Orthopedic surgeon Jeff Barry, MD, presents a guide to identifying and managing the all-too-common conditions of hip and knee arthritis, with a wealth of tips on assessing histories, performing physical exams and ordering imaging studies. He breaks down the treatments – from weight loss to joint injections to surgery – and clarifies what works, what doesn’t, and when to consider joint replacement.
and thank you so much for inviting me. Um really great to be here and hopefully I can share some good tips about how to manage hip and knee arthritis. So I don't have any disclosure of relevant to this. Talk to share a little bit about me. That's my contact info up there, so feel free to reach out at any time to me about any questions really, the orthopedics. Um my email myself, my chart works to um I grew up in the area and went to development for high school if you're familiar with South Bay at all, and then went to north Carolina for training in college and then back here for med school and residency. And I've been here the last three years on faculty. Um and definitely subscribe to the mantra of you can stay forever here at UCSF. Um We uh this is the UCSF arthur plastic surgery team. There's five of us who do joint replacements um with Dr Bill also being the chairman of the department and then we have clinics for our capacity all around the Bay area. So in the city at the orthopedic Institute, also in the North Bay and marin East Bay and Berkeley and South Bay and san Montano. The future in Redwood shores as well. So any of the patients that you guys have that you want to send over, we can generally meet them a little closer to home. Um This is what I wanted to talk about today is just kind of the burden of arthritis, how how I would recommend and how I do evaluate hip and knee pain and then what treatments work, What's kind of snake oil, what to avoid? We'll go over a little bit of the basics of hip and knee replacements, which can help with sort of the early um expectation management for some of the patients that may end up in that direction and then hopefully we'll have plenty of time for questions. Um So first getting into the burden of disease um if I was to ask you the most common impatient surgery in the US given that we're talking about hips and these that probably gives you a little bit of a hint. But actually knee replacement is number one and hip replacement is number four for the most frequent. Oh our procedures in the U. S. Hospitals. So this is a very common problem. The end results of arthritis is a very common problem. It's also a very costly problem. We're talking hundreds of billions of dollars a year. This these numbers are a little bit older but it only goes up um in a large percentage of your patients have arthritis. And and you know a quarter of them have doctor diagnosed arthritis. Mhm. As a result of those increasing uh percentage percentage of patients, the number of hip and knee replacements goes up exponentially, especially knee replacements right now. Um we're doing over a million a year in the us. It's predicted to be up to 3.5 million needs by 2030. There's a lot of lot of patients with this problem. Now, some of the reason that the numbers are going up is the population is aging, but also as we get better at the surgery. Um and and and better at the recovery from the indications kind of broaden as well as the patients who are quote unquote healthy enough for joint replacement province. And then the other problem that we have going concurrently is this issue with obesity and patients getting bigger joints wearing out faster. Um And as a result more and more needs that are more and more replacements needs in particular with the obesity. So what does arthritis this kind of an umbrella term? It just means joint inflammation. Um, it comes in a lot of different flavors, but ultimately is the disease of the cartilage. So as the cartilage degenerates causes pain, uh, patients then start losing function, get limps, you get swelling in the knee, they lose the range of motion and eventually can get pretty significant deformities as a result of bone loss. That happens after that car, which cap is gone. Now, there's no ways to make college come back for arthritis despite what the airplane magazines and things might have, you have, you believe? Um, and so a lot of arthritis management is kind of trying to keep them as functional as possible and keep the symptoms at bay when that fails them, then joint replacement comes into the picture. So we think of cartilage is kind of like a road and pavement starts off nice and smooth, some wear and tear. You start getting cracks and fissures in the cartilage. Then you get potholes and kind of whole areas that are bare and eventually the entire road just kind of falls apart. Um And this is what, what knees can knees and hips can start to look at. So these are some pictures from the or just last week, just got some examples of this is a hip replacement, There's a ball of someone's hip, you can see sort of normal white, that's that's kind of dying or dead cartilage. This yellow is kind of very diseased bone underneath, exposed cartilage is gone. You can see some of that cartilage flakes off sometimes and creates little little pearls in the, in the, in the joints. Um And then this is a knee or you can see that bone just exposed large bone spurs or osteo fights. Um and then kind of disease cartilage throughout. Uh huh. So arthritis has a big effect on our patients lives and quality of life, you know as you know the movement and walking and just mobility is a huge part of of of self esteem. Um your your image of yourself and also just how you interact with the world affects family life and sleep also, that's those are common complaints. This is kind of where it comes from. Is is these are different ways that we can get to that end result of cartilage missing. So where in tariff writers were in tears a little bit of a misnomer, we don't think it's necessarily the result of using it more. You start wearing it out more. We know that activity is actually good for cartilage. and there's obviously plenty of marathon runners with very healthy joints and there's plenty of people just sitting on the couch who get arthritis and actually maybe in verse that the less activity you're doing, the unhealthy, the more unhealthier cartridges, but that would be kind of osteoarthritis, the most common type. And then there's other other ways that the joint can can degrade. Um So inflammatory arthritis is probably about 10% of the patients that end up with replacements. And that number is going down is DeMars get better and better but but still a significant portion. Um And then there's also people with crystal and arthropods. These that would be kind of this X ray down below if you see a patient with joint space but kind of a very calcified looking looking gap there, that's often a crystalline arthropod, the or studio count which is which is probably underdiagnosed. Mhm. Uh huh. Um Prior traumas. Another frequent reason that you may come across people starting to get joint pain. So these are examples of pelvic fractures or hip fractures that have gone on to develop problems with the joint osteonecrosis is the most common reason that a young patient might need something like a hip replacement. Um And that's a disease of the blood supply to a tenuous portion of the body, such as the femoral head. So the ball actually the bone dies um and can start to collapse and then as a result, you know, have a round ball and around socket is kind of a square peg in a round hole. The most common reason for this would be things like steroid use for a lot of, a lot of times after cancer treatment for example. Um alcohol use HIV, uh sickle cell anemia. And those are some of the common reasons that patients as young as you know in their teens can end up meeting hip replacements. And then childhood diseases like G. D. H. Where people develop with the hip dislocated. Or another common common reason that people end up getting hip replacements. So how do you evaluate hip and knee? Um Was kind of the bulk of this So you know I kind of separate these into two categories. One is what do the X rays look like and then the other is how is the patient feeling and what's under examination? So starting with the how they're feeling and the examination history is really important. Part of an arthritis work up the most common ways that people present as kind of this intermittent waxing and waning pain uh well describe it as dole but then also sharp at times can be activity related but also can be at rest. Um so very, very specific. There a lot of people will bring up a history of trauma, An important part of the history as well for a hip arthritis patient is trying to figure out what are their expectations of treatment. A lot of people, they just want to be able to walk to the mailbox again or be able to walk outside their house and and walk their dog. Other people are complaining of pain at mile 23 two of a marathon. So it's a big difference in terms of what are they trying to get out of it out of treatment? What are the end goals? And it's important to kind of figure that out pretty early in the, in the pathway. Um you want to know what they tried to date and then what's their current function? When is it bothering them? Are they changing their activities as a result of their hip and knee pain? Or is it just kind of a new sense that they kind of know about when they are doing their activities that they like. Um BDS is a big one as well so people start losing the ability to put on socks. A lot of people come into clinic with like loafers and no socks on. That's kind of sometimes a tip off someone's got to laces, they're tied. That's often you know their hips probably working okay if they can get down there and do that on a daily basis. And these are some of the common findings that people will complain about with hip in the L. A. Um With hip arthritis we generally think of the pain being in the growing increase in the front, That's the classic location. It can radiate down to the need but not usually beyond. Um And then it can also be in the buttock area sometimes but that's not the classic location. It's rarely on the lateral side, so rarely on the outside kind of over here. That is generally not hip arthritis, pain or not associated with the hip joint. Um They typically complain of this first when they're trying to get up out of a chair or getting out of a car. Um And they're still often able to do a lot of activities with hip arthritis. You know biking doesn't usually bug I'm swimming, doesn't usually bug them. Um But things like like uh running that that starts to become more of an issue with these. The pain is more localized generally to where the pain is. So they usually will point right to the knee, right to the inside of the right, to the outside of the knee, start complaining about stairs or going downhill first. They will complain of swelling, which you can't usually see or, or don't usually complain about it with a hip. And then seemingly everyone with the knee has some story from high school about an injury that they will bring up. That's probably irrelevant. But they all, they all say, well, I was in high school and hurt this thing, you know, 30 years ago and that's when all this started. So just just that's just the common thing. Probably not relevant though. Things that you also want to pick up from a history for any patient or things that would be signs of a meniscal problem. So that would be stuff like catching or locking and it's not popping, like niece can pop and that's not necessarily an abnormal thing, but catching where it actually gets stuck and they have to physically kind of pop it to move it again. Or sharp pain that comes and goes after a pot. That would be things that would be more consistent with a meniscal problem. That might more a little bit of a different workout than just the wear and tear arthritis type thing. Now, in terms of how to do a physical exam, these would be the things that I look at in my clinic. Um, so in observation, when they're walking in the clinic, that's a huge part of the orthopedic exam is, how are they walking? Do they have an anti algae gate? Which means every limb thing and putting a less amount of time on one leg? A cox algae gate would be a specific gate that's related to hip arthritis. That's kind of, this lean over during that shorten the stance phase. A trend. Ellenberger gained would be where their hips kind of can't stay stable and they're kind of uh dropping one hip out when they stand on. It often can be assigned some muscle issues around the hip, also looking at their skin and the general appearance of the patient. That's more of a surgeon thing. Um, in terms of the physical exam. So the next step would be kind of palpitating around the joint is hurting. Um, So with the hip that's obviously a little bit harder, you can't really palpate the hip joint, but you can feel the outside of the hip where the truck and Terek Bursa is, and that's usually a very reproducible thing that if they have truck and terry crews scientists, which is often one of the differentials for hip arthritis pain, you can generally reproduces by pushing right in the right spot, right over that greater truck came on the side of the hill knee. You can often palpate the painful anatomy. So whether that's the meniscus or the bone spurs on the side or at the joint line, um, and then getting a good neuro exam can often be a good part to throughout the spine as a contributing factor um, in testing range of motion. That would be the next kind of step in any good orthopedic exam with the hip, People can very, very differently, uh, can be very variable in terms of what's normal for them. Um, a lot of I will test this, usually the patient seated and their hip flexed to 90, um, and then rotating the leg in and out, flexing up, having them stand up. So if they can extend all the way people start to lose internal rotation first. Which would be your kind of if your knees are together like this and this is your legs kind of being able to rotate out the feet out, that internal rotation of the hips um they often lose that first with arthritis, so if this kind of motion is causing them pain and stiffness, that maybe a tip off that there's something going on and the other people think that people lose pretty quickly is the ability to extend your hips fully. So if you have them lie flat, can their legs go all the way flat on the bed? A lot of them will not be able to because they'll start getting contractions and those hips will be stuck. Fuck flex stuff. Yeah, with the knee, the common nomenclature would be a fully extended straight me at zero and then going from that to whatever their maximum flexion is, A normal needs should get in the kind of 1 30 to 1 35 range. Um If people are short on max flexion we would normally annotated as kind of. So if you have a 10 degree contract should be 10 to 1 30. Um We don't usually write negative unless that's a hyper extended knee. So hyper extending, you're being the negative. You know you only need about 105 or so to do most functional activities within the um so you generally will see people losing some collection but not usually contracted past. You know about 105. Mhm. These would be the provocative test that I would recommend you guys know about when you're trying to examine a hip. Um These are the most sensitive test for hip arthritis and also the ones that will be the most provocative and and they'll be able to feel that pain that they're experiencing. Um You can often tell you that the hip joint is the problem. So the stench field test is just a Shown in this top right here. You have them like flat, have them raise the legs off the bed about 20° and then resist. So have them push towards the ceiling as you're pushing down. That should reproduce whatever pains coming from the hip line. What it does is it loads that ball into the socket. Um And can often say they're having pain in the buttock when they do that. That that may mean that that buttock pain is actually coming from the hip. Um The other one would be what we call a fader test or flexing, adopting an internally rotated. So that's shown in this picture down here, have them lie down and really rotate that leg. What that's doing is that's also kind of loading the most common area where people get arthritis or have liberal problems. And so if they're getting paid with that motion, that can often be a reason the center to see us, okay. And that should reproduce what they're experiencing as their hip. Think wherever that may be with the knees, it's more about just joint line tenderness, kind of finding that area that sword with pal patient, They may have pains at the extremes of emotion. Um, you can learn, there's a lot of kind of, there's, there's dozens and dozens of special knee exam maneuvers to kind of find a nuanced findings that I wouldn't expect. Um each necessarily grass. There's a lot of orthopedic residents that can't grasp a lot of these tests. So um, but one that's pretty helpful for our name and this gets exam would be the athlete tests which is shown here, just flexing the knee. Kind of pushing the leg together and just grinding, just rotating it that reproduces their pain. That can often be assignment is um and it's still problems. Mhm. Um An important part of this too is making sure you're checking joints above and below. So very often uh knee pain is master or hip pain is masquerading as knee pain or vice versa. So kind of checking the hips for anyone who's complaining of knee pain, checking the ankles as well, checking the back. All those things would be an important part of this. Now there's some special cases where hip pain isn't really from the hip, what people describe as their hip can be anything from um you know, hernia, to tendonitis, to cyanotic or back pain. So some of these are a little bit harder to differentiate, but you can generally find bursitis by pushing on the side of the hip. Like you talked about spinal stenosis, the buzzwords would be anything kind of radiating down the leg into the foot, so starting in the back and the button and then rating down to the foot or electric pain. That kind of the point you towards nerves hernias. You need to kind of just check for that. It's not uncommon for us to diagnose a hernia in the art of plastic opponents. So that's the clinical exam. The radiographic exam um would be the other part of this. So, uh there's one, there's a couple of things that I think would be really big takeaways that I recommend you guys you guys do when you're evaluating these patients. The one thing would be a weight bearing X rays. So weight bearing X rays are much more sensitive for arthritis. You can see in this picture, this would be a normal X ray that a lot of you know, clinics would get just when you order a knee ap and lateral. It's not a weight bearing looks pretty normal. So as you add weight to it, they're going on boat. Okay? So uh we bring x rays are key to any sort of X rayed series. If you're gonna pick one X ray to get, I would recommend you get this ph event nephew, which is called the Rosenberg all the radiology text with that, what this is. This is the most sensitive for early away. So weight bearing Rosenberg, if you're going to one X ray to evaluate to me, that would be the one to do okay. Um it often highlights the area where that cartilage is lost. 1st. Um buzzwords that you'll see in the radiology reports. That kind of point to to arthritis bone spurs. You can see those on the joint edges sclerosis, meaning that's kind of hardening of the bone that starts to happen as the edges touching the cartilage cap is gone. Um cysts, little holes in the bone and then joint space nearing is the most obvious and the easiest to pick up. Um All the radiologist at UCSF have now started putting these KL grades for all the X rays and knees and hips. That's kelvin Lawrence. That's kind of just the standard one in orthopedics that we use to grade arthritis severity on an X ray. Um So you'll see these numbers like grade KL one or K. L. Two um In general just so that you know the threes and fours or where it starts to get bad enough that we would consider joint replacement ones and twos are generally mild and moderate that we wouldn't necessarily you know in in some you know there's obviously circumstances that are different but usually that would be someone who will be considering a joint replacement on Jessica for the hips. It's uh similar. There's usually two films that we get an ap pelvis and a fraud lateral. We don't usually get weight bearing views for the hips because the hip, the muscles actually are at rest tense enough that they load the joint so you don't have to be standing on it to get that narrowing to occur. But an ap and a lateral, some type of frog lateral is a very easy one for people to get. And and you can even evaluate pretty well. This is an X ray of someone with a T. And you can kind of see a normal left hip. And on the right side you can see this kind of cap. Um that's sunken down, That would be a dead spot of coal. And that's that's something in. Um The radiologist will break these well in chaos scale as well. So you'll see those same kale 1234 and can just give you a quick sense of kind of how bad is this really? You know, one would be mild to moderate threes and fours or so here. So another thing that I like to share with you guys is that mris for older patients especially, but degenerate conditions in general are not going to be helpful. Um MRI doesn't add anything for me when I see the X ray, I know that they're going to have certain findings based on the amount of joint space that they have narrowed based on the age of their activity where they're having pain. This MRI is costly. It's not going to usually change my treatment or my recommendation. Um and the other thing now with my chart that I'm sure you guys are running into is that as patients get more and more access to all their studies, it adds about 30 minutes to the visit when someone was injured, Jeremy has an MRI report in their hand just because they're going to have meniscus tears, they're gonna have partial thickness car was lost. Perhaps they're going to have a label tariff there over 45. That's that's more the norm than the exception and just adds kind of this just to the discussion that's that's not necessarily going to be productive for either party. So I'd really encourage you not to get mris unless there's a specific thing that you're looking for. Um And X rays are generally going to be the way to go. Especially people over about 45 for hip and knee pain. Mhm. Um Susan will be a quick case example of someone. Um You know this is a patient who went to an academic center down the road a little ways, had some knee pain, had some X rays. They actually went through several rounds of stem cell injections for their need pain out of pocket, paying over $10,000 didn't get any relief. So they had a knee replacement done. Um This is a knee replacement. They were sent to us for persistent need pain. Um You know, on examination, knee felt okay. Actually look okay. This knee replacement but when you rotate their hip around their hip is stiff and they had severe hip arthritis. So, you know, this is an example of definitely checking the joint above and below. They got a hip replacement actually did fantastic. The knee pain went away and moving really well. So just to point out that, you know this, even though a patient says their knee hurts, you need to check other other times. Okay? Um so early treatment, you diagnosed them with some sort of hip arthritis, what are we going to do next? So this is uh often very confusing. If you look at a lot of the specialty societies, they are not helpful at all. Um like if you look at this european whatever, I don't know if this one that someone of the european rheumatology groups has said that pretty much everything is beneficial, but in some instances, whereas a lot of other ones will say uncertain or not recommended sometimes beneficial. So what I'm gonna try to do here is say the things that at least the hip and knee replacement groups would would generally say, or have good evidence behind them. So, these are things that have proven benefit and should be tried or offered to all arthritis patients. The number one most consistent improvement in pain scores is weight loss. Um, your VMS over even 25. You know, that if you're obese uh weight loss can help £1 of weight loss in your knee is £5 through the need. A £1 of weight loss, everywhere is £5 of force going through the need. So, you know, just encourage them to lose 5 to £10. That could be £50 of force that there needs. Getting off. Physical therapy and activity modification are also important interventions. You generally try to get people to at least try 4-6 weeks of this. A lot of people will say, well, I'm really active, that's not going to really be helpful to me, but there are certain things that certain muscle groups that can improve, especially around the need, um, the stability of the need. So if your knee is not kind of balanced, you get a lot of slop and a lot of shearing kind of all over the place, you get those muscles working properly, It's nice and smooth through the motion. You don't have as much slop. Um, and that can help with some of their symptoms, encouraging activities like biking and swimming and elliptical or much better than a lot of these crossfit and things of that nature that are really pounding on the new joint or a hip joint. Uh, anti inflammatories have really good proven benefit. The one I use most commonly in patients without kidney disease without stomach issues as Malagasy cam because it's easy, it's cheap, take it once a day um usually have them take it for at least a two week trial and then start weaning off if people can't take the ore ALs, but it's okay for them to take a topical and the Voltaren gel. So it's pretty effective for knees, topic was not going to work for hip joint arthritis. Obviously it only penetrates about things like less than a centimeter. But um, a lot of people swear by it so we still still can be worth a try. And then the other thing would be a cane for arthritis. Most people, a lot of patients will not use it, but encouraging them to try it, you need to put the cane in a good hand And that gives you a better moment arm. I'm sure you guys all remember these force diagrams from physics and things, but if you put the cane in the good and the good hand that helps offload the bad leg. So even about 15% of your weight through that cain will reduce the forces through your hip on the bad side by 50%. So these can be really impactful interventions using a walking stick or cane. Just tell them the mirror in the good hand, the bad leg. Oh um other things that are shown to be effective or injections um steroids and hyaluronic acid in particular um steroids and anti inflammatory and then hyaluronic acid. The way it's working is probably as an anti inflammatory. Also it's marketed as a lubricant but that's not how it's gonna work. Um realistically row piva cain would be the other thing that I would encourage you to use as a development for um your injections as opposed to lidocaine. McCain's actually counter toxic. So someone without severe arthritis, you keep giving them injections of steroid really taking your your kind of destroying the cartilage every time you do that. So I encourage you to use rope of a cane instead. Just .2% is the usual dilution. You can put five ccs of .2% relative a cane with whatever steroid of choice works just as well as the light of king. If not better, it's not going to kill the cartilage. Um And then trying to use these injections sparingly for normal looking joints is important. Um The picture of the rooster here is because how like acid people often call it rooster comb. They'll call it Simba's deflects. Uh um There's a lot of different names for the same substance, the data and the knees for these injections that they can give temporary relief. They're not going to reverse the arthritis a lot of times. It is kicking the can down the road but it can you know, some patients go years and years with regular injections. Um For H. A. In my practice I'm only using it for patients number one where the insurance will cover it because I don't think it's good enough for someone to have to pay cash for it. It's a little expensive and cash and I don't think it's that much better than a steroid. Um And I'll usually use in patients who still have good cartilage where I'm trying to reduce that exposure of the cartilage to to steroid. Um For hips injections have never really been shown to be that beneficial unfortunately. So usually I usually only use usually I only am doing hip injections for patients um That I'm confused as to what the true diagnosis is and trying to rule in or out hip problems has to be done guided. Um And so this is a referral to either one of the busy interests who can do it with ultrasound or with to radiology group to do an under philosophy. I don't trust any injections into a hip joint that are not done guided, it's too small of an area to get into without without guidance. Um And another important thing to note is that if someone does get an injection, they're not gonna be able to get a surgery for three months in that same joint. So there's a higher risk of infection uh in that same joint if they've had steroid rage a or any injection within three months. For me, these are things that are pretty low cost and safe that sometimes will offer to patients but don't have as good of evidence behind them. Things like bracing. So either just a compression sleeve or a medial on loader brace like shown here, which tries to kind of jack the area of arthritis back open and divert some of the stress to the better areas. Acupuncture has some evidence behind it but not consistent. I would say don't do this after a joint replacement because these needles are even though they're clean, can introduce um bacteria. And we definitely have seen patients who have gotten infections of prosthetic joints either from acupuncture from uh therapists doing what's called dry evil. Um The other thing would be heel wedges. This is super easy. You just put a wedge in um if they have medial arthritis, you give them a lateral heel wedge. It's just, it's similar to that on motor brace that's trying to tilt the leg into a different alignment and can help load more of the normal joint than the than the disease part. Um like here, um patches CVD creams, task facing creams, all those things have some some inconsistent method is kind of a hit and miss. Things that I would say should rarely if ever be used are glucosamine and chondroitin. Um We know that this works really well in dogs. There's good evidence for dogs, but bad evidence for humans. It's never really been shown better than placebo in any study in humans. So, uh, save that for the dog food. Um arthroscopic cleanup surgery. So just going in with a scope and cleaning it out doesn't work. Makes things worse. Actually. Can hasten arthritis progression. So that's something that was a big thing 10 years ago. No more any any orthopedic surgeon kind of proposing that you should be a little bit cautious. Um That is a very old school way of thinking. And then the other thing would be, opioids, opioids do not work for arthritis. And so this is an article just from today and the national press on drug overdoses in 2020 or the highest ever. The vast majority of these being prescription opioids, not, um, not like fentaNYL and kind of street drugs. Um, orthopedic surgeons are as much to blame as anyone else. Um, but it's really important to try and minimize the use of these for arthritis because they don't work. Um, the risk of opioid use addiction, stop spikes as soon as that, you know, you're just going to try it for a week and get them through this period doesn't work like that. A lot of them get hooked right off the bat. It becomes this chronic pain issue that makes all of our lives worse. Um, the people that are overdosing, it's not usually a direct prescription, it's left over from someone else. So this is also on us that we need to reduce the number of prescriptions that we're giving um if patients get pushed back for hip and knee arthritis and encourage you to to put them towards the hip and knee replacement. Um Group's website Aucas is kind of what most joint replacements, urgency is the main body for hip and knee replacements. They have a lot of good literature on their site um that we often will will push patients to that when they say that nothing helps for their pain, accepted allotted. Um Probably not the case and it's also going to result in a worse outcome from any sort of future treatment we're trying to be free of helps. So no opioids for arthritis doesn't work. Yeah. Now um other things to avoid would be stem cells. Prp lasers, anything that's cash only should get your kind of buddy sense tingling a little bit. Um stem cells and pr pr way too far ahead of their time right now there's no evidence that they work the chance that a cell that we can barely grow in a Petri dish with the right uh environment into cartilage. The chance of that cell is gonna turn into cartilage in your knee with none of the right growth factors and land in the right spot where there's arthritis grow into the right type of cartilage. Stay there with enough buddies around it to cause any sort of difference is just ridiculous. So you cannot recommend this to patients in my opinion at this time there's a couple centers doing early trials. They're not going to probably show any benefit. But if they want to be part of a trial, that'll be the only case I would do this. Trying to discourage them from paying out of pocket the tens of thousands of dollars that people are charging for this. Mhm. Um A lot of these things, you'll see like these advertisements. Well you know my friend had it and their joint space came back. They had Carlos grow back. This is a standing X ray pre and then a non weight bearing X ray post. This is kind of like it should be malpractice. Um Also the amounts that they're charging for these things are just ridiculous. You know, it's the same stem cells but they charge it $8500 for erectile dysfunction versus 5000 per joint injection. It's just like it's just ludicrous. Um This would be a kind of recommended maybe treatment pathway that you could do for arthritis. Um So you know, starting with weight loss if they're overweight, starting with P. T. Uh then going to medications that they're still not responding, sending them to one of us for evaluation. We're happy to see these people anywhere on the spectrum of their disease. So feel free to send them over whenever. Um I'm just gonna really quickly kind of fly through some of the basics of hip and knee replacement the next five minutes and then we'll hopefully have some time for questions. But the surgery that I do is is a replacement or arthropod nasty. I don't do arthroscopy. Um That's usually that's what the cameras and kind of that's usually sports medicine doctors. So arthur classy is a joint reconstruction replacement of the joint surface with some sort of prosthetic. Hip replacements in particular are always kind of number one or two in terms of the quality of life improvement that people can get from this hip arthritis can be debilitating and the hip replacement is one of the best procedures in medicine. Um The way it works is there's metal components usually made of titanium that are placed into the bone. Bone grows into those titanium implants and kind of bonds to it. The bearing itself is usually ceramic and plastic. Um that plastic is probably the most engineering part of the whole equation and is designed to last for decades. I usually tell people that I would hope they're getting 20-30 years easy. These new plastics have been around for about 10 to 15 years and don't seem like they wear out. That used to be the old failure mechanism is, I'd say 15 years is gonna wear out. Um Now that's not the case. These new classics may last indefinitely. So the longevity of this is definitely improved. Knee replacements are similar. Uh some sort of metal cap on the ends of the bone, and then a piece of plastic in between. Um in the knee replacement is usually held in place with bone cement as opposed to when hips where they grow into the the implant. So a little bit different than we also do a lot of uh redo surgeries here at UCSF. So if you have patients with painful prosthetic knees or hips done elsewhere, you send them back and see us. Uh These are things like infections when they come loose when they break or they're unstable. Um You can start getting people who are more metal than than bone, and this is a full femur replacement for a patient. Um So the things that you can replace your pretty pretty wild revision hips, same deal, you get people that end up with kind of real bad complications of things coming loose and go in places they shouldn't um need to get taken care of. So when you choose a joint replacement, try no up and failed. They have pain that's limiting them and affecting their quality of life. And then they have X ray radiographic evidence of disease. The patients that they're going to be good and patients usually tell us when they're ready for a joint replacement. Um We're getting good at these. You know, we do them often in the same day, go home. Uh Most patients go home the next day, stairs aren't an issue. Everyone has them in san Francisco but social support is important to a successful replacement and recovery. Um a lot of the improvements and why patients aren't staying in the hospital for a week or two like they did maybe 20 years ago is that we're better and better at controlling pain with different kind of approach is different types of medicine and keeping the narcotics and opioids down patients need them after surgery, but it's generally for just a short period of time, about a month with the knee is kind of the longest. Um And a lot of this is just expectation management that you're going to be able to walk, you can move around, your pain will be managed and it can be done so without opioids. Um we're also doing an older patients like I mentioned before, so, you know, not routinely in patients in their 80's if they're still active and have uh you know, they're going to benefit from their mobility, they can usually benefit from the joint replacement. Um Now, bad things can happen. It's obviously a low complication rate, luckily, but there's certain complications, their devastating like infections of joints. Um And so this is where optimization and risk reduction. This is kind of where we often are coming in in communication with with you guys the most is trying to get patients optimized for surgery. These are kind of our criteria here that are generally recognized across the country and most places will use similar things. So I think if we're all on the same page with this, it can definitely help guide a patient to what's going to be the best to get a good a good outcome for them. But diabetes management with a well controlled uh well controlled, relatively, but a one c below eight seems to be the best for joint replacement risks. We are pretty strict about no nicotine around the time of surgery affects wound healing, infections, obesity. Tryry to get a bme below 40 is the safest um decreasing their opioid use if they're using it beforehand. This has been shown to be beneficial. Um uh and then having social support in place and obviously heroin, cocaine methamphetamines. Those are ones that we worry about for substance abuse. Not necessarily. Uh marijuana doesn't really bother. And then people live heavily heavily happily ever after after the joint replacement. Um I think a lot of joint replacement companies use the same advertising executives as by Admiral Cialis. But you know, people do get back to good activity after after the hip replacement. They can go back to no restrictions, doing things that they enjoy without limitations. Um So if there's there's nine things I could share. Um these would be them. Uh We burning X rays are really important for evaluating these. Uh The Rosenberg benton is the best one to see early arthritis rarely if ever do older patients need mris to evaluate their joints. Uh, anti inflammatories, physical therapy and weight loss are going to be the best evidence, inventions and no opioids for arthritis, avoiding any of these kind of snake oil, things like stem cells right now. Um, and then optimizing patients before surgery is going to be an important part of a successful outcome and then joint replacement can be life changing. And I encourage you guys to reach out to me or any of my colleagues. We're all happy to hear from you guys at any point. Any questions? Hey, can you look at this x ray? Hey, this patient tried this. What would you do next? Hey, do you mind seeing this patient of mine? We're always going to say yes, we love the stand and hopefully can see them closer to their home, wherever our clinic is. Okay. Um, so with that I'll leave it and hopefully uh, if you guys have any questions, feel free to put them in there. Otherwise again, I really appreciate the invite and sharing some of this information. And um, no, thank you.