Mar 11, 2015

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Interviewer: In this series of podcasts we've been talking about total joint replacements for the hip or the knee, and trying to figure out if it's right for you. If you do decide you want the procedure we're also in the series covering what to expect before, during and after. And in the first segment we talked about if a replacement may be right for you.

But another consideration is have you tried more conservative measures to alleviate your pain? And to help sort through them is Dr. Chris Pelt. He's a joint replacement expert at University of Utah Healthcare's Orthopedic Center. Tell us about some of the options patients should try before they make the next step to a complete joint replacement.

Dr. Pelt: Well the first thing that most people already do before they even come to a doctor is they that either have not addressed the fact that they have pain or they've started to modify their activities. Most people start to do that on their own, and it's one of the indicators that they're being bothered by their joint pain and arthritis. Things like they stopped running as far, or they stopped running altogether. Their hikes may become walks around the block instead of hikes in the mountains, maybe they're not skiing the double black diamonds anymore, or avoiding the moguls and they're sticking to the groomers now. Starting to change the things they do at work, starting to do the things they do at home differently. Maybe they can't even go to the grocery store as much as they used to, or they're having to use a walker or a wheelchair at times. So people start to modify their activity.

When we start to provide conservative treatments through our primary care colleagues, non-operative specialists or even ourselves, when we're trying to avoid surgery, we utilize other modalities. Things like physical therapy. Perhaps braces, or compression wraps. I mentioned wheelchairs or crutches, or walkers. Things like assistance devices. Some people start to use a cane. We can often offer medications. The mainstay in the treatment of arthritis pain is to attempt to decrease pain associated with inflammation. Arthritis is simply when we lose that smooth cartilage on the end of the bones in our joints, it creates a rough mechanical problem. That also creates inflammation so using a medication like an anti-inflammatory can decrease the inflammation and therefore also decrease the pain associated with it.

There are other things besides just anti-inflammatories, and some patients may not be able to take an anti-inflammatory. Patients with renal or kidney problems, patients with stomach issues or ulcers. They may have other reasons that they can't take an anti-inflammatory, so there are other things to take as a medication for pain as well. Things like Tylenol. Over the counter Tylenol works very well. Acetaminophen as an analgesic or a pain relieving medication. There are other types of pain relievers we often try to avoid, but they do exist for the treatment of arthritis based pain, like narcotics. Norco, or Tramadol or other similar types of medications can be tried as well. Again, we try to avoid those because there are other, better modalities often than giving people narcotics.

There are creams, topical creams. Anti-inflammatory creams. Joint relieving bio-freezes and Ben-Gay type of creams that people also can use. And we have some over the counter as well as some prescription based types of creams as well. Injections are another method that obviously we will try to use. And the idea there again is trying to decrease the inflammation and decrease the pain in the joint without performing a big surgery.

There are two types of injections that are typically tried, Cortico-steroid injections. A lot of people refer to these as the cortisone injection. It isn't actually cortisone that most surgeons or doctors are providing, but it's a type of a medication designed to decrease inflammation and therefore pain in the joint. A lot of patients will ask us about these injections. "Is this going to make my arthritis go away?" And the answer is "Probably not, but it may make you feel better that you don't care that the arthritis is there." It decreases your pain and allows you to do the activities you need to do without having to have a big surgery.

A second type of an injection might be something that is commonly known as a joint lubricant, or some people hear it referred to as a chicken comb based injection. And that's based on the material that the companies are providing in these types of injections. What this is is the building blocks of cartilage. And when injected into the joint it may provide two potential effects, one of them being to act as a joint lubricant. When we look at it in the studies it may not be that that lasts very long, sometimes even only a couple of days of this lubricating effect in the joint.

But secondly what it does is it starts to, your body starts to break down these injections it also creates an anti-inflammatory reaction or response to suppress the inflammation in the joint as well. And these injections may last even longer, with months if not years of relief for those patients that are well indicated and have a good response for that. More and more we're seeing insurance companies and others have stricter criteria for patients that might be candidates for those joint lubricant injections, but nonetheless it's one of the other things that exists as possibility for treating pain without surgery.

And the final option is a surgery of some sort. And there are two types of surgeries in general for people with hip or knee conditions. One of them, arthroscopy or minimally invasive camera type surgery, and then the other being joint replacement surgery. The lesser invasive things like arthroscopy may not be suitable for all patients with arthritis though, and that will be a discussion best had with a surgeon.

Interviewer: So it sounds like before we get to surgery, is it your goal as a surgeon to try a lot of these things before you actually do the replacement?

Dr. Pelt: It's our goal, not because we're trying to make patients jump through hoops or delaying the inevitable, but we're trying to prolong the life of their native joint. So once again, when we're putting in a joint replacement, these are parts that may not last for the rest of these patients lives, and we want to maximize the life expectancy of the implant that's going to be replaced and some point, but also to maximize their function with the current joint that they have, without perhaps undergoing a major surgery. At least not yet, if that's inevitable for them.

Interviewer: In the next episode we'll talk to Dr. Chris Pelt about the similarities and the differences between knee and hip surgery. There are a lot of things you need to know about both surgeries that are the same, and there are a few differences as well.

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