Published: Synapse 2015, Vol 1
We've heard it time and time again: As we age, our risk for certain health conditions increases -- cancer, heart disease, stroke, diabetes, among many others. So does our risk for osteoarthritis, sometimes referred to as "wear and tear" arthritis. It's a fairly common form of joint disease in which the cartilage -- the rubbery connective tissue between two bones -- breaks down, roughens, and ultimately wears out. Early symptoms such as stiffness or pain are typically mild, but over time the loss of cushioning and rubbing of bone-on-bone can cause significant pain. Any joint can be affected, but larger joints such as the hip, knee, and shoulder often cause the most noticeable symptoms.
Aging isn't the only risk factor for osteoarthritis. Long-term high-impact exercise can wear down cartilage and increase risk, which may explain why more active adults in their late 40s, 50s, and 60s are being diagnosed today. Obesity is a risk factor, as are genetics: If family members were affected, our own joints are more prone to the condition.
Most people with osteoarthritis-related joint pain first consult their primary care physician. Initially, common-sense measures such as over-the-counter pain relievers, medicated rubs, heating or cooling pads, and changes in exercise routines are often enough to manage the pain. If these stop working, though, it's in your best interest to consult an orthopaedic surgeon.
Chester County Hospital orthopaedic surgeons Christopher Lyons, MD, Adrienne Towsen, MD, and Chet Simmons, Jr., MD, offer their best advice for people who suspect they could have osteoarthritis-related joint pain. Here are their "Top 5 Things to Know."
#1. Pain that persists despite common-sense measures requires specialty care.
"It's possible to have an abrupt onset of pain due to osteoarthritis, but it's usually a gradual progression: 'I can't walk as much as I did, stairs are harder, I can't reach as high,'" says Dr. Adrienne Towsen, who specializes in knees and shoulders. "Night pain with sleep disturbance is common. When routine daily activities are interrupted or altered, it's a good time for an orthopaedic consultation."
A set of X-rays is often the first step, as the images can immediately show the loss of cartilage between bones. Other imaging tests, such as MRI, are sometimes needed. Just as essential are a complete physical exam, an assessment of the painful joint and treatments to date, and a complete medical history.
"During that initial consultation, we sit down and talk about the patient's complaints and their experiences to date," Dr. Towsen says. "What are their limitations? What kinds of treatments have they tried and how effective were they? We assess their range of motion. And we consider all of that in relation to their imaging results."
Dr. Towsen notes that patients with a high degree of visible damage on X-rays can sometimes have fairly mild symptoms, while others with minimal damage can have intense pain. That's why both imaging tests and patient reports are essential for developing a plan of action.
#2. Seeing an orthopaedic surgeon does not mean you'll automatically need surgery.
"It's not unusual to see dozens of patients with this condition in a day and not refer any of them to surgery," notes Dr. Christopher Lyons, who specializes in hips and knees. "An overwhelming majority of my patients have been seeing their primary care physicians and can still be managed for a significant period of time -- or even permanently -- with conservative measures."
Dr. Chet Simmons, who also specializes in hips and knees, agrees, "Once in a while you might see a patient who has been stoic about his or her pain, and the joint damage is so advanced that joint replacement surgery is their best option. Usually we can come up with a plan that buys someone months or even years before surgical joint replacement would even be considered. When patients delay seeking help from an orthopaedic surgeon, they sometimes miss out on management strategies that could have delayed surgery."
In addition to oral anti-inflammatory medications, a management plan may include some or all of the following:
- Corticosteroid injections in the affected joint
- Viscosupplementation for the knee, which injects a gel-like substance into the joint
- Counseling about exercise or changes in workout routines -- swapping running for swimming, for example, or squats and jumps for lower-impact cardio
- Working with a physical therapist to keep the joint moving without pain
Over time, the orthopaedic surgeon gets to know you, your joint issue, your life situation, and what can be used to minimize the pain and keep you as active as possible. Not using the joint can make stiffness worse and further reduce range of motion.
#3. The decision to proceed to joint replacement surgery happens over time and is driven by the patient.
Joint replacement surgery becomes an option only when you and your doctor have exhausted all other strategies and your normal lifestyle has been affected. This varies widely from person to person. For people who love sports and exercise or those who have physically demanding jobs or responsibilities -- such as caring for children, spouse or parent -- their decision to have surgery may come sooner. For those with lower levels of activity, the decision often comes when pain makes walking, sleeping, or even a trip to the grocery store next to impossible. The goal of joint replacement surgery is to replace the rough, damaged bone ends with smooth materials that recreate the pain-free function of a healthy joint.
"Patients will tell me when it is their time to proceed to surgery," Dr. Simmons observes. "The most common reasons are unbearable pain and intolerable impact on their lifestyle."
Dr. Lyons agrees. "Many do eventually come in for an appointment and say, 'It is time.' Life circumstances enter into it as well: Maybe they are finally cutting back on work or their home responsibilities have eased. They feel like they finally have time to take care of themselves. Patient management is really about the patient's expectations."
#4. If you have joint replacement surgery, you'll benefit from decades of advancement in techniques, materials, and rehabilitation practices.
Every patient's situation (and physical anatomy) is different, but in many cases surgeons are able to make smaller incisions and spare more muscle and tissue than they could in the past. They also have a wider array of approaches to choose from, along with more durable materials.
"The field is improving technically all of the time, and what we offer now combines the most minimally invasive techniques, whenever possible, with the strongest materials available," says Dr. Towsen. "It's reasonable to expect a joint implant to last 20 years or more, which is different from what we had available just a decade or so ago."
All three surgeons point to the fact that rehabilitation approaches have also improved, contributing to faster recovery times. The process typically starts with "pre-hab" physical therapy sessions before surgery to strengthen the joint and range of motion. In the hospital, physical therapists get patients moving the same day or at least the day after -- a practice that has been helped by new pain management protocols, notes Dr. Simmons. Post-surgery narcotic medications have been replaced by a combination of pre- and postoperative anti-inflammatory and non-narcotic pain relievers, which helps avoid the nausea and drowsiness associated with narcotics.
"As a result, patients can start rehab sooner and get back on their feet more quickly," Dr. Simmons says.
#5. Chester County Hospital, with the full support of Penn Medicine, offers an outstanding experience for joint replacement patients.
Orthopedic surgery patients are now cared for in a new unit on the third floor of the Lasko Tower.* The unit has "state-ofthe- art everything" to care for joint replacement patients, says Dr. Towsen, including an inpatient physical therapy center on the same floor.
But the attention to the patient's needs begins long before the day of surgery. All Chester County Hospital orthopaedic surgeons educate joint replacement surgery candidates about the procedure over multiple visits, using models and printed materials and recommending online resources. Patients are encouraged to take Chester County Hospital's class on joint replacement surgery and establish a relationship with a physical therapist.
All of the physicians appreciate the experience of the hospital's orthopaedic care team, from the operating room (OR) to post-operative care.
"I have been operating here for almost nine years, and I can say that everyone a patient meets -- from the person who welcomes them the day of surgery, to the nurses on the floor, to the physical therapist -- is very seasoned," Dr. Towsen says. "That fact, now combined with the new unit, really does make for a great experience."
"I try to help my patients understand that this surgery and recovery are a team effort: Yes, they have to be comfortable with me, but they'll also be spending time with other members of the team," says Dr. Lyons. "Chester County Hospital has teams in the OR who are experienced in orthopaedic procedures. The nurses on the unit know how to take care of patients after surgery, and they recognize what's normal and what's not and they can make the right adjustments."
He adds, "The key to good outcomes for these surgeries is good and competent people, and that's exactly what Chester County Hospital offers."
By Kristine M. Conner
* Featured in Synapse, 2013 Vol 2
Zero Incidences of Infection
In 2014, Chester County Hospital had zero incidences of infection among its total hip and knee replacement surgery patients. The Pennsylvania Department of Health's latest data showed an average infection rate across the state of 0.76 infections per 100 procedures performed and 0.57 for knees. National data from the Centers for Disease Control and Prevention (CDC) shows a 0.64 rate for hips and 0.54 for knees, per 100 procedures performed. The hospital's infection rate is significantly lower than outcomes reported by the State of Pennsylvania or the CDC. (PA's and CDC's most recent comparative rates were published in May 2014 and reflect data from 2011.)
Walking Hip-to-Hip with Penn Medicine
L. Scott Levin, MD, FACS, Chair of Penn Medicine's Department of Orthopaedic Surgery, and his colleagues have worked to develop well-coordinated musculoskeletal services in the new Penn Musculoskeletal Center. This thoughtful realignment will help shape the approach to orthopaedic services at Chester County Hospital in West Chester, PA. "Penn Medicine patients with a bone or joint disorder see the right provider at the right time with the right set of medical evaluations to optimize care and improve efficiency," says Dr. Levin. "We are focused on quality, patient safety, improving outcomes and customizing programs, such as pain management, for our patients." He adds, "We have a great opportunity to create a similar approach at Chester County Hospital. Really, it is an achievement for us to partner with them, given their great leadership, the new orthopaedics floor in the Lasko Tower, and plans for additional upgrades. We can lend our expertise to Chester County in areas that a traditional orthopaedics program does not always provide. And if a patient needs a highly specialized service that is only available downtown, we can get them in immediately on the same day." This spring, two orthopaedic surgeons on the Medical Staff at Chester County Hospital - Dr. Christopher Lyons and Dr. John Manta - will join the Penn Orthopaedics team. This integration creates a direct connection between the services they offer in Chester County, PA and an expanded set of resources available at the Penn Musculoskeletal Center in Philadelphia, PA.