 All right, great. So let's get started. Thank you again, everyone, for your patience. So my name is Suman Nandi. I'm a hip and knee replacement surgeon at the University of Maryland. I'm really excited to have the opportunity to speak to all of you today. Just to tell you a little bit about myself. I'm originally from Maryland. I was born in Baltimore. I grew up in Howard County. I then went to medical school at NYU. I did my orthopedic surgery residency training at the Cleveland Clinic and then did my specialty training in hip and knee in Boston where I was in practice before returning home. So today I'd like to speak to you about the symptoms, diagnosis and treatment of hip and knee arthritis. This is going to be a real informal talk. So if you have any questions, please do write in. The session moderators have asked that I answer all the questions at the end of the talk, but I'd be more than happy to do so, and I'm happy to stick around as long as you want to hear me answer your questions. With that, let's get started. So first and foremost, 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 let me draw your attention to the left hand side of the slide. It's a cartoon of a knee. So you'll see the top bone is the thigh bone or femur. The bottom bone is the shin bone or tibia and the ends of these bones are coated by a surface, a smooth surface called cartilage and it's depicted here in this reddish pink color. So it's good to have cartilage. It allows you to walk without pain. So if you take a camera and look inside a normal knee, what you'll see is the image in the middle of this slide. So here at the top is the end of the thigh bone. Here at the bottom is the end of the shin bone and you can see these smooth surfaces look like an ice skating rink, right? You can imagine how it'd be nice to walk on these surfaces. It would be pain free and that's what a normal knee looks like. Well, when someone gets arthritis, right, once again, a process, a process by which the cushion in the joint wears away and the bones grind against one another, which causes pain. When someone gets arthritis, if you take a look inside a knee that has been affected by arthritis, what you see is the image on the right hand side of the slide. Now take a look at this, very different from the panel in the middle, right? So you can see that it's no longer nice smooth surfaces, but you can see exposed bone here and here on both the thigh bone and shin bone side. The smooth surfaces have been replaced by this beat up crab meat looking substance, which is essentially the cartilage that has just been worn away and where it's been worn away completely, you have exposed bone. Now you can imagine someone with a knee that looks like that is going to hurt when they walk on it and they do. And that's really the problem with arthritis. There are different kinds of arthritis. Many of you have likely heard of rheumatoid arthritis. So let's talk about rheumatoid arthritis first. It's an autoimmune condition. It's a condition where the body attacks its own joints. It tends to be bilateral, what that means it affects both sides of the body at the same time, both hips, both knees, both hands, both elbows, and it can cause deformity. It can be so severe that it can cause deformity, as is shown in the picture on the left hand side of this slide. So take a look here at these hands of a patient with rheumatoid arthritis. You can see that these fingers are no longer straight. They should be, but they're not. These bones are nearly a 90 degree angle to one another when they should be perfectly straight. Well, if you take an x-ray of this patient's hands, you'll see what is shown on the right hand side of this slide. And in fact, you can see that the bones are in fact at a 90 degree angle to one another. They are no longer straight. So this really demonstrates how severe and significant rheumatoid arthritis can be. And as you can imagine, patients with rheumatoid arthritis can be quite debilitated. So that's the first type of arthritis. What's another type of arthritis? Well, there's a family of arthritic conditions called crystalline arthropathies. Crystalline, you'll, you'll understand why these are called crystalline arthropathies in just a moment. Arthropathy refers to a problem affecting joints. So I'm certain many of you have heard of gout. Gout is one of the members of this family of conditions called crystalline arthropathies. So a patient with gout can have a hand that looks like what you see on the left hand side of the slide. Patients with gout can have these large deposits over their joints. And if you take a look inside that large deposit, it's filled with this cottage cheese-like material. And these are called TOFI. And if you take a sample from within that joint and put it underneath the microscope, you see what's shown on the right hand side of the slide. And now you're starting to see why these are called crystalline arthropathies. So that fluid has millions and millions of these needle-shaped crystals inside. And as you can imagine, that would hurt. And it, in fact, does. So the joint fluid has crystals in crystalline arthropathy. One member of the family of these conditions that are called crystalline arthropathy is gout, which I'm certain many of you have heard of. And now you've seen a little bit more about. Now let's get to osteoarthritis. So osteoarthritis is the most common type of arthritis. It is unilateral unlike rheumatoid arthritis, which is bilateral most of the time. So what I mean by unilateral is that it affects one joint at a time. It is certainly possible that a patient can have osteoarthritis on both sides of the body, but usually one side is, at the very least, more affected. It's a wear and tear phenomenon, just like the treasure in your tires wears away. Similarly, the cushion in the joint just wears away over time. And that's what causes osteoarthritis. So if you take a look at the picture on the left hand side of this slide, you can see that this knee is the normal knee. So it's on the right hand side of this picture, but it's the patient's left knee because he's facing us. So this knee is the normal knee. And you can see how the leg is nice and straight. The knee is not too puffy. But take a look here. This knee is an arthritic knee. And you can see how the leg is starting to bow or be curved. And you can see how it's quite swollen compared to the other knee. Now if you take an x-ray of both of these patients' knees, you'll see what's shown on the right hand side of the slide. And I promise you all you folks are going to be experts at reading x-rays by the time we're done. And we're going to start with that right now. So if you take an x-ray of this patient's left knee, which is on the right hand side of this picture, you'll see this is the normal side. And a normal knee x-ray looks as follows. Here's the thigh bone. Here's the shin bone. On an x-ray, when you have an empty space between the bones, when you have an empty space between the bones, that means you have cushion left. You can't see cartilage. It's not as dense as bone. So it doesn't show up as a thing on an x-ray. It shows up as a space. So when you have space, that means you've got cartilage. But look here at the other knee. There's not one bit of space there. Not one bit. Those bones are grinding against one another. And as you can imagine, that hurts. And it does. We talked about how arthritis, of course, causes pain when that cushion in the joint wears away. What are the symptoms? Well, we just talked about one, which is pain. That's first and foremost. So when someone has arthritis in their hip, where do they feel pain? Interestingly, they feel it in the groin where the thigh meets the body, in the side of the hip, as well as the rear end. So hip arthritis can cause pain in a bunch of locations. What about when someone has knee arthritis? Well, it can cause pain within the knee. The knee is simpler. Here's what's interesting. When someone has arthritis in their hip, they can actually feel pain in their knee because of how the nerves in our body are wired. So whenever someone comes to my office telling me they've got knee pain, I always examine the hip and I also get x-rays of the hip. Because I've had patients come to see me with horrible knee pain. And I'll examine the knee and get x-rays of the knee and the knees are fine. But when I examine the hip and I get x-rays of the hip, it turns out they've actually got very severe arthritis within the hip. So I'm very careful about that. What else can patients with arthritis feel? They can feel stiffness. Well, that makes a lot of sense, right? You've got bones grinding against one another, right? So of course you can feel some stiffness. You can have swelling, as we showed you in the image in the slide before. You can have swelling. You can have grinding because that's exactly what's happening. The bones are grinding against one another. All right. So how do we diagnose arthritis? We've touched on this a little bit, but let's go about it in a systematic manner. Let's start at the beginning. Well, first and foremost, I talk to my patients when they come to see me. First of all, I enjoy talking to my patients. But secondly, it's very, very informative. So I ask my patients, where does it hurt? When did it start? How bad is the pain? What makes it better or worse? And what have you tried for the pain? This really tells me a great deal about what my patients are going through. One of the other things I really am certain to talk to my patients about is what can't you do as a result of this pain? It allows me to get to know my patients a little bit better. What activities are important to my patients that they can no longer enjoy? And that also tells me about how severe the pain is and what kinds of things they would like to get back to doing. So first and foremost, I talk to my patients. Secondly, I'll examine them. And again, you can really glean a lot of information by examining patients. So first, I look, I look at the knee, look at the hip, see if there's any redness, all right, over the skin. It can tell me if there's any evidence of infection. I'll watch my patients walk, okay? Do they have a limp? What kind of limp is it? I'll move the knee, push on the knee, move the hip, push on the hip, just like is shown in the images on the right hand side of the slide. So examining patients is also very important. And next, we'll get some x-rays. So I promised you, you'd be experts by the end of this talk and you will be. I showed you some knee x-rays. So let me show you some hip x-rays. So look at the left hand side of the slide. Look at this picture. This is a normal hip. Here's the ball of the ball and socket joint of the hip. Here's the socket. Here's the rest of the thigh bone. You can see that there's an empty space between the bones. Remember how I told you, cartilage shows up as a space, not a thing on the x-rays, shows up as a space. Well, what does that mean? Well, we got space here. So that means we've got cartilage. What does that mean? If you've got cartilage, then you don't have arthritis because arthritis wears is the process by which the cartilage wears away. So this is a normal hip. Space is good. Look here. There's not one bit of space here between the bones. You can barely tell where one bone begins and the other ends. All right? So there's not one bit of space there. So the bones are grinding against one another. And as you can imagine, that hurts. So on the right hand side of the slide, that is an arthritic hip. I'm sure you can tell me which knee is normal and which knee is arthritic. But just to review it once more, look here. You got some space. Space is good. That means you got cartilage. This is a normal knee. Look here. Not one bit of space. So this, on the right hand side, is an arthritic knee. You can imagine how walking on those bones would hurt and they do. Well, fine. So we know that we got arthritis. So what do we do about it? Well, first we try stuff that's simple, that's short of surgery first. One of the things we can try are oral anti-inflammatory medications. So first let me tell you, don't just go out and run and take pills if you've got hip or knee pain. Check with your primary care doctor because anti-inflammatory medications are wonderful medications, but they can have side effects. So certainly do not take them if you've got ulcers, kidney problems, heart problems, or take any blood thinners. Do not. But your primary care doctor knows your medical history better than I do. Okay, we're just meeting today. So check with your primary care doctor before you start popping these pills. If your primary care doctor does say it's okay to take them, here's how you take them. You take them like the bottle says, but you got to take them every day for at least two weeks. It takes two weeks to build up in the system. All right. Every day for two to four weeks straight, if it bothers your stomach though, stop and you should take them with food. All right. But again, talk to your primary care doctor. Something else we can try for arthritis is physical therapy. And you may say, well, doc, it hurts me to walk from just here to my kitchen. How can I do physical therapy? What's the point of physical therapy? Well, the point of physical therapy is to strengthen the muscles around your joints so that those muscles can function like a shock absorber when your natural shock absorber isn't working so well because it's wearing away. And so these are images that demonstrate how physical therapists can work to strengthen those muscles around your joints. What else can we try? Well, we can try steroid injections. All right. So the steroid injections I'm talking about are legal. This is not what the baseball players are taking. All right. So what steroids are are powerful anti-inflammatories. They're not in the same class as the oral anti-inflammatory medications I spoke to you about a few slides ago. They're a different type of anti-inflammatory. They're far more potent. And if they're injected directly into the joint, they can decrease the inflammation, decrease the pain and make one feel better. So the question is, after you've tried anti-inflammatory medications, physical therapy, not doing the things that bother you, cortisone injections, braces potentially, when do I need surgery? Well, I never tell my patients when to have surgery. When my patients tell me I've tried everything short of surgery, it is not working. I can't live like this anymore. Well, that's when you start thinking about surgery. All right. And only then. And what do I mean by surgery? Well, I'm referring to a total joint replacement, a hip or knee replacement. This is really the most effective treatment, surgical treatment, for arthritis. And it turns out it's one of the most effective things that a doctor can do for a patient. If you look at the Medicare data, two out of the three most effective treatments that a doctor can administer to a patient are hip and knee replacements. So let's talk about hip replacements first. I'm going to show you a movie about a hip replacement. Let me talk you through the movie first, and then I'll show you the video. All right. That'll allow you to digest the video a little bit better. So what we do in a hip replacement, remember the hip is a ball and socket joint, we remove the arthritic ball, 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. So let's take a look at the video. So first we 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 another. And that takes away your pain. As easy as that. All right. So let's show you some before and after images. Again, by now, you're all experts, so you can clearly see that this is an arthritic hip because there's no space between the bone. Sure, after image, after the joint replacement is done, here's a metal socket, plastic liner, which you can't see just like you can't see the normal cartilage in a joint. All right. So you can't see plastic on an x-ray because it's not as dense, but you can see that there's a space there. And there's a stem down the thigh bone and a ball on top. So that's what the hip looks like after a hip replacement. Now, let me show you a video about an knee replacement. Again, let me talk you through it, and then that'll just help you digest the video that much better. So what we do in a knee replacement is we enter the knee, we resurface the beat-up ends of the thigh bone and shin bone, we cap the end of the thigh bone with metal, cap the end of the shin bone with metal, and then put a piece of plastic in between. 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. So let's take a look at this video. So we enter the knee, we remove or resurface the beat-up arthritic portions of the end of the thigh bone and shin bone, we 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 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. Again, as easy as that. Here's a before and after. Take a look at the left hand side of the slide. You can see, look at this nose face, a familiar sign, right? This is an arthritic knee. On the right hand side of the slide, you can see the after image, after the knee replacement has been done. So here's metal capping the end of the shin bone, or rather thigh bone, metal capping the end of the shin bone, and a piece of plastic in between. Again, you can't see the plastic on the x-ray, but you can see that there's a space. So before and after. So what can you expect after surgery? Well, we get patients up and walking the same day of surgery. Everybody, why? Well, the studies have shown that when you get patients up and walking the same day of surgery, it improves the speed and quality of their recovery, which is of course very, very important. Once we get patients up and walking, many patients are eligible to go home the same day. As long as you don't have an organ that's failing or sleep apnea, you are eligible to go home the same day. You may say, well, isn't that rushing things? Why go home the same day? Well, let's rely on the evidence and the facts. So this has been studied very extensively. Over a million people a year get joint replacement. So we've got a lot of data on how to get patients to do well after surgery. And that's my primary goal, how to get my patients to do perfectly after their surgery. And some of the older data showed that there was no increased risks with sending patients home the same day as compared to keeping them overnight in the hospital. Well, more recently, there's been data that shows not only are there no additional risks, but if you send patients home the same day, there are actually fewer risks than if you keep patients overnight. So the more quickly patients get up and get moving and get out of the hospital, the better they do. So when patients go home the same day, the outcomes are plain and simple better. Now, for patients who have to stay overnight because they've got significant medical problems or sleep apnea, we certainly do that. And at the University of Maryland, we have a wonderful total joint program with dedicated anesthesiologists, nurses, occupational therapists, physical therapists, just for our joint replacement patients. We've got private rooms available in the hospital for those patients who must be monitored overnight. What we don't do is keep patients in the hospital longer than that because that has been shown to increase the likelihood of patients getting blood clots in their legs that can go to their lungs and cause problems. In fact, we go to great lengths to prevent those by giving everyone blood thinners after surgery. So we certainly don't want to increase those risks by keeping patients in the hospital longer. And of course, as we discussed earlier, the more quickly patients get up and get moving, it improves the speed and quality of their recovery. And the more quickly patients go home, the better they do after a joint replacement, which is, of course, important. Well, what happens after that? Well, you enjoy being paid free, just like the folks in the slide, all right? So with that, I'm happy to answer any questions you may have. And I really enjoy the opportunity to speak to all of you today.