 Hi, everyone. My name is Meredith. I am in the marketing department here at University of Maryland Medical Center. Thank you all for tuning in to today's presentation with Dr. Suman Nandi. He is the Chief of Adult Reconstruction and also an Associate Professor of Orthopedics at the University of Maryland. He will be discussing hip and knee arthritis and joint pain today and treatments for long-term relief. So take it away, Dr. Nandi. And just a reminder, you can leave your questions for him in the questions or chat feature and we'll get to those at the end of the presentation. Go ahead. Great. Thank you again. So good afternoon, everyone. I'm really excited and looking forward to the opportunity to speak to all of you today. Again, 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 Baltimore, was born in Baltimore, grew up in Howard County. I then went to medical school at NYU, did my orthopedic surgery residency training at the Cleveland Clinic, did my specialty training in hip and knee in Boston where I was faculty before returning home to Maryland. So today's talk is going to be very informal. Please, I encourage you to ask questions as you think of them, write them down, send them into our moderators who would like me to answer questions at the end of the talk and I'm available to answer questions and speak to you as long as you'd like to listen. So today I'd like to speak to you about symptoms, diagnosis and treatment of hip and knee arthritis. So the first question is 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 you take a look at the left hand side of this slide, you see a model of a knee. You see the top bone is the thigh bone or the femur and the bottom bone is the shin bone or the tibia. The ends of those bones, which are depicted in pink, are coated by a smooth, glistening surface called cartilage. That acts as a cushion and it's good to have cartilage because it allows you to walk without pain. So if you were to take a camera and put it inside a normal knee, what you'd see is the panel in the middle of this slide. On the top is the end of the thigh bone and on the bottom is the end of the shin bone and you can see those surfaces are absolutely pristine. They're nice and smooth and you can imagine how that would be a wonderful surface to walk on like an ice skating rink and patients who have a knee that looks like that walk without pain. Well, when you get arthritis, those nice smooth surfaces, that cushion wears away and if you take a camera and put it into an arthritic knee, you get an image that you see on the right hand side of the slide. And as you can see, these surfaces of the bones are now really beat up. You can see that there's exposed bone at the top on the end of the thigh bone and there's exposed bone on the bottom at the end of the shin bone. And as you can imagine, those bones grinding against one another hurts the patient that this knee belongs to and the rest of the cartilage or cushion that's left in the knee has been frayed and looks like crab meat that you can see in the corner. So instead of a normal knee that's like an ice skating rink, this arthritic knee on the right hand side of the slide looks like and feels like sandpaper grinding against one another. So again, arthritis is a process. It's not a thing. It's a process by which the cushion in your joint wears away and your bones grind against one another and that causes pain. Well, there are different types of arthritis. So let's first talk about one. I'm sure many of you have heard about rheumatoid arthritis. What is rheumatoid arthritis? Rheumatoid arthritis is an autoimmune condition. And what do I mean by that? It's a condition whereby the body attacks its own joints. It tends to be bilateral, which means it affects both sides of the body at the same time, both hips, both knees, both wrists, and it can cause deformity as you can see on the left hand side of the slide. So this patient's hand should be straight, but those fingers are anything but. They're almost at a 90 degree angle to the rest of his hands. And there on the right hand side of the slide, you can see an x-ray of this patient's hands. You can see the bones are not straight. They are in fact essentially at 90 degree angles to one another. And that's what you see in rheumatoid arthritis, significant deformity. And both sides, meaning left and right hands being affected. So that's rheumatoid arthritis, which I'm certain many of you have heard of. Well, there's another type of arthritis called crystalline arthritis or arthropathy. One type of crystalline arthropathy or arthritis is gout. I'm sure again, many of you have heard of gout. Well, what happens in gout? Well, the joint fluid develops crystals inside of it. And as a result, you can have a hand that looks like this with large deposits right on top of the joint. And those large deposits that you see there are called TOFI. Here in the image, you see it forming on the hand, but you can get it on the back of the elbow and in other areas throughout the body. Well, if you take a look inside that large collection and take a sample of that and put it underneath a microscope, you get what you see on the right hand side of the slide. You see these needle-shaped crystals. And you can imagine having millions of those inside your joint would be painful. And in fact, they are. They cause significant inflammation and can be very painful and ultimately can cause degradation or destruction of the joint. So this meaning gout is a type of crystalline arthritis or arthropathy. Now, we move on to osteoarthritis, which is the most common type of arthritis. It's unilateral, meaning it affects typically one side of the body at a time. That's not to say it can't occur on both sides, but it's typically on one side of the body or affects one side more than the other. And why does osteoarthritis occur? Well, it's thought to be a wear and tear phenomenon, just like the tread on your tires wearing away over time. The cushion in the joint that I showed you in the first slide just wears away over time. Well, let's take a look at the left hand side of the slide. This is a picture of a patient who has osteoarthritis. Well, if you take a look at the left hand most side of that picture on the left, that is the painful or arthritic knee. You can see how it's swollen, it's puffy, and that leg is starting to bow outward compared to the knee on the right hand side of the picture. That knee is not swollen, the leg is straight. So the patient is facing us. So the knee on the right side of the picture is actually the patient's left knee. But the knee on the right side of the picture is normal. The knee on the left side of that picture is not normal. It's osteoarthritic. Again, you see puffiness, you see the knee bowing out, all hallmarks of osteoarthritis and the arthritic process. Now, if you take a look at the right hand side of the slide, you see an x-ray of this patient's knees. And you folks will be experts at reading x-rays by the end of this talk. I promise you. So this will be the first, and I'm sure you'll be able to tell me exactly what the next x-ray shows. So on the right hand side of this x-ray, you see a normal joint. So on the top bone is the thigh bone, the bottom bone is the shin bone, and you can see there's an empty space between the bones. There's an empty space here between the bones. That means there's plenty of cushion left. You can't see the cushion on the x-ray. All you can see is the space that it occupies. So that means there's cushion left. But take a look here. There's no space whatsoever. The bones are grinding against one another and that causes pain. It also causes things like swelling and the knee to bow, and causes the knee to bow out depending on where the arthritis is. So when this, when the inside of this knee becomes arthritic and there's no cushion left, the outside of the knee gets jacked open, and that results in the knee bowing out. All right. So that is osteoarthritis. Well, what symptoms do you have from osteoarthritis? We talked about this a little bit. Well, first and foremost, you have pain. What happens when you have hip arthritis? Well, you feel it not only in the side of your hip, but you can feel it in your groin, and you can also feel it in your rear end. Those are the places where people feel pain from hip arthritis. You can also feel pain in your knee. All right. When you have knee arthritis, of course. All right. Here's what's interesting. When you have hip arthritis, you can also feel it in your knee. So hip problems cause knee pain, and that's due to how the nerves in our body are wired. Knee problems, however, don't cause hip pain. But hip problems always or often cause knee pain. That's why whenever patients come to my office telling me about knee pain, I always get x-rays of the hips, and I always examine the hips. So it is not uncommon that patients will come to my office telling me that they've got horrible pain in their knees, and I'll examine their knees, and I'll get x-rays of their knees, and their knees look just fine. But I'll examine their hips, and they hurt. And I'll get x-rays of their hips, and it'll show that they've got horrible arthritis in their hips. So hip problems can cause knee pain. So it's very important. What else can arthritis do? How else can it make one feel? Well, it can make the hip or the knee feel stiff, as you can imagine, with the bones grinding against one another. That can make the joint feel stiff. It can cause swelling, like we saw in the picture in the slide just before this one. And it can also cause grinding sensations, because that's exactly what's happening. The bones are grinding against one another. Well, how do you diagnose arthritis? Well, first I talk to my patients. I enjoy talking to my patients, and it's important. You can find out a lot just by talking to somebody. So I ask, where does it hurt? When did it start? How bad is it? What makes it better or worse? And what have you tried so far for the pain? One of the other things I also like to glean from my patients by speaking to them is, what are the kinds of things that you like to do, but can't do? Because it's important in my practice to be able to give patients back their quality of life. So it's an important piece of information that I always strive to get from my patients. Next I examine patients. So I'll first look. I'll look at the knee, look at the hip, look at how my patients are walking. You can really learn a great deal by looking at someone walk if they're limping. What kind of limp do they have? Then I move the knee, push on the knee just like the pictures show. I move the hip, push on the hip, and that gives me additional information. And finally, I also get x-rays. X-rays are actually quite informative about the arthritic process. Oftentimes even more informative than fancier tests like CTs and MRIs. So I promised you that you'd be experts at reading x-rays. So we're working towards that. You're almost there. So on the left hand side of this slide you see an x-ray of a hip. The hip is a ball and socket joint. So here you see the ball of the ball and socket joint. Here is the socket. Between the bones you see a space. And that's again occupied by cartilage or cushion. That means this patient has plenty of cushion left and they're able to walk without pain. That's a normal hip. On the right hand side of the slide you see here's the ball, here's the socket. But look, you can't see a bit of space between these bones. You can't barely tell where one bone begins and the other ends. These bones are grinding against one another. And as you can imagine, that would hurt and it does. And by now you're all experts. So I don't even need to tell you what you're seeing here. But I'll go ahead and point it out. On the left hand side of the slide, this is a knee with space. So this is a, as you all know, a normal knee. But look at this knee. On the right hand side of the slide there's not one bit of space there between the bones. This is an arthritic knee on the right hand side of the slide. The bones are grinding against one another. That cushion is worn away and this patient has pain. So what do you do about arthritis? Now that we've diagnosed it, how do you treat it? Well first we start with simple stuff first. One non-operative treatment, meaning a treatment short of surgery, is anti-inflammatory medication. So first and foremost, any of you with arthritis out there, don't go out and start popping pills, you know, anti-inflammatories or things like Advil, Aleve, Motrin, Aspirin, okay? Check with your primary care doctor before you start taking these medications. You certainly shouldn't take it if you've got heart problems, kidney problems, ulcers, or you're on blood thinners, absolutely cannot take them if you have heart problems, kidney problems, ulcers, or on blood thinners. But if your primary care doc does say it's okay to take, you should take them every day for two to four weeks straight. It takes at least two weeks to build up in your system. You should take them with food, but if your stomach hurts, stop right away, okay? Because it can do damage and we don't want that. So check with your primary care doctor before you start taking these medications. The next is physical therapy. You may say, well, doc, it hurts me to walk from here to, you know, here to the next room. What good is physical therapy going to do? Well, the purpose of physical therapy is to strengthen the muscles around your joints so that those muscles can function as a shock absorber because your natural shock absorber has worn away. So that's the means by which physical therapy can be helpful, as is shown in these pictures here. The next potential nonoperative treatment is a steroid injection. And these steroids aren't what the baseball players are taking, right? These are legal. What steroids are are potent anti-inflammatories. They're not the same medication as Advila Leave, Motrin, Ibuprofen, all right? They are anti-inflammatories that are far more potent and they're injected directly into the joint and they can decrease the inflammation in your joint and help relieve pain. So the next question is, when do I need surgery? So I don't tell my patients when to have surgery and I don't twist anyone's arm into surgery. When my patients tell me I've tried everything short of surgery and I can't live the way I want to live anymore, then it's time to think about surgery. And what do we mean by surgery? Well, the most reliable treatment, surgical treatment for arthritis, is a total joint replacement. And that's what I mean by surgery. So a hip or knee replacement. So I'm going to show you a cartoon of a hip replacement. So what I'm going to do is first I'm going to talk you through a hip replacement and then I'm going to show you the video, all right? And that'll help us really understand what we're seeing to the best of our abilities. So in a hip replacement, again, the hip is a ball and socket joint. So 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. So first we enter the hip 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. Great. And it's as easy as that. So this is a before and after image of a hip replacement. So on the left hand side you can see there's no space between the bones. This is an arthritic hip. This is an after image of a hip replacement. Here's the metal socket, plastic liner which you can't see, stem 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. So now I'd like to show you a cartoon of a knee replacement. Let me talk you through it and then I'll show you the video. So what we do in a knee replacement is we cap the end of the thigh bone with metal, cap the end of the shin bone with metal and put a piece of plastic in between. 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 knee, we resurface the ends of the thigh bone and shin bone and remove the beat up arthritic surfaces, 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. Great. Again, as easy as that. Here's the before and after image. On the left hand slide, bones are grinding against one another, no space, no cushion. Now here you have metal capping me into the thigh bone, metal capping me into the shin bone, piece of plastic in between, which gives you nice smooth surfaces again that glide against one another and that takes away your pain. So what can you expect after surgery? Well, we have everyone walk the same day of surgery. Why is that? Well, the studies have shown that the more quickly we get patients up and walking, the better and faster the recovery is. And that's very important to us. So that's why we get everyone up and walking the same day of surgery. After a joint replacement, patients go home either the same day or stay overnight in the hospital. So everyone who's medically suitable is able to go home the same day. And what do I mean by medically suitable? As long as you're, as long as you've had less than 90 birthdays, all right, you're medically suitable, as long as you haven't had organ failure, meaning congestive heart failure, a kidney or liver transplant, all right, as long as you don't have a actively failing organ and as long as you don't have sleep apnea, those patients do need to stay overnight for monitoring in the hospital, but everyone else is eligible to go home the same day. Why send patients home the same day? Is that just a matter of Russian folks out of the hospital so we can make room for the next patient? Or is this something that insurance companies are telling us to do? Or are we running out of room in the hospital? Actually, none of those things. The reason why we like to send patients home the same day, if possible, is it's because it's better for patients. So the studies done on outpatient, meaning patients going home the same day, versus inpatient joint replacements, when patients stay at least overnight, the studies have shown that there are no increased risks with going home the same day. The most recent study done on this subject has actually shown that if you go home the same day, the risks are actually less. So outcomes are better and risks are less if you go home the same day. Well, why don't we keep patients longer than overnight? Well, in the late 60s and early 70s, when hip and knee replacements first started, patients would come into the hospital a week before, would undergo the sterilization process for their skin that would stay for a week or longer after surgery. Why don't we do that anymore? Well, because we've learned a lot over the years, and the studies have shown that if you stay in the hospital longer than overnight, your risks of getting a blood clot in your legs that can go to your lungs and cause significant problems is higher. We do everything we can to minimize that risk by giving everyone blood thinners to prevent blood clots as you see on the slide. But we really ideally need to do everything we can to minimize that risk, and that includes getting patients up and walking the same day and not spending longer than overnight in the hospital. And once we do all that, you enjoy being pain free, just as is shown in the picture at the bottom of the slide. So at this point, I'd love to take your questions, and I'm certain that our moderators have been collecting them as we speak, and I'm happy to stay as long as all of you have questions. Thank you, Dr. Nandi. Again, we invite you to leave your questions for him in the questions feature here in GoToMeeting. If you would prefer to send us more private message, you can email us as well. The email address is fpi, as in Frank, fpi, underscore communications at fpi.umaryland.edu.