nonsteroidal
anti-inflammatory medication, abbreviated NSAID. The over-the-counter versions are Advil, Aleve, and Motrin IB. They’re decent medicines. I don’t really care for the ads for Aleve, but I tell patients, “The stuff works.” The prescription versions of these are Motrin, Naprosyn,
Mobic is kind of nice because it’s a once-a-day medicine, Voltaren, Celebrex, Relafen, Daypro, Clinoril, and Lodine. These are all older ones that are now available as a generic. Celebrex and Voltaren are the only ones only available as a non-generic or branded product. Celebrex is kind of nice because
it has less stomach upset. Then there’s some topical
anti-inflammatories that work very nice, particularly in joints like for the knee and for other joints, not so much the hip. These are called Volteran gel, Pennsaid, and a Flector patch. The most commonly used
one is Voltaren gel. Now, side effects of the nonsteroidals. I always have to laugh at
the Celebrex commercial, because they spend 15 seconds
telling you why you use it, and then they spend 45
seconds telling you of all the awful things that are gonna
happen to you if you use it. The more serious side
effects are gastrointestinal, like bleeding ulcer, heart attack, stroke,
liver and kidney damage. Now, the chances of those things happening are about one in 100,000. If you drive a car in the Lehigh Valley, your chances of being
killed in a car accident every year are one in 20,000. So you’re out there on the road with all the rest of us ding-a-lings who talk on our cell
phones, put makeup on, at least the ladies do, read their magazine, eat,
drink, play the radio, and yet we all drive our car. I mean, nobody walked here tonight, right? So I say to patients, “Look, “if the medicine is helping
you, take the medicine.” The NSAIDs can interact
with other medications, so if you’re on warfarin or plavix, you probably should not be using oral nonsteroidal
anti-inflammatory medicines. You can use the topicals, though, because you don’t really absorb that much. Aspirin, if you’re on a baby aspirin, baby aspirin doesn’t count.
You can use the NSAIDs. If you’re on full dose aspirin, you kind of have to talk to
your doctor about that one. The topical ones tend to
have fewer side effects, and I tell patients, when I give them a prescription for Voltaren gel, “When you read the side effect labels, “remember, you’re not
gonna eat this stuff. “You’re gonna rub it on, “so you’re not gonna get
all these crazy things.” And, of course, we get this big list of all the side effects.
Why do we do that? Well, it’s this group right here. Here’s a quote from Shakespeare
with which I kind of agree, at least on some days,
depending on what’s going on. OK, so let’s say you’ve tried
medications, didn’t work. What’s our next step? Usually it’s a cortisone
injection, and, honestly, these are not nearly as
bad as some patients– “Oh, my friend had one
and it was terrible.” We use a small needle, we freeze the skin. I mean, I’ve been doing this for 30 years, and I probably inject
five or ten knees a day, and a couple of shoulders a day. We know what we’re doing.
We hope so, anyway. The steroid injection helps
about 65 to 75% of the time. The improvement might be temporary, but temporary can be anything
from a few days to years. I’ve had patients come in and say, “Yeah, I got a cortisone shot 10 years ago “and my knee just started
hurting last month.” OK, so you got a pretty good result from that steroid injection. The question of repeat injections. There is no hard-and-fast rule that you can only get three injections or you can only get one injection a year. Talk to your doctor. What I say to patients is, “Look, “define what ‘repeat’ stands for. “If you come in once a month
to get a cortisone injection, “that’s not a good thing. “If you come in twice a
year, not a big deal.” Why do we not like to do
the repeat injections? Because frequently-repeated injections can actually damage the joint. So, again, I don’t want
you to come in once a month and say, “Hey, Doc Williams, “my knee was doing good for three weeks. “Let me have another cortisone shot.” I’m gonna say, “Look, let’s back up “and see what else we need to do.” What kind of side effects
from cortisone injections? About 10% of patients actually have a little more pain that night. I tell them, “Put ice on it.” In folks who are darker complected, you can actually get
some little white spots. We call that atrophy of the
pigment from the cortisone. Systemic side effects. If you’re diabetic, I tell my patients, “Your blood sugar’s gonna go
up for three or four days. “If you don’t absolutely need to, “just don’t test your sugar
for those couple days, “because you’re just gonna get upset, “and I promise you your blood sugar’s “gonna go back down again.” Now let’s talk about the
other kind of injection, which the big medical name
is viscosupplementation. Why do I have a picture of a chicken? Because the medication, most
of it’s made from rooster comb. I tell patients, “It’s the one “that didn’t make it to Kentucky Fried.” And they process that material,
and it’s sort of like a gel, and it cushions and lubricates
the inside of the joint. Unfortunately, it’s only
approved by the FDA for the knee. I have actually done it in the shoulder, but we have to get free
samples from the drug company, and I have to explain to the patient, “Look, it’s really not
approved for this joint,” but sometimes it helps. There are about six different brands. Synvisc, Supartz, Hyalgan,
Orthovisc, and Euflexa. They all work about the same. Each company will tell you why their product is better than the next one. It’s sort of like the
presidential debates. Flip a coin. The only difference is that Euflexa is not a poultry-based product. It’s actually bioengineered from bacteria. It works, and I sort of save that one for folks who come in and they’re allergic to feathers or chicken or whatever. It’s a series of between
one and five injections, depending on which brand. It helps 65 to 70% of the time. Remember what I said about
the cortisone injections? Kind of about the same. It can be redone in six months. If a patient comes in,
they get good results for at least six months, and then they say, “Doc, I was doing good, “but now my knee’s hurting again.” I’ll say, “Fine, we’ll
do the injections again.” And patients can get six
to twelve months of relief, and you can repeat the
injections for eternity. There’s no increased side effect by repeating the series if it helps. Side effects, the only side effect, again, think about 10% of the people, the knee is gonna be sore that night. Sometimes the knee gets
so sore that we think, “Gee, do they have an infection in there?” That soreness usually passes, and that’s really it for the side effects. It doesn’t interact with
other medications or anything, so the stuff is pretty safe. OK, so let’s talk about
surgery for arthritis. There’s different kinds of surgery. There’s arthroscopic surgery, there’s what we call open surgery, which means you make a big incision where maybe you didn’t
replace the knee or hip, and then there’s joint replacement. Let’s talk about arthroscopic surgery. It’s most commonly done
for knee arthritis, although they’re starting to do it a little bit for hip arthritis as well. It’s usually done to– In the knee, you’ve got a
structure called the meniscus, which is a little shock
absorber which wears out, and usually what we do
is go in and take out the worn-out part of the meniscus. We can sometimes smooth
down the arthritic surface which kind of looks rough. Think of in a cave, you know,
the stalactites or mites, I can never remember which, hanging down, we can sort of go in and smooth those off. The nice thing about arthroscopic surgery is that it’s outpatient surgery, so you come in, you have
it done, you go home. The bad thing is that you
only get a good result about 60% of the time in
somebody that’s got arthritis, so it’s not something
that I commonly recommend, because I like things that work
better than 60% of the time. Here’s a picture of a
relatively normal knee. Nice smooth surface, here,
that’s the end of the femur bone. Here’s the top of the shinbone. And then, here, this wispy thing here is that thing we call the meniscus. And, as you can see, there’s a little bit of a difference here. This is what arthritis looks like. It’s no longer a nice smooth surface. It’s rough, it’s nasty, it looks like a pothole out here on 512. Now, what about open surgery for the knee but not a replacement? If you look at this person here, you can see that this leg sort
of comes down and goes out. That’s a relatively normal position. But this leg kind of goes the reverse, it goes out and then in. So this part of the
joint is very arthritic. Think of, your shocks are worn on the one side of the car. The nonreplacement open surgery is usually done for the knee. What we do is called an osteotomy. We actually go in and cut the bone and kind of bring it out this way. We usually do that in
younger, active patients who are too young and too active
to have a knee replacement. It’s about 70 to 80% effective. We don’t do this operation much anymore, because the trend has just been getting more and more to joint replacements. So let’s talk about joint
replacements for the hip and knee. The first successful total hip replacement wasn’t that long ago. It was in 1962. It was done by Sir John Charnley, who was an Englishman, and he is sort of the father
of total joint surgery. I went to a conference many years ago where a couple of his junior attendings, guys that had worked
with him for many years, presented cases, and it was like being in church. I mean, I’m Catholic,
and so when I go to Mass, at certain sometimes,
anything that’s said, you know, you bow your head or whatever. Well, these guys were the same way. You really expected somebody
to come out throwing holy water because Sir John Charnley
was pretty much a saint according to these guys. And, of course, his
development of hip replacements and, ultimately, knee replacements, has been a godsend for
people with arthritis who have a lot of pain. There’s about 250,000 hip replacements and 500,000 knee
replacements done annually in the United States. That’s
a lot of replacements. The nice thing about joint
surgery, total joint surgery, is that it has at least
a 90 to 95% success rate. Most of the time, you
see a marked improvement in the quality of life of that patient. And what I tell patients is, “Look, what number would
you put on your pain? “Zero is nothing, ten is the worst.” And, most of the time,
if somebody’s thinking about joint replacement, they’re thinking, “I’m kind of in the
seven, eight, nine range.” I’ll tell them, “Look, I’m not
gonna get you down to zero, “but I can probably get you
down to point five or one, “which is a marked improvement
over seven, eight, or nine.” There are age considerations. We try not to do joint replacements
in much younger patients because they’re gonna wear them out. There’s really not a maximum
age for joint replacement. The oldest patient I did
a total knee on was 94, and she came in and she
was having terrible pain. We tried all of those other
things, couldn’t get her better. I said, “Ma’am, you need
a joint replacement.” She said, “But I’m 94.” I said, “Well, how long
are you going to live?” She said, of course, “I don’t know.” I said, “Look, the life
insurance people will tell you “you’re gonna live at
least five more years. “Do you wanna have that pain?” She said, “No.” I said,
“Have your joint fixed.” I saw her about a year after
we did the joint replacement. She was 95. I said, “Ma’am, how are you?” She said, “Oh, my knee is great. “The rest of me’s falling
apart.” This is 95 years old. Some years later, I
bumped into her daughter at a nursing home because I was going in to visit one of my relatives, and she said, “Do you remember my mother?” I said, “Yes, I do. I’m sure
by now she’s passed on.” The woman said, “Oh, no,
Mother’s here at the home. “Would you come in and say hello?” I said, “Well, sure.” So I went in to see her.
I said, “How are you? “I’m Dr. Williams. I did
your knee replacement.” She’s like, “Who are you?” I said, “Well, never mind.” I said, “How’s your knee?” She said, “My knee is doing great.” I turned to the daughter, I said, “Ma’am, how old is your mother?” She said, “Mother’s 103 years old.” Mother lived to be 104. Not because of my knee replacement, but the moral of the story is, age is just a number. (audience member speaking quietly) Pardon? – [Audience Member] And the knee lives on. – And the knee lives on! Yes. The knee is somewhere. I
don’t even want to go there. OK, let’s talk about
total hip replacement. The hip is a ball and a socket, if you remember the X-rays
I showed you before. What we do is we replace
both the ball and the socket. We almost never do both
hips at the same time. Once in awhile, at some
of the university centers, they’ll do that, but up
in the Lehigh Valley, we usually just do one hip at a time. This is sort of what a
total hip replacement looks like in the body. This is metal and plastic. This is metal. With a hip replacement, you’re
able to walk the next day. You’re able to put weight
on it the next day. You start physical therapy the next day. My patients, usually they use a walker for two to four weeks, and then a cane. What I tell them is,
“When you come to see me “two weeks after surgery,
you’ll be on a walker. “When you come to see me
six weeks after surgery, “you’ll either be using
a cane or nothing.” I usually let patients drive at about six to maybe eight weeks. In terms of returning to work or sports, depends on what kind of job you do. If it’s a heavy lifting job, obviously that’s gonna
be months and months. If it’s a sedentary job, maybe six weeks, eight weeks. Sports, we usually recommend staying away from impact or twisting sports. Golf is OK. Doubles tennis is OK. Skiing not so much, unless you were a really, really, really
good skier to start with. Singles tennis, not a good idea. Distance running, not a good idea. In total knee replacement, we replace three joint surfaces usually. The femur, that’s the
end of the thigh bone, the tibia, that’s the shinbone, and the patella, or the kneecap. This is sort of what it looks like. This part would go with the tibia. This is the end of the thigh bone, and this thing here is
the kneecap, or patella. Both hip and knee replacement
surgery can be done without bone cement or with bone cement. In hip replacements, we
almost never use bone cement. In knee replacements, some
doctors do, some doctors don’t. I happen to use bone
cement because I think it gives a better fix of the
artificial joint to the body. We can do both knees at the same time. I would say probably 10 to 20% of the patients I do knee replacement on, they get both knees done at the same time. The advantage is you’re done, you don’t have to come
back for the other one. The disadvantage is, the first two weeks you’ll think you got hit by a truck, but most of the time it
works out very nicely. Again, just like the hips,
you’re able to walk the next day. You get started in physical
therapy the next day. Return to activities, kind of the same as for a hip replacement. Walker for two to four weeks, and then a cane, and then nothing. In knee replacements,
post-op physical therapy is very, very, very, very important. The few patients that
I’ve had who refused to go to therapy afterwards have not done well, because you’ve gotta move the knee and you have to get the leg strong. Now, there’s been a big thing in marketing in the news and on the Internet about what we call
minimally invasive surgery. The incisions have gotten
smaller as time has gone on. Even my own incisions from 30 years ago were bigger than they are now. Unfortunately, the
minimally invasive surgery has what we call a steep learning curve, which means it takes a long time to learn how to do it properly. You don’t really want
to be the first person that someone’s trying to do one of these minimally invasive surgeries on. The complication rate
can be higher because, well, you’re sort of the
guinea pig, the student, while the doc is learning
how to do this new operation. My philosophy is you
really need to be able to see what you’re doing when you do a hip or a knee replacement. Also, computerized surgery.
Some folks will advertise, “Well, I do your hip or knee
with computer assisted.” That sounds really great, except it makes the surgery
time longer, which means a little bit, theoretically,
chance of infection. And the studies in the
orthopedic literature say it doesn’t make a difference
whether you use a computer or you have a good surgeon who knows what he’s doing or she’s doing. The ultimate goal is a properly
implanted joint replacement. Smaller incision or faster surgery does not necessarily mean you’re
gonna get a better result, and sometimes can result
in something like this. Let’s talk about the
possible complications of joint replacement. We’ve talked about the good things. Infection. The infection rate
is a little bit less than 1%. We give antibiotics to
try and prevent that. If you get an infection in a total joint, sometimes it means you
gotta start all over again, take that one out and put a new one in, and it’s not a good situation. Persistent pain. You know,
I said 90 to 95% of people are happy with their joint replacement? About 5% of people have
substantial persistent pain, and even after we do all the studies and the X-rays and the CAT
scans and the lab work, we still can’t quite figure
out why they still have pain. This thing called DVT or PE,
this is blood clots in the leg, which can eventually travel to the lung. We give anti-clotting medicine
to try and prevent that. Both of these are at least
potentially dangerous. The PE, the pulmonary embolism,
can be life-threatening. Medical issues, things like
heart attack, stroke, pneumonia. We obviously try to keep
an eye on these things and prevent them from happening, but again, it’s just like driving a car. Every once in awhile, the
hand of God reaches out and says, “It’s time.” Loosening. The loosening rate on most total joints is about 1% per year. What I tell patients is,
“Look, if you’re 60 years old “and you have a joint replacement, “by the time you reach 80, “still 75% of those total joints “should be working properly.”
That’s pretty good. So it’s not like they only
last 10 years or 15 years. There’s an ad for one on TV that says it’s tested for 30 years. Unless you have a bad prosthesis, and those are very few and far between, they tend to loosen at 1% per year. Recalls. – [Audience Member] What
does loosening mean? – Loosening means, OK… When you put the hip or knee in, you either use bone cement, which actually is more like a grout. Think of a Thomas’ English muffin. Most of my analogies involve food. And it’s got the nooks and crannies. That’s what your bone is like. And so the bone cement gets
into those nooks and crannies and it also gets into
the nooks and crannies of the prosthesis, and
then when it hardens it locks everything together. Well, just like anything mechanical, if you put it through enough cycles, the bolts on your car
might loosen a little bit or your cabinet door at home,
you’ve gotta retighten… That’s the same thing. And in the joints that you
have not used bone cement, you’ve got the nooks and
crannies of the prosthesis and the nooks and crannies of the bone, and you sort of jam them together in surgery and they kind of lock in. But, again, still with
millions of cycles of walking, it can loosen a little bit. – [Audience Member] Can it be retightened? – No. No, what you have
to do is put a new one in. But, again, the loosening
rate is about 1% per year, so most people, loosening is not an issue. Loosening is an issue
in a younger patient, or in a patient who’s very,
very, very, very overweight, but for those of us here in the room, except for the young folks in the back, a prosthesis that’s put in this year should last your lifetime. Recalls. Of course, if you put
on the news in the morning, there’s always something about
something being recalled. “You may have legal rights, please call.” Most of the prostheses that are in use now have never been recalled. Some of the metal-on-metal
prostheses have been recalled, and some of the companies will
have one or a particular one. Once we find out that
they’ve been recalled, we obviously don’t use that one anymore, and if you have one in
that has been recalled, it’s not like your car,
where you go in and, “Oh, we’ll just change the parts out.” If you’re not having a problem
with it, you leave it alone. Usually the total hip
or total knee prostheses that are recalled are recalled because after they’ve been put
in for a couple of years, we’ve recognized that that
particular design is inferior. Obviously, it’s supposed to be tested. They are tested, but sometimes you gotta do a couple thousand of them before you say, “Oh, wait a minute. “This one is not working
as well as it should.” And that’s me. We do these wearing space
suits to keep things clean, keep the air in the room clean. We try to fight infection,
and that’s why we do that. So anyway, thank you for coming tonight. I’ll be happy to take any
questions that you have. Yes? – [Audience Member] I have one question. I saw a commercial on TV where it said for knee replacements, quadriceps-sparing surgery. What are they talking
about from old to new? – OK. The quadriceps muscle is the one on the front of the leg, and the standard knee replacement, we cut part of the tendon
to get into the knee. So that’s a quadricep-splitting incision. You know, that’s the standard one. It’s the one that’s been used
for I’m gonna say 40 years. It works pretty well in most patients. It does take a lot of rehab
to get the quadriceps… You know, once you’ve insulted
it, it doesn’t wanna work, and we’ve gotta kind of coax it. There is an operation
where you actually go in under the muscle instead
of splitting the muscle, and in theory that may be better, but it hasn’t been tested enough to know is that in fact a better way
to do it than the standard way? The hospital that is advertising that, I believe, is in South Jersey. It’s called Virtua Hospital. And, again… My question to those doctors would be how many of these have you done? What are your results? What are your five-year, ten-year results? Are they any better than
doing it the standard way? If you saw an ad from me that says, “Dr. John Williams is doing “quadriceps-sparing total knee surgery,” my suggestion would be call somebody else, because I don’t do them, and, again, you don’t want to be the first
or tenth or twentieth person. You want to be the 2000th person that is having an operation. So I just caution you about things like the quadriceps-sparing, the mini incision, the computerized. It sounds great, but,
you know, let’s prove it. What is really the result?
What’s the long-term result? Example. A lot of patients want something after knee surgery called a CPM machine. It’s a machine that
moves the knee for you, and that’s the trend.
Well, it really isn’t. Because we’ve actually
done studies that prove that it doesn’t really help
that much in the short term, and if you look at patients a year out, if you compare the patients
that have had the CPM machine and the ones who didn’t,
there’s no difference, and yet it costs a lot of money. So, again, we have to
do the studies to prove that whatever that innovation
is is truly a good innovation. (Audience member mumbling) Well, we do what’s called templating, and we can do that in
the office on computer. But when we do the hip
and knee replacements, assuming that we’ve properly
evaluated the patient and know it’s not some really
weird kind that we need, we actually have a cart
right outside the OR door that has, in the instance of total knees, we have C, D, E, F, G, H. We have six sizes of femur. We actually have women’s and men’s. And we have about six
different sizes of tibia. So we go in and we measure, we say, “OK, this is a size D. “I’m gonna want a right D. That’s fine.” And we measure the tibia
right after we cut it, and we say, “OK, this tibia
looks like it’s a size three, “so I want a size three.” And if we pick the wrong
size and we go to put it on and say, “Oh, this is not gonna work, “we need the next size up,” it’s just like being in
the Macy’s shoe department. “Go get me the size whatever.” It’s always an educated guess, more with the emphasis on
“educated” than “guess,” as to size. – [Audience Member] Is
it the same for hips? – Yes. Yeah. – (Audience Member) And do they have hips for females and males? – No, the hips are the same. – [Audience Member] …smaller ones? – Well, they have smaller ones.
They do have smaller ones. Just like the knees, they
actually go down to a size that we don’t use in
this country very much, but it’s used in Asia,
because they’re smaller bones. But, yeah, the hips are sort of unisex, whereas the knees, some companies, and I use a Zimmer product, and it’s a woman’s knee, and it’s actually a little bit narrower, and there’s some modification
where the kneecap goes, because women’s kneecaps
are a little different. But yeah, we have all the… We have all the parts in
stock before we start. Yes, sir? – [Audience Member] What’s the benefit of a partial knee replacement over
a complete knee replacement? – The benefits of a partial. First of all, we would do
a partial knee replacement if only one side of the joint is worn out. And the benefit of the partial is that usually you’re only in the hospital one night instead of three, and the recovery is usually faster. The other advantage is if
10, 15 years down the road you need to have that part changed, it’s not quite as much
surgery as taking out a full total knee that was in and putting in a new total knee. That’s called a revision. So there is a bit of an advantage. You don’t want to do a partial or have a partial knee replacement if you have arthritis in more than one of the three areas of the knee. The knee has three different compartments. You can’t do two thirds. It’s either one third or the full tilt. – [Audience Member] Do you
always get a patella, or…? – You can do without a patella. In years past, I would look at the knee as I was doing it and decide whether or not I
wanted to replace the patella. It seems as I’ve gotten older, my patients have gotten older, and when I look at their knees there’s usually no question that the patella needs to be done. The problem is, if you
don’t do the patella and then later on they
still have front knee pain and you go back in to do the patella, the results are not quite as good. When you do the patella,
there is a little bit of an incidence of complications
with doing the patella, like the patella can fracture or whatever, but again, most of my patients anymore, they get the patella replaced as well as the rest of the knee. But remember that list of
all those treatment options? Surgery was at the bottom. Doesn’t mean it doesn’t work, but it means we try a
lot of other things first to see if we can help
patients without surgery. Yes. – [Audience Member] I took prednisone for arthritis in my knee for about a week, and he said if I wasn’t better, he’d give me a shot after that. Is it OK to take that (mumbling)? – Yes. If you came into
my office and said, “Dr. Williams, I was on a
Medrol Dosepak for a week. “It didn’t help. Can I
have a cortisone shot?” I’d say, “Not a problem.” Now, you wouldn’t want to do that, come in then the following week and say, “Can I have another cortisone
shot?” and the following. To have followed the oral
prednisone with the injection, not usually a problem. – [Audience Member] How soon
could I have another shot? – Everybody’s different. I don’t want to box your
doctor into a corner. What I tell my patients is,
it depends on their age. In somebody most of our
age, I would probably say, “Look, absolutely no more
often than three months.” I’d really rather it be
closer to six months. And the only time I make
an exception for that, if somebody comes in,
they got a cortisone shot, and they come in six
weeks or two months later and they say, “Listen,
the shot worked great, “but I’m going on vacation tomorrow “and my knee is hurting again. “Can I have another cortisone shot “at least to get me through vacation?” I’ll say, “Fine, but when
you come back from vacation “you’ve gotta come in and talk to me, “because we’re gonna have to do “some other different things.” So flexibility, I think, is the word. Any other questions? Yes. – [Audience Member] I was wondering. I was just diagnosed,
I guess, with my hip. I thought I had pulled a
muscle and, come to find out, I guess it’s degeneration of the hip. I opted to start to have
some physical therapy. Today was the first one. (mumbling) But is this a smart thing to do before, if you had to have
surgery, to have PT before, the therapy before you have the surgery? – PT is almost never a bad idea. To have the PT, to start to
get the muscle stronger– (audience member mumbling) I think that’s a good idea. In fact, Medicare is
coming out with new rules that is gonna mandate
three months of therapy before joint replacement. Now, I think that’s silly, but obviously I’m not
a government official. – [Audience Member]
They’re also coming back on how much therapy you can have. – Yeah, it’s sort of unfair, because on the one hand,
Medicare is saying, “OK, you have to have
three months of therapy “before you can have a joint replacement,” and then on the other hand they’re saying, “Well, we’re cutting back on therapy.” Well, which is it? You
want them to have therapy or do you not want them to have therapy? – [Audience Member] But
you do think it’s… – I think it’s very reasonable, yes. – [Audience Member] The other thing is, the time they put me on Mobic, which is the anti-inflammatory.
– Yes. – [Audience Member] That doesn’t take away a lot of the pain. You know, like at night,
can I take some kind of… I’m an aspirin person. I’ve always taken aspirin for everything, although it hasn’t
helped in this situation. Could I try it again? Like tonight? – You’re taking the Mobic.
– Yes. Once a day. – Yeah, don’t take aspirin
when you’re taking Mobic, because the combination is
really not good for your stomach. I mean, you could do Tylenol. You could do extra-strength Tylenol, because they’re different drugs, but, yeah, you don’t
want to mix Mobic with Advil, Aleve, aspirin. (audience member mumbling) Yeah, if you’re gonna take the Mobic, and I personally think
the Mobic is a good drug, if you’re gonna take the Mobic, then you gotta stay
away from the other ones except for the extra-strength Tylenol. – [Audience Member] Is there any way to slow down arthritis,
like osteoarthritis? – Not really, but just
because the X-rays look worse doesn’t always mean that
the symptoms are worse. Again, the glucosamine will
sometimes help calm things down. The repeated, the
viscosupplementation shots. But if they’re not working,
then you have two choices. Grin and bear it, do the best you can, or it’s time to fix it. And I tell patients, “You’ll
know when it’s time.” When you look in the mirror in the morning and you say, “I’m getting
really tired of this,” then it’s time. If you’re looking in the mirror saying, “Eh, it’s not so bad.
I can deal with this,” then you’re not ready yet. But when you look in the mirror and say, “You know what, I don’t
want to live like this. “It’s too much, it’s just
too much,” it’s time. (upbeat funky music) – [Voicoever] We live in a
fast-paced, on-demand world where everything is available
at a moment’s notice. Now your healthcare can
be on demand as well. Coordinated Health, the name
you trust for superior care, now offers care on demand,
where you can walk in, no appointment necessary,
and receive immediate care for all non-life-threatening emergencies. With specialist in
primary care, orthopedics, cardiology, and women’s health, and locations throughout the
Lehigh Valley and Poconos, quality care is never out of reach. Coordinated Health. Your
prescription for better health.

Leave a Reply

Your email address will not be published. Required fields are marked *