Surgery an Option – But Not the First – For Arthritis
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Surgery often provides relief of arthritis pain, but it’s typically not considered until after other treatment options are tried without success or, over time, lose their effectiveness.
“Surgery is often a very good option for patients to relieve arthritic pain after they have been through an extensive course of conservative, nonsurgical treatment options,” says orthopedic surgeon Michael Raab, MD.
Dr. Michael Raab explains how conservative, nonsurgical treatment techniques are typically tried before surgery to relieve arthritis pain.
Click play to watch the video or read video transcript.
The first step in any arthritic problem is non-surgical or conservative treatment measures. The first question many patients have in the office is do I need surgery? The answer is most of the time not. Many, many arthritic problems can be treated without surgery. The simple, conservative, or non-surgical approaches that may help the patient, may start out simply with exercising the joint. Exercising motion of the joint nourishes the cartilage, helps strengthen the joint, increases the flexibility of the joint. And even though there might be arthritis on the x-ray, we treat the patient not the x-ray. So even though your x-ray may show arthritis, if you do simple exercises, weight loss, take an anti-inflammatory such as Tylenol or Motrin or Aleve, those simple measures may go a great – give you a great amount of relief. Following that, if you continue to have pain or discomfort, a joint injection in other words placing a needle in the joint and injecting a steroid and painkiller, may give pain relief to the patient for either a short time or very long time. Each patient is different in how they respond to the cortisone injection. The other type of injection that may be helpful is a gel injection in which a thick gel is injected typically into the knee to help cushion the knee. So these simple approaches such as medication, exercise, therapy, injections may relieve a great deal of pain for great many patients and avoid the need for any sort of surgery. Beyond that, the other options that may help without involving surgery could include ultrasound-guided injections for some of the deeper joints such as the hip, such as the spine which are often done under C-arm or under x-ray magnification.
He adds, “The first question many patients have in the office is, ‘Do I need surgery?’” Most of the time, he answers no. “Many, many arthritic problems can be treated without surgery.”
Nonsurgical options include:
- Exercise and physical therapy. “Exercise and motion of the joint nourishes the cartilage, helps strengthen the joint, increases the flexibility of the joint,” Dr. Raab explains. Physical therapy can also strengthen muscles around the joint to lessen joint stress.
- Medication. Over-the-counter medications such as acetaminophen and
nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin) and naproxen (Aleve), can control mild pain. Prescription medications also are available for stronger pain.
- Heat or ice. Heat may help relax muscles around the affected joint. Ice can relieve pain and swelling after activity or exercise. Your doctor may give you a gel or cream to help your joint pain.
- Weight loss. Losing weight, if you’re overweight, can reduce stress on joints and contribute to relieving pain. Each pound lost can take 3 to 5 pounds of pressure off lower extremity joints.
- Wearing braces. External braces or supports can also help reduce joint pressure.
- Cortisone injections. If pain medications don’t bring you relief, your physician may recommend injecting cortisone into a joint. This may temporarily help relieve pain and swelling. Patients react differently to cortisone, so the length of relief varies, usually from six weeks to six months.
- Gel injection. Injection of a gel, typically in the knee, can help cushion the joint to relieve pain.
If nonsurgical measures prove ineffective, your physician will talk with you about surgical options for treating your arthritis. Dr. Raab says that surgical options available to treat pain that results from the wearing down of a joint fall in four general categories:
- Joint replacement (arthroplasty). This procedure, used most commonly in the hip, knee, and shoulder, involves removing the damaged, arthritic parts of the bone and replacing them with a new covering of metal or plastic that provides the same flexibility
and mobility as a natural joint.
- Joint fusion (arthrodesis). Typically used in smaller joints, in the hand, wrist, and feet, this procedure is performed by scrapping off damaged cartilage from each side of the joint and screwing the two bones together “so that a painful joint becomes one solid, painless, stable, functional joint,” Dr. Raab explains.
- Ligament reconstruction and tendon interposition (LRTI). In this procedure for thumb arthritis, damaged surfaces at the base of the thumb are removed. This leaves space in which a tendon is rolled up and placed to provide cushioning. LRTI helps alleviate problems with gripping and grasping, Dr. Raab explains.
- Joint realignment (osteotomy).
This involves removing bone above or below the joint to redirect force in the joint, creating a wedge of bone that realigns the joint. “This is not done as commonly, but may be an option for younger patients,” Dr.
Raab says.
Dr. Michael Raab discusses surgical options for patients to treat arthritic pain after first trying conservative, nonsurgical treatment options.
Click play to watch the video or read video transcript.
Surgery is often a very good option for patients to relieve their arthritic pain after they have been through an extensive course of conservative non-surgical treatment options, which includes anti-inflammatories, weight loss, exercise, therapy, external braces or supports, and possibly injections. If the patient continues to have pain despite going through extensive appropriate conservative measures, then we can have a surgical discussion about what options may be available to relieve the patient’s joint pain.
And in general, arthritis being wear and tear or wearing out of the joint for whatever reason, the different strategies that are available to address that joint pain fall into about four different surgical categories. Probably the most common category that everybody is aware of is joint replacement as with the hip, the knee, and the shoulder being the most commonly replaced joints. And in this operation, we remove the arthritic portions of the bones and replace them with a new covering of metal and plastic to create a much less painful situation for the patient. So, joint replacement or total knee arthroplasty, total hip arthroplasty, shoulder arthroplasty, are all the means of replacing the worn out joint with a new joint made of metal and plastic. This is what we’re most familiar with, what lots of patients are familiar with. There are other options other than replacing the joint that may be helpful, particularly in the hand or some of the smaller joints rather than replacing the joint we may fuse the joint by scraping off the bad cartilage from each side of the joint and then screwing those two bones together solidly so that the painful joint becomes one solid painless stable functional joint. This is most often done in the hands, in the feet, and in the wrist. And joint fusion or joint arthrodesis can very helpful as well. One other option rather than replacing the joint or fusing the joint, is to simply remove the joint and leave a space with a cushion, a rolled up tendon cushion to replace the arthritic area. And this is commonly done at the base of the thumb. Many times patients have arthritis of the knee, will also have pain at the bottom of the thumb with gripping and grasping, and it’s surprising how many patients don’t realize that arthritis can occur at the base of the thumb as well as the major joints throughout the body. So removing the joint and replacing it with a rolled up cushion is another option as well. Lastly, not done as commonly, is realigning the joint or performing an osteotomy, in other words, cutting the bone above or below the joint to redirect the force by making a wedge of bone to realign the joint. This is not done as commonly but maybe an option for younger patients.
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Source: Michael Raab, MD, Premier Orthopedics; Arthritis Foundation
