“Although I am a surgeon, I believe that you should have an operation only as a last resort. Our approach to arthritis is very conservative, and we try common-sense steps first before recommending surgery.” – Dr. Romano
My approach to arthritis care is very conservative. Although I am a surgeon, I believe that you should have an operation only as a last resort. Total joint replacements are wonderful and can be life changing. However, they also can be painful, wear down prematurely and become infected. For the latter, we take great precautions to prevent infection such as daily scrubs with antibiotic soap days before surgery, appropriate and timely antibiotics, recommending good dental care before surgery, meticulous operative techniques and sterility precautions, silver-coated dressings and short hospital stays.
As far as wearing down of the prosthesis goes, we know that a total joint replacement in a 70-year-old patient will last approximately 15 years. With the average life expectancy being 85 years, chances are that this would be the only knee replacement that he or she would need. For a 45 year old, who is much more active than a 70 year old, his or her knee replacement may last only 10 years.
“No problem, go ahead and replace the knee again in 10 years.”
Big problem! The total knee consists of metal moving on plastic. Like the heel of your shoe, the plastic will wear down over time. The more active you are, the faster the plastic will wear down. Add obesity to the equation, and the plastic will wear down even more.
The problem is the plastic debris. We know that in the future we will have a problem with our garbage because our plastic waste will not break down and will last for over 1000 years. The same goes in the knee. Over time, the plastic debris will accumulate in the knee joint. The more active you and the more you weigh, the more plastic debris. Now your white cells in your body will recognize this plastic debris as foreign bodies and try to break it down. The more debris, the more white cells will appear. Again, the plastic cannot break down. Instead, the white cells will breakdown the surrounding bone. Therefore, when it becomes time to replace the plastic, we would also have to replace the bone. That is a big surgery that I don’t enjoy, and I guarantee, you won’t enjoy either.
The best approach for arthritis of the knee is to wait as long as possible before replacing the knee. This way, when it comes time to replace the knee, the replaced joint won’t have to last as long. Furthermore, the longer you wait, the better the knee replacements will be with advances in science.
“I see on the internet that they have new knee replacements that will last 30 years.”
Do not believe everything you see on the internet? Although technology is improving daily, these knee replacements haven’t been around for 30 years. It’s better to wait a little while to make sure they prove themselves. When it comes time for a knee replacement, you will get the best one available at that time.
I recommend a 6-step approach for arthritis that you can do without the need of a medical professional.
#1. Good Shoes with Arch Supports:
With weight bearing, the arches in our feet tend to fall. Good shoes with arch supports will improve the alignment of the foot and ultimately improve alignment of knee. In addition, the foot and the ankle act as a shock absorber for the knee. The better the shoe, the less stress you will have on your knees. Here are some recommended arch supports:
- Spenco, Sof Sole or Superfeet (best of the soft ones, between $20-$30)
- Dr. Scholl’s computer fitted arch suppurts in Wal-Marts and Walgreens ($50)
#2. Hinged knee brace as needed for support:
Although a knee sleeve may be enough to relieve some stress to your knee, a hinged knee brace may be even better. Best is a hinged knee brace that unloads the arthritic area and allows you to pursue more pain-free activities, which you may not have been able to do otherwise. The sturdier the brace, the bulkier it is. I recommend that you wear the smallest brace that makes you most comfortable and that you will wear, not for everyday activities, but for extra activities such as shopping, golfing or exercise. You may as well be as comfortable as you can. Note that if you need a brace as soon as you get up in the morning and take it off before you go to bed, it may be time to get a knee replacement.
#3. Over the counter pain medication and anti-inflammatories for pain or discomfort
- 500mg every 6 hours
- Maximum dosage: 2000mg in 24 hours
- Beware of other medications that contain acetaminophen!
- Too much Tylenol may damage your liver.
Non-steroidal anti-inflammatory drugs (NSAID)*:
- Advil (ibuprofen):
- 1 – 4 tablets, of 200mg each, 3 x/day
- Maximum dosage: 2400 mg in 24 hours
- Aleve (naproxen):
- 1 – 2 tablets, of 220 mg each, 2 x/day
- Maximum dosage: 880 mg in 24 hours
Topical pain relieving creams
- Cortisone, Aspircream, Anica
- Prescription combinations
*Note: Do not mix NSAID’s.
NSAID’s should be taken with food. Beware of possible side effects: bloody or dark, tarry stools. If so, stop immediately and contact you physician.
*If you are taking NSAID’s for an extended period, consider taking Pepcid, or any other over-the-counter PPI, to protect your stomach from ulcers.
#4. Dietary Supplements
- 1000mg, 2x/day
- Glucosamine and chondroitin sulfate are amino acids, which are the building blocks of protein. Together they make up our cartilage. While research is inconclusive, some studies show that glucosamine can help 50-75% of patients; whereas, placebo only helps up to 20% of patients. Furthermore, owners of large dogs report that their dogs are much more active while taking glucosamine. I am not aware of any placebo effects on dogs. Furthermore, studies showed that when large dogs take glucosamine as puppies, they do not develop arthritis as adults.
- I recommend buying a 2 months’ supply of glucosamine. If it works, great, continue using it. If not, stop. I also recommend that all long-distance runners should be taking glucosamine as a preventive measure. It can’t hurt.
*Note: There are two types of glucosamine on the shelves, glucosamine sulfate and glucosamine HCL. Glucosamine sulfate is better absorbed, and is used more commonly in Europe where more studies say that it works. Check the label carefully and choose glucosamine sulfate.
“What about chondroitin sulfate?”
Many brands of over-the-counter arthritis medicine contain a combination of glucosamine and chondroitin and many other ingredients. Chondroitin is poorly absorbed so that if you take it orally, it may not get into your system. Combination pills are also larger. So if you have difficulty swallowing large pills, you may choose plain, “unleaded”, glucosamine sulfate and break the pills in half.
Omega 3/Fish Oil
- 1-2000mg, 2X/day
- Omega 3 has been shown to help your heart, brain and joints.
- It’s a 3-for-1 deal! Why not take it?
Vitamin D3, 2000mcg/day
Dietary Calcium 1200mg/day
*Note: It is important to keep our bones strong and healthy. People with arthritis and osteoporosis have more pain than people with arthritis and healthy bones. If warranted, we will obtain a bone density exam for you.
#5. Daily exercise program. (Use it or lose it!)
Studies show that arthritic patients who exercise do much better than those who don’t. I recommend at least a 20-minute daily exercise for all patients with arthritis. Remember that the old saying, “No pain, no gain?” That’s old school. Pain is telling you, “Stop! You’re hurting your joint.” Exercise should not be painful and should include stretching, aerobic activity and strength training. If physical activities or exercises cause discomfort, you should consult a physical therapist.
#6. Nutrition and Weight loss
Doctor: “Does carrying groceries up the stairs hurt your knees?”
Patient: “I never do that, it hurts too much.”
Doctor: “Why is that?”
Patient: “Too much weight.”
Doctor: “Exactly! That’s why if you lose a ‘few bags of groceries,’ your knees would feel so much better.”
Weight loss will reduce the stress on your knees, limit further injury, increase mobility, and reduce the risk of associated health problems. I know that it is not easy to lose weight. And if you simply starve yourself and don’t exercise, your body will go into the hibernation mode, making it more difficult for you to lose weight. We will help you find a good nutritional diet and exercise program to help you achieve your goal.
If conservative therapy is not enough, a knee injection may help. They are not a cure. They cannot rebuild your cartilage, but they can “buy time” so that you may resume your normal activities in comfort and delay the need for surgical intervention. Injections may last up to 3 months to a year. There are three types of injections.
Cortisone is a steroid that stops the inflammation in the joint which relieves pain. I do not like to give it to younger patients or in patients with little arthritis because it may contribute to the further breakdown of cartilage. Given around the clock, steroids may be necessary in some patients with specific diseases, but in the long term can make you retain water, weaken your bones, raise your blood sugar, cause cataracts and many other side effects. However, steroids in your knee joint, given 4 times a year, is usually safe.
Hyalgan (or similar name brands):
Hyalgan is a hyaluronic acid that is found naturally in your knee joint and acts as a lubricant. Derived from the coxcombs of roosters, hyaluronic acid is deficient in arthritic knees. Injecting it in your knee can give you up to 1 year of relief. Since these injections are very expensive, Medicare and most insurance companies regulate its use. They only will allow injection given no more than 6 months apart. Studies have shown that a series of five injections, spaced one week apart, will improve your pain more a single injection. Furthermore, if you receive an injection in 6-month intervals, your pain will be much better than if you wait to receive your next series of injection when your pain is unbearable. Therefore, in the Hyalgan shots do help you, then I recommend that you schedule your next series of injections 6 months and a day after your last injection.
PRP and Stem Cell Injections:
Platelet Rich Plasma (PRP) and Stem Cells are your own cells which are injected into your joint to stimulate cartilage re-growth. (PRP comes from your own concentrated blood and Stem Cells come from your bone marrow.) Numerous studies have found these methods to relieve pain and improve function, yet insurance companies still consider them experimental and refuse to pay for such treatments. We have had good results from these injections and will consider them for certain patients in special situations where surgical correction is not a good option.
When all the above is tried and stops working and you are not ready for that rocking chair, then surgery may be your best option. If surgery is necessary, rapid and successful recovery is possible by optimizing your physical and nutritional health before surgery, performing surgery with computer-assisted, patient-specific total joint instrumentation and using an aggressive rehab program, like the ones we give our athletes.