Osteoarthritis of the Knee - Craig McAllister, MD

Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopodTV. Today I have with me as a guest, Dr. Craig McAllister. Dr. McAllister is an orthopedic surgeon from Kirkland, WA where he practices complex surgery of the hip and knee. Dr. McAllister did his medical school training at the University of Washington. He then went on to complete an orthopedic residency at Albert Einstein College of Medicine in New York. From there he completed an orthopedic fellowship in joint reconstruction and arthritis surgery of the hip and knee at the Cleveland Clinic Foundation. Today we're going to be talking about topics associated with the hip and knee arthritis. Thank you Dr. McAllister for joining us.

McAllister: Thank you for inviting me.

Sechrest: Today what I would like to talk about first is the concept of degenerative arthritis of the knee. I mean, we've all hear the term osteoarthritis. We've heard the term wear and tear arthritis, degenerative arthritis. Tell me a little bit about degenerative arthritis of the knee. How does that start? What causes it and what sort of symptoms are we apt to see with that patient?

McAllister: Well, I think the way one of the phrases that you used to describe it is one of the most comprehensive and easiest to understand when you just called it wear and tear arthritis. There are an awful lot of different types of arthritis that are recognized and wear and tear arthritis or degenerative arthritis is certainly the most common. I think one of the most difficult aspects of wear and tear arthritis for patient's to understand is that the problem as far as the knee or the hip or any of the joints are concerned is usually they're well before the symptoms are ever noticeable to the patient. They might be a sore knee after a sporting event, they might be a knee that stays sore after exercise. It might even be a joint that seems sore and swollen and stiff just with weather related changes. So, I think for a great majority of patients with wear and tear arthritis, they're having some awareness of symptoms well before they ever present to an orthopedic surgeon.

Sechrest: Now, one thing, a lot of people come into the office and they have these symptoms that you're talking about. They have pain and usually it's pain associated with activity and the first thing they want to know is when did the injury occur, how have I injured my knee. What I hear you saying is that maybe this isn't an injury. Maybe this is something that just occurs over time.

McAllister: And, it really can be both or other things. Certainly for an orthopedic surgeon who is specializing in knee, a lot of the wear and tear problems have to do with alignment issues. They may have been born with legs that are slightly bow legged or too knock kneed and they can get wear and tear in one part of their knee. In the hip as you know, sometimes they can have childhood developmental problems that go on later in life 40s, 50s, 60s to cause premature arthritis in the hip. And then there are the patients with true trauma and most surgeons will call that post traumatic arthritis but even though it's related to the trauma it's still a basic wear and tear type of arthritis with the same symptoms and the same appearance on the x-rays.

Sechrest: Now, do you distinguish between the terms osteoarthritis, degenerative arthritis and you've just given us a new term, post traumatic arthritis and then that whole wear and tear problem. There's been a lot of controversy as to whether osteoarthritis is genetic in any way. I mean, do you think of this as a genetic disease?

McAllister: I think those three terms that you mentioned, wear and tear arthritis, post traumatic arthritis and osteoarthritis all share this element of wear and tear but they, I think for the physician and for the orthopedic surgeon in particular and for the patient, they are distinct entities. And, there are a couple of important differences that patients need to understand about them. Osteoarthritis is a very common disease state that probably is related to genetics, probably related to environment. By the time we are in our 70s, fully 70% of people get it and only 15% are aware of it and so it tends to be a more benign type of arthritis, a little bit less severe in terms of its prognosis, but it also tends to hit multiple joints, so when grandma and grandpa talk about their rheumatism affecting their back and their shoulders and their knees and their hips, but being pretty well tolerated, that's very accurate. That different from post traumatic arthritis which tends to be only one joint, tends to leave many patients with a very severely affected joint, it hits earlier in life in the active patient, may or may not have been preventable either before the injury or with proper treatment after the injury and has a poor prognosis overall. And then, of course, the third one is that malalignment type of arthritis that also has an equally poor prognosis

Sechrest: Now, let's go back and look at the injuries that can case post traumatic arthritis. What type of injuries are we talking about? Are we just talking about fractures that involve the joint, ligament injuries, all of the above? What other things can be injured that can lead to post traumatic arthritis?

McAllister: Well, the answer to that is probably is as many as there are patients who have stories about their injuries. But, realistically, I'd say the three that you touched on are the most common. There's the badly fractured joint, the patient who has the fracture that goes into the knee, or fracture that goes into the hip and that disrupts the joint surface, what we call the articular cartilage, that smooth cartilage and if the fracture actually goes into that cartilage, they're set for arthritis early in life. Another real common one are the ligament injuries that leave joints unstable, and you know as well as I do that historically, a lot of those ligament injuries went untreated and I think that most surgeons recognize that that's a set up for later arthritic problems. Another real, real common one is the meniscal tear, and we've chatted about that previously where a patient loses part or all of their cartilage, their meniscus and we know that if they lose all of their meniscus, 85% of those patients are going to have arthritis within 30 years after that index injury. So, that's a very, very common sequence of events in patients that I am now seeing at age 55, 58, 60 who are needing a knee replacement will report an meniscal injury and a meniscectomy when they are in their 20s.

Sechrest: Okay, so they injured then twisted their knee, went in and had their cartilage removed, like you hear football players, basketball players, lots of athletes and then what you're saying is that they pay the price 30 year later.

McAllister: Yes.

Sechrest: It's not like they have pain immediately, but 30 years later that knee is worn out.

McAllister: Right.

Sechrest: The other thing I think that people don't realize sometimes is that you don't actually have to injure the joint itself. I mean, sometimes you can fracture the bone below it and that creates that malalignment that you're talking about which now all of a sudden that joint's not working appropriately and the pressure is unbalanced and that causes, over time damage to the cartilage.

McAllister: I think that orthopedic surgeons uniformly will agree that we are becoming increasingly aware of the impact of these malalignment problems. You know, being bow legged is not all that innocent. It's certainly innocent when we're 10 and 20 and 30 and maybe even into our 40s, but it doesn't take much more than a two or three degree shift from a nicely, normally aligned leg before we're starting to see selective wear in one part of the knee and it probably also has an impact on the hip and even the spine, but certainly it's the knee that's taking the real brunt of that malalignment.

Sechrest: You know, another thing that I think the MRI scan has taught us, you know, it's an old wives tale that we used to tell everybody before the MRI scan, that you don't bruise bones. You know, there's no such thing as a bone bruise. Now, we're seeing that sure enough, there's a bone bruise and you see them in the knee a lot, you see them in the ankle a lot. And, the other question is, is what does that do to that articular cartilage?

McAllister: Right.

Sechrest: You know, we used to just think that articular cartilage was not injured like that, but now with the MRI scan, we're seeing more and more of these damages to the articular cartilage that take months to years to sort of play themselves out and end up wearing that articular cartilage down.

McAllister: Well, and it becomes a profoundly important point when that 38-year-old, 42-year-old, 50 some year old is presenting to their orthopedic surgeon with the idea that I need a meniscus tear taken care of and the MRI is actually already showing a little bit of early degenerative arthritis on the rest of the knee. It has implications in terms of the success of that meniscectomy, but it also has implications in terms of a long-term course for that patient. That meniscus tear that is going to be managed arthroscopically is actually part of the early arthritis. And, then so it has bearing on the whole role of arthroscopy in that arthritic knee.

Sechrest: You know, I think we ought to back up too and and clarify a couple of terms, and one is this term arthritis. And, what we need to do, I think, is distinguish osteoarthritis and all of these things, post traumatic, wear and tear arthritis from the other thing people associate with arthritis and that is what we would call rheumatoid variance or different type of systemic illnesses. Rheumatoid arthritis, psoriatic arthritis, gout even. Some of these things that cause what we see as arthritis is a term that's just used to describe a whole bunch of things. But, differentiate rheumatoid arthritis, psoriatic arthritis, lupus, those things from osteoarthritis. How do they differ?

McAllister: You've mentioned five or six different types of arthritis, but I think for the patient it's very helpful to break them down to simply degenerative or wear and tear arthritis and inflammatory arthropathies or inflammatory types of arthritis and it's meaningful for the patients because they really do, those two groups of arthritis sort of aggregate in terms of how they present for the patient and also how they're managed and what kind of doctor manages them. Certainly I would say that the overwhelming majority of simple wear and tear arthritis is going to be managed either by their primary care physician or by an orthopedic surgeon with some overlap with rheumatologists. But, the overwhelming majority of orthopedic surgeons who specialize in surgical management of inflammatory arthritis will want to make sure that that rheumatologist was on board first because they respond very well to medicines. But, rheumatoid arthritis, you mentioned crystalline arthropathies like gout, pseudo gout, other types of psoriatic arthritis, infectious related arthritities that may have been from an exposure to a virus or other food related. Really, arthritis only means inflamed joint. So, whether it's a food related allergy or anything else, it can fall into the definition of arthritis and that's why the arthritis foundation recognizes over 140 different varieties.

Sechrest: Yeah, and I think that's sometimes confusing to patients. They don't really understand the difference between, for example, rheumatoid arthritis and osteoarthritis. From them, their knee hurts for example, but like you say, the rheumatoid arthritis, that is primarily treated medically. I mean, it's treated with chemotherapy and that's not the same for these wear and tears. They're treated primarily with mechanical means, surgery and that sort of stuff. We can control the symptoms, but we can't stop the disease process.

McAllister: Right.

Sechrest: Rheumatoid arthritis, you can actually stop or slow down the disease process and slow down the destruction with the right medications.

McAllister: Sometimes.

Sechrest: That's the important part.

McAllister: Sometimes, yeah. Some of those patients will go on and require major orthopedic surgical interventions, but we certainly need to know that the majority of them will be well managed medically.

Sechrest: Well, let's move on to symptoms from the standpoint of what does a typical person with knee and hip arthritis, how do they present to your office. What sort of symptoms are they complaining about at the time they present?

McAllister: Well, it's important, you've mentioned knee and hip. I think you need to differentiate those in order to be able to talk about that intelligently. I also think you need to separate them in terms of where they are in that disease. Early, mid term or late disease because they're dramatically different. But just for the purpose of conversation, let's say we're going to talk about that first onset. Let's talk about early disease in the hip and knee. I think the symptoms that they'll have in common will largely be some type of achiness and discomfort and maybe some stiffness and sense of swelling even if they can't see it. They won't see their swelling in their hip but they'll see the swelling in their knee. It will very commonly be mainly in the morning. They'll have some start up discomfort, it'll tend to ease up, get a little bit better as they move along. It will typically respond nicely to routine medical interventions that most patients actually doing on their own. They'll go and find some anti-inflammatories, maybe take some Tylenol and quite honestly a lot of patients simply put up with it early. By the time they are getting to their orthopedic surgeon, it's usually because either mediations have failed and their primary care doctor has encouraged an orthopedic consult or because of the pain and the symptoms and the stiffness and maybe even poor function will have persisted to the point where it's starting to interfere with their every day activities and while it might ease up a little when they start to walk, it then actually gets worse as the day progresses.

Sechrest: And, late phase, we're talking about people who are having pain at night, probably it's really getting in their way. I mean, it's not just the discomfort, these folks are unable to do the things they want to do.

McAllister: And that's where I think increasingly you then now need to differentiate hip from knee because their presentation will be considerably different.

Sechrest: And, how so? I mean how will the hip person differ from the knee person?

McAllister: The truth is that the knee does not tolerate, or let me rephrase that. Patients aren't able to accommodate to bad knee function as well as they can to bad hip function. Once they start to lose that certain amount of motion in that knee, it's just plain old hard to go up and down stairs. And, every day activities start to get more and more difficult, particularly if it's a malalignment disease because as it gets later into the disease, every body will notice that the leg is getting more and more bow legged. It will get unstable and walking on uneven ground becomes more and more difficult. The knee is much less responsive to simple interventions like the use of a cane. The hip on the other hand tends to be one of those joints where as long as their back is doing well and the other hip and their knees, patients will accommodate that pretty well unless the pain simply gets so intense that they can't tolerate it and you mentioned that nighttime discomfort to where they can't sleep. A lot of patients will find that they can position their knee on a pillow or whatever and get away with the sleep, but with a hip if they just roll over then it tends to wake them up at night, interferes with, you know, even simple functions like with a hip of reaching down to get to your toenails and tie your shoes gets more and more difficult, that's the stiffness element. But, the location of hip pain is very characteristic which tends to be in the groin and in that inner part of the thigh where is in the knee obviously it's more located in the knee.

Sechrest: Well, let's move on to how you as an orthopedist assess and make the diagnosis of what's going on. When this person is referred to your office and you see someone who you're suspecting of knee arthritis or wear and tear degenerative arthritis of the knee, what are you going to do? What sort of steps do you go through to try to figure out how best to treat this person.

McAllister: Now, it's important to go back to where they are in the stage of their disease and it's particularly important __????__of these things like MRIs and very expensive technologies. Let's first, let's take it early. Let's take that 38-year-old, 42-year-old whose had some achiness and they're coming in and obviously the first thing that any orthopedic surgeon or physician for that matter is going to do is hopefully a good history and physical examination. A lot of information quite honestly can be derived by simply talking to the patient, taking a quick look at how they walk, a five minute examination of their knee and hip and a lot of these problems, surgeons are pretty clear on what they think they're seeing before they ever even get to the x-ray. The x-ray unfortunately can be very unhelpful in early stage disease. Plenty of patients who were told, no your hip or knee is fine because the x-ray was normal actually have early degenerative arthritis and a little bit more focus on that clinical exam would have made the diagnosis or at least the suspicion. But, the x-rays can be normal and I think that's where an MRI can be very, very helpful, especially in the knee. It might uncover that meniscus injury even though it's degenerative and was not related to an injury. It's torn and that's part of their symptom complex and it can recognize early arthritis at the same time. That can help guide the indication for surgery either for or against and likewise in the hip, especially now as hip arthroscopy is coming on to the scene as a very powerful tool. More and more hip MRIs are guiding management in patients who otherwise would have been diagnosed.

Sechrest: So the routine in your office and most orthopedists office is first as we were all told as medical students, history is 85% of the diagnosis and a good physical exam will help you and then those x-rays to look for alignment, look for early signs of arthritis are very useful but as you say, sometimes they don't tell the whole story.

McAllister: Right.

Sechrest: Do you typically do an MRI scan on everyone with knee pain?

McAllister: Yeah, that's a really important question. You know, as you and I have both talked before about how important the Internet and information technologies are for patients as they're getting online and finding out good information. But, they're also sometimes coming in with wishes or desires or perceptions that they think should be done that actually aren't befitting them and an MRI too early in the sequence quite honestly is expensive, it's unnecessary and unnecessary technologies can lead to unnecessary surgeries. Now, if that patient has truly had clinical management, conservative management and it's failed, they truly are in a lot of pain and by the time they are presenting to me, if we need to, they're real surgical candidates, that 's a great time to get an MRI. But, a lot of patients will actually pretty much expect to have that MRI as their first thing that I do and I don't think that serves the patient. It might actually lead to a surgery they might not otherwise have had.

Sechrest: Well, I think there's a lot of fear that the MRI scan is too good. Showing abnormalities that may not actually have much relevance to what the patient is experiencing.

McAllister: Well, what I'm fond of saying to patients is that getting an MRI to look at an arthritic knee that's already arthritic on the x-ray is like using a magnifying glass to look at the wear and tear on your tire. You know, it can be very frightening if you think about it and it's just not an appropriate way to look at that level of degeneration in a case with the knee so yeah, it can definitely be an abused technology. When it's used correctly and aimed appropriately, then it's a very powerful tool and it should be used.

Sechrest: Well, any other tests that you would use? I mean, are there any lab tests that you like to do? Are there any other tests like a bone scan or anything like that, that you feel like are necessary to try to make this diagnosis or is it pretty much the MRI scan?

McAllister: Well, clearly, you know, the orthopedic surgeon needs to be sensitive to the fact that some of these types of arthritis are common like the inflammatory arthropathies and the degenerative arthritis that some patients will have both. Alright, so, lab work that might be specifically directed toward rheumatoid arthritis can really be an important tool for the orthopedic surgeon as well because as we point out, that would lead you down the road towards medical management instead of surgical. You know, other x-rays, I think that there is some real value especially as we talk about malalignment arthritis because I think that this technology that allows us to do long access weight bearing films is a very powerful tool. Unfortunately it's not that wide spread and available to orthopedic surgeons but as we look more and more down the alignment issues long access x-rays. Bone scans, I think bone scans can be helpful when we're looking for that multi joint arthritis. When we're concerned that patients have generalized symptoms. It can show you in one quick picture how many different joints are involved and I think sometimes that can have a bearing on treatment, but rarely for the orthopedic surgeon, more for the rheumatologist.

Sechrest: How about aspiration of the knee. I mean, some folks come in with fluid on the knee. Do you routinely take a sample of that fluid and send it to the lab or do you do that just on a case by case basis? How do you deal with that?

McAllister: definitely the surgeon needs to be prepared to do that. There's no question. I think that for the majority of patient's, by the time we're doing a good history and physical examination, if we're doing an aspiration, it may be part to help with the diagnosis but also part to help with treatment and aspiration with an injection of steroid can be almost as affective as arthroscopy in the arthritic knee. But, most of the time I'm not really having to rely on that aspiration to make the diagnosis. Very helpful in the inflammatory arthritities however. If I am suspicious of gout, the only way I can clench the diagnosis is with an aspiration and seeing those crystals under light microscopy. I think every surgeon out there eventually learns to be very sensitive to the potential for an infectious cause of the arthritis and the only way to really safely rule that out is with an aspiration. So, it's an important tool for the rheumatologist and the orthopedic surgeon.

Sechrest: Okay. Well, let's move on a little bit high level concepts of treatment and you mentioned sort of three stages of wear and tear arthritis. You mentioned that early stage where the person's having some discomfort, it may not be affecting their function but they're just wondering what's going on. Then that middle phase where, yeah, it's beginning to sort of, I can no longer hike 12 miles, I can now hike 6 miles and my knee swells up and I don't want to do it anymore. And then you've got that late stage where it's really beginning to impact my ability to function, either at work, in my sport or even in my life.

McAllister: Right.

Sechrest: Let's go back and sort of define how you approach those three patients and start with that early person. What do you tell them? What do you do in terms of treatment? What are their treatment options at that point?

McAllister: Well, now is when we're going to start talking a little bit more like doctors to doctors instead of just doctor to patient because it's a complex conversation and it spans a wide variety of patients but, lets get past the medical management. The patient that's already had the anti-inflammatories and is coming to the orthopedic surgeon. I like to divide those into early operative management, mid term operative management and then end stage operative management. And, early, I would lump the aspiration injection, to me anything that involved something sharp that goes through your skin is surgical. So, I kind of consider a needle part of that early surgical management. But, for the most part, that first surgical management from the patients point of view is going to be that arthroscopy in the early arthritic knee and the surgeon needs to be very judicious about helping making sure that he or she is deciding that this is truly early arthritis. Unfortunately arthroscopy, or fortunately arthroscopy is a loved minimally invasive procedure that any reasonable patient would prefer to have over more extensive surgery. But, if we do it in arthritis that's more mid term or late, our success rates are going to be low. But, in that early arthritic case that if it is apparent on the x-ray it's very mild. Now the knee is pretty well aligned. The symptom complex fits more the isolated meniscus tear instead of generalized arthritis. Those patient's can enjoy an 85, 90% success rate long term, 2, 3, 4 years out after an arthroscopy focused more in the meniscectomy than on the actual arthritis.

Sechrest: So, you're really looking in and trying to take care of anything that's torn, anything that's getting caught, anything that's getting in the way of the knee and just pretty much cleaning the knee up a little bit, washing it out and seeing what you get at that point.

McAllister: Okay, so well actually let's talk in more detail about what does arthroscopy to the arthritic knee really entail and it's quite a bit different than it is for arthroscopy for the simple meniscectomy. The typical arthritic knee will have the meniscus tear, it might even have two of them and it will also have some wear and tear on the ends of the bone. If patients, people who are viewing this just go to your website and look up knee arthritis, they'll see some nice schematics showing loss of that articular cartilage on the end of the bone and so the arthroscopy is pretty limited in what it can do about that. You know, contrary to the media and our wishes, we don't really have a way of planting new cartilage back in there yet, but we'd like to address it somewhat. So, one of the things that surgeons will typically do is clean up the edges, the margins of that worn out cartilage. If they're very small areas of wear and tear, there's been some promise with the microfracture techniques where we're trying to actually stimulate a little bit of repair in those areas of wear and tear, and that's shown some promising results. There is a well documented wash out affect of arthroscopy in the arthritic knee. Any surgeon who's stuck an arthroscope into an arthritic knee recognizes a reasonable amount of debris, just cartilage that's worn off and is in the joint as well as considerable debris of inflammation. The joint looks inflamed, there's a lot of tissue that's bloody and thick and looks angry. So, we know that washing some of that debris out has at least a short term benefit for the patient. And then, you know, I think that realistically just the diagnosis, helping to stage the joint, getting good photographs to show the patient what the real nature of their disease is, is helpful.

Sechrest: So the patient should not expect this to cure the problem. You're really buying time to try to treat this and I think that's true for all arthritis surgery. Where really everything is temporary to some degree.

McAllister: Yeah.

Sechrest: So, what about that late stage. I mean, if you've done these and probably we should talk about that person with the malalignment because that's a totally separate issue. And, when do you look at that patient and say, you know, I need to do something to this whole leg?

McAllister: Right.

Sechrest: I need to rejigger the leg, so to speak, to make the alignment more normal and try to take the pressure off of those areas that are showing increased wear. Is that an early stage problem?

McAllister: No. You're right, I'm glad you're making that difference because you said let's go to the late and I would say that well, no, that early arthritis is amenable to the arthroscopy and I would consider end stage typically the total joint replacement and realistically people between the ages of 45 and 65 very commonly are in that middle range where they are appropriately seeking alternatives to joint replacement. They may not feel like they're quite at the end of their rope and historically, orthopedics has had very little to offer those middle groups. They did well with their arthroscopies, the orthopedists historically have done well with their joint replacements but there has been an increasing demand and need for interventions that meet that middle group. I would consider those realignment surgeries, high tibial osteotomies, partial knee replacements would be another example of that. Let's talk about the high tibial osteotomy first. This would be a patient who's 36 years old, has always known that he was bow legged, kind of joked about it, it was no big deal. Now, he is coming into my office and thinks he might have a little cartilage tear because he had an MRI and it showed a cartilage tear but we look at the x-rays, particularly those long access weight bearing films and we see that that joint space has collapsed down bone to bone. And, when I measure his axis instead of begin straight as an arrow like a plum line, he's 7, 8, 9, 10° off. Now, this is a patient who, depending on when you catch them, whether their joint space loss is complete or partial, realigning their leg can cure their arthritis. You said everything is temporary and I had to kind of smile, well the one thing that's not temporary is if we catch early medial compartment disease in the bow leg and we correct that bow leggedness, we've curred their problems. Unfortunately the majority of them, by the time the come to us already have established arthritis and we're doing a high tibial osteotomy just to delay joint replacement for 14 or 12 or 10 years. But, you know, I've had a few patients where we catch them in their early 20s and fortunately, or unfortunately for them they were painful before they got severely arthritic and by correcting their bow leggedness their cured of the arthritis.

Sechrest: So, the cartilage degeneration stops at that point, or you can at least...

McAllister: If you get it early, it can number one stop and there are some studies that show that it has some potential to heal and will actually reverse and those are a little bit more controversial and now with new cartilage enhancing technologies like cartilage transplants and OATS transplantations and such, some of that repair can be facilitated at the time of high tibial osteotomy surgically.

Sechrest: Let's talk a little bit about what something you mentioned, and I think it's sometimes confusing. There is this procedure called OATS, where we actually take the patients cartilage, take a chunk of bone and cartilage and move it and then there is a cartilage regeneration where we actually takes cartilage cells, send them to the lab somewhere, they grow for a while, we put them back in and we're trying to grow them. Distinguish those two things if you could and when is one appropriate and when is the other appropriate?

McAllister: Okay. Well, some of that's going to be controversial and difficult to answer honestly. Some cartilage enhancing technologies I think are reasonably well accepted by the orthopedic community and are done frequently. Certainly and example of that would be the microfracture where we're simply puncturing the bone to try to bring some of the marrow elements up to the articular surface and let it do it's own natural healing power. Then there's the OATS procedure. People can go online and read about this, they can see it on a variety of websites, but the way I describe it to patients if you've ever seen the way they move the cup on a golf green, basically they go and they dig a core and in a way a normal joint is like a pristine golf green, it's smooth and it's flat and there aren't any ridges or ripples but the arthritic joint has ridges and ripples and defects. So, if you had a golf green that somebody took a divot out with their nine iron and you needed to repair it quick, you could go to another part of the green that you didn't think was so important like the edge, take a core of dirt and the grass, place it in that more important part, pound it down and make it level and it's essentially cured because that grass on the top of that core is already supported by the soil underneath.

Sechrest: And, it's alive and it continues to grow.

McAllister: It's alive and as it continues to grow, it'll actually merge with the surrounding grass and it will be totally normal within days for grass. In the knee, we do a similar sort of thing where we go to a part of the knee joint that we don't consider to be as critical as the area of cartilage loss and we virtually take a core of cartilage cap and underlying bone that's just ever so slightly larger than the defect and then we got to the defect and take out just a core of bone and we make it flush and perfect and in theory, the cartilage underneath is already supported. Now, the key here is that the surrounding in the golf green, the rest of the golf green has to be healthy, right. So, if I take that core it will survive. Well, if the rest of the golf green isn't helping and we just keep walking over the top of it, neither the grass surrounding the core or the core will survive. So, what we have to be careful about with OATS and why it has such a limited application is if the knee is badly aligned and that's why they're getting their wear and tear disease and I go take a core and put it there, then it's just going to die the same death. So, whatever we call the etiology, the cause of the problem needs to be addressed just as aggressively as the little arthritic lesion. You mentioned another technology where it's possible to take cartilage and culture it. To take cartilage cells, send it to a lab in Arlington, have it cultured and get it back in a vile of goo, and then go find that cartilage defect, take the lining around the bone called the periosteum and seal it over and then inject that goo into that space and hope that that's going to also enhance cartilage healing. That technology has been around now and in practice for 10, 12 years. The data on it is inconsistent, sometimes promising, other times not so promising. It's very expensive and it involves two surgeries, one for the harvesting and one for the implantation. And, I think it's very promising from a future point of view because certainly on a lab level it's shown some promising results. Wide spread application in patients is not here yet but it's yet another technology. Another one that you haven't mentioned are meniscal transplants and I get patients commonly coming in and talking to me about that. Cartilage, meniscus cartilage that's actually kept in a donor refrigerator. Somebody dies and wills their body to medical science and their meniscus is kept on a freeze and it can be transplanted into a human knee, but the complication rate is very high and it's another very expensive surgery and with very, very limited applications because it's thought to be only appropriate for patients whose symptoms of arthritis are, you know, the patient needs to hurt but it can only be done in patients whose arthritis is very early. But, if you remember earlier in our conversation, most of those patients who have early arthritis aren't that symptomatic so you're talking about a very large surgery in patients whose knees don't hurt that much. So, it's again another technology that has limited application.

Sechrest: So it sounds like in that middle range, there's lots of choices and usually there's lots of choices is because nothing works 100% of the time.

McAllister: Right, exactly.

Sechrest: Then we get to the end stage person. Typically the person that you and I would probably recommend an artificial knee replacement of some sort, either a partial artificial knee or a full artificial knee. One question patients always ask, because I think we've trained them this way and that is, you know, 20 years ago surgeons would say you can't have an artificial knee replacement until you're 65. That's not the same today I'm assuming. Tell me what you're guidelines are. I guess in the overall situation, how do you advise a patient when it's time to have an artificial knee joint? When it is appropriate?

McAllister: Okay. Well, that's another important conversation because it's changed. Joint replacement, knee and hip replacement really had it's origins in the late 60s, early 70s and weren't really being done on a large scale in the United States until the early 80s. And that isn't that long ago when you look at the evolution of surgery long term, 20 years is not very long. When joint replacement was first being done, it was a reasonably crude operation compared to what we're doing now. Instruments were not that good, the materials weren't that great, the wear properties weren't well understood, even the techniques were still under evolution and it was characteristically described as an operation that was reserved for the elderly, low demand patient whose arthritis was so severe that they were in such agony that they really couldn't stand to live that way. And, that was appropriate for that technology. But, things have changed. A lot of things have changed. The bearing surfaces have changed. The methodologies and the surgical techniques to put the joint replacements in, they are much lower profile. The don't consume as much bone. We are much better at putting them in very precisely and we have seen systematically decade by decade, these implants lasting longer and longer. Also, the other thing that has changed quite honestly is when you look at the average age of onset of arthritis being in the 50s and the fact that our baby boomer population is right there in the thick of joint replacement in the younger patient, mid 50s, mid 60s. You know, the idea that we would just take these old techniques and force them into young patients has really given way to a much higher level of surgical techniques and implants and such. So, now, in my practice the average age of the patient getting a knee replacement or hip replacement is 63. So, when you figure a good number of them in their 70s that means we're doing a reasonable number in their mid 50s.

Sechrest: So that old rule of you can't have a knee replacement until you're 65 just doesn't hold water anymore. I mean, there is no lower...

McAllister: Yeah, I think patients will still hear that. I shouldn't say it doesn't hold water, I think the patients need to talk to their doctors and really get a good feeling for it because we certainly don't want to be doing them in younger patients unless it's truly necessary. However, because of the circumstances that I've just mentioned and because of technologies an increasing number of patients are getting them done younger.

Sechrest: Well, and I think one of the things that people were afraid of is that the younger you do the total knee, because they only last for so long. Again, it goes back to this temporary notion. And, in the old days if you got ten years out of an artificial knee, you thought you were doing pretty good. So, you knew you were going to have to do that second one and then that second one always had a much lower success rate than that first one. So, everybody wanted to get that patient to the age to where they could really count on that knee replacement hopefully to take then through their whole life.

McAllister: Right.

Sechrest: I think that part of the thing that has changed, not only has the knee replacement lasting longer, but those second ones are a lot better. We're getting better results from the second, or revision knee replacements and so we're not so scared of doing that second one again.

McAllister: Well, and even our first ones that we're doing are much more bone preserving and there are more options instead of just doing full knee replacements in people. Some of their first ones are partial knee replacements that have been well documented now to help set up the situation where their second operation might be a primary total knee. Yeah, so we're doing well in terms of improving our long term results on that first knee, putting that first knee off as long as possible, inserting some even less invasive and more bone preserving options in front of that total knee and once that total knee is done, setting a stage for that first revision that for all intents and purposes is the primary total knee. So, what I encourage patients to do instead of looking at their age and saying how long is my knee going to last, looking at their situation and asking what's my plan. If I'm 78 and I'm getting my first total knee, my plan can realistically be that that's going to be my only total knee. Unless something unusual happens, that's likely going to be my only one. Total hip, total knee. If I am 65, it's probably going to be my only one, but I need a plan in case I'm wrong, I need a back up that would be a good revision. If I'm 55, no matter how gifted the surgeon is, no matter how well you behave, no matter how good the implants are and how good our results tell us they're going to be, your plan should include a second operation in your lifetime. If you're lucky you won't need it, but a person particularly in their early 50s needs to anticipate that that first joint replacement won't be their only one.

Sechrest: Yeah, I agree. Let me summarize sort of where we've been with this whole discussion and one is we began by discussing primarily degenerative arthritis or wear and tear arthritis, or osteoarthritis of the knee and for those folks who have had a significant injury post traumatic arthritis. We've looked at early, mid and late stage sort of options and how those patients differ and how the treatment options differ. Have we missed anything? I mean, if you look back at all the things we've discussed with this whole continuum from the young patient with arthritis all the way to the 78-year-old that you said whose getting that one total knee that's expected to last the rest of their life. Have we missed any options that patients should be aware of? Something they should really ask their doctors about?

McAllister: Well, there's one that I get asked a lot because we've really focused on traditional non operative and operative management. We haven't really talked about alternative medicines and certainly those are very common. They're common in the late literature, they're common on the Internet. I get asked a lot about it. Some of them have been demonstrated to be very effective and some of them not so effective, but you know, interventions like glucosamine sulfate, gin soaked raisins, magnets, all kinds of things that patients hear about which actually is my favorites topics to talk in public about, that's another real common one and to the extent that it might be an environmental issue or food allergy, I think some of those are very important. I don't think the orthopedic surgeon is the person to talk to about them, but it does come up frequently in my practice.

Sechrest: Let me put you on the spot about a couple of those. One is glucosamine. How do you tell patients? Do you recommend glucosamine sulfate? Do you feel like the studies support it's utilization?

McAllister: Yes, I do. You know, and I've constantly reevaluated that and looked at the numbers and looked at the statistics and I would say that glucosamine sulfate and it's combination with chondroitin sulfate, mangenes and some of the other common mixtures is probably the only alternative non pharmaceutical intervention that I would say has actually earned a place in terms of double blinded clinical trials. And, it has some advantages and disadvantages. It has one distinct advantage that it doesn't cause any real side effects of real significance. It takes a long time for it to have it's effect and patients tend to need to be on it for a long time but certainly I counsel patients to try it. Especially in those early cases. It won't have much impact later, but it can be equivalent to some of the more common anti-inflammatories.

Sechrest: For symptom control.

McAllister: Right.

Sechrest: Do you feel like there is any basis to tell patients that it actually either slows down the arthritis or it actually regenerates cartilage.

McAllister: You know, I think what happens is when they read the late literature, they get this impression that it actually grows cartilage and there is no data to support that and I don't think that's reasonable to expect that. We all know that short of that malalignment disease that gets corrected or the post traumatic arthritis that gets fixed, there is no cure for arthritis and it relentlessly progresses, particularly wear and tear arthritis. So, expecting glucosamine sulfate or any of these medicines to actually reverse or halt arthritic change wouldn't be rational.

Sechrest: Well, there is one other thing that we haven't discussed and we probably should in the face of discussing glucosamine and that is the injectable hyalgan, the injectable stuff. Not cortisone, I mean a lot of people confuse it with cortisone. Cortisone just calms down inflammation, but hyalgan, or synvisc are a couple of the brand names, but basically what we refer to these as viscosupplementation.

McAllister: Right.

Sechrest: What's your position on that?

McAllister: It's evolving. Another one that seems to, it's a recent player when you look at the last 20 years. Basically, as you know, normal joint fluid has this, has you've mentioned, visco elasticity. It's a fluid that compresses well, that provides a nice lubrication layer and the reason it does that is because normal joint fluid is this very long chain polymer called hyaluronic acid, and it's that long chain nature that gives it it's visco elastic quality. In the arthritic knee particularly inflammatory arthritis and wear and tear arthritis, the long chain gets cut up into smaller chains and it starts to lose that visco elastic quality. That's why some patients will talk about this like an oil change. Basically, the insight was well, maybe if we can supplement that, we can help to relieve those symptoms and hyaluronic acid turns out to be available in other sources, chicken's cox combs, horses hooves and that can be “purified” not synthesized, it's purified and then injected into the human joint. The original players required five injections, they weren't necessarily purified all that well, so a second series sometimes caused reactions because it is an animal glycoprotein so patients can get sensitized to it. More recent formulations are more highly purified, may be a little bit safer. When you look at trials that have been really focused at trying to evaluate the results, unfortunately some of those trials have been conducted by the companies that are producing it so we always feel like those need to be corroborated elsewhere and they haven't always been corroborated well in other studies. But, the general consensus out there that I have experienced and that I hear other surgeons expressing is that a reasonable number of their patients with early to mild arthritis who have failed medicines and failed steroid injections will respond for 8-12 months to these injections series. I think it's a very reasonable entry in our arvum and terium particularly for temporary solutions.

Sechrest: So you think it's worth trying and it's relatively safe. But there's always a risk of infection and the allergic reaction you're talking about, but relatively safe for the most part if done appropriately.

McAllister: I think there's some, you know, there's a technique to it and it can be done wrong. And, if it's done wrong then that can cause some pain for the patient, but as long as it's done well, and surgeons and physicians are judicious about the repeated sequences then they'll be fine.

Sechrest: Okay. Well, this has been a great discussion about primarily degenerative arthritis of the knee. Anything that we haven't covered that you feel like patients should know who are faced with making decisions about their own health care if they've got that first episode of knee pain or maybe they've had knee pain for a year and they've been putting it off and they just have finally made the decision it's time to think about it. Any parting remarks or any advice you would give that patient?

McAllister: Well, you and I have chatted about this before, the opportunities for patients to do their discovery on the Internet or with their sources of information within their family and friends is increasing all the time. In the end, it's way to complex a topic to try to satisfy in a 20-30 minute interview and every patient is different. And, what I counsel my patients to do is formulate your questions. Really probe and if you don't feel like you're getting good answers, be willing to go on to the next physician, whatever it takes, but in the end, you need a good counselor who will guide you through all of these issues because they are complex and their unique to every patient.

Sechrest: Well, thank you. Excellent information and I think this will help patients choose the right path for themselves. Thank you.

McAllister: Thank you.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.