2. 2
The information in this presentation was provided to
the presenter by the American Academy of
Orthopaedic Surgeons and may be modified.
Endorsement of this presentation by the AAOS is not
implied or inferred.
4. 4
What is an orthopaedic surgeon?
◻ MD who specializes in treatment and
health maintenance of
musculoskeletal system (bones,
joints, ligaments, muscles, tendons,
cartilage and spine)
5. 5
What is an orthopaedic surgeon?
◻ The expert in treating the
musculoskeletal system
◻ The expert in maintaining
musculoskeletal health
6. 6
Educating an Orthopaedic
Surgeon
◻ College
◻ Medical School
◻ Internship
◻ Orthopaedic Residency
◻ Fellowship (optional)
◻ 2 Years Practice
TOTAL
4
4
1
4
(1)
2
16 years!
7. 7
What do orthopaedic surgeons do?
◻ Diagnose
◻ Treat
Medication
Physical Therapy
Exercise
Brace
Surgery
◻ Prevent
9. 9
Osteoarthritis
◻ Nearly 27 million Americans age 25 and
older have osteoarthritis
◻ 46 million U.S. adults report doctor-
diagnosed arthritis
◻ As the U.S. population ages, these
numbers are likely to increase dramatically.
◻ People who have doctor-diagnosed arthritis
is projected to increase to 67 million in 2030.
14. 14
Who is affected by osteoarthritis?
◻ Before age 45, osteoarthritis occurs
more frequently in males.
◻ After age 45, it occurs more frequently
in females
Gender:
15. 15
Burden of Disease
◻ 11 million visits to physicians offices
◻ 815,000 hospitalizations
16. 16
Symptoms
◻ Pain in affected joints
◻ Pain worse with
prolonged overuse
◻ Pain better with rest
and exercise
◻ Stiffness relieved by
flexing
21. 21
Diagnosis
Before your appointment:
▪ Prepare to describe your symptoms
▪ Gather medical history
▪ Make list of medications
▪ Write down questions and concerns
22. 22
Diagnosis
During Your Appointment
1. What should I expect from my
treatment?
2. What effect will my treatment have on
my daily activities?
3. What can I do to prevent further
disability?
24. 24
Causes
Primary Osteoarthritis: Most Common
◻ Thought to be result of aging
◻ Decreased ability of cartilage to repair itself
◻ Ligaments and muscles supporting joints
weaken
30. 30
Vitamins & Nutritional
Supplements
◻ Glucosamine
◻ Chondroitin Sulfate
◻ Some positive results
Mild to moderate pain relief
If benefits not seen within 8 weeks, not
likely
◻ Proceed with caution
35. 35
Exercise Dos
◻ Include flexibility, strengthening, and
aerobic exercises
◻ Exercise when pain and stiffness
lowest
◻ Exercise when you are not tired
◻ Exercise when medication having
greatest effect
36. 36
Exercise Dos
◻ Always warm-up and cool down
◻ Start slowly, progress gradually
◻ Avoid becoming chilled or
overheated when exercising
◻ Use heat, cold, & other pain
reducers
37. 37
Exercise Dos
◻ Use aids like walking sticks or
canes if needed
◻ Expect minor discomfort
◻ Use two-hour rule: No more pain
two hours after exercising than
before you started
38. 38
Exercise Dos
◻ Talk to your doctor first
◻ Consider athletic
trainer or physical
therapist
39. 39
Exercise Don’ts
◻ Do too much too soon
◻ Hold your breath while
exercising
◻ Take extra medication before
unless your orthopaedic surgeon
suggests it
40. 40
Heat & Ice
◻ Moist Heat
Towels, hot packs, bath, or shower
15-20 minutes
3 times each day
41. 41
Heat & Ice
◻ Cold Therapy
Ice packs
10-15 minutes at a time
42. 42
Too Much Exercise
Consult your doctor if these symptoms are
present:
◻ Unusual or persistent fatigue
◻ Increased weakness
◻ Decreased range of motion
◻ Increased joint swelling
◻ Continued pain 1 hour after exercising
44. 44
Asking Questions About Surgery
◻ Duration of recovery?
◻ Assistance at home? How long?
◻ Disability after surgery?
◻ Physical therapy?
◻ Return to normal activity?
51. 51
AAOS Research Agenda
◻ Developed a summary of common
OA research questions
◻ Moving beyond drug testing and
surgical outcomes
52. 52
AAOS Research Agenda
1) Inflammatory response & OA disease
2) Important risk factors
3) Genes that trigger OA
4) Impact of improved implant design
5) Biological & mechanical factors that
influence OA
53. 53
OA Knee Research Agenda
6) Cartilage cell transplantation & other soft
tissue grafts
7) Impact of standardized criteria for
diagnosis
8) Exploration of factors that account for high
incidence rates
9) Societal impact of OA
10) Activity and exercise levels and OA
54. 54
Osteoarthritis
◻ If you are experiencing chronic
or recurring pain, stiffness, or
swelling around a joint, consult
your physician
◻ Your orthopaedic surgeon can
determine what type of arthritis
you have and make treatment
recommendations
57. 57
◻ Thank you for participating today
◻ Remember, your orthopaedic
surgeon can help get you back in
the game
Osteoarthritis and You
Editor's Notes
Good [morning/afternoon]. I’m Dr. [Name], an orthopaedic surgeon at [office] and I’m here to today to talk to you about some of the most common musculoskeletal problems, how they are treated, and what you can do to keep your musculoskeletal system as healthy as possible.
The information in this presentation was provided to me by the American Academy of Orthopaedic Surgeons and may be modified. Endorsement of this presentation by the AAOS is not implied or inferred.
We will begin our discussion today by discussing orthopaedics and the Bone and Joint Decade. We will then talk about osteoarthritis, the causes of and risks for developing this condition, and the treatment options available.
An orthopaedic surgeon is a medical doctor with extensive training in keeping your bones, joints, ligaments, muscles, tendons, cartilage, and spine in good working order. Together, all of these parts of our bodies make up our musculoskeletal system
Orthopaedic surgeons have the greatest knowledge of and experience with the wide range of conditions and treatment options available in musculoskeletal care, many of which do not involve surgery. However, if surgery is the best recommendation for recovery, the orthopaedic surgeon is the best trained to provide that surgical treatment.
As this chart shows, it typically takes 16 years or more of formal education and training to become an orthopaedic surgeon. Beyond that, special certification and life-long learning is essential, as orthopaedics is a field that is continually growing and evolving.
Orthopaedic surgeons use the most effective and efficient diagnostic tools and our experience in musculoskeletal treatment to determine the best course of treatment for our patients.
Now let’s talk more about osteoarthritis—its causes, its symptoms, prevention, and treatment.
If we x-rayed everyone’s joints every year, we would see that most people eventually develop some osteoarthritic changes to joints as they age. However, some people do not develop the symptoms of pain and swelling that we usually associate with osteoarthritis.
Nevertheless, nearly 27 million Americans age 25 and older have osteoarthritis[1]. 46 million U.S. adults report doctor-diagnosed arthritis[2]. As the U.S. population ages, these numbers are likely to increase dramatically. People who have doctor-diagnosed arthritis is projected to increase to 67 million in 2030[3].
[1] http://arthritis.webmd.com/news/20080102/about-21-percent-of-us-adults-have-arthritis.
[2] http://arthritis.webmd.com/news/20080102/about-21-percent-of-us-adults-have-arthritis.
[3] The Burden of Musculoskeletal Disease in the United States, 2008.
To understand osteoarthritis, it is helpful to first look at a joint and understand how it works. A joint is the place where the ends of bones meet. These bone ends of the joint are covered with a smooth material called cartilage. Cartilage cushions bone and allows joints to move smoothly and without pain. The synovium is a smooth lining that encloses the joint and produces fluid that helps reduce the friction and wear on that joint. Ligaments connect bones and keep your joints stable. Finally, muscles and tendons power joints and allow them to move.
Osteoarthritis strikes the weight bearing joints of the hips, knees and feet most frequently, followed by the fingers and the spine.
Arthritis is, simply put, inflammation of the joints. Inflammation is a normal reaction to injury or disease. Inflammation in turn results in visible swelling, pain, and stiffness, because as the joint becomes painful with movement, the individual avoids moving it, which causes the muscles to tighten, making it harder to use that joint. This results in more pain.
Usually this inflammation is temporary. But in an arthritic joint it may cause long-lasting and sometimes permanent disability. Osteoarthritis is a particular type of arthritis which affects the cartilage in the joints, causing it to break down and eventually be lost altogether.
Osteoarthritis frequently occurs in knees, a weight-bearing joint, that sometimes has experienced trauma, infection, or injury, and leads to deterioration or loss of the cartilage that acts as a protective cushion between bones.
As the disease progresses, the cartilage thins and becomes grooved and fragmented, while the surrounding bones react by becoming thicker, growing outward, and forming spurs.
Additionally, the synovium, a lining that produces a thick fluid that helps nourish the cartilage and keep it slippery, becomes inflamed and thickened. The synovium may produce extra fluid, often known as “water on the knee,” that causes additional swelling.
A joint affected with osteoarthritis attempts to repair itself, and non-weight-bearing joints, such as those in your fingers, may be able to slow down the process. However, in the knee, the repair process is usually unsuccessful, and over a period of years, the joint slowly changes. In severe cases, the cartilage may no longer cover the thickened bone ends, resulting in rubbing and wearing away of the bone. Deformity of the joint may occur, and normal activity becomes painful and difficult.
Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in males. After age 45, it occurs more frequently in females [1].
[1] http://health.nytimes.com/health/guides/disease/osteoarthritis/risk-factors.html
In 2004, people with osteoarthritis made 11 million trips to the doctor’s office [1].
There were also 815,000 hospitalizations due to osteoarthritis in 2004. [2]
[1] 2008. The Burden of Musculoskeletal Diseases in the United States
[2] http://www.hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit2_1.jsp
Unlike other systemic forms of arthritis, osteoarthritis does not affect the other organs of the body. Symptoms vary greatly from patient to patient, but the most common early symptom is pain in the affected joint or joints. This pain gets worse with prolonged overuse and is relieved by rest and moderate exercise. In addition to pain, many osteoarthritis sufferers experience a stiffness that is relieved by flexing the joint a few times. This stiffness, called gelling, is generally most pronounced in the morning or with prolonged sitting, such as during long car travel.
The effects of osteoarthritis can be fairly significant, but with proper treatment, we can get you back into the game, living your life to the fullest. Your orthopaedic surgeon will use a combination of an evaluation of your symptoms, a physical examination, and x-rays to make an arthritis diagnosis. Your physician may order blood tests, to evaluate for other forms of arthritis as well as other ailments that could be causing your symptoms.
These x-rays show the difference between an osteoarthritic and a healthy knee. You can see how the inflammation and cartilage damage is affecting the joint.
Before you see your orthopaedic surgeon, it’s a good idea to assemble your records and make written lists of medications you are taking, your medical history, including things you may not think are related to your osteoarthritis, and your concerns about your condition.
Many of my patients also decide to bring a friend or family member along. It’s common to be nervous or forgetful when you are seeing your physician for a health problem, so it’s usually beneficial to bring a relative or friend to help you understand and remember what went on during your visit.
We find that it is usually helpful when patients, or their companions, take notes. It’s very important to ask questions about anything you don’t understand. Three key questions are:
What should I expect from my treatment?
What effect will my treatment have on my daily activities?
And, what can I do to prevent further problems?
It’s usually helpful to ask your orthopaedic surgeon for any handouts or brochures that may help you and your family understand your condition and treatment. Your orthopaedic surgeon may refer you to an Internet web site, such as the AAOS site, orthoinfo.org, for more information.
Your orthopaedic surgeon will carefully analyze the location, duration, and character of your symptoms and the appearance of your joints as well as the results of other clinical diagnostic tools to develop a diagnosis and a treatment plan.
There are two types of osteoarthritis: primary and secondary. Primary osteoarthritis results from aging. Cartilage is about 80 percent water. As we age, the water content decreases, and the ability of the cartilage to repair and rebuild after injury also decreases. Further adding to these developments, the ligaments and muscles supporting our joints are weakened with age so that the joint is less stable and more easily injured.
In contrast, secondary osteoarthritis is caused by another disease or condition. Obesity, repeated trauma and infection are common causes of secondary Osteoarthritis. In addition, abnormal joints at birth, gout, diabetes and various hormone disorders can also be a factor.
Obesity not only puts excessive pressure on the joints—it also causes the production of enzymes that cause cartilage damage. Obesity is a risk factor in the development of gout and diabetes. Even if you have already developed osteoarthritis, losing weight can help reduce your pain and stiffness.
The primary goals of osteoarthritis treatment are to relieve pain, increase motion, and improve strength. There are several different kinds of treatment and several options within each of them. The most conservative treatments, with the fewest risks, include rest, exercise, weight reduction, and physical and occupational therapy. In addition, your doctor may recommend medication. In some severe cases, surgery may be beneficial.
Your treatment plan may include a combination of:
Modification to activities and behavior to improve your overall health, such as nutritious eating, losing weight, or quitting smoking; Taping or bracing; Medications; Injections directly into the joint; Surgery; and Experimental or alternative treatments.
There are a variety of medications that can provide some relief from the effects of osteoarthritis. Over-the-counter pharmaceuticals like aspirin, ibuprofen, and naproxen may be used to effectively control pain and inflammation. These medications are all nonsteroidal anti-inflammatory drugs, or NSAIDs. Even though they are over-the-counter, they are not risk-free when taken for prolonged periods of time. Acetaminophen may also be used to control pain, although it does not reduce inflammation, and in high doses can cause liver problems.
Vitamin supplements and nutraceuticals have offered some positive evidence to suggest their use in the treatment of Osteoarthritis, but care should be taken, as they may interact with other medications. Always consult your orthopaedic surgeon to be sure that any vitamins or neutraceuticals you take are safe for you. The neutraceuticals glucosamine and chondroitin may help treat osteoarthritis. However, there is some disagreement in the medical community about how effective they are.
Glucosamine and chondroitin sulfate are two of the more popular dietary supplements. Both are derived from animal products and have become very popular as treatments and even as supposed cures for osteoarthritis. While some positive results have been reported, the treatment effects are probably exaggerated. Some patients do report mild pain relief, but it seems to be similar to that resulting from NSAIDs. If there is no change in symptoms after an eight-week trial, it is unlikely that these supplements will be of benefit to you. Again, check with your orthopaedic surgeon before taking any supplements.
As a note of caution, while glucosamine and chondroitin are safe, they are sometimes sold with substances which are not proven to be safe. There is no oversight from any governmental agency that controls and regulates manufacturing practices for these supplements. Further, some brands have been found to have much less of the active ingredients than is claimed on the label. Therefore, if you wish to try one of these supplements, ask your orthopaedic surgeon to see if he or she recommends a particular brand.
Alternative therapy options for the treatment of osteoarthritis are great in number, but their effectiveness and even safety are often unclear. These treatments may include yoga, hypnosis, biofeedback, or dietary changes. While complementary medicine is not a cure-all, it may help you take an active role in your health care and ease some of your symptoms, especially pain, stiffness, stress, anxiety, and depression. It can also improve your outlook, your attitude, and the quality of your life. This is why complementary treatments should be used in conjunction with traditional medical approaches, with the approval of your orthopaedic surgeon.
While complementary medicine can work with conventional medicine to promote wellness, it can not treat acute illnesses, replace proven medical treatments, or cure chronic diseases such as osteoarthritis. Avoid any practitioners who claim that they can provide a cure or who refuse to work with your orthopaedic surgeon.
Perhaps one of the most beneficial of the joint protection treatment options is exercise. Exercise usually does not aggravate osteoarthritis as long as it is kept at levels that do not cause pain. Exercise strengthens muscular support around the joints, prevents joints from “freezing up,” improves and maintains mobility, helps you lose weight, and promotes endurance. As part of a comprehensive arthritis treatment plan, your orthopaedic surgeon and physical therapist will work with you to determine the amount and form of exercise that will work best for you. In general, exercise that focuses on improving your range of motion is recommended daily, with strengthening exercises daily or every other day, and endurance exercises about 3 times per week for 20-30 minutes unless you are experiencing severe pain or swelling.
Strengthening exercises can make use of small free weights, exercise machines, isometrics, elastic bands, and resistive water exercises to strengthen your muscles and help take some of the burden off of painful joints. Correct positioning is critical during strengthening exercises. Done incorrectly, these exercises can cause muscle tears, more pain, and more joint swelling. Ask your orthopaedic surgeon if you should participate in strength training, and if so, do so under the supervision of a trainer.
There are some key dos and don’ts when it comes to exercise for Osteoarthritis sufferers:
Do
Build a program that includes the three important kinds of exercise: Flexibility movements, strengthening exercises, and aerobic exercise.
Exercise when you have the least pain and stiffness.
Exercise when you are not tired.
Exercise when your medication is having the greatest effect.
Always include a warm-up and cool-down.
Start slowly, and increase your activity gradually.
Avoid becoming chilled or overheated when exercising.
Use heat, cold, and other strategies to minimize pain.
Use aids like walking sticks or canes if you need to.
Expect some minor discomfort.
Use the two hour rule: You should not have more pain two hours after exercising than you did before exercising. If you do, talk to your physician or physical therapist about how to modify your exercise plan.
The first step in any exercise program is talking about it with your physician. If you have osteoarthritis, it is advisable to begin a new exercise program with the supervision of your physical therapist or a qualified athletic trainer.
Here’s what you don’t want to do when exercising:
Don’t
Do too much, too soon.
Hold your breath when exercising.
Take extra medication before exercising to prevent joint or muscle pain, unless suggested by your orthopaedic surgeon.
Heat and ice can be beneficial treatment options when used properly. Moist heat in the form of warm towels, hot packs, a bath, or a shower can be used for 15-20 minutes three times a day to provide relief from osteoarthritis pain symptoms. However, deep heat is NOT recommended for patients with acutely inflamed joints.
If you elect to use cold therapy, wrap an ice pack in a towel before applying it to affected areas for 10-15 minutes at a time. Do not apply ice directly to the skin.
Can you get too much of a good thing? Yes! If you are experiencing any of the following signs, you may be doing too much exercise and should consult your orthopaedic surgeon:
Unusual or persistent fatigue,
Increased weakness,
Decreased range of motion,
Increased joint swelling, or
Continued pain (pain that lasts) one hour after exercising.
In some cases of osteoarthritis, surgery may be warranted.
If your orthopaedic surgeon recommends surgery, it’s a good idea to ask questions to be sure that you understand why the procedure is recommended, what your options are, and how you can expect to benefit from it.
Part of understanding the course of action your orthopaedic surgeon recommends is being aware what your recovery will be. Some questions to ask are:
How long will the recovery take? Will I need assistance at home afterwards? For how long?
Will I have any disability following surgery? Will I need physical therapy? When can I safely return to normal activity?
There are several surgical options for osteoarthritis patients. Repair or partial removal of damaged knee or shoulder cartilage in arthroscopy is one of the less invasive procedures, as it is usually performed on an outpatient basis through the insertion of an arthroscope into a small incision in the joint. You and your surgeon will discuss the best options for your circumstances, taking into consideration the latest research on effectiveness of each course of action.
Realignment of joints and fusion of bone ends of the joint to prevent joint motion and relieve joint pain are surgical possibilities.
Many patients with osteoarthritis of the hip or knee now benefit from total joint replacement. We are receiving good to excellent long-term results for more than 90 percent of the patients who have total joint replacement [1]. These surgical procedures involve the removal of the diseased or damaged joint and replacement with a prosthetic joint, made of a combination of metal, plastic, or ceramic materials. Many of the millions who choose this procedure enjoy a full return to their lifestyle before osteoarthritis limited their joint functioning, with only some modest modifications or cautions.
[1] http://orthoinfo.aaos.org/topic.cfm?topic=A00233
Karen Skinner is a cattle rancher in Oregon. When the negative impact of the pain and decreased mobility of her knee became too great to allow her to participate fully in her life, she knew it was time to take action.
[Presenter: You can download a short video on this case study at the AAOS web site, to use in this presentation. If you do not wish to use the video, please delete this and the preceding slide.]
Continuous advances being made in joint replacement procedures and prosthetics, molecular biology, and genetics are likely to contribute to more available treatment options for osteoarthritis. Application of knowledge gained in the areas of gene therapy, tissue engineering, and cartilage repair and re-growth to the treatment and prevention of osteoarthritis could lead to significant developments in patient care. There are ten critical areas of research focus for knee osteoarthritis that are most likely to net positive results in patient care.
To maximize opportunities for advancement in the treatment of osteoarthritis, the American Academy of Orthopaedic Surgeons proposes the development of a comprehensive research agenda. AAOS reviewed key research questions for guiding understanding and treatment of osteoarthritis by a number of sources and organizations to develop a composite summary of some common osteoarthritis research questions that move the current research activity beyond drug testing and surgical outcomes.
The ten issues that the AAOS identified are:
The relationship between inflammation and the progress of the disease, which may have great importance in developing treatment protocols.
The risk factors associated with the development of osteoarthritis.
The genetic component of osteoarthritis—specifically, which genes are responsible for triggering the onset of osteoarthritis?
The implants used in total joint replacements, and whether technological improvements in this area can reduce the number of patients who need a repeat surgery.
The biological and mechanical factors that influence the progression and repair of osteoarthritis, leading to cures in the early stages or a reduction in the number of patients who require surgery.
Other possible modes of treatment that could prevent the late changes of osteoarthritis that lead to the need for joint replacement.
Whether the criteria for diagnosing osteoarthritis can be standardized, so that researchers can more easily compare cases.
The comparative rates of osteoarthritis among different races, genders, and ages.
The societal impact of osteoarthritis.
Whether an increased level of activity or exercise plays a role in the development of osteoarthritis.
Many of those who have osteoarthritis do not know which type of arthritis they have and can not make informed decisions about their care because treatment options vary among the more than 100 forms of arthritis. If you have pain, stiffness, or swelling in or around a joint, for more than two weeks, it’s time to see your orthopaedic surgeon. While there is no cure for arthritis, there are many strong treatment options available for osteoarthritis. If you think you have arthritis, or you are interested in learning more about the treatment options available to you, consult your orthopaedic surgeon. As experts in musculoskeletal health and the care and treatment of arthritis, we can guide and direct you to the best treatment for your specific situation, and help get you back in the game.
To find an orthopaedic surgeon in your area, AAOS has a “Find-A-Surgeon” feature at www.aaos.org. In addition, the Arthritis Foundation website (www.arthritis.org) and the AAOS patient education website (www.orthoinfo.org) will provide you with more information about arthritis.
Do you have any questions or concerns that we have not yet addressed?
Thank you for participating today. I hope that you have each learned something helpful about dealing with osteoarthritis and its causes. If you or someone you love is suffering with osteoarthritis, your orthopaedic surgeon is your best resource to guide you on the road to recovery and get you back in the game.
