Arthritis affects all of us. Ninety-one million Americans are affected by arthritis, mostly osteoarthritis. Forty-five percent of people have a lifetime risk of developing some degree of symptomatic knee arthritis.

What is arthritis and why do I have it?

A normal joint is like a well-oiled hinge: it has healthy cartilage, is lubricated, has good motion and is pain-free.

An arthritic joint is more like a rusted hinge: it’s damaged, the cartilage has tears in it, it’s lost motion and is painful.

In a healthy hip or knee joint, there is space between the bones, smooth surfaces, no bone spurs, no cysts, and the bone is in the original shape and position. In an arthritic hip or knee joint, the bone space has been reduced or eliminated by cartilage being worn or damaged. As a result, bone spurs or cysts may occur and the bone may change shape or position. An arthritic knee, for example, may bow in or out, changing the shape of your leg.

Arthritis is a spectrum, and it can cause pain even before it reaches bone-on-bone or end-stage arthritis.

How do we treat arthritis without surgery?

Treatment for arthritis is about functionality and keeping your quality of life high.

Staying active

Why stay active?

  • Exercise reduces fatigue.
  • Aerobic exercise reduces many metabolic and medical diseases, including helping control blood sugar in diabetes, keeps blood pressure down and keeps your heart strong to help avoid cardiovascular disease, and helps with the avoidance of cancer and treatment of cancer.
  • Exercise activates the immune system so you’re less likely to develop respiratory disease and autoimmune disease.
  • Exercise reduces tension, promotes relaxation and decreases depression to improve your overall quality of life.
  • Exercise maintains muscle strength and mobility, decreases falls and reduces age-related cognitive decline.
  • Exercise can help you live longer overall.

As we age, we tend to be less active. Inactive people lose muscle at a rate of 3-5% every decade after 30. Not staying active leads to decreased strength, which leads to decreased balance and impacts on the activities of daily living, resulting in needing more help and being at a higher risk for falls.

While activity may be uncomfortable, it treats arthritis pain. A recent study in the American Family Medicine Journal showed if you exercise 20-30 minutes 2-3 times a week there is a 30-40% decreased risk of needing surgical intervention on your joints.

How to stay active

Modifying activities allows you to stay active even when your joints hurt or you’re weaker overall. Lower impact activities like biking or water aerobics can help.

If you can’t do an impact or weight-bearing exercise, you can still get a benefit from doing movement therapy like yoga or tai chi to help bring blood flow to your joints, encourage muscle strength and isometrics to stabilize the joints and decrease your arthritis.

While I’m not an expert, alternative therapies may be helpful. You may look into acupuncture, manipulative therapies like massage, and cognitive therapies like meditation.

Weight Reduction

Your joints aren’t wearing out only because of your weight, but it is one of the factors that contributes to them wearing out. Your hips and your knees see 4-6 times your body weight every time you take a step, especially doing stairs or getting out of a chair. Any weight you lose takes stress off your joints, helps with pain, and helps decrease the wear out of your joints over time. If you do need surgery in the future, weight loss may make you a safer candidate for surgery.

Medications: Anti-Inflammatories

The gold standard medicine for arthritis is anti-inflammatories. There are many versions available, including over-the-counter and prescription medications. Talk to your medical doctor or your orthopedic doctor about which anti-inflammatories are best for you, as some may be contraindicated for certain conditions or diseases.

Medications: Injections

Injections vary in out how much relief they provide people, but sometimes an injection can manage the pain and allow you to keep moving.

Steroid injections, an anti-inflammatory injection, are the most common kind of injection. They can be given 3-4 times a year. There is some concern about the effects of steroid injections on cartilage over the long term, but when they’re used for an arthritic joint you already have a compromised joint. Over time they will have fewer effects and different treatments will need to be tried.

Lubricating injections (hyaluronic acid injections) and stem cell or PRP injections have variable effects. They are intended to decrease inflammation, and do not regrow cartilage, reverse arthritis or prevent you from having future issues. They are for current symptom relief.

Medications: Supplements

Glucosamine chondroitin sulfate is the most common supplement discussed for arthritis. It’s made of a material in cartilage, with the hope that a higher store of it your body will be able to keep your cartilage healthy. However, there is no good data showing it reverses arthritis or that it prevents the progression of arthritis. It’s a low risk and low cost treatment without major issues.

While various specific diets (low inflammatory, anti-inflammatory, low carb, low glucose, low fat, etc.) may have some effect, there’s no standardized answer on diet. Many anti-inflammatory foods exist, but there is no one recipe or diet to suggest.

How do we treat arthritis with surgery?

Surgery can be the treatment that allows you to get back the functional quality of life and an active, fulfilling lifestyle that also helps minimize other medical comorbidities. Arthritis surgery is not a limitation to your future but a gateway to your future.

Anterior approach total hip replacement

I do the anterior approach for total hip replacement, doing the hip replacement from the front instead of the back. It uses a smaller incision, so there is less soft tissue disruption. The robotics and special table I use also allow me to minimize the soft tissue dissection, recreate bony anatomy, and cause less trauma to the body, hopefully leading to less pain for the patient, a quicker recovery and fewer restrictions after surgery so you can get back to your activities.

I restrict patients’ activities the first couple of months after a hip replacement, but after 3-4 months, patients are allowed to do any activities that they can tolerate. Most people can get back to doing their pre-surgery level of activity with less pain, but hopefully their activity level can improve from there. I have patients who get back to running or triathlons after hip replacement, as well as fairly aggressive recreational sports like pickleball, tennis, or cross-country bike riding.

Partial knee replacement

A partial knee replacement is a smaller surgery that is less invasive and has less soft tissue disruption than a total knee replacement. It feels more like a native knee because we leave the other parts of the knee, including the ligaments, alone. It gives you a more natural feel to the knee that allows you to get back to doing high energy sports like tennis, running, and biking.

More people are candidates for partial knee replacement than get partial knee replacements. In a study, almost 50% of people qualified for a partial knee replacement but in the United States, we only do about 8-10%. In my practice, around 20% of the knee replacements are partial knee replacements, and I think it could be higher. I’m always looking for the right candidates.

Some old assumptions about who partial knee replacements are for have been overturned, and I think it can be a great surgery for all patients in the right situation. In my hands, a partial knee replacement is a 20- to 30-year replacement and it hopefully allows you to get back to your active lifestyle.

Robotic assisted total knee replacements

Robotic assisted total knee replacements allow me to do patient-specific surgery: I’m not trying to change your anatomy or change your soft tissue tension. This surgery allows for better use of in-growth knee replacements that hopefully lead to better longevity and a more natural feel in the knee, which can allow for a return to more normal activity afterwards.

While I cannot guarantee that you get back to everything you did before a knee replacement, we do everything to try to minimize the impact on you and allow the knee to feel more natural. After 3-4 months, you’re cleared from restrictions to do activities you can tolerate.

Longevity After Replacement Surgery

If you have a replacement that will last for 20-25 years, that doesn’t mean that it will fall apart at 26 years. It’s about 0.5% to 1% revision rate per year, so at 10 years after surgery, there is a 90-95% survivorship of the implants. At 20 years, it’s 80-85%. Even after that, the implant may wear out or loosen, but there are surgical interventions that we can do, sometimes even minimally invasive ones, to allow you to stay active and have a good quality of life.

My goal as an arthritis joint replacement doctor is to keep people active for as long as possible without surgical intervention through non-operative methods, whether it be medicine, injections, therapy, braces, or other things. When all those things start to fail, surgical intervention is available not as a resolution to a change in lifestyle but as a liberation to keep you active and keep the quality of life you want.

Frequently asked questions

Are knee braces while exercising good if someone has knee arthritis and wants to stay active?

Knee braces or sleeves can be very liberating for some patients, but they’re not for every patient. You want to check if it feels more supportive than without the brace and if it is comfortable. If not, I wouldn’t wear a brace or sleeve just for the sake of wearing it.

Some people get benefits, while others feel that the brace is constrictive and uncomfortable and they don’t like it.

How do you know when it’s time for a joint replacement?

If we can keep you comfortable with conservative measures, that’s what we should do. We don’t jump ahead to surgery just because you have arthritis on your x-rays. If you have good quality of life, I can’t make that better with a surgery. So you’ll live with your good quality of life with your arthritic joint as long as you can through the medications, injections, therapy and bracing.

However, once there’s an impact on your quality of life, with more bad days than good days and feeling like you can’t keep going with the joint the way it currently is, that’s the right time to move forward with surgery.

I never want you to feel like you’re pushed into a joint replacement. My goal is to give you the treatment you need at the time you need it.

How often can the hyaluronic acid injections be repeated?

In general, the hyaluronic acid injections can be done every six months. Most people do a similar schedule for 3-6 months for the stem cell injections or PRP injections.

Hyaluronic acid injections may or may not be covered by insurance. Stem cell and PRP injections are not covered by insurance.

Are there exercises that you suggest doing or ones that you suggest avoiding when you have knee arthritis?

Deep knee bending exercises are going to be more aggravating to the knee, but we still want to encourage motion. I recommend avoiding lunges and deep squats. I also suggest not doing open chain exercises like leg extension machines and leg curl machines at the gym, which are more aggravating on your kneecap.

Are robotic knee replacements the norm now or do the majority of surgeons still do traditional knee replacements?

Robotic joint replacement is a growing field inside joint replacements. It is not the gold standard or the majority of joint replacements, but it is a rising trend. More doctors who are coming out of training are being trained on the robotic systems and are seeing the benefits mentioned earlier.

However, any surgeon who does robotics needs to be able to do traditional instrumentation in case the robotics fail or something comes up in the surgery. You need to understand the basics of a good joint replacement with traditional instrumentation to be able to do a good joint replacement with robotic instrumentation.

You want to go to a surgeon who does a high volume of joint replacements, at least 50 per year, so that they have proficiency in it, they have familiarity with it and they know how to take care of issues if issues arise.

What is the recovery time after a partial knee replacement?

All joint replacements have ongoing recovery for the first year after surgery. A partial knee replacement’s initial recovery time is quicker than a total knee replacement. I tell patients a total knee replacement takes about 3-4 months to get over the hump and recover from, while a partial knee replacement takes about 4-6 weeks.

What happens when both knees need a replacement?

In my practice, I have gone away from doing bilateral knee replacements. Although I know how to do it, it has a large impact on the patient and puts extra risk on you that we can avoid if we stagger the replacements. Commonly, I will do one replacement and then do the second one about four weeks later. Staggering the surgeries allows for your blood stores to come back up so you’re at lower risk of getting a blood transfusion, you have less pain because you’re not recovering from both knees simultaneously, and you’ll have a “good knee” to offload your replaced knee in the recovery so it allows you to get up and get moving a little quicker.

If you have both knees replaced at the same time, you’re at higher risk of needing to go to a rehab facility or a skilled nursing facility to recover. My goal is to get you home and allow you to recover at home, which has better functional recovery, lower depression rates, lower delirium rates, and an overall better outcome.

In terms of which knee to operate on first, sometimes we choose to do the right one first so you have an earlier return to driving while you’re recovering from the left one. Other times, my general recommendation is whichever knee is the most painful.