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Shoulder pain can be more than just a…
Date Recorded
November 29, 2023 Health Topics (The Scope Radio)
Bone Health
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We use our thumbs for just about everything,…
Date Recorded
June 15, 2022 Transcription
Interviewer: You don't realize how much you really use and depend on your thumb until you can't use it anymore because it hurts so badly. And if you're suffering from thumb pain, it can have a drastic impact on your quality of life. Luckily, if you have thumb pain from thumb arthritis, there are some excellent nonsurgical and also surgical options to relieve the pain and get functionality back.
Dr. Brittany Garcia is a hand surgeon and an expert on thumb arthritis. And today, she's going to talk us through both the nonsurgical options to give you some relief from your thumb arthritis and also the surgical options and their effectiveness.
So let's start out here. If somebody has thumb pain, is it a good idea to go see their family doctor or a general practitioner first, or go to a specialist like yourself?
Dr. Garcia: First up is primary care physician because they have a lot of non-operative options that they can offer patients. So, usually, when you present to your primary care, most people will take some X-rays and then they'll be able to parse out, "Are there arthritic changes on your X-rays that we think are probably causing your pain? Or is this something else like the trigger finger, or carpal tunnel, or things like that?"
And then primary care can start with some of the non-operative options, such as splinting, activity modifications, referring to a hand therapist who can work on a home exercise program to strengthen the muscles around the joint.
I like to think of strengthening, which is a really good option, similar to an ACL. So if you've got weak quads and hamstrings and calf, you're probably more at risk of developing ACL tear. Well, similar to the base of the thumb. It seems silly, but you've got lots of small little muscles that attach around the base of the thumb, and strengthening those muscles likely offloads the forces and supports the joint in general.
Interviewer: Let's talk about some of those non-operative treatments first. So are there any downsides to any of those, or is it always kind of a best practice to start with the non-operative stuff first?
Dr. Garcia: Definitely best practice to start with non-operative treatment. And by doing non-operative therapies and trying those first, you don't necessarily drastically change what we're going to do surgically. So it's not like you're losing time or making the surgery much more complicated for us by trying these things first.
And certainly, for some people, while non-operative options don't necessarily take away the arthritis, and we know that, many of them can help quiet the arthritis.
And so the things that come to mind that are most common that we do is bracing, where we do a hand-based brace for the thumb to kind of support it from loading consistently in those types of movements that cause it to be painful. It's basically a rest thing. So if it hurts, then you rest it.
The other things that are commonly used are anti-inflammatory medications, as long as you don't have any other medical problems that would prohibit you from having them, such as kidney disease or issues with your stomach. But anti-inflammatories can be really helpful, both those that you take by mouth, as well as some topical anti-inflammatories.
I like to sell it to you straight. I'm not going to say this is a magical topical cream that's going make you feel 100% better, or take away your arthritis, or anything like that. But the goal with non-operative therapy is really to try to make you more comfortable to be able to do your normal activities of daily living, as well as your hobbies and things that you want to do without having pain that's limiting you.
Interviewer: When you do splinting to help relieve the pain, I thought I had read somewhere that that could relieve pain, but it could also cause weakness, which would be a concern to somebody who does use their hands for a living. Is that true?
Dr. Garcia: That's always a catch-22. Usually, my prescription, when I'm doing splinting with a patient, is I will try to have them wear that splint full time for about six to eight weeks to see if we can calm it down. So that includes daytime and nighttime with the exceptions of taking it off for showering and washing hands and hygiene and things like that.
Theoretically, there's a risk that, because you're not using those muscles, you get some weakening of that muscle. But I think if you can calm down the pain, then you're probably going to increase your function and gain that use back and bulk, so to speak, those muscles back up.
And the other thing is when you're having so much pain, you're probably not using it normally anyway. So there's probably some degree of deconditioning that people get just by having the pain and doing the splinting. But I think if you can get the pain under control by immobilizing that joint, then likely you bounce that back quite well.
And then the other thing I didn't mention, which is a nice non-operative option, is corticosteroid injections or steroid injections, which is commonly used in musculoskeletal conditions to help calm down the inflammation around the joint. So I sort of think of those as you're taking a dose of . . . it's sort of like putting ibuprofen right inside the joint to calm down inflammation.
"Itis," which is the end part of arthritis, is inflammation, so really this is an inflammatory process that's caused by the joint being overworked or overloaded. So putting steroid in that area can help calm down that inflammation and give people some pretty good relief.
Interviewer: Are there any downsides to the steroid injections?
Dr. Garcia: I like to use steroid injections for people who respond well to them and get a fairly long-lasting effect. It's really hard to predict exactly who's going to respond to them or who's not. And even if you've had an injection in the knee or the shoulder and it hasn't worked as well, it doesn't necessarily mean that it's not going to work in your hand. I've definitely had patients who've had injections in other places that haven't worked that well, and it's worked really well in the hand.
Interviewer: For surgical treatments, talk me through what considerations you have there. I think there are two different types of surgery, or is there just really kind of one that you tend to use most of the time? Help me understand that.
Dr. Garcia: There have actually been lots of different ways described to take care of arthritis here. Basically, they all culminate on taking out the trapezium bone, which is a small, little bone in the wrist that makes up the joint at the base of the thumb. And this is where most of your arthritis at the base of your thumb typically goes. So regardless of which type of procedure people choose to do, usually it all begins with taking out the trapezium.
And then there are a number of things that can be done to sort of stabilize or support the base of the thumb after you've taken out that little bone. That bone typically supports your metacarpal bone, which is the longer finger bone. It sits on that little bone.
So most people will take out the trapezium and then you can do a number of tendon-type procedures to support the base of the thumb. I like to do something called the suture suspensionplasty, which is where you take two of the tendons that are nearby and you suture them together underneath the metacarpal bone, which sort of acts as a soft tissue hammock or supportive structure for the base of the thumb now that that little arthritic bone is out. But people do a number of different iterations of that particular procedure.
Interviewer: And then after you get that procedure done, the goal is to reduce pain and improve functionality. How successful is that procedure at doing those two things?
Dr. Garcia: This CMC arthroplasty, which is what we call our surgery for this condition, is something that takes a long time to recover from, but people typically are very happy once they get recovered. So usually it involves some sort of immobilization like casting or splinting for about three months, exercises with our hand-specific occupational therapist to get the thumb back in good working condition and strong and get the range of motion back.
So people are sore for three to six months, but once they . . . They're slowly getting better, and once they get to kind of their maximum, I guess, potential of recovery, people are typically really happy with this surgery.
Interviewer: And that treatment, that pain relief will last for a while? The mobility will last for a while?
Dr. Garcia: Yeah, the goal is for that to kind of be one and done for people, that they get the surgery and then most people don't need any sort of revision surgeries or other procedures down the line for it. It typically takes care of it for the duration of their life, which is the goal of it.
Interviewer: And you've removed a bone, so is there going to be from a mobility standpoint anything different? Or when you go in and you make the other adjustments, it usually takes care of that?
Dr. Garcia: When we put the sort of supporting stuff at the base of the thumb, typically, people have pretty good motion. Obviously, after you come out of your splint or your cast after surgery, everybody is stiff. And any surgery around an area will make you stiff, particularly in the hand. But it doesn't necessarily take away motion.
Certainly, we have other options for different types of arthritis in your hand where we're actually fusing joints, and those are types of procedures we're definitely . . . you're very clear preoperatively with patients that they're going to lose motion at the joint that you're operating on. This is not one of those where we're talking to them about drastically decreasing motion.
Usually, people are using their thumb better because it no longer hurts. And so once we get them through that initial therapy period of getting the swelling down and the stiffness from surgery down, people's motion comes back pretty good.
And then the other thing I wanted to bring up, because we see it not infrequently, is carpal tunnel. People who have arthritis at the base of the thumb, we see in about 30% of patients, they also have carpal tunnel symptoms when they present to clinic. So that's always something that we're looking for at the same time because we don't want to miss that and not release their carpal tunnel if it's surgically something that makes sense based on their exam.
So any time they're coming to clinic, we're always teasing out, "Is your pain due to arthritis at your thumb? Is it due to the carpal tunnel? Is it due to both? And how much is contributing to what's going on?"
Interviewer: Oh, so you can get both of those done kind of at the same time.
Dr. Garcia: Exactly.
Interviewer: Dr. Garcia, that is some great information. I hope that it helps some people find some relief from their thumb pain and thumb arthritis. Before we go, though, do you have a takeaway, something we should take away from the conversation today?
Dr. Garcia: The most important thing is to know that we've got lots of options, both non-operative stuff that works really well and can get many people through without needing surgery, and then we have a good surgical option. It's just important to know that with the surgical option, there's a reasonable amount of recovery that goes along with it. MetaDescription
We use our thumbs for just about everything, especially these days with smartphones. For people suffering from painful arthritis in the thumb, the condition can make daily life extremely difficult. Learn about the different surgical and non-surgical options available to bring relief to patients with thumb arthritis.
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For most kids who are active, complaints about…
Date Recorded
July 23, 2018 Health Topics (The Scope Radio)
Bone Health
Kids Health Transcription
Dr. Gellner: Juvenile rheumatoid arthritis is one diagnosis parents often worry about when their child says their joints hurt. I'll give you the basics on JRA on today's Scope. I'm Dr. Cindy Gellner
Announcer: Keep your kids healthy and happy. You are now entering "The Healthy Kids Zone" with Dr. Cindy Gellner on "The Scope."
Dr. Gellner: Whenever an adult says their joints hurt, especially if they're older, the first thing everyone thinks about is arthritis. Well, that's not true for kids. Being active is usually the cause of joints hurting often because of an injury. But here are some key symptoms when your pediatrician may start to think about something called juvenile rheumatoid arthritis, JRA, also known as juvenile idiopathic arthritis.
Why some kids get it and the cause of JRA isn't well known. But it is an autoimmune disease where your child's body loses the ability to tell the difference between their normal body and something harmful like a bacteria or a virus.
Their immune systems go into overdrive and release chemicals that damage healthy tissues and cause pain and swelling. Your child will need to have symptoms for at least six weeks on a daily basis before JRA is considered. When the arthritis starts, what body parts are affected and how bad the symptoms are differs based on what type of JRA a child has.
Pauciarticular JRA affects four or fewer joints, usually the hips, knees, the shoulders, and elbows, but can also cause visions problems as well. About half of the cases of JRA are this type.
The second type is polyarticular JRA, which affects 5 or more joints, and about 30% of kids have this type. Small joints like those in the hands and feet are often affected, as well as those larger joints.
The third and worse type of JRA is systemic onset JRA, which is also called Still's disease. It affects joints and internal organs, such as the heart, liver, spleen, and lymph nodes. About 20% of children with JRA have this type.
If your pediatrician suspects that your child may have JRA, they may order blood tests. These include an ANA test for inflammation and autoimmunity and something called a rheumatoid factor test. Your child will also be referred to a rheumatologist who specializes in treating autoimmune diseases such as JRA. Your pediatrician and rheumatologist will work together to help take care of your child.
Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.
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Spinal stenosis is a very common condition,…
Date Recorded
June 07, 2016 Health Topics (The Scope Radio)
Bone Health
Brain and Spine Transcription
Dr. Miller: What is spinal stenosis? Could you have that as a problem? We're going to talk about that next on Scope Radio.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists with Dr. Tom Miller" is on The Scope.
Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Ryan Spiker. He's an Orthopedic Surgeon and a Professor of Orthopedics here at the University of Utah. Ryan, what is spinal stenosis and who gets that?
Dr. Spiker: It's a great question. Spinal stenosis is very common, especially as we age. So in the elderly population, what happens is you get some reason for compression of the nerves in the low back. This is often from arthritis, degenerative changes, and slowly that compression can lead to pinching of the nerves in the low back, which leads to weakness and pain in the legs.
Dr. Miller: So the anatomy is . . . tell me about that. The spinal cord goes down through the vertebrae, which are the bones of the spine and they travel through a tunnel. And what happens? That tunnel becomes narrow, is that what happens?
Ryan. Absolutely. So at the bottom of the spinal cord, there are still nerve roots and all those nerve roots end up innervating our legs, providing sensation and strength to our legs. And in that bottom part of the spine, just above the pelvis, it's common for arthritis to lead to hypertrophy or thickening of the ligaments, thickening of the disk and then compression of those nerve roots. And that compression leads to the pain that often shoots down into the legs.
Dr. Miller: So is spinal stenosis then a condition that someone who is a farmer or a laborer would get more commonly than somebody who was maybe working at a desk, or does it matter?
Dr. Spiker: So it does matter. There's some effect of environment so what we do. Sitting is actually very bad for our backs and so that can be a risk factor in and of itself.
Dr. Miller: So a clerk or a professional who's sitting a lot might be at greater risk than even somebody who is out working all day?
Dr. Spiker: Absolutely. Depending on the type of the work and there are also some genetic risk factors that we've studied here at the U that have been shown to impact how often family members will get spinal stenosis.
Dr. Miller: Well, tell me a little bit about what the symptoms are.
Dr. Spiker: The most common symptoms are pain or weakness or heaviness of the legs and it's usually worse when people are standing up and walking and improved when they bend forward. So if they're using a shopping cart or if they're using a walker, it feels much better. But again, it's worse when they attempt to stand up straight or extend their back.
Dr. Miller: What kind of pain is it? Is it a burning pain in both legs generally, if they're walking more than a block, I mean if it's severe?
Dr. Spiker: Often, people will describe some burning sensation. Commonly, it's a heaviness. It's a feeling that their legs are disconnected from their body. It can be a sharp pain that shoots down the spine. There's some variation with nerve pain, but invariably, it's worse with walking and usually goes down the back of the legs and can go all the way down into the feet.
Dr. Miller: What age groups are most susceptible to spinal stenosis?
Dr. Spiker: So, for most patients, it's as they get older so usually in patients that are 50 or 60 or above. Certainly, there are causes of spinal stenosis such as fractures or really large disc herniations that can occur in a younger population, but the vast majority of patients are a little older.
Dr. Miller: In a previous talk, we talked about sciatica and how that's caused by disc herniations mostly. Would spinal stenosis be more common or less common than disc herniation-related sciatica?
Dr. Spiker: So similar in different groups. So at a national level, certainly more common to have spinal stenosis than disc herniations that would cause somebody to see a spine surgeon like me. Most spinal stenosis patients will have some progression over time or continue to have symptoms, whereas most patients with disc herniations will get better on their own and this won't require to come in to see a spine surgeon.
Dr. Miller: So tell me about the therapies, treatments, for spinal stenosis. Obviously, it depends on the severity of the problem.
Dr. Spiker: Absolutely. So our first line treatments are anti-inflammatory medications, non-steroidal anti-inflammatories.
Dr. Miller: Ibuprofen, naproxen, aspirin, things like that.
Dr. Spiker: Exactly. They help calm down some of the inflammation from the area of compression. And then getting people into physical therapy to help strengthen their core, take some of the stress off the bones and the nerves of the back.
Dr. Miller: Would you say that physical therapy is kind of an underused and underappreciated modality?
Dr. Spiker: Absolutely, absolutely. And often, I would say 60, 70, 80% of patients that I see in my clinic have not yet undergone physical therapy and anti-inflammatories. And sometimes, these simple interventions can really change the quality of their life.
Dr. Miller: How long would it take before someone would know if physical therapy was actually working?
Dr. Spiker: It's a great point that it does take time so often the first few weeks can be frustrating because it's difficult and it can cause some pain, but usually, within six to eight weeks, people start to see the fruits of their labor.
Dr. Miller: In your experience, when then do you start talking about a surgical solution to the problem?
Dr. Spiker: So surgery is always the last option, it's never the first option. And fortunately, we can usually get people better with the anti-inflammatories, the physical therapy, some nerve medications, neuromodulatory medications like gabapentin, sometimes even injections. If all of these fail and the symptoms are progressive and really causing a change in their quality of life, that's when we talk about surgery.
Dr. Miller: And surgical outcomes, how well does it work?
Dr. Spiker: So surgical outcomes are excellent in well-selected patients. So in patients that have gone through the right preoperative therapies and interventions, it ends up about 80-85% of people are much better after surgery than they were before.
Dr. Miller: That's a great outcome.
Dr. Spiker: Yes.
Dr. Miller: And over time, does that hold?
Dr. Spiker: It does. So we have great data up to about eight years now showing that people have continued benefit with surgical intervention for at least eight years and we certainly think longer.
Dr. Miller: Well, thanks, Ryan. So for our audience, basically surgery is the last option, but it has an excellent outcome. But prior to surgery you want to think about a good trial of physical therapy and the use of over-the-counter non-steroidals like ibuprofen and naproxen just to try to control the pain while you're testing physical therapy and working with your therapist.
Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com
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Most people with hand arthritis just live with…
Date Recorded
May 16, 2019 Health Topics (The Scope Radio)
Bone Health Transcription
Dr. Miller: Are there surgical solutions for your painful hand arthritis? We're going to talk about that next on Scope Radio.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.
Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Doug Hutchinson. He's a Professor of Orthopedic Surgery here at the University of Utah. Doug, I have a lot of patients that come to see me with arthritis in their hands as they get older. They're asking me from time to time if there are any surgical solutions for their pain.
Dr. Hutchinson: Everyone gets arthritis in the hand at some point in time as long as we last long enough. Most arthritis in the hand is something that people live with and I think that's appropriate. Surgery is not going to solve everything that comes down the road, but there's no question that some people have certain fingers that get arthritic changes that hurt them on a daily basis and really get in their way of doing certain things in the kitchen, doing certain things in the garden, doing certain sports activities, and those we probably in some situations can help a lot.
Dr. Miller: How do we do that?
Dr. Hutchinson: For example, in the fingers the most common place to get arthritis is near the tips in the last joint, called the distal interphalangeal joint, right underneath your nail. Some people get cysts that grow out of those that become a problem on the nail and they're painful. Those can be taken care of if we get rid of some of the arthritis there.
Primarily, if the joint of the finger is stiff and painful and has arthritis on x-ray, which is common, one of the things we'll do the most commonly is fuse that joint. That just means putting a screw across the one bone into the other bone and making that joint effectively go away. You can't bend it at the end, but it stays straight the whole time.
Dr. Miller: And that eliminates the pain?
Dr. Hutchinson: That totally eliminates the pain, and the other joints still make you use your hand very well. Functionally, you're normal without that last joint working.
Dr. Miller: Are there any particular joints in the hand that are more amenable to surgery than others?
Dr. Hutchinson: Yeah, other than the DIP joint of the fingers, which is the last joint near the nail, the base of the thumb, which is all the way back closer to your wrist. Some people even think that they have wrist pain but in fact it's the base of the thumb that's hurting them. Typically a patient will really have a hard time with certain grips. They won't want to shake hands as much. They really hate the fact that they can't open a jar at home. They've got to give it to their wife or their husband to figure that out. It's generally a thumb pain problem that is really, in the world of humans the thumb is overwhelmed by what we do with our hands, and there are more forces put through our thumb joint than was originally intended.
Dr. Miller: Do you perform a similar stabilizing surgery where you put a pin or screw in the joint?
Dr. Hutchinson: Yeah. For a thumb arthritis, the most common solution is to remove a bone at the base of the thumb, which means the two ends of the bone that were grinding on each other causing pain, now one of them is gone. There's no longer a bone grinding on a bone. The word arthritis means "arth" which is joint, and "itis" which is inflammation. I tell my patients that if you don't have an "arth" you can't have arthritis. The getting rid of the "arth" is either a fusion, like we do in the distal joint of the finger, or a resection of the bone which means it can still move very well as opposed to a fusion. The pain is gone and we use a tendon to help stabilize the joint.
Dr. Miller: Would you recommend conservative therapy prior to considering surgery for either a distal interphalangeal arthritis or base of the thumb arthritis?
Dr. Hutchinson: Yes. We always recommend conservative care first, and most times that usually works for a lot of people for a good bit of time. A thumb arthritis, the mainstay for treatment is to get them a splint. The splint is something no one wants on their hand and no one wants on their thumb in particular, but it's worn at night when no one theoretically is using their thumb in the middle of the night. It allows the thumb to rest. That may make it better during the day when you take the splint off and use your thumb for normal activities.
We always want them to avoid certain activities. You don't want to open a can with a hand crank if you have thumb arthritis. You want to go out and buy an automatic can opener. That's something our hand therapists insist on. They think that should be done; at age 20 we should all get automatic can openers.
Dr. Miller: In your opinion, what would be the best conservative therapy? What do you advise patients to take?
Dr. Hutchinson: We generally tell them to wear a splint during the night that's fairly rigid that holds their thumb. We give them a strap type of a splint that's easy to wear during the day that they can wear when they want. When they don't want to they can not wear it at all. It sometimes helps when they're gripping things and gives them a little bit more support and decreases their pain.
If they get to the point where it's worse, we'll often inject them which helps them for two to three months at a time and really makes their pain go away, again, can delay the surgery if they want to have the surgery. Some people come back to me every six months and say, "Give me another injection. I don't want that surgery. I ain't got time for that. Let me just have three, five, six months of peace, please."
Dr. Miller: What is the durability of the surgery? Is it long-lasting?
Dr. Hutchinson: Yes. The surgery for base of the thumb arthritis is actually one of the best we have in our armamentarium. It works well in most any surgeon's hands. There are different procedures that can be done, all of which work about the same or as well as the others. I would caution a patient that it takes three months of being good and wearing a splint, and therefore it's a longer rehabilitation than they would like.
Other than that being a negative, the rest of it is positive. They maintain their motion. They actually increase their grip strength a little bit. Their pain is effectively 100% resolved at that particular joint. Again, a person with a lot of arthritis in their hand is not going to get the rest of their arthritis to go away, but that one is usually the one that is causing the most problem.
Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.
updated: May 16, 2019
originally published: January 19, 2016 MetaDescription
Two types of surgery that can effectively eliminate arthritis pain and improve your quality of life.
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Unlike knee and hip arthritis, ankle arthritis…
Date Recorded
July 14, 2015 Health Topics (The Scope Radio)
Bone Health
Sports Medicine Transcription
Dr. Miller: Who gets ankle arthritis and what to do about it. We're going to talk about that next on scope radio.
Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.
Dr. Miller: Hi, I'm here today with Dr. Alexej Barg. Alexej is a professor of orthopedic surgery here at the University of Utah. Alexej, who gets ankle arthritis?
Dr. Barg: This is a very particular problem. We don't know actually why that people do develop, for example, knee osteoarthritis or hip osteoarthritis, however, we know exactly who does develop the osteoarthritis of the ankle joint or the subtibiotalar joint.
Dr. Miller: That's really interesting. I mean, we are more commonly used to hearing about knee and hip arthritis, not so much about ankle arthritis.
Dr. Barg: The most common reason to develop ankle osteoarthritis is previous trauma. It can be the bony fracture, but it can be also the repetitive ligament sprain of the ankle joint.
Dr. Miller: Due to sports injuries typically? Or is this some line of work that would be a problem?
Dr. Barg: Both injuries can lead or can end up final in end-stage ankle osteoarthritis. And many people do speak about hip or knee osteoarthritis however the ankle osteoarthritis is a growing problem. Upcoming in Europe and in Europe right now every tenth patient who is coming to an outpatient clinic for an orthopedic problem is coming with a problem of ankle or the foot, including ankle osteoarthritis. So this is a growing problem. It should not be underestimated. There are some studies showing that the patient having end-stage ankle osteoarthritis have the same pain, the same disability in daily activities comparable to those patients having, for example, hip osteoarthritis.
Dr. Miller: So it's obviously painful. So again, what is it that causes this arthritis? What sorts of people are prone to develop ankle arthritis?
Dr. Barg: In the past decades, several studies have been published to figure out which are the risk factors to develop ankle osteoarthritis, especially posttraumatic ankle osteoarthritis. And I would say in my opinion there are two very important factors: the first is definitely the severity of the initial injury. For example, if you have a fracture of the lower leg including the tibiatalor joint surface, that means that those patients have also the cartilage lesion at the time of the initial injury. And the second significant risk factor is for sure the deformity because some people or the most people, more than the half of all patients with ankle osteoarthritis, have a concomitant lower leg deformity. That means they have uneven load distribution within the joint, which finally leads to end-stage disease.
Dr. Miller: So it sounds like fracture of the foot, fracture of the ankle can lead to ankle arthritis. Is that correct?
Dr. Barg: This is correct. This is absolutely correct. And . . .
Dr. Miller: So automotive accidents, industrial accidents can lead to arthritis.
Dr. Barg: Yes, absolutely correct. However, the bony fractures of course they are severe injuries and everybody is aware of it. However, I mentioned this before, also there are repetitive ankle sprains and ankle sprains are definitely the most common sports injury in this country but also worldwide. I would say if you have at least two or three ankle sprain a year that means you are at high risk to develop, sooner or later, ankle osteoarthritis.
Dr. Miller: And so does ankle arthritis develop at a younger age typically than we see hip and knee arthritis in the United States? I think in general we will see knee and hip arthritis at the age of 55 and above.
Dr. Barg: This is another challenging problem specifically in this patient group. You mention this correctly. The patient with knee or hip osteoarthritis, they are usually in their fifth or sixth life decade. Patients with end-stage ankle arthritis, they are much younger. So sometimes I even see patients that are 30, 35 years old and their ankle joint is really gone. That makes the treatment is this patient group specifically very challenging because whatever you plan to do in those patients they should usually last for many years. That means for another 50 or maybe even 60 years in the future.
Dr. Miller: Typically patients with ankle arthritis will present with pain and, I suppose, immobility, some type of immobility in the ankle. So what then are the next steps? Obviously they make their way to you, they know about your practice. What do you advise them?
Dr. Barg: First of all, I take a very exact medical history. So I want to know exactly how long the patient had the pain. What type of injury, if they had an injury, what type of injury exactly they had? Usually, I collect all possible medical records from the past. And the second step is definitely the clinical assessment, the clinical investigation. I do see how good the movement of the ankle is. I want to also check the alignment. That means they ask whether the ankle joint is straight or not. I also check the stability. And then finally I go further with the imaging, which is an extremely important part.
Dr. Miller: X-rays, typically?
Dr. Barg: Yeah, I always stay with a weight-bearing radiograph. Weight-bearing if very important. Many patients come from the family doctors, for example, with some imaging, but this imaging is not useful. I call is accidental imaging. Because you see just a very small part of the ankle, not weight bearing. That means you still see some ankle osteoarthritis, however, because they are not weight-bearing radiographs, you cannot really assess for example the alignment of the ankle joint.
Dr. Miller: So you're going to do a more thorough radiographic examination based on weight-bearing than typically you would see in a standard practice. Okay.
Dr. Barg: Yes.
Dr. Miller: Then, moving on to treatment, there are obviously different types. You can fuse the ankle, but there are other aspects of that care as well, I gather.
Dr. Barg: In the literature, mostly two treatments are described for the end-stage ankle osteoarthritis. This is to fuse the ankle or to replace the ankle. That means to use an ankle prosthesis. An ankle prosthesis, especially in the last two decades, experienced a really great progress. Regarding the design of prosthesis, they are definitely some designs are more anatomical design, which may really mimic much better the normal anatomy and normal biomechanics of the ankle joint.
However, in my opinion, both treatment options are not perfect. And so, therefore, in my clinic, we always try to use the joint preserving procedure. That means a surgery where you try to correct the underlying deformity. And you don't have to fuse the ankle. You don't have to replace the ankle. That means the patient still has their own ankle.
Dr. Miller: For our listeners, fusing the ankle, what does that mean?
Dr. Barg: To fuse the ankles means that you can do it actually laparoscopically, that means minimally invasive. Or you can do an open procedure. You just remove the remaining cartilage, you stabilize the tibiatalar joint using different implements. It can be screws, it can be plates.
Dr. Miller: These are the large joints at the back of the ankle, I guess.
Dr. Barg: Yes. And this for many decades has been the gold standard procedure for end-stage ankle osteoarthritis. The problem is for those patients the ankle joint does not move. That means that the functionality of the ankle joint should be taken over by adjacent joints. For example, by the subtalar joint, which is the joint underneath. And that means sooner or later those patients will develop diminutive changes in their adjacent joints. That's the biggest problem following ankle fusion.
Dr. Miller: Similar problem to folks who have disc fusions in their back.
Dr. Barg: This is maybe a similar problem, yes. Absolutely.
Dr. Miller: Some of them develop arthritis above and below the fusion.
Dr. Barg: I agree with you.
Dr. Miller: So because the points of stress change.
Dr. Barg: I agree with you.
Dr. Miller: Interesting. Alexej, in your experience, rebuilding the ankle joint, how durable is that? How long-lasting is that surgery? How much relief will it give and how long can one expect that to be helpful?
Dr. Barg: These questions cannot be answered clearly with a certain number, like two years, five years, 10 years. In my experience, if you do the joint preserving procedure, approximately 20% of all patients still need a bigger surgery like ankle fusion or ankle replacement within 10 years after the surgery. Which maybe the first sign is not that encouraging number, however, I can just tell you that if you do a very exact selection for this procedure, the patients are very happy because they still have their own joint. They don't have any restrictions doing, for example, recreation or sports activity. And actually this number is very dependent on how severe the ankle osteoarthritis is. I do communicate this very often and very clearly with the patient and I tell him what his expectation should be in the particular case.
Dr. Miller: It sounds like you have a great knowledge of the prognosis of each of these procedures that would help your patients make a decision on what to do.
Dr. Barg: Yeah, most likely we can say and predict exactly whether the procedure will last for two years or five years or for the 10 years. And for two years, sometimes if the patient is, for example, a hard worker and has to work on the street and has to lift heavy weight, this patient will not profit immediately, for example, for ankle fusion or ankle replacement. He'll want to wait another two or five years until he's retired and then he's ready for another surgery. Those patients are very thankful that you can offer them the joint preserving procedure.
Dr. Miller: Are there other tips for people who might have ankle arthritis? How do they find their way to a particular orthopedic surgeon? Should they see a specialist? Should they see a generalist orthopedic surgeon or should they see someone else, like a sports medicine physician?
Dr. Barg: I would suggest if the patient has ankle osteoarthritis, it doesn't mean a late stage. If it's at the early stage or the end-stage, this is a very challenging problem with many concomitant problems, which can be overseen by a person who is not that experienced in this area. By concomitant problems, I'm speaking, for example, about a concomitant deformity, a concomitant instability and so forth. So I do really think that those patients should really be seen be a person who has experience in dealing with this problem and who can also offer a different treatment option. Because the treatment options in the beginning of ankle osteoarthritis are definitely different, for example, than for patients with end-stage ankle osteoarthritis.
Dr. Miller: So bottom line is if you have ankle pain, try to have that diagnosed earlier rather than later. And if you have ankle arthritis, find your way to an orthopedic specialist who specializes in lower extremity problems.
Dr. Barg: Yes, absolutely. I agree with you.
Announcer: thescoperadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com
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University of Utah researchers have discovered a…
Date Recorded
December 16, 2013 Science Topics
Health Sciences
Innovation Transcription
Discover how the research of today will affect you tomorrow. The Science and Research Show is on the Scope.
Interviewer: My guests are Dr. Janis Weis, a Professor of Pathology at the University of Utah and Postdoctoral Fellow Dr. Kenneth Bramwell, have identified a gene deficiency that makes individuals susceptible to developing severe inflammatory arthritis. Their work provides new insights into how the condition develops, and could one day lead to new treatments. When you started this study what were you hoping to understand?
Dr. Weis: We were hoping to understand, two things really. The mechanism by which infection with this bacteria, borrelia burgdorferi that is responsible for Lyme Disease, the mechanism by which it can cause severe arthritis in mice, and therefore, using that as a model for understanding severe arthritis in patients as well. And we were also hoping to identify genes that were responsible for the differences in disease severity.
Interviewer: And you've been working on this for some time, Dr. Bramwell you've started on these studies, I think just a few years ago, what was the state of the research when you came on board?
Dr. Bramwell: When I came into the lab the size of the interval contained about 350 different genes. My project was to find the needle in the haystack, to find the one or multiple genes in this interval that were regulating this disease severity. So we generated an animal that had 24 genes, so we'd excluded more than 90 percent of the genes. From those 24 genes our next step was to try to identify if there were any mutations or polymorphisms, and it turns out that 23 of these genes were 100 percent identical, at a DNA level. There was a gene that did have a polymorphism in the DNA sequence and it's called beta glucuronidase or GUSb, and so when we first found this and identified that this was a potential candidate, it was actually a disappointment because this is not the type of gene you go looking for in a study like this. It turns out, this is what's called a housekeeping gene, it carries out the normal boring processes of the cell, and if you look in the scientific literature, which I did, you back several years and almost every paper that's been published on this is not studying this gene at all, it's using this as a reference to study something else more interesting. So, I wasn't very pleased with that at the beginning, but I didn't let that get me down and I thought, OK, well, this looks to be what's causing the effect so let's follow it.
Interviewer: So Dr. Weis, how about you? Were you disappointed?
Dr. Weis: No, I wasn't disappointed. I think when you undertake an unbiased genetic mapping project, you go where the genetics takes you. I think you just say, well, we've got our work cut out for us, we have to do the correct experiments to really establish that there is plausibility for this gene to be associated with Lyme Arthritis severity.
Interviewer: So Dr. Bramwell, how do you follow up on that finding? And can you explain that experimental model?
Dr. Bramwell: Turns out that this is an enzyme, so we can measure the enzymatic activity, to see if it is fully functional or not. So we did that and it turns out that the C3H inbred strain of mice, which is the susceptible strain in our model, has a polymorphism. This polymorphism makes it so the beta glucuronidase function is reduced by about 90 percent below the activity of the wild type or the black 6 mouse, which is the resistant strain.
Interviewer: So what does GUSb do?
Dr. Bramwell: It's normal function is to breakdown what are called glycosaminoglycans. So these are always being produced, and because it's constantly being produced it also has to be degraded, it has to be removed. GUSb, and a variety of other enzymes that are of a similar type of enzyme, will nibble down these GAG chains to dispose of theme. And so, if you have a severe deficiency in any one of those genes, what happens is you end up with these GAG chains not being degraded properly, you get an accumulation of partially degraded compounds that then build up in the cell. So that's why it's called a lysosomal storage disease, you're storing these GAGs in the lysosome. That was kind of something interesting to think about because we really wanted to try and understand, we had very strong genetic evidence that GUSb was doing something, and this was the most plausible explanation, that it was related to its natural function.
Interviewer: And so you found this GAG accumulation in your mice with arthritis?
Dr. Bramwell: Right. So the next step that we wanted to do was to see if we could asses that. It turns out that there's a histochemical stain called Alcian blue, that will bind to these negatively charged glycosaminoglycans, you can see it visually, and so we did that and we saw a very striking difference. It turns out that in a variety of strains that have normal wild type GUSb activity, we always saw that if there was any arthritis severity, it would be minimal. And there was very little GAG alcian blue staining in these joints. And yet when we looked in a variety of different deficient strains, were they had either a partial or a more severe deficiency, and we stained for alcian blue, we saw that there was an extreme amount of the deposition of these GAGs that seemed to be in those areas that we were seeing the most inflammation.
Interviewer: So what is your model for how GAG accumulation is involved with arthritis?
Dr. Bramwell: Well, we're still studying this. There's a variety of different possibilities. It seems like these may be directly activating the innate immune response, that's one possibility. It could be that you actually have a modification of the GAGs that are being produced in these different cells, that's something that we're pursuing to understand. Right now we're really at the point where we've observed that this seems to be directly related and we're trying to understand it better.
Interviewer: You also found a connection between GUSb deficiency and rheumatoid arthritis.
Dr. Weis: He found that an increase in arthritis severity was also regulated by GUSb. So this was a very exciting finding, and I think that it tells us something about rheumatoid arthritis, something that was not predicted at all, so a novel new finding.
Interviewer: Is there any evidence that GUSb is involved in human arthritis?
Dr. Bramwell: Not at this point, and that's something that we have established with some new collaborations either with doctors at the University of Utah Hospital and Primary Children's Hospital, to begin to address some of these questions because a lot of the doctors we've spoken to who have familiarity with rheumatoid arthritis or juvenile rheumatoid arthritis or lysosomal storage disease, are quite excited about these findings and it seems obvious once you have identified it then, it seems like, oh we should have known this, we should have expected this or predicted this, so we've had a very positive response from a lot of clinicians that see patients. And we're just on the beginning stages of trying to transition into studying the effects, perhaps, in human populations
Interesting. Informative. And all in the name of better health. This is the Scope Health Sciences Radio.
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