 Thanks everyone for joining us today for our knee and hip arthritis webinar with Dr. Suman Nandi from University of Maryland Orthopedics. Dr. Nandi is the Chief of Adult Reconstruction for University of Maryland Orthopedics and he's also an associate professor of orthopedics at the University of Maryland School of Medicine. Dr. Nandi will go through his presentation about the symptoms diagnosis and treatments for hip and knee arthritis. We invite you to leave your questions for Dr. Nandi in the chat or questions box and we will get to the Q&A at the end of the presentation. We hope you enjoy. Dr. Nandi, take it away. Thank you very much. So thank you everyone. It's wonderful to have the opportunity to speak to all of you this afternoon. Just to tell you a little bit about myself, I am one of the total joint replacement surgeons at the University of Maryland. I'm originally from the area I was born in Baltimore and grew up in Howard County, went to school at NYU for medical school, did my training in orthopedic surgery at the Cleveland Clinic, and then did my specialty training in hip and knee in Boston where I was faculty before having the opportunity to return to Maryland. So today's talk is going to be very informal. I would love to hear questions from all of you, from each and every one of you, please do write your questions in. And at the conclusion of my talk today, I'd love to answer any questions on your mind. So again, today I'd like to speak to you about the symptoms diagnosis and treatment of hip and knee arthritis. So first things first, what is arthritis? Well, arthritis is a process. It's not a thing. It's a process by which the cushion in your joint wears away and then your bones grind against one another and that causes pain. So if I could just draw your attention to the left hand side of this slide, the panel on the left, that's a cartoon of the knee. So you see at the top, there's the thigh bone or femur. At the bottom, there's the shin bone or tibia. And the ends of these bones are coated by a smooth glistening surface called cartilage and it's depicted in this picture in pink. Well, if you take a camera and put it into a nice normal knee, what you see is the picture in the middle of the slide. And you can see those surfaces are nice and smooth. And as you can imagine, it'd be a nice surface to walk on. It'd be pain-free and that patient is pain-free, all right, because that's a normal knee. Now again, what happens in arthritis? The process by which the cushion in your joint wears away and then your bones grind against one another and that causes pain. Well, what happens is what you see in the panel on the right. So if you took a camera and put it into an arthritic knee, that's what you'd see. And even looking at it, you can tell that must be painful to walk on. You can see how instead of the smooth glistening surfaces that you see in the middle slide, you have these beat-up surfaces like crab meat that are floating in the knee and you can see towards the right-hand side of the picture on the right-hand side of the slide that there's exposed bone. So there's literally bone rubbing against bone and that hurts. And that's what happens in arthritis. Well, there are different types of arthritis. So let's go over a few of these types. I'm sure many of you have heard of rheumatoid arthritis. What's rheumatoid arthritis? Well, it's an autoimmune process. It's a process by which the body attacks its own joints. One of the hallmarks of rheumatoid arthritis that differentiates it from other types of arthritis is that it's bilateral. And what does that mean? That it affects both hands, both knees, both hips at the same time. And it can be so significant that it can cause deformity as you see on the left-hand side of this slide here. If you take a look at that gentleman's hands, you can see that his fingers are no longer straight. And his x-ray of his hands is shown on the right-hand side of the slide. And as you can see, those bones are no longer straight. And that's what's happened as a result of the rheumatoid arthritis. The arthritic process is so deforming that it's caused his fingers to be no longer straight, to be bent. So this is rheumatoid arthritis. Well, there are other types of arthritis as well. One group of arthritic conditions is called crystalline arthropathy. And it's a family of conditions. And one member of this family is called gout. And I'm sure many of you have heard of gout. Well, what happens in gout? Well, the fluid within the joint fills up with crystals. And as a result, you can get joints that look like the image that you see on the left. Where there are large collections or deposits that form right above the joints. And those large collections are called TOFI. And if you took a look inside those large collections, it would be filled with this cottage cheese material. And if you then put that underneath a slide, you would see what you see on the right-hand side of this slide under a microscope. All right, you would see these millions and millions of needle-shaped crystals underneath the microscope on the microscope slide. And as you can imagine, that would hurt. So these crystals all cause a lot of inflammation within the joint and pain. So what I've shown you here in this slide is gout, which is one member of a family of crystalline arthropathies or arthritis. Well, this is not the only type of arthritis. We've got more. So in this slide, what I'm showing you is osteoarthritis. This is the most common type of arthritis. And many of you in the audience may have osteoarthritis. It is, as I've said, the most common. It is unilateral. So remember when we talked about rheumatoid arthritis, I said it was bilateral. So it affects both knees, both hips, both hands. Well, typically osteoarthritis is unilateral. It affects one side of the body at a time. That's not to say that it can't affect both, but it typically affects one side at a time, or at least one side is worse than the other. And what happens in osteoarthritis? Well, it's just like a wear and tear phenomenon. It's just like treading your tires, right? You drive enough miles, the tread wears away. Similarly, in osteoarthritis, the cushion in your joint just wears away over time. You have enough birthdays and this happens, happens to everybody. So let's take a look at the picture on the left-hand side of the slide. All right. So this gentleman has one arthritic knee and one normal knee, and you can probably already tell me which one is which. So the knee, the left knee for this patient, which is actually on our right-hand side because it's the patient facing us, the patient's facing us. The knee on the left-hand side, okay, or the patient's left knee on the, again, on the right-hand side of the slide is the normal knee. You can see how that leg is straight, right? It's straight. It's not particularly swollen. But if you take a look at the patient's right knee, which is actually on the left-hand side of the picture on the left, the patient's right knee is swollen. His knee is bowed. He's become bow-legged over time. And that's as a result of the osteoarthritic process. Now, let me show you this gentleman's x-rays, which are on the right-hand side of the slide, and all of you are going to be experts at reading x-rays by the end of this talk, okay? I promise you. All right, I'll show you this one, and I'll show you a bunch, and by the end of the talk, you guys will just think it's as easy as pie to tell what's going on on x-rays, all right? So let's go ahead and get started. So on the right-hand side of the slide is the x-ray of this gentleman's knees, and on the right-hand side of the x-ray is the patient's left knee, the good knee, all right? So what you see on that side is the thigh bone on the top, the shin bone on the bottom, and in between, you have a space. And when you have a space between the bones, that means on an x-ray, you've got plenty of cushion left. Well, compare that to the gentleman's right knee, which is on the left-hand side of the x-ray, okay? And you can see that there's a part of his knee that has absolutely not one bit of space in that knee, and that's because of osteoarthritis, all right? The wear and tear phenomenon where all the cushion is worn away. Now there's no space between the bones. The bones are grinding against one another. And again, that causes pain, like we talked about in one of the previous slides. So this is osteoarthritis. Well, what are the symptoms? Well, like we just talked about with regard to the x-ray, right? With regard to the x-ray, the bones are grinding against one another. With that picture that I showed you, with the camera inside the joint, you have the exposed bone rubbing against one another. So what do you feel with arthritis? Well, you feel pain. So for folks who have hip arthritis, you feel pain in the hip, meaning the side of the hip, the groin. You can actually feel it in your rear as well. Well, what happens when you have knee arthritis? Well, you feel pain in your knee, all right? Well, here's what's really interesting. When you have hip arthritis, you can also feel it in your knee. And that's why when patients come to see me in the office, I examine both the hip and the knee for every patient. And I also get x-rays of the hip, even if patients are just having knee pain because knee pain can come from the hip. And that has to do with how our nerves are wired. Very interesting, isn't it? So if you got hip arthritis, you can feel it in the hip, meaning in the side of the hip, the groin and the rear end. But you can also feel it in your knee. If you got knee arthritis, you just feel it in the knee, all right? Well, as you can imagine, if you've got a really arthritic joint and your bones are grinding against one another, your knee or your hip can feel real stiff. Your knee or hip can swell up. And you can feel grinding within your joint, as you'd expect, right? Because that's exactly what's going on. Your bones are grinding against one another. Well, how do you diagnose arthritis? Well, when patients come into my office, I speak to them and I enjoy speaking to them. And it can actually give me a lot of information. I ask folks, where does it hurt? When did it start? How bad is it? What makes it better? What makes it worse? What have you tried for the pain? I also ask folks, and this is very telling, what are the things that you like to do that you can't do because of the arthritis? That tells me how bad things are. And it also tells me the kinds of things that patients want to get back to doing, all right? So that's a very important part of our patient interaction. Well, next, I examine patients. First, I look. I look at the knee, look at the hip because it can tell me just by looking at a patient, whether there's any evidence of infection, whether there's redness. I can, by seeing a patient walk, I can tell from the limb, if there is one, what's going on, all right? So just by looking, I'm able to glean a great deal of information. And then I move the knee, push on the knee, just like it's shown on the pictures on the right-hand side of the slide. I move the hip, push on the hip. And again, the exam tells me a great deal. And for patients who come to my office, I examine both the hip and the knee because, like we talked about in the last slide, hip problems can cause knee pain. So for patients who come to my office with knee problems, I always examine the hip and take X-rays of the hip as well. And that leads us to this slide right here. I promised you that all of you would be experts and I'm going to make good on that promise, okay? So we went over some knee X-rays. Let's go over some hip X-rays. So in the X-ray on the left, that is a normal hip. So here what you see is the ball and socket joint of the hip. The hip is a ball and socket joint. Here is the ball. Here is the socket, all right? And you see that there's an empty space here between the bones. And just like within the knee, when there's an empty space between the bones, that means there's cartilage left. That means there's cushion left. That's a good thing. It's good to be able to walk on cushion. That means that that patient is going to be pain free. But look what happens when you get arthritis and you have an X-ray that's shown on the right-hand side of the slide. Here you have the ball of the ball and socket joint. Here you have the socket. But now look, there's not one bit of space between the bones. The bones are grinding against one another. You can't tell where one bone ends and the other begins because there's not one bit of space. And again, because the bones are grinding against one another, you can imagine that this patient hurts because of the changes that have resulted from the arthritic process. I bet everyone in the audience can tell me what's going on here, all right? I'm sure you're already pros. But here I show you an X-ray of a knee, a normal knee on the left. Here's the thigh bone. Here's the shin bone. And look, you got plenty of space. So this is the normal knee. But look here, not one bit of space here in the knee. This is an arthritic knee and this patient hurts. So as you can tell, X-rays are very helpful in the diagnosis. You actually don't need any fancy imaging like MRIs or CTs. You can tell what's going on based on the X-rays. And in fact, X-rays are even more helpful in many regards because when I get X-rays, I have my patients standing when they get the X-rays. So I see what they're going through when they're walking. MRIs and CTs are done with the patient laying flat. So you don't see what patients' joints are doing when they're standing upright. So again, in a lot of ways, X-rays are actually more informative. Well, fine. So we know that we have arthritis on our hands. What do we do about it? Well, first, we always start with the simple stuff. Always start simple first. We always start with nonoperative treatments. And one of the things that we can try are oral anti-inflammatory medications. First of all, folks, if you have arthritis, don't go out and start popping pills that you get at the drugstore after this talk. Check with your primary care doctor before you start to take anti-inflammatory medications, which include Advil, Aleve, Motrin, Ibuprofen. Tylenol is actually not an anti-inflammatory. That helps take away fever and pain, but it's not an anti-inflammatory. Advil, Aleve, Motrin, Ibuprofen, Moxican, Di-Clophanac, these are all anti-inflammatory medications. And check with your primary care doctor before taking them. Anything that can help can also do harm. Certainly do not take anti-inflammatory medications if you got heart problems, kidney problems, ulcers, or if you're on blood thinners. Because anti-inflammatories can cause bleeding. If your primary care doc tells you it's okay for you to take them, then you can take them. The way to take them is every day for at least two weeks straight because it takes two weeks to build up in your system and really give you the relief that you need. And certainly stop if your stomach hurts. You should always take it with food, but stop if your stomach hurts. Right? And again, check with your primary care doctor before you start taking these medications. All right? Good. But anti-inflammatory is an important first step. What else can we try? Well, we can try physical therapy and you may say, Doc, I can barely walk from here to the room next door and you want me to do therapy? Well, here's what the goal of therapy is. The goal of therapy is just strengthen the muscles around your joints so that those muscles can function like a shock absorber when your natural shock absorber ain't working so well. All right? So if you go to physical therapy, as it's shown in these images, they can work with you to strengthen those muscles to help those muscles function like a shock absorber. It may not work, but we always try everything short of surgery. Something else we can try is steroid injections. What do I mean by steroid injections? Well, steroid injections are really powerful anti-inflammatories and these steroids are legal. These are not what the baseball players are taking. All right? These are legal. And what you can do is you can inject these very powerful anti-inflammatory medications directly into the joint and they decrease the inflammation within the joint. And it can provide some temporary relief. Relief that lasts varying periods of time, but sometimes it can provide relief for a good long while. Okay? Good. So now, suppose you've tried all these things. You've tried the physical therapy, the anti-inflammatory medications, steroid injections. Suppose you've tried an ebra. Suppose you've tried not doing the things that bother you. Suppose you've tried and gotten to the point where you're even using a cane. Well, how do you know when you need surgery? Well, I don't tell my patients when to have surgery. I listen to my patients. When my patients tell me, I've tried everything short of surgery. It's not working and I can't live like this anymore. Then we start thinking about surgery. And when I say surgery, what do I mean? I mean total joint replacement surgery. Total joint replacement surgery is really the most reliable and effective surgical treatment for arthritis. In fact, if you take a look at the Medicare data, the most effective surgical treatments that a doctor can provide a patient are as follows. Number one is cataract surgery. But number two and three are hip and knee replacements, which is why I love what I do. It is really possible to change someone's life for the better with total joint replacement surgery, which I'd like to talk to you about in the next few slides. And I look forward to hearing your questions too. So I'm going to show you a little video on total hip replacements. And first I'm going to talk you through the video and then I'll show you the video. That way you know what you're going to be seeing. So what we do in a hip replacement is we remove the arthritic ball of the ball and socket joint, all right? Resurface the socket with a metal socket and a plastic liner, put a stem down the thigh bone and a ball on top. And that gives you nice smooth surfaces that glide against one another, as opposed to your bones grinding against one another. And that takes away your pain. It's as easy as that. So what we do is we first enter the hip, we remove the arthritic ball, resurface the socket with a metal socket and a plastic liner, put a stem down the thigh bone, put a ball on top. And that gives you nice smooth surfaces that glide against one another, as opposed to your bones grinding against one another. And that takes away your pain. It's as easy as that. So this is a before and after picture, all right? So again, all of you are pros now. So you know that that x-ray on the left hand side of the slide shows really bad hip arthritis, right? Here's the ball, here's the socket. There's not one bit of space there. That patient is hurting. And after they have a hip replacement, they have an x-ray that looks like this. Here's a metal socket, plastic liner, stem down the thigh bone and a ball on top. They've got nice smooth surfaces gliding against one another as opposed to their bones grinding against one another. And this patient is now pain-free. Now I'd like to show you a video on total knee replacements. Again, let me talk you through it first and that way you'll know what to look for when you actually look at the video. So what do we do in a knee replacement? We enter the knee. We resurface the end of the thigh bone and shin bone, cap the end of the thigh bone with metal, cap the end of the shin bone with metal, put a piece of plastic in between. And again, that gives you nice smooth surfaces that glide against one another as opposed to your bones grinding against one another. And that takes away your pain. So let's take a look here. We enter the knee. We resurface the ends of the thigh bone and the shin bone, cap the end of the thigh bone with metal, cap the end of the shin bone with metal, put a piece of plastic in between. That gives you nice smooth surfaces that glide against one another as opposed to the bones grinding against one another. And that takes away your pain. So now let's do another before and after. Again, I don't need to tell you what's going on here. This patient is hurting because they've got really bad arthritis. Their bones don't have any cushion left. The bones are grinding against one another. And here is the patient after a knee replacement. You've got metal capping the end of thigh bone, metal capping the end of the shin bone and a piece of plastic in between that you can't see because on an X-ray, you can just see very dense materials like metal, can't see plastic. The X-ray beams just go straight through it. And this patient is pain free. Well, what can you expect after surgery? Well, we have all our patients walk the same day of surgery. Why is that? Well, all the data shows that when you get patients up and walk in right after a hip or knee replacement surgery, it improves the speed and quality of your recovery. And that again, that's based on the data. So all the advice I give my patients is based on the studies and the data. That's what I use to guide my practice. Okay, because when it comes to something as important as your joints, your surgery, your quality of life, really, we need to have the data guide our practices and the decision making. So you'll hear me talk about the data over and over again as I go through the remainder of this talk and I answer your questions. For patients who are interested and are medically suitable, those patients go home later the same day. So the studies show that there are no increased risks with sending patients home the same day. Before the COVID era. This was very appealing to patients. They're able to recover in the comfort of their own home. They're able to have their own family members take care of them who takes better care of you than family nobody. All right. And now in the COVID era, it's particularly appealing to patients to minimize the time spent in the hospital. Now that being said, the University of Maryland has done a wonderful job performing elective surgery in the COVID era and doing it safely. So fortunately, I can say that I have not had a single patient develop COVID as a result of having elective surgery. Okay, so the University of Maryland has done a wonderful job. However, patients still have an added sense of comfort being able to leave the same day and minimize their time spent in the hospital. Now, our goal is not to make anyone feel like they're being pushed out the door. So for folks who have an added sense of comfort with spending the night in the hospital, we certainly allow that. And we make the experience as wonderful as possible. We've got a dedicated team of nurses for our joint replacement patients. We've got private rooms dedicated for our total joint replacement patients. So we really make it a wonderful experience. What we don't do is have patients stay longer than overnight. And the reason for that is, again, based on the evidence, based on the studies that show that if you spend longer than overnight in the hospital, there's an increased risk of developing a blood clot in the legs that can go to the lungs and cause problems. And we don't want that. We don't do anything that increases the risks after surgery. And speaking to our efforts to minimize risks, that's why we give everybody blood thinners to prevent blood clots after hip and knee replacement surgery. That's standard of care. And after your recovery, you enjoy being pain free, just like you see in this picture at the bottom of the slide. Thank you for the opportunity to speak to all of you today. I really enjoyed it, and I'm really looking forward to answering any and all of your questions.