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Tom: You have osteoarthritis? What can you do about that before you require a total joint replacement? We're going to talk about that next on Scope Radio.

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Tom: I'm here with Dr. David Petron. He's a professor of sports medicine. He's a non-operative physician and he works in the Department of Orthopedics here at the university.

David, what options does one have, prior to a joint replacement, in order to treat that pain and dysfunction?

David: Well, ultimately, you want to try to stay away from a joint replacement obviously. And the thing that leads to that is osteoarthritis of the joint, most commonly weight-bearing joints like hip or knee. And a lot of people don't even know what osteoarthritis is, but it's generally the wearing out of articular cartilage, which is that smooth shiny cartilage at the end of bone. So it's more of a wear-and-tear process, and ultimately the joint narrows and you start to get bone spurs, and aching, and stiffness, and swelling. And then really what drives the patient to the doctor is pain.

Tom: Does everyone anticipate that type of wear and tear over their lives, or are just some people prone to that?

David: Some people are prone to it. So there is a genetic predisposition to it. But if you're overweight or you've had prior trauma, that also can predispose you to arthritis. But it's really insidious, so most people are surprised when I tell them they have arthritis because they didn't have an injury, and they said their knee just started hurting and swelling . . .

Tom: Slowly comes on, over time, and it's nagging. And after a while, they just can't take it anymore.

David: And finally they figure out, "Well, I can't run, anymore. I can't do the things I want to do, anymore, so I'm going to go see the doctor."

Tom: So, by that time, I'm assuming they've maybe tried some home therapies. They've taken over-the-counter pain relievers like ibuprofen, or Naprosyn, or even aspirin, and, at some point, maybe those aren't really cutting it and they're not able to do the things that they used to do. What do you offer them?

David: Well, there's really three things they can do that they can control themselves. One is to get the muscles around the joint as strong as possible. So if it's a knee, quadricep strengthening, and usually doing lower-impact activity.

Tom: So that improves function. Does it help with pain?

David: It does help with pain. So if they can increase strength, that helps the pain, really the muscles surrounding the joint are the shock absorber for the joint. So the stronger, the more balanced, the more strength you have, the less likely you are to have pain in that joint.

Tom: So first tip is physical therapy. That's the way to start. And don't go with the old adage, don't use the joint. You know, don't slack off. Don't rest the joint.

David: Well, exactly. That's when people get in a vicious cycle. It hurts, so they quit doing anything, so the joint stiffens. And because they're not doing anything, they gain weight, which makes the joint hurt more, and on and on it goes.

So really there are three things they can control: one, keeping the strength up, two, avoiding high-impact exercise, and the third thing is keeping your weight right.

Tom: Now, by high-impact exercise, I assume you're talking about running, jumping rope, skydiving?

David: Right. Lower-impact things are okay, so usually walking, which can . . . you know, there's some impact with that, but that's usually not too bad. But biking can be a really good exercise for it, or even weight-lifting. So it's usually the high energy things. So, like, if you jump even off the height off the stair step, that could hurt the knee. But if you slowly low that up by, like, getting out of a chair, that doesn't hurt the knee, and you build strength with it.

Tom: So how about running on a treadmill? So for people who like to run, and there are a lot of them, plenty of people don't bike and they love to run, I guess they could switch to swimming, but what about walking or running on a treadmill versus being outside?

David: Absolutely, that can be easier on it. And we actually have a running clinic at the Orthopedic Center, and we, a lot of times, evaluate runners and find that they can be putting too much stress on their quadriceps and not running enough out of their hamstring and their gluts. So they tend to over-stride, which makes them load up the quadricep, which puts more stress on the knee. So sometimes it's something as simple as learning how to run a little bit differently, a lot of time, shortening the stride, and having more of the energy through the gluts and through the hamstring.

Tom: So let's say that they do these things and they're very diligent about the physical therapy, and they lose weight, but they still have pain. What else can be done?

David: There's different injections that can be done. One of the things that can be done that's usually a short-term answer to the problem is a corticosteroid injection. But a lot of times, that can kind of reset the pain. So it can settle down inflammation and settle down the pain so that we can institute some of these other things that we're talking about.

Tom: Now, there are other things besides corticosteroid injections that you have used in the past, I think.

David: Right, there's something called viscosupplements which are more of a lubricant for the joints, so it's like . . .

Tom: Those 50 weight [inaudible 00:04:41].

David: Yeah, that's it. It has a thickness to it, and that's either in a series of one to three injections, and it kind of resets the environment of the joint so that the arthritis doesn't progress as quickly. So there's some evidence to suggest that it may slow down some of the progression of arthritis, but it certainly can help with the symptoms.

Tom: And how long can that effect last if it works?

David: That tends to last . . .

Tom: I guess the question might be: How many patients will respond to those viscous injections?

David: I would say, in general, the less advanced the arthritis is, the more likely it is to respond. So if somebody gets down to bone-on-bone, a lot of times I don't even try it, and that's when you start looking at surgical options. But if there's still some joint space left, then those patients can respond well to these injections.

Tom: That's the importance of getting in early and making correct diagnosis.

David: Right.

Tom: So with the corticosteroid injection, as well as the viscous injections, they last for a few months, and maybe longer in certain people. When can you repeat those, and how often can you repeat those injections if they work well?

David: Oh, that's a great question. With corticosteroids, kind of a general rule is I wouldn't do it more than about three times a year. With viscosupplements, insurance companies will cover that about every six months. So most people with viscosupplements, it lasts a little bit longer. And typically with a viscosupplement, it's usually a series of three injections. And with the first injection, we put a corticosteroid in with the viscosupplement. So you get kind of a quick onset of the corticosteroid and the longer lasting on set with the viscosupplement itself.

There's a couple other injections, too . . .

Tom: Yeah, let's talk about those.

David: . . . that can be done. One is called PRP, or platelet-rich plasma. And platelets have certain growth properties, healing properties, so we draw the patient's blood, spin it down, separate the platelets and inject that into the joint. And then I think a lot of people have probably heard about stem cells, and there's been a lot of publication about that. And I think if you think about it more as pain-relieving and maybe slowing down the progression of arthritis, rather than that it really heals or reconstitutes the joint, then stem cells can also be a good treatment for the joints.

Tom: Let's talk about the stem cell therapy for just a little bit. Now, is that obtained from the patient's own blood? And then, how do you do that?

David: There's different ways to obtain it. One is through bone marrow, so we do a bone marrow aspirate, usually out of the pelvis, which is a relatively pain-free procedure. Another way is derived from peripheral fat, so we can take fat cells and obtain the stem cells. And the third way, and this a little bit more controversial, but there's more and more amniotic stem cells that are out there. But there are some question about how many stem cells there really are, depending on how they're stored. A lot of times those are stored freeze-dried, and it's a little bit questionable on whether there's significant stem cells in that, or not. But there's no question that some of these amniotic stem cell treatments have helped patients, myself included, with arthritic pain.

Tom: That's great. You've listed a whole list of procedures and treatments that can perhaps delay and improve patients' function and decrease pain prior to considering a total joint replacement. I think the first thing you said is, one, be healthy, lose weight, and then keep fit, use a physical therapist to strengthen the ligaments and tendons, muscles around the joint. And then moving on from there, to seek a diagnosis early on so that certain therapies can be applied before things get to be too advanced, and then, you know, eventually you just have to move into a joint replacement.

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Dr. Miller: Artificial joints and infection, we're going to talk about that next on Scope Radio.

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Dr. Miller: I'm Dr. Tom Miller and I'm here with Jeremy Gililland. He is a Professor of Orthopedic Surgery here at the University of Utah in the Department of Orthopedics. For patients and people who have prosthetic joints or artificial joints, are they at higher risk of having an infection in that joint?

Dr. Gililland: Well, the joint itself we put in is a metal and plastic joint. It inherently doesn't have its own immune system like our own joints do. So if you get an infection, even an innocuous infection in the blood stream that would have normally been cleared, there is a chance that could get to the joint and take over and so you are at more risk of that joint becoming infected.

Dr. Miller: So how does one become infected? I mean, is that due to a cut or some other site in the skin that could be infected or is it some other way that you are infected? How does that happen?

Dr. Gililland: The answer is, probably most of the time we don't know how it happens. It comes about as an infection that we probably wouldn't have picked up otherwise or have been aware of otherwise. Sometimes we are aware, they had a bad urinary tract infection or they do get an infection in the skin and that then gets to the joint, but most of the time we don't know and these come on seemingly out of the blue.

Dr. Miller: How often does it happen? I mean, it's not common, right?

Dr. Gililland: It's not common. We would say that in most big registries, infection in any given practice should be about 1% to 2%. There is difference in infection that happens right around the time of surgery which would be a surgical site infection which can come from either the wound itself.

Dr. Miller: The wound itself, healing, the incision.

Dr. Gililland: Exactly and that's different than infection that ensues say two or three years down the road in an otherwise well-functioning joint.

Dr. Miller: So you see infection more commonly after surgery or two or three years down the road?

Dr. Gililland: Generally what we see here is our infection rate here at the university is very low. It's less than 1% of our own infections and in cases that happen here in terms of patients getting surgical site infections, but we definitely see infections coming in from outside or infections in patients that have had well-functioning joints and that's probably a bigger problem in terms of dealing with those long-term.

Dr. Miller: So dealing with an infection in a prosthetic joint is a different kind of beast than having an infection in a joint . . . in a normal joint.

Dr. Gililland: Correct. Dealing with an infection in a prosthetic joint is rather difficult because now you have a piece of metal in there that's infected and we are starting to learn more about infections and the way that they form and bacteria is just a single bacteria creating infection. They create a big environment of what we call a biofilm that's almost . . .

Dr. Miller: Sticky.

Dr. Gililland: Right.

Dr. Miller: They stick to the plastic and the metal and . . .

Dr. Gililland: Exactly. They almost create their own colony and their own surface that sticks to the metal and it's almost impossible to get rid of with just antibiotics.

Dr. Miller: So I think most people would believe that you might just take an antibiotic for a few weeks and then the infection would go away, but that's not really true in this situation.

Dr. Gililland: Yes, it's very, very unlikely that that's going to be successful and often we get patients that have come in and have been on antibiotics for a long period of time and that's been rather unsuccessful for them and it makes our job somewhat harder because now these bacteria can be somewhat resistant to some of these antibiotics.

Dr. Miller: Well, let's talk about the patient who might have an infection. What signs would they look for, what symptoms would they have that would alert them to the fact that they might have an infection in that new prosthetic joint?

Dr. Gililland: Yeah, the biggest thing is pain. Most of these patients are patients that were functioning well, doing well with their arthroplasty, their joint replacement, and then they started to develop pain down the road. And whenever that happens, the patients need to go and be seen and be evaluated to make sure the parts aren't loose and there is no fracture, and most importantly, they don't have an infection.

Dr. Miller: But there could be other reasons for pain aside from the infection.

Dr. Gililland: Absolutely. Pain in and of itself does not mean infection, but it's certainly something that we ought to be looking for. Any painful joint that comes in that was otherwise well functioning always gets an infection workup in my clinic.

Dr. Miller: Would there be other things going along with the pain? So would the joint be swollen or red or will the patient have fever or chills? What kinds of things are you typically seeing in these infections that occur two to three years out?

Dr. Gililland: Yes. So certainly there you can have swelling about the joint, redness. You can get drainage from the wound or start to develop draining sinus tracts or sites of drainage.

Dr. Miller: That would be bad.

Dr. Gililland: Yeah, that's obviously, obvious signs of infection. Patients can have fevers or systemic symptoms where they start to feel sick, nauseated, lightheaded, those kinds of things. That could be a sign that they are becoming septic from this. Those are the things that are . . .

Dr. Miller: What is septic?

Dr. Gililland: Sepsis is when the body system actually becomes infected, it gets into the bloodstream and you start to have multi-organ involvement from the infection.

Dr. Miller: Fever, chills, sweats, dizziness . . .

Dr. Gililland: Blood pressure issues . . .

Dr. Miller: . . . nausea. That's actually a very severe infection and of course should be treated quickly.

Dr. Gililland: Absolutely.

Dr. Miller: So what do you do if antibiotics alone are not going to fix this problem? You as an orthopedic surgeon intervene and what are the things that you do to cure that infection?

Dr. Gililland: Generally, this chronic situation where the patient has been well functioning but now has an infection, the likelihood is it's usually an infection that's probably been there for longer than we think. We treat those infections, it's a rather invasive process. Meaning, we need to go in, we need to take out all the metal because again the metal has the slime layer that's created by the bacteria that we can't just get rid of. We think we can scrub it, but reality is our data which show that we're not very good at that. So we go in, we take all the parts out.

Dr. Miller: So this is a real big deal and somebody who has had a hip replacement, now their prosthetic is removed and they're going to need a new one at some point.

Dr. Gililland: Absolutely. In our minds most of the time it involves the two-stage process. Meaning, we take out all the parts, we put in a temporary joint replacement usually made out of cement with antibiotics impregnated in that cement that gives antibiotics to the bone, to the tissue. And after a period of IV antibiotics and a period of time off the antibiotics, if everything looks like it's been eradicated successfully, then we go back and try to rebuild the joint.

Dr. Miller: You talk about a period of time, how long is that actually?

Dr. Gililland: Usually three months minimum.

Dr. Miller: The other thing that comes to mind is now that the prosthetic joint is out, how does the patient get around? What do they do?

Dr. Gililland: That all depends on what we put back in. Usually we can put back in something that functions. Meaning, they have structured limb and they can still use the limb, but most of the time we don't let them put much weight on the limb, so they're using a walker or crutches to get around and trying to keep the weight off of it because again we are putting in a temporary part that's really not designed to be structurally sound for a long period of time.

Dr. Miller: So they're also on long-term antibiotics during this time, is that correct? Once you take the hardware out.

Dr. Gililland: Absolutely. They're usually on a period of six weeks of antibiotics IV and then after that if everything looks like it's getting better and their labs are normalizing, then we'll stop that, we'll give them what we call an antibiotic holiday to see if their labs remain low and make sure the infection does not recur once they're off of their antibiotics.

Dr. Miller: Once you complete this treatment and get to the point where you're going to put a new joint in, how successful are you in terms of really knocking out that infection, making sure it doesn't come back?

Dr. Gililland: That's a tough question to answer. I think everybody thinks we're better at than we really are. If you look at the literature, it's probably somewhere in the realm of about 75% success with that type of a two-stage process. But I think it really has to do with the patient and the patient's medical comorbidities and it has to do with the bug and how receptive that bug is to the antibiotics, what kind of bug it is, how virulent it is and then how many times they have attempts at prior surgeries.

We sometimes have patients that come in that have had four or five other attempts at surgery and at that period of time, he got an infection that's been really dwelling in there for many upwards of several years and it's very, very difficult for us in those cases to get rid of it. And I would say sometimes during the realm of about 50-50.

Dr. Miller: Obviously, this is a very big deal for somebody who has had a prosthetic joint put in. What tips would you give to patients or what advice would you give patients to prevent infection if that's possible?

Dr. Gililland: Absolutely. I think that's the ultimate crux to this is how do we prevent the problem from happening in the beginning. There are several things that we know put patients at risk for infection. Uncontrolled diabetes is a big risk. Being a smoker is a big risk. Morbid obesity with body mass index is probably somewhere above 40 puts you at risk. Other risk factors for infection such as rheumatoid arthritis or being on immunosuppressive drugs can put you at risk.

All these things need to be evaluated by your surgeon preoperatively before you have the initial joint replacement and that's something that we do very vigilantly here at the university. We make sure that we try to mitigate any risk factors that we can preoperatively to avoid infection in the beginning.

Dr. Miller: What about little cuts and nicks on the skin? Does that bother you?

Dr. Gililland: No, I don't think. I mean, if you have a little cut and nick on the skin, as long as it's healing well and it doesn't show any evidence of infection, I don't think you have to be extra vigilant about everything in life. I mean, I think most people have a well-functioning joint and get along very, very well and we're talking about a small percentage of people here. But I think it just takes a reasonable approach.

Dr. Miller: So bottom line is if you have a hip or a knee that's been replaced, and you have pain, you should have that checked out by your orthopedic surgeon or another competent provider that can actually look to make sure that you don't have an infection as a cause of that pain. And if you have infection, that needs to be treated aggressively.

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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.

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Interviewer: In this series of podcasts we've been talking about total joint replacements for the hip or the knee, and trying to figure out if it's right for you. If you do decide you want the procedure we're also in the series covering what to expect before, during and after. And in the first segment we talked about if a replacement may be right for you.

But another consideration is have you tried more conservative measures to alleviate your pain? And to help sort through them is Dr. Chris Pelt. He's a joint replacement expert at University of Utah Healthcare's Orthopedic Center. Tell us about some of the options patients should try before they make the next step to a complete joint replacement.

Dr. Pelt: Well the first thing that most people already do before they even come to a doctor is they that either have not addressed the fact that they have pain or they've started to modify their activities. Most people start to do that on their own, and it's one of the indicators that they're being bothered by their joint pain and arthritis. Things like they stopped running as far, or they stopped running altogether. Their hikes may become walks around the block instead of hikes in the mountains, maybe they're not skiing the double black diamonds anymore, or avoiding the moguls and they're sticking to the groomers now. Starting to change the things they do at work, starting to do the things they do at home differently. Maybe they can't even go to the grocery store as much as they used to, or they're having to use a walker or a wheelchair at times. So people start to modify their activity.

When we start to provide conservative treatments through our primary care colleagues, non-operative specialists or even ourselves, when we're trying to avoid surgery, we utilize other modalities. Things like physical therapy. Perhaps braces, or compression wraps. I mentioned wheelchairs or crutches, or walkers. Things like assistance devices. Some people start to use a cane. We can often offer medications. The mainstay in the treatment of arthritis pain is to attempt to decrease pain associated with inflammation. Arthritis is simply when we lose that smooth cartilage on the end of the bones in our joints, it creates a rough mechanical problem. That also creates inflammation so using a medication like an anti-inflammatory can decrease the inflammation and therefore also decrease the pain associated with it.

There are other things besides just anti-inflammatories, and some patients may not be able to take an anti-inflammatory. Patients with renal or kidney problems, patients with stomach issues or ulcers. They may have other reasons that they can't take an anti-inflammatory, so there are other things to take as a medication for pain as well. Things like Tylenol. Over the counter Tylenol works very well. Acetaminophen as an analgesic or a pain relieving medication. There are other types of pain relievers we often try to avoid, but they do exist for the treatment of arthritis based pain, like narcotics. Norco, or Tramadol or other similar types of medications can be tried as well. Again, we try to avoid those because there are other, better modalities often than giving people narcotics.

There are creams, topical creams. Anti-inflammatory creams. Joint relieving bio-freezes and Ben-Gay type of creams that people also can use. And we have some over the counter as well as some prescription based types of creams as well. Injections are another method that obviously we will try to use. And the idea there again is trying to decrease the inflammation and decrease the pain in the joint without performing a big surgery.

There are two types of injections that are typically tried, Cortico-steroid injections. A lot of people refer to these as the cortisone injection. It isn't actually cortisone that most surgeons or doctors are providing, but it's a type of a medication designed to decrease inflammation and therefore pain in the joint. A lot of patients will ask us about these injections. "Is this going to make my arthritis go away?" And the answer is "Probably not, but it may make you feel better that you don't care that the arthritis is there." It decreases your pain and allows you to do the activities you need to do without having to have a big surgery.

A second type of an injection might be something that is commonly known as a joint lubricant, or some people hear it referred to as a chicken comb based injection. And that's based on the material that the companies are providing in these types of injections. What this is is the building blocks of cartilage. And when injected into the joint it may provide two potential effects, one of them being to act as a joint lubricant. When we look at it in the studies it may not be that that lasts very long, sometimes even only a couple of days of this lubricating effect in the joint.

But secondly what it does is it starts to, your body starts to break down these injections it also creates an anti-inflammatory reaction or response to suppress the inflammation in the joint as well. And these injections may last even longer, with months if not years of relief for those patients that are well indicated and have a good response for that. More and more we're seeing insurance companies and others have stricter criteria for patients that might be candidates for those joint lubricant injections, but nonetheless it's one of the other things that exists as possibility for treating pain without surgery.

And the final option is a surgery of some sort. And there are two types of surgeries in general for people with hip or knee conditions. One of them, arthroscopy or minimally invasive camera type surgery, and then the other being joint replacement surgery. The lesser invasive things like arthroscopy may not be suitable for all patients with arthritis though, and that will be a discussion best had with a surgeon.

Interviewer: So it sounds like before we get to surgery, is it your goal as a surgeon to try a lot of these things before you actually do the replacement?

Dr. Pelt: It's our goal, not because we're trying to make patients jump through hoops or delaying the inevitable, but we're trying to prolong the life of their native joint. So once again, when we're putting in a joint replacement, these are parts that may not last for the rest of these patients lives, and we want to maximize the life expectancy of the implant that's going to be replaced and some point, but also to maximize their function with the current joint that they have, without perhaps undergoing a major surgery. At least not yet, if that's inevitable for them.

Interviewer: In the next episode we'll talk to Dr. Chris Pelt about the similarities and the differences between knee and hip surgery. There are a lot of things you need to know about both surgeries that are the same, and there are a few differences as well.

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Dr. Gellner: Growing pains. You hear doctors and parents talk about them a lot. But what are they, and as a parent, when should you worry about them? I'm Dr. Cindy Gellner for The Scope.

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Dr. Gellner: Several times a month I have a child come in and the parents have the concern that the child has leg pain, mainly at night and it doesn't keep their child from playing during the day. Sound familiar? These are growing pains. They're a normal occurrence in about 25% to 40% of children, and they generally strike in 2 periods -- in early childhood among the 3 to 5-year-olds and later in the 8 to 12-year-olds. This is also the time when kids have big growth spurts.
Growing pains concentrate in the muscles rather than in the joints. So kids will report pains in the front of their thighs or in their calves or in their shin bones or behind their knees, but it's always in a long bone. I've even had kids complain of growing pains in their arms.

Joints are not affected by growing pains. So knees, wrists, elbows, your child is not going to have pains in those very much. Joints are usually affected by more serious diseases, and you'll know because the joints in serious diseases are swollen, red, tender, or hot. Joints of kids having growing pains look and feel normal.

Although growing pains often strike late in the afternoon or early evening before bed, the pain can sometimes wake a sleeping child depending on their pain threshold. The intensity of pain varies from child to child. So your child may not seem that bothered by it, and they're like, "Yeah, my legs hurt, but they're not too bad." Where another child who's sensitive to pain may be balling on the ground and just holding their legs and crying, and you're like, "My child didn't fall. He didn't have any injury. What could possibly be going on?"

Most kids who have growing pains actually won't have them every day either. They may just have them a couple of times a week.

So we always say growing pains is because the bones are growing. Well, this hasn't actually been proven to cause the pain. Growing pains might just be aches and discomfort from jumping, climbing, running, things that active kids during those age groups do every day. And the pain can usually happen after the child has had a particularly busy day.

One symptom that most doctors find most helpful in diagnosing growing pains is how the child responds to touch while in pain. Kids who have pains from a serious medical cause do not like to be touched. The movement can make the pain worse. Even just gentle touching can cause excruciating pain.
But those with growing pains actually feel better when they're held, when their legs or their arms are massaged, when they're cuddled, they get to curl up on your lap. Kids with serious illnesses will not do that. They want to be completely left alone.

So how can you help your child when they have growing pains? You can massage the area, stretch, use a heating pad on the area, or give ibuprofen or Tylenol. Do not give aspirin to a child because it can be linked to something called Reye Syndrome, which is a very serious disease.

So your child keeps having these growing pains, and you want to make sure are they really growing pains or is something else starting? You just are worried.

When do you call the doctor? Call your doctor if the following symptoms occur with your child's pain. The pain is long lasting. You have swelling in one particular joint. Your child has pain associated with an injury, and you're worried that they may have actually broken the bone. Your child has a fever and bone pain and that's it. Your child is limping and it's not due to an injury. They have unusual rashes, usually over the joints or over the knuckles.

So while growing pains aren't usually related to illnesses, they can't be very upsetting to kids and their parents because the parents don't know how to help their child. Anytime your child is in pain you want to be able to help them. And if something keeps happening over and over and over, you feel helpless. You don't know what to do.

You can be reassured that growing pains will pass as children grow up. Give them your support and reassurance and do the supportive measures that we discussed. And if they have any of those concerning symptoms, be sure to follow up with your doctor.

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Interviewer: What exactly is rheumatology? We'll examine that next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Tracy Frech is a rheumatologist at the University of Utah. What is a rheumatologist?

Dr. Tracy Frech: So a rheumatologist is a doctor that specializes in autoimmune diseases. Your immune system is a good system if it's fighting off infections, or patrolling the bodies for cancers. If it's attacking cells for no good reason and multiple organs, primarily the joints, then a rheumatologist can help determine how to best suppress the immune system so that doesn't happen.

Interviewer: So would a rheumatologist be involved in HIV and AIDS?

Dr. Tracy Frech: Fantastic question. No, those would be infectious disease doctors specializing because in that case your immune system is not functioning because of a virus.

Interviewer: Okay.

Dr. Tracy Frech: In autoimmune diseases, the etiology for why the immune system is not functioning is really not clear and so the way that you would treat an autoimmune disease would be to suppress the immune system, whereas in HIV an infectious disease doctor would give treatments to rid the body of the virus.

Interviewer: What are some examples of autoimmune disease that you would look at?

Dr. Tracy Frech: So examples of autoimmune disease can include Rheumatoid arthritis, that's 1% of the population, that's an inflammatory disease of the joint. Systemic lupus erythematosus or SLE, lupus can involve the kidneys and in that case a rheumatologist would work closely with a nephrologist, but also involves the skin, the joints, seizures can be seen, fluid around the heart and lungs, abnormal clotting and problems with the blood count. Systemic sclerosis or scleroderma is something that I myself specialize in and in this condition the immune system doesn't like the small blood vessels of the body and we work to improve both blood flow and modulation of the immune system's response to that poor blood flow.

Interviewer: So I might be a little bit behind here, but it sounds like you specialize in the immune system attacking the body.

Dr. Tracy Frech: Exactly.

Interviewer: How does the body get the point where it doesn't like itself? And it starts attacking itself? How does that happen?

Dr. Tracy Frech: So that's the million dollar question and there's a lot of interest. Is it because we're having more genetically modified foods, is it environmental pollution, why are we seeing more and more autoimmune disease nowadays then we did several years ago? And better understanding the immune system is actually a real interest in the University of Utah, better phenotyping or understanding that clinical presentation and how that ties into molecular medicine is really a push of our division and our interest of how we move forward in the future.

Interviewer: Is there a thought out there that's kind of the thought as of right now?

Dr. Tracy Frech: It's probably multifactorial, so you're born with genetics and how those interact with the environment is probably the critical question. It's a better understanding of the genetic background and those environmental triggers is really the forefront of how we're trying to understand these conditions.

Interviewer: Is it kind of comparable to a switch getting flipped?

Dr. Tracy Frech: So exactly. So why your immune system at one point in time does a really good job fighting off infections and then fights self is an important part of understanding these conditions. Lots of interest in molecular mimicry, meaning did a bug look a lot like self or modify self and so now after you clear the infection, is your immune system now recognizing self as foreign, there's interest in that. Lots of cool theories, particular interest in things like microcrymerism, is the mother pregnant with a child, her subsequent child cells from the first sibling somehow cross the placenta, get into the other child and now that's a little bit like self but not quite, and your immune system is triggered.
Lots of different theories on why your immune system suddenly decides not to act right and lots of really active interest in trying to understand, how as rheumatologists we can better understand these conditions. Whether it's not the same trigger in all individuals, yet all individuals look the same when they present with the disease, is one of the pushes for sort of better defining the molecular basis to disease and again, an interest of the University of Utah.

Interviewer: So it sounds like the immune system goes out and it goes, oh, this is bad, now I'm going to make a little note of what this looks like so if I ever see it again, so it's constantly being programmed.

Dr. Tracy Frech: Exactly, it's constantly being programmed and it has a great ability to diversify and be able to recognize similarities between viruses and bacteria and whether ourselves get in the middle of that, that's a lot of active interest in trying to better understand that.

Interviewer: Is there a, kind of a generalized symptom somebody might have if their immune system is starting to attack themselves?

Dr. Tracy Frech: So what we generally as rheumatologists take great interest in is inflammatory joint disease, so a joint that's red hot and swollen, that is not normal.

Interviewer: Okay.

Dr. Tracy Frech: So you know lot of people ache and a lot of people are fatigued and that can be a symptom of rheumatic disease, the important one is that red hot swollen joint and that's not something that rheumatologists really like to see because, again, not only define our profession early on but allows us to engage in a cost effective workup.

Interviewer: Does a patient need to go to their primary care physician before they can see you, or if they feel that something is very familiar in this conversation that we had, can they come straight to you?

Dr. Tracy Frech: So unfortunately we actually do require referrals from primary care physicians and the main reason being is fatigue and achiness is so common in the community and rheumatologists are so few that we actually do like the primary care provider to say, oh yes that is a red hot swollen joint and then they would call and get the patient right in, if the wait list was long they would call the fellow on call to get any patient with a red hot swollen joint in expeditiously so we could move forward.

Interviewer: What's the thing that really excites you about what you do? What do you love about it so much?

Dr. Tracy Frech: We make people feel better, so there's nothing better than to have someone come in and be able to really affect their quality of life by getting inflammation under control.

Interviewer: Is there something that you would like a listener to know or take away from this discussion.

Dr. Tracy Frech: Again, rheumatoid arthritis is 1% of the population and young, female, we like to catch early and make sure we prevent joint destruction or disease progression.

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