Several studies have had mixed results about the benefits of quadriceps strength on knee arthritis.  Some show that weaker quadriceps are associated with greater knee pain and impaired function while others do not show a difference.  Most of the studies, however, focus on the main part of the knee where the femur (thigh) and tibia (shin) bones meet the tibiofemoral joint, neglecting to include the area of the knee where the patella (kneecap) and femur meet (patellofemoral joint).

A new study out has looked at both areas of the knee as well as knee arthritis symptoms.  The authors studied 265 men and women for 30 months.  Baseline MRIs were obtained as well assessment of quadriceps strength, severity of knee pain, physical function and knee alignment. 

The results showed that greater strength had no influence on cartilage loss at the tibiofemoral joint, but greater strength did protect against cartilage loss at the outer part of the patellofemoral joint, a common site for cartilage loss.  Also, those with the greater quadriceps function had less knee pain and better physical function.  The authors of the study believe that greater strength of the vastus medialis (part of quadriceps muscle) helps to pulls the kneecap inward, stabilizing and preventing cartilage loss.

Furthermore, several short-term studies have shown that greater quadriceps strength is associated with improved knee function and less pain.  The bottom line . . . keep those muscles in shape!!

URL: http://www.medicalnewstoday.com/articles/135408.php

Shreyasee, A.  "Quadriceps Strength and the Risk for Cartilage Loss and Symptom Progression in Knee Osteoarthritis."  Arthritis and Rheumatism 60:1 (2009): 189-198.

Osteoarthritis of the Knee

• Leading cause of physical disability
• 33 million Americans affected
• Most common in aged 65 or older
• Affects activities of daily living like climbing stairs or walking

Symptoms include:

• Pain
• Joint stiffness
• Swelling in knee

Factors that increase a persons risk of developing osteoarthritis:

• Heredity
• Weight
• Age
• Gender
• Injuries or trauma to the knee
• Poor posture or bone alignment
• Lack of aerobic exercise and muscle weakness

The AAOS Guidelines and Evidence Report Recommendations:

AAOS recommends:

• Patients should be encouraged to begin or increase their participation in low-impact aerobic fitness.
• Patients who are overweight should lose a minimum of 5% of their body weight
• Overweight is a body mass index (BMI) of greater than 25
• you can calculate your own body mass index by multiplying your weight in pounds by 703 divided by your height in inches
• Weight loss has the highest potential to slow the progression of osteoarthritis

• AAOS recommends for pain control:
• Tylenol
• NSAIDs (common include ibuprofen and naprosyn)
• Steroid injections into the knee like depomedrol or cortisone

• AAOS recommends against:
• Glucosamine and or chondroitin sulfate or hydrochloride
• Drawing fluid from the knee with a needle
• Custom made foot orthotics or foot supports
• Performing a knee arthroscopy (knee scope) as a clean out procedure for arthritis when no other problems are present like loose bodies or cartilage tears
•   "The current science shows us that just washing out the joint does not decrease the patient's osteoarthritis symptoms and can expose the patient to additional risk," said John Richmond, MD, chair of the AAOS work group.

• AAOS does not recommend for or against:
• Bracing
• Acupuncture
• Hyaluronic acid injections like synvisc or hyalgen

"AAOS Issues New Clinical Practice Guidelines for Osteoarthritis of the

Knee." American Academy of Orthopaedic Surgeons.  11 DEC.  2008 http://www.aaos.org/home.asp.

Can Bone Mineral Density (BMD) Testing Prevent Osteoporosis-Related Fractures?

The National Osteoporosis Foundation Reports:

• Osteoporosis is a major public health threat for an estimated 44 million Americans or 55% of people age 50 or older.
• In the United States 10 million people are estimated to have osteoporosis and 34 million or more are estimated to have low bone mass (increasing their risk for osteoporosis).
• Of the 10 million estimated to have osteoporosis, 8 million are women and 2 million are men.
• 1/2 of women and 1/4 of men over age 50 will have an osteoporosis related fracture .
• Women can lose up to 20% of their bone mass in the 5-7 years following menopause.
• Osteoporosis is often unrecognized in elderly men.

What Can You Do to Prevent Osteoporosis-Related Fractures?

Bone Mineral Density Tests (BMD)

·      Specialized tests that measure bone density in various sites of the body

·      Detect osteoporosis before a fracture occurs

·      Predict chances of future fracture

·      Determine rate of bone loss

·      Monitor effects of treatment by repeating BMD every year

·      BMD is recommended in:

o      Women ages 65 and older

o      Postmenopausal women who have a history of fractures or who have multiple risk factors

o      Men who have certain conditions that are high risk for osteoporosis (like steroid use)

o      Men and women who have been treated for osteoporosis for prolonged periods

·      Increase in BMD testing and osteoporosis treatment is ASSOCIATED WITH A DECREASE IN HIP FRACTURE INCIDENCE!

o      Secondary causes of osteoporosis should be excluded before initiating treatment with common causes being medications and parathyroid and thyroid problems

What Are Other Ways to Prevent Osteoporosis-Related Fractures besides BMD Testing?

• Adequate calcium and vitamin D intake
• Weight-bearing exercise
• Possible biphosphonates (Fosamax, Actonel, Boniva)
• Strategies to reduce falls such as eliminating rugs and using an assistive device such as a cane when outside
• Reduction of risk factors including smoking, low physical activity and poor diet

For more information visit:  www.highmarkbcbs.com.

Black, Judith and Mary Weaver.  "Bone Mineral Density Testing Can

Prevent Osteoporosis-Related Fractures."  Practitioners Journal of Highmark Blue Cross Blue Shield (2008): 24-25.

BACKGROUND INFORMATION:

• Arthritis is one of the most common reasons for disability.
• Primary diagnosis for 430,000 hospital discharges
• $14 billion in hospital charges
• 12.1 % of Americans older than 60 years of age had symptomatic knee osteoarthritis (wear and tear arthritis/most common type)

Johnston County Osteoarthritis Study

This study analyzed the lifetime risk associated with developing osteoarthritis of the knee and hip.  The study was designed to be representative of a civilian English speaking black and white population 45 years or older.  Participants had to be physically and mentally capable of completing the study.

The lifetime risk of developing symptomatic osteoarthritis of the knee by 85-years-old was 44.7%.  There were no significant differences by race, sex and education, but obese participants had a significantly higher lifetime risk (60.5% compared with 30.2% and 46.9% among those who were normal weight and overweight, respectively).   In addition, patients with a history of knee injury had a higher lifetime risk of 56.8% compared to 42.3%. 

Overall, this study demonstrates the high lifetime risk of symptomatic osteoarthritis is likely due to the aging of the population and the alarming rates of obesity.  One in two people is at risk of developing symptomatic knee osteoarthritis and two out of three obese people.  The link of obesity to symptomatic osteoarthritis demonstrates yet another reason to educate the public about weight loss and weight management.  Osteoarthritis is associated with enormous health costs as well as disability.  By educating the public on how to manage or even eliminate obesity and weight issues, we have the potential of decreasing the public health burden of this condition.

Murphey, L.  "Lifetime Risk of Symptomatic Knee Arthritis."  Arthritis and Rheumatism 59 (2008): 1207-1213.

Dr. DiGioia has been selected as an "Everyday Hero" as part of Wellsphere's "Yes, We Care! Campaign."  This program honors those who make extraordinary efforts to help, support and care for others.  As part of this program, you can see Dr. DiGioia and other "Everyday Heroes" on the Map of Caring at www.wellsphere.com/YesWeCare.  If you click this link and scroll about halfway down the page, you will be able to read entries about Dr. DiGioia's work.  The page also features an "Everyday Heroes" video.

Vote now for Dr. DiGioia as the world's best health blogger!  Wellsphere created the first annual "People's Health Blogger Awards" to recognize health bloggers who have made a difference in others' lives.  Voting began on December 15 and will end on January 15.  Go to Dr. DiGioia's Wellsphere page at www.wellsphere.com/Tony-profile/95977, and Click the "Vote for Me" badge to cast your vote.  The winner and the World's Top 100 Health Bloggers will be announced on January 19.

Dr. Tony DiGioia http://www.amd3.org/ROblog/

               Everyday Hero Badge:

Pastor Barbara recently underwent a joint replacement and wanted to share her experience with a video posted on You Tube that is for friends and family members so she can update all on her Journey to Wellness and road to recovery.  The video even shows Pastor Barbara playing a Wii video game (the hula hoop) as part of her post-operative therapy only two days after her surgery.  Dr. Tony DiGioia of Renaissance Orthopaedics performed the surgery as part of the unique Orthopaedic Program at Magee-Womens Hospital of UPMC which is grounded in the principles of Patient and Family Centered Care.

http://www.youtube.com/watch?v=yrMf3StIBXM

RESTLESS LEG SYNDROME (RLS)

What is "restless leg syndrome?"

Restless leg is a neurological disorder in which people feel the urge to move the legs when at rest.  People often describe the sensation as burning, creeping, or pain in the legs, which can range from uncomfortable to extremely painful.  This sensation usually occurs deep inside the leg, between the leg and ankle, and less commonly in the feet, arms, thighs and hands. Because of this sensation to constantly move the legs that does relieve the pain, it is often difficult to sleep and stay asleep, causing extreme daytime fatigue and exhaustion.  The lack of sleep can then cause impaired memory, difficulty concentrating and inability to perform activities of daily living. 

Restless leg syndrome is slightly more common in women and usually occurs in patients middle aged and older.   Events which can trigger restless leg are long car trips, sitting in a movie or any other periods of prolonged inactivity.  In most cases the cause of restless leg syndrome is unknown, but it can be caused by certain medications, chronic medical conditions, pregnancy, and even caffeine, alcohol and tobacco.  Temporary restless leg syndrome can be caused by total joint replacement. 

RESTLESS LEG SYNDROME AFTER TOTAL JOINT REPLACEMENT

After a total joint replacement, patients can often experience a "restless leg-like syndrome."  That is not a true restless leg, but rather a temporary condition resulting from muscle and joint healing as well as the swelling from surgery.  It is more likely to occur after knee replacements, and it can involve a feeling of diffuse pain, calf pain, cramping or the sensation to move leg around.  It is mostly experienced at night and resolves as the muscles and joints heal - approximately 6-10 weeks after the surgery.

TREATMENT OF RESTLESS LEGS SYNDROME

AFTER TOTAL JOINT REPLACEMENT

Treatment of restless leg after total joint replacement involves just moving the leg.  When awakened at night by the sensation, the best thing to do is stretch and walk around.  Also, for most patients the symptoms are less noticeable in the early morning, allowing time to rest.  Decreasing caffeine intake and tobacco and alcohol use can also lessen RLS.  Moderate exercise, regular sleep patterns, ice and massage can help eliminate the urge to move the leg.

·      Walking

·      Exercising or moving your joint, especially at night

·      Stretching

·      Ice and massage

·      Regular sleep patterns

·      Anti-inflammatories or other medications on a case-by case basis

Please keep in mind that restless leg syndrome caused by total joint replacement is a temporary condition and usually will resolve 6-10 weeks after the surgery.

WHAT IS A CONTINUOUS PASSIVE MOTION (CPM) MACHINE?

A motion machine will be used post-operatively to improve your range of motion more quickly and to make you feel more comfortable following the knee replacement surgery.  Even with the less invasive procedure, the healing of your incision can cause scar tissue to form, which causes your tissues to be stiffer than normal tissue.  The use of the CPM machine after your total knee replacement guides tissue growth, increases motion and helps reduce stiffness.  Your new joint also likes to be moved so this motion machine can make you feel more comfortable too!

You can use the CPM machine based on your comfort level, and it can be used as much or as little as you would like to use it.  We recommend that you use the CPM machine at least two times daily for one to three hours at a time.

WHAT TO EXPECT...

• The Day of Surgery

A CPM machine will be set up on your bed.  The motion will be set to full straightening with an initial bending of up to 90 degrees.  Even when you are resting, the CPM machine will work your knee!

• Post-op Days One to Three

Your bending will be increased based on how much bending you achieve in physical therapy.  In general, the bending will be increased by 10 degrees more than achieved during your last exercise session.  The goal will be for you to achieve 110 degrees or more of bending.  A portable CPM machine also will follow you to home.

·               Bruising may last for up to 6-8 weeks.  This is part of the normal healing process.

·               Being on the blood thinner after surgery can contribute to this bruising too.  However, this medication is very important so please continue to use it as you are directed.

·               Swelling of the leg, and down into the foot, can sometimes last for two or three months.

THINGS YOU CAN DO TO MINIMIZE THE

SWELLING AND BRUISING:

·               Elevate the leg when you are not doing your exercises or when you are resting.

·               For the first two to three weeks after your surgery, ice your knee or hip for 20 minutes every hour and also after exercising.  This will help to minimize both the swelling and the bruising.  After a total knee replacement, using your CPM (Continuous Passive Motion) will improve your range of motion, make your knee feel better and reduce swelling.

Explore Latest FACTS (and Fiction)

in Non-Operative and Operative Treatments of Hip, Knee and Back Arthritis

By Paula Deasy

ARTHRITIS IS THE LEADING CAUSE OF DISABILITY IN THE U.S; 42.7 MILLION AMERICANS HAVE ARTHRITIS AND MORE THAN A THIRD REPORT THAT ARTHRITIS PAIN LIMITS THEIR DAILY ACTIVITIES.  For many, anxiety or fear of the unknown prevents them from seeking help that could improve their quality of life. 

On Saturday, June 21, Dr. Anthony M. DiGioia, III, a leader in Patient and Family Centered Care and one of the pioneers of less invasive and computer assisted orthopaedic surgery, will chair an event for patients in the Bone and Joint Health Series entitled Let Your Journey to Wellness Begin!  Boomeritis: Help for those Aching Hips, Knees and Back. The Bone and Joint Health Series presents four events each year.  The upcoming program on June 21 will be held at the CCAC Boyce Campus and is open to the public and free of charge! 

"In this age of having massive amounts of information available at one's fingertips, patients and families can have a hard time sorting through it all," said Dr. DiGioia, a practicing orthopaedic surgeon at Renaissance Orthopaedics and founder of The Orthopaedic Program at Magee-Womens Hospital of UPMC.

"The program on June 21st is designed for patients and their families who have an interest in learning more about those aching hips, knees and back," DiGioia explained. "The goal is help people sort out fact from fiction and let them hear directly from the experts about the non-operative as well as the operative treatments. Our hope is that these events will improve communication and knowledge and reduce anxiety so that patients can make informed choices regarding treatment and maintenance of health."

A keynote presentation entitled "Patient and Family Centered Care: Reducing Anxiety and Providing Exceptional Care Experiences and Outcomes" will be given by Dr. DiGioia. He will be joined by orthopaedic and spine surgeons, a rheumatologist and a physical therapist to discuss the evaluation, diagnosis, treatments and exercise possibilities for those suffering from hip, knee and back pain. In addition there will be an "Ask the Doctor" panel discussion as part of the program.

Another resource for those seeking help for aching bones and joints is the blog at

www.amd3.org/ROblog. "The site was created on the advice of our Patient and Family Advisory Council and in response to all of the information about bone and joint health, " DiGioia continued. "We have a 'Fact & Fiction' column that can help patients obtain current and accurate information, and the blog site enables people to learn from patients' stories and to ask questions of patients and families living through similar experiences."

For more information or to register for the June 21st event, visit www. boneandjointhealth. org.

For questions, call 412-683-3260 or send an email to info@ boneandjointhealth. org. 

• What restrictions do I have after total joint replacement?
• There are very few restrictions for patients after surgery.  The only activity we do not recommend for patients is jogging for exercise as it accelerates the wear on your new joint.  Patients with hip replacements are told not to cross the operative leg over the other leg at the knees as this can put you in a position where you could potentially dislocate. You can cross at the ankle and bend all the way down as long as the legs are apart at the knees. You can resume all other activities based on your comfort and confidence level.
• Do I need to take an anticoagulant after surgery?
• All of Dr. DiGioia's surgical patients are to have Lovenox injections for 2 weeks postoperatively and then ASA (aspirin) for 2 weeks. Some patients have a higher risk for blood clots and have to take the blood thinners for a longer time. 
• How soon after my total joint replacement can I return to work?
• You may return to work as soon as you feel comfortable. Following a normal TKR/THR a patient should be out of work no longer than 4-8 weeks, but many patients can return to work in as little as 3 weeks.
• Will I be able to go to a rehab facility after surgery?
• 99% of our patients are able to return home after surgery without any problems. You are full weight bearing the night of your surgery and are able to climb stairs right away as well.  For 2-5 days following discharge, a physical therapist will come to your home to work with you, and you will attend outpatient therapy for 2 to 4 weeks at a physical therapy location close to your home.  On occasion, however, if there are medical or surgical issues, patients will be sent to a skilled nursing facility, but we always prefer for our patients to go home.  For the most part insurance companies are no longer covering stays in rehabilitation facilities after joint replacement.

• How do I know when I am ready for surgery?
• When you have endstage or "bone on bone" arthritis, injections are helping the pain less than three months and your pain is affecting your quality of life then you will be a surgical candidate.  Until you reach this point Dr. DiGioia will continue to advise conservative treatment.
• Why have I been asked to lose weight prior to my surgery?
• Knee and hip replacements wear out just like your regular knees and hips.  For every pound of extra weight that is six pounds of pressure on both your knees and hips!  If you are 10 pounds overweight, that is 60 pounds on your knees and hips! If you would wear out your new knee or hip, it would require a revision or redo surgery which can have more complications and higher risks. We know it is hard to lose weight because of pain, but the role of the injections is to relieve pain and allow you to be more active.  Dr. DiGioia wants you to be in the best shape possible before your surgery so that you can have the best results afterwards.
• What is arthritis?
• Cartilage acts as a cushion for the weight bearing surfaces of the joint.  When arthritis sets in, the cartilage between your joints begins to wear over time, and eventually the bone wears down too.   This causes the inflammation and pain which prevents you from maintaining your active lifestyle. 
• What is minimally invasive total joint replacement?
• This surgery is not truly "minimally" invasive, but, more accurately, "less" invasive.  There is a smaller incision and less muscle work involved, but the implants are still the same.
• What medications do I stop prior to surgery?
• All medications with ASA base (aspirin), blood thinners, NSAIDs (such as Aleve and ibuprofen), all arthritis medications (except for Celebrex) and vitamin E.  Please ask about any herbal supplements you may be taking.
• Can I take Tylenol?
• Yes.
• Can I take Celebrex?
• Yes.  Unlike other arthritis medications, you can take Celebrex right up to the day of your surgery. We also use Celebrex as a pain medicine after surgery.
• How long can I expect my total joint replacement to last?
• 75% of people are still with their original implants in place and doing well at 15 years. This is not to say that once it is year 15 that you will start having problems. TJR can wear out just like your normal knee, and the longer you have the joint replacement the greater the risk wear.  Also, the modern implants are modular systems so we can often catch wear early enough and replace ONLY the part that is worn. This is why we recommend that you get new x-rays every three years!