 Good afternoon, and thank you for joining us today for achy-breaky joints, hip and knee arthritis. Today's topics are focused on the symptoms and types of arthritis and the treatment options available. I'm Meredith Marr with the University of Maryland Medical Center. Presenting today is Dr. Suman Nandi, Associate Professor of Orthopedics at the University of Maryland School of Medicine and Chief of Adult Reconstruction. Before we begin, a couple things to note. Submit your questions during the presentation and Dr. Nandi will answer them at the end of the presentation. We've left time for Q&A. The seminar will be recorded and an email of this recording will be sent out next week. Thank you, and I will now turn this over to Dr. Nandi. Hello, everyone. How are you? It's such a pleasure for me to have the opportunity to speak to all of you today. My name is Suman Nandi. I'm a hip and knee replacement surgeon at the University of Maryland. 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 and then went to medical school at NYU. I did my training in orthopedic surgery at the Cleveland Clinic and then subsequently did my fellowship training or subspecialty training in hip and knee replacements in Boston, where I practiced for several years before having the opportunity to return to Maryland, my hometown. Today, I'd like to talk to you about the symptoms, diagnosis, and treatment of hip and knee arthritis. Today's talk is going to be very informal, so I would love for you to please write in your questions so that we can make this session interactive. We will be taking questions at the end and hopefully I'll be able to answer everything on your minds. So with that, let's go ahead and get started. So first and foremost, what is arthritis? We all heard the term, but what is it? Well, it's a process. 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's take a look at the cartoon of the knee on the left hand side of this slide. So you can see at the top, there's the thigh bone, the shin bone, and then in this reddish pink, what's depicted is the cartilage. Cartilage is a smooth glistening surface that coats the end of the bones within all of our joints. And here you see it coating the end of the thigh bone as well as the shin bone. So if you took a camera and stuck it inside a normal knee, what you'd see is the picture in the middle of that slide. And you can see these wonderful smooth surfaces at the end of the thigh bone and the shin bone. It looks like a like a skating rink, right? So you can imagine how that knee would be a wonderful knee to walk on those nice smooth surfaces. Now, when you get arthritis, look at what happens on the right hand side of this slide. You can see how all those smooth glistening surfaces have now been beat up and there's exposed bone and what used to be a nice smooth skating rink is now beat up and frayed and it looks like crab meat here. And you can imagine how the owner of this knee is hurting, right? These are not the nicest surfaces to be walking on. And that's what arthritis is. There are different types of arthritis. So I'm sure many of you have heard about rheumatoid arthritis. So what is rheumatoid arthritis? Well, it's an autoimmune condition. And what does that mean? It's a condition where the body attacks its own joints. It's usually bilateral. And what that means is that it affects both sides of the body. So both knees, both hips, both wrists, both hands. And it ends up causing deformity. So if you take a look at the left hand side of this screen, you'll see a picture of a gentleman who has rheumatoid arthritis. And on the right side of the screen, you'll see an x-ray of this gentleman's hands. And as you'll know, those bones are far from straight and those fingers are far from straight as they should be. And that's the deformity that's caused by rheumatoid arthritis. So arthritis really can be a very, very, very big deal and be very debilitating. So what's another type of arthritis? So there's a whole family of arthritis or arthritis called crystalline arthropathy. Arthropathy is just another name for arthritis. So one member of this group of crystalline arthropathy is gout. And I'm sure many of you have heard of gout. Well, what happens in gout? Well, the joint fluid fills up with crystals. And if you take a look at someone who's got really bad gout, you'll see what I show you on the left hand side of the screen. You'll see that these large deposits called TOFI are formed on the back sides of many of the joints throughout the body. And if you take a look inside those deposits, it's filled with a cottage cheese type of material. And then if you look inside the joint and take a sample of that fluid and put it underneath the microscope, you'll see what is shown on the right hand side of this slide. Underneath the microscope, you'll see these needle-shaped crystals. And you can imagine how having a million of these crystals inside your joint would hurt and cause inflammation and end up destroying the joint. And that's exactly what happens. So that's gout or one of the types of crystalline arthropathies. Well, now we get to osteoarthritis, the most common type of arthritis. And maybe some of you in the audience have this kind of arthritis. Again, it's the most common. It's unilateral. What does that mean? It affects one side of the body, one side of the body. Contrast that with rheumatoid arthritis that affects both sides of the body. Can osteoarthritis affect both sides of the body as well? Yeah, absolutely. But it usually affects one side at a time or one side more than the other. Well, what happens to osteoarthritis? Well, it's a wear and tear phenomenon, just like the tread in your tires. You drive long enough, the tread in your tires are going to wear out. And that's exactly what happens to the cushion in the joint, that cushion that I showed you in that first slide. All right. So when that wears away, then you get bones grinding against one another, as I'll show you on the x-ray in the slide, and you get pain. So let me show you a picture of this gentleman who has arthritis. So if you take a look at this gentleman's knees and he's facing us. So his left knee is on the right hand side of the picture. And that's the normal knee. You can see how it's nice and straight. It's not swollen or puffy. But now take a look at the patient's right knee, which is on the left hand side of the picture. Look at how it's swollen. It's puffy. And this gentleman is becoming bow-legged. And I'll show you why on the x-ray, on the right hand side of the screen. So let's take a look at some x-rays here. All of you are going to be experts at looking at x-rays by the end of this talk. All right. I promise you. And we'll give you a little quiz. I know all of you will get it, get a hundred on it. All right. So take a look at the knee on the right hand side of this x-ray, which is the patient's left knee because they're facing us. Here's the thigh bone at the top. Here's the shin bone at the bottom. And as you can see, there's an empty space here between the bones. And what that means is that there's cushion left. When there's an empty space between the bones, that means there's cushion left. And that's a good thing. You want cushion to be there. Now look at what's going on on this left hand side of this x-ray. Look at this. This is not one bit of space between these bones. Those bones are just grinding against one another. As you can imagine, that hurts. That brings us to the symptoms, all right, of arthritis. And pain is right at the very top. What do you feel when you get arthritis? You feel pain. So when you have hip arthritis, where do you feel pain? You can feel it in the groin where your thigh meets the body in the front of your body. In the side of your hip, you can feel it in the rear end too. What happens when you get knee arthritis? Where do you feel it? Well, you feel it in the knee. Now here's the interesting part. If you get hip arthritis or have hip arthritis, you can feel pain in your knee. It doesn't work the other way around. If you get knee arthritis, you don't feel it in your hip. But if you have hip arthritis, you can feel it in your knee, interestingly. So when folks come to my office complaining about knee pain and they say, hey doc, my knee hurts, I always get x-rays of the hip and I always examine the hip. Because not uncommonly, when patients tell me they're having knee pain, I examine their knee, it doesn't hurt. But when I examine their hip, when they move their hips around and when I get x-rays of their hips, it shows that they've got a horribly arthritic hip and they end up needing a hip replacement. They're knee pain. So very interesting how the human body works. What else does arthritis do? How does it make you feel? Well, it can make you stiff, right? And that makes sense. Because the bones are just grinding against one another like we talked about. Like I showed you in that first slide, that slide with the crab meat with the exposed bone, right? Just looking at that makes you understand how painful arthritis can be. So it can make you feel stiff. It can make your joints swell like I showed you in the picture in one of the prior slides. And of course it can make it feel like bones are grinding against one another because that's exactly what's going on. So how do you diagnose arthritis? Well, first I get a history. And what does that mean? That means I talk to my patients when they come to see me and I enjoy talking to my patients. And I get a lot of information by talking to my patients. So I ask my folks, let's start, how bad is it? What makes it better? What makes it worse? What have you tried? That really gives me a lot of information. And it tells me where patients are at as far as their symptoms go. Something else that's really helpful to me is asking my patients, what do you like to do? What do you like to do? What did you like to do before you got arthritis? What do you want to get back to doing? This really gives me a great picture of my patients. The next thing I do is I examine my patients. So I look at the patient. I look at their joints. Is it red? Is it swollen? Is the patient becoming bow-legged? All right. Then I'll have my patients walk and I'll see, are they limping? They're all of different kinds of limbs. You can tell a lot about how a patient is doing based on their limp. When I push on the knee, move the hip, press on the hip, just as is shown on the right of this slide. So after I examine the patient, then I get x-rays. So these are some hip x-rays. I showed you some knee x-rays before and now I'm showing you some hip x-rays. So let me talk to you about hips. So on the left-hand side of the slide is a perfectly normal hip. A hip is a ball and socket joint. Here's the ball. Here's the socket. You can see between the bones that there's an empty space here between the bones. And just like for the knee, that means that there's cushion left when there's an empty space and that's what you want. You want cushion when you're walking. Now contrast that to the right-hand side of the slide. Here's the ball. Here's the socket. But what's not there? There's no space there. You can only tell where one bone begins and the other one ends. There's just no space there whatsoever. And that tells us that all the cushion is gone. This patient has a very, very, very arthritic hip and they are hurting. Now let me show you some knee x-rays. I showed you some knee x-rays before and usually when I give this talk in person, I am able to ask folks which is the normal knee and which is the arthritic knee on the right. If it weren't in the COVID era and we had the opportunity to be face-to-face and I could quiz you a little bit, all of you would get this right. But as you can see, there's a very stark difference between the normal knee on the left where there's space between the bones and the very arthritic knee on the right where there's not one bit of space between those bones. The bones are just grinding against and as you can imagine, that hurts. Well, so now we know we've got arthritis. So how do we treat it? How do we make this better? Well, first we start with the simple stuff. We always start with simple things first. Always try everything shorter surgery first. One of the things you can try are anti-inflammatory medications. Now, first and foremost, do not, folks, check with your primary care doctor before starting any medications. First of all, what are anti-inflammatory medications? They're Advil, Aleve, Motrin, Ibuprofen. Those are all anti-inflammatory medications. Is Tylenol anti-inflammatory medication? It's not actually. It helps with pain and fever reduction, but it is not an anti-inflammatory medication. Again, do not start taking any medications before consulting with your primary care doctor because anti-inflammatory medications can be problematic and folks with heart problems, kidney problems, ulcers, and certainly can't be taken in anyone who's already taken a blood thinner. If your primary care doctor does say it's okay to take anti-inflammatories, the way you take it is every day for two weeks. It takes about two weeks to build up in your system. So if you take it for less long than that, it probably hasn't even gotten a chance to get started working. And if you're taking anti-inflammatory medications with food as you should and your stomach still hurts, then stop taking them. We don't want to create any problems. Great. So anti-inflammatories, if your primary care doctor says it's okay. What else can we try short of surgery? We can try some physical therapy. Well, you may say, Doc, I'm moving room to the kitchen without my knee or hip just hurting and hurting. How am I going to do physical therapy? Why would I want to do physical therapy? Well, the goal of physical therapy is to strengthen the muscles around your hip or knees so that those muscles can function like a shock absorber. When your natural shock absorber isn't working so well because you don't even have much shock absorber. You don't even have much cushion. All right. So you see pictures of physical therapists working with some hip and knee patients here. What else can we try? Well, we can try a steroid injection. And by steroids, I don't mean what the baseball players are taking. These are legal. All right. So steroids are a very powerful anti-inflammatory medication. The other medications I talked about that can be taken orally like Advil, leave, Motrin, Ibuprofen, those are oral anti-inflammatories and the steroids I'm talking about are a supercharged version of those medications. It's a completely different medication, but it's still an anti-inflammatory but just far, far, far more potent. And they can be injected directly into the joint and they help decrease the inflammation and the pain. All right. And you see a picture here of a patient getting an injection into their knee. All right. So that's a common question. I've got arthritis, but when do I need surgery? Well, I never twist anyone's arm into having surgery. When my patients tell me I've tried everything short of surgery, it's not working and I can't live like this anymore. That's when we start thinking about surgery and talking about surgery. And by surgery, what do I mean? I mean total joint replacements. And by far and away, the most reliable surgical intervention for arthritis. So let's talk a little bit about hip and knee replacements. So I'd like to show you a little bit, a little video of a hip and a knee replacement. And first I'd like to talk you through what you're going to see and then I'll show you the video. And then we'll do the same for the knee replacement. It'll just make it easier to follow. So what do we do in a hip replacement? Well, first we enter the hip and I showed you before how the hip is a ball and socket joint. What we do is 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. Good, perfect. And it's easier that so let's go over to the next slide. We'll show you how we do this. We just put the knee replacement and the knee replacement. You're going to find out how we did this. This is the knee replacement. And with the knee replacement we press the knee replacement and I'm going to show you how the knee replacement is going to be done. Now we'll start So let's go over a before and after shot here, okay? So on the left-hand side of the screen is a before shot. And as I'm sure all of you would be able to tell me correctly if we were face to face, this patient has a very arthritic hip. There's no space between the ball and socket joint, no space, bone on bone, bones are grinding against one another. And this is an after shot. You can see the metal socket plastic liner, which you can't see on the X-ray, stemmed down the thigh bone and a ball on top. 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. Now let me talk you through a knee replacement. What do we do in a knee replacement? Well, first 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 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 now show you the video. So first we enter the knee, cap the end of the thigh bone with metal, cap the end of the shin bone with the metal, 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, easy. All right, so again, so before and after shot. So on the left hand side of the screen, I know all of you are pros by now. Very arthritic knee, no space between the bones, bones grinding against one another, after shot here, metal capping the end of the thigh bone, metal capping the end of the shin bone, piece of plastic in between that you can't see on the X-ray, and this patient is pain-free. So what can you expect after surgery? Well, you can expect to get up and walk the day of surgery. And after you walk, then you can go home the same day for folks who are interested in doing so. So all the advice that I give to patients and everything that I'm telling you today is based on data, all right? I try to stay away from opinion, all right? And counsel my patients based on the data, all right? So the data shows that there's no increased risks with going home the same day as compared to staying in the hospital after a joint replacement. And it's appealing to a lot of folks. There's no one who takes better care of you than your family at home. And so it was appealing to many patients even before the COVID era, but now during the COVID era, many patients have an added sense of comfort being able to just get in and out of the hospital and go home. We don't like to have anyone feel like they're being pushed out the door. So for patients who have an added sense of comfort with spending the night overnight, we absolutely do that. So at the hospital where I do the vast majority of my joint replacements, we've got a dedicated team of anesthesiologists, recovery room nurses, floor nurses who take care of patients in the unit that all of my joint replacement patients go to, dedicated team to take care of all the joint replacement patients, private rooms, patients are able to get up and walk the same day of surgery with either the nursing team or the physical therapy team, physical therapy, then sees the patients the following morning and then you go home later that morning, okay? What we don't do is have patients stay in the hospital longer than that and that's a data-driven decision. That's because we do have good data demonstrating that if you stay in the hospital longer than overnight, then there is a proven increased risk of getting a blood clot in your legs. They can go to your lungs and cause problems and there are a multitude of other papers that have been published that show even other types of problems that can occur if you stay in the hospital longer, all right? Every surgery is different, but for hip and knee replacements, if you stay in the hospital longer than overnight, it's been shown that there's an increased risk of issues and we don't want that. We want everyone to have a wonderful experience and a smooth experience. As I talked about previously with regard to blood thinners, we give everyone blood thinners. We don't want anyone to get a blood clot after surgery. That's standard of care, we do that for everyone. And once you recover, you enjoy being pain-free just like the folks shown in the picture at the bottom of the slide. Well, I wanna thank all of you for your attention. It really was my pleasure to have the opportunity to speak to all of you today. If I can be of service to you, please feel free to call me and make an appointment. We're doing both telehealth visits as well as in-person visits. Please visit us on our website at the bottom of the slide. And I would love to answer any and all of your questions. Thank you very much.