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Glenn D. Braunstein, M.D.

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Baby Boomers: Bone Up on Treatments for Arthritic Hips and Knees

Posted: 06/04/2012 2:04 pm

It seems like only yesterday you were bounding across the tennis court with the finesse of a Williams sister. Now your hips and knees ache just getting out of bed in the morning. Well, you're not alone. About 27 million Americans suffer from osteoarthritis, a deterioration of the cartilage tissue that cushions our joints. What's more, that number is expected to swell to 67 million by 2030, when all Baby Boomers will have turned 65.

Though there are a wide range of treatments available to help relieve pain and maximize joint function, there isn't now a cure or means of stopping the disease's progression. We know the risk factors of osteoarthritis are age, obesity, genetics and the overuse of joints from work or sports. Women older than 45 are at a higher risk than men. Still, we don't fully understand what causes cartilage to degenerate. And once it does, it doesn't grow back.

Cartilage is a firm, slick tissue that allows joints to move with minimal friction. In osteoarthritis, the surface of the cartilage grows rough. When it wears down completely, you're left with bone rubbing on bone. That can cause fragments of bone and cartilage to break off and float in the joint fluid. Bony spurs or extra bone can form around the joint. The result is pain, stiffness, decreased mobility and often a lot of creaking whenever you stand up or sit down.

Osteoarthritis can occur in any joint, but hands, knees and hips are among the most common. Onset usually occurs after age 40 and progressively worsens. Severity differs widely; about a quarter of those who suffer from osteoarthritis are severely disabled.

Treatments aim to reduce pain, increase movement

As scientists work to unravel the complexities of osteoarthritis, patients have sought to relieve pain and increase flexibility with all sorts of remedies, including such dubious ones as rubbing WD-40 on their joints and wearing magnets and copper bracelets.

The medically recommended course starts with over the counter anti-inflammatory medicine and or painkillers, topical analgesics or physical or occupational therapy. (I've posted previously about correct, cautious use of the over-the-counter medications.) If those don't work, prescription pain medication or corticosteroid injections are tried next. Corticosteriods injected into the affected joints can offer temporarily relief but shouldn't be used more than a few times a year.

Some patients, such as baseball Hall of Famer Hank Aaron have found relief with injections of hyaluronic acid, which acts as a joint lubricator. It is a thick gel-like substance that occurs naturally in the fluid that surrounds the joints and acts as a lubricant to help them glide smoothly and absorb shock. With osteoarthritis, the amount of naturally produced hyaluronic acid is reduced.

The procedure involves injecting the gel directly into the cavity around the knee joint. A typical course is one injection a week for three- to five-weeks. Benefits take several weeks to be felt and are most effective in treating mild to moderate symptoms. Hyaluronic acid has only been FDA-approved for the knee. These products are usually made from processed chicken or rooster combs and should not be used in people with egg or poultry allergies.

The nutritional supplements glucosamine and chondroitin once were thought to have potential for reducing osteoarthritis pain. Although they still are marketed widely as improving joint health, recent studies, including an extensive work by the National Institute of Health, have determined they offer little demonstrable benefit to most patients with knee osteoarthritis, although they may offer some help in patients with moderate to severe knee pain.

Neither does clinical evidence support use of transcutaneous electrical nerve stimulation, a device to stimulate nerves with low-voltage electrical current.

One new source of relief may be Botox. Yes, the same botulinum toxin type A (Botox is a brand name) used to eliminate forehead wrinkles and crows' feet showed promising results for patients with osteoarthritis of the knee in a small preliminary study, conducted at the VA Medical Hospital in Minneapolis. This is still in the study phase and exactly how it works is not completely understood.

Surgery is the next option

If conservative treatments don't provide relief, the next step is surgery. There are a number of options for hips and knees. A popular one on which the evidence still is out is arthroscopic lavage and debridement.

In this minimally invasive procedure, a physician inserts a pencil-size camera and small instruments through a tiny incision. Then the joint is flushed with a sterile saline solution (lavage) and tissue fragments are surgically removed from the joint. Several studies, most notably a 2008 review from Britain's The Cochrane Collaboration suggest the procedure is ineffective; other papers have recorded short-term relief in early-stage cases. Among these, a study just published in Current Orthopedic Practice reported that all 31 patients who received knee debridement enjoyed significant improvement; those with grade III osteoarthritis reported a 60 percent loss of that improvement after two years, versus a 10 percent loss in those with grade II. A recent study among patients with hip involvement showed that frequent arthroscopic procedures may extend the time before a total hip replacement is needed, especially in those who were younger and had milder arthritis.

Younger patients may be candidates for an osteotomy, in which joint bones are cut and repositioned to improve alignment.

The last resort is joint-replacement surgery, in which the damaged joint is removed and replaced with a prosthetic. Part or the entire joint may be replaced. In a procedure, called hip resurfacing, instead of removing the damaged hip ball, it is reshaped and capped with a metal prosthesis. Leaving more bone intact may be beneficial down the road if a second hip replacement is needed. More than 200,000 hip replacements and 600,000 knee replacements are performed every year in the U.S. By 2030, the numbers are expected to soar to 572,000 annual hip replacements and 3.48 million knee replacements, according to the American Academy of Orthopedic Surgeons.

Some surgeons recently have advocated a new, less invasive joint replacement, involving a smaller incision or two. In hip replacements, this approach also calls for the surgeon cutting between muscles rather than through them. The technique is debated among surgeons, with proponents contending that benefits include less pain and blood and a quicker recovery. Opponents question these benefits and counter that the surgery is significantly more difficult and takes longer to perform; they say it is therefore prone to an increase in complications. The American Association of Hip and Knee Surgeons says there is insufficient data now to recommend widespread use of this technique.

Metal woes

While joint replacement overall is one of the most successful surgeries in orthopedics, thousands of all-metal hip implants, put in place between 2003 and 2011, have created great concern here and abroad. These devices, dubbed metal-on-metal implants, are prostheses in which both the cup (which fits into the hip socket) and the ball of the joint both are made of metal, rather than a combination of metal and plastic or ceramic.

Early models of all-metal implants were abandoned in the 1970s because they were considered unstable. But nearly a decade ago, new models were introduced and aggressively marketed as the durable choice for active adults eager to bike, hike and pursue other exercises into their golden years. What physicians and patients have found, however, is that the metal ball and the metal cup in this set up, slide against each other during walking or running, causing metal fragments to flake off into the space around the implant; this, in turn, damages surrounding bone and tissue. The mountain of complaints has moved one major manufacture to issue a worldwide recall of some of these products in 2010.

And while artificial joints are expected to last 15- to 20-years, many of the all-metal models have failed within just a few years, with the highest such rates among women.

In a small number of patients, high levels of metal ions also have been found in the bloodstream, and this has raised the fear that toxic metal ions may cause cancer. However, a study published in the April 3 issue of The British Medical Journal concluded that patients with all-metal hip replacements do not have an increased risk of cancer in the first seven years after implant, though researchers added that long-term data need to be collected, as some cancers can take years to develop.

The number of Americans with problematic hip replacements is unknown, though an estimated 500,000 people here received all-metal hip implants. More than 3,500 of them have filed lawsuits against manufactures. The first case goes to trial in December in Las Vegas.

Walk, swim or bike

There's a long way from the onset of osteoarthritis to the need for joint replacement. And though we have no means of stopping its progression, there are ways to lessen risk. The unsurprising prescription: Weight management and exercise.

Running or tennis may be tough with joint pain. But swimming, walking, biking and yoga are among exercises that can reduce joint-stress by strengthening surrounding muscles. Mayo Clinic researchers have found that strengthened quadriceps prevent deterioration of cartilage behind the kneecap.

As for weight, one recent study determined that 27 percent of hip replacements and 69 percent of knee replacements may be related to obesity; the more you weigh, the more pressure gets put on hips and knees.

So Boomers and seniors, make them Golden Years by staying as active as you can for the sake of your joint health; try different kinds of activities if some exercises are uncomfortable or give you twinges. And keep talking with your physician and other care-givers so you know about advances in technology, therapies, and, yes, surgeries, if these may keep you moving, feeling better, and experiencing less pain.

 
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