Medications & Supplements
	What are Chondroitin and Glucosamine sulfates and are they effective in the management of arthritis?
	Showing the most promise as a natural treatment to arthritis is the combination of glucosamine and chondroitin sulfate. They are building blocks of joint cartilage and are considered a food supplement. They can be as effective as ibuprofen for approximately 75% of people treating joint pain.  Glucosamine works to normalize damaged joint cartilage and protect it from further harm. The recommended dosage of glucosamine sulfate for osteoarthritis is 1,500 mg daily. It may take anywhere from one to four months to experience partial pain relief. Patients who include chondroitin sulfate have a slight additional benefit. Other joint-protective compounds include: Vitamins A, B6, and C, and the minerals copper and zinc, are all required for the body’s manufacture of collagen and normal cartilage.   Vitamins A and C, when used in combination, may help slow down the deterioration of afflicted cartilage.   Vitamins C and E, used in combination,, protect cartilage from free-radical destruction.
	When should I start taking an iron supplement before surgery and what is the best kind to take?
	If your hemoglobin is below 13, it is advised to take an iron supplement to boost your red blood cells. Begin taking supplements at least 6 weeks prior to surgery, especially if you’re anemic. Pure elemental iron (ferrous sulfate) is recommended. It can be purchased over the counter at your pharmacy, or your physician may write a prescription. Be sure to take the iron with a meal and drink plenty of water; this will help avoid any digestion problems. Take the below up until surgery: Iron, 1 tablet 3 times a day.   Vitamin C, 250 mg twice a day.   Folic acid, 1 mg once a day.
	What are symptoms of avascular necrosis (AVN) and how is it treated?
	Avascular necrosis is a disease resulting from the temporary or permanent loss of blood supply to the bones. Without blood, the bone tissue dies and causes the bone to collapse. If the process involves the bones near a joint, it often leads to collapse of the joint surfaces. This disease is also known as osteonecrosis, aseptic necrosis, and ischemic bone necrosis. Although it can happen in any bone, avascular necrosis most commonly affects the ends (epiphysis) of long bones such as the femur, the bone extending from the knee joint to the hip joint. Other common sites include the upper arm bone, knees, shoulders, and ankles. The disease may affect just one bone, more than one bone at the same time, or more than one bone at different times. avascular necrosis usually affects people between 30 and 50 years of age; about 10,000 to 20,000 people develop avascular necrosis each year. Orthopedic doctors most often diagnose the disease. The amount of disability that results from avascular necrosis depends on what part of the bone is affected, how large an area is involved, and how effectively the bone rebuilds itself. The process of bone rebuilding takes place after an injury as well as during normal growth. Normally, bone continuously breaks down and rebuilds-old bone is reabsorbed and replaced with new bone. The process keeps the skeleton strong and helps it to maintain a balance of minerals. In the course of avascular necrosis, however, the healing process is usually ineffective and the bone tissues break down faster than the body can repair them. If left untreated, the disease progresses, the bone collapses, and the joint surface breaks down, leading to pain and arthritis. Causes of Avascular necrosis: Avascular necrosis has several causes. Loss of blood supply to the bone can be caused by an injury (trauma-related avascular necrosis or joint dislocation) or by certain risk factors (non-traumatic avascular necrosis), such as some medications (steroids), blood coagulation disorders, or excessive alcohol use. Increased pressure within the bone also is associated with avascular necrosis. The pressure within the bone causes the blood vessels to narrow, making it hard for the vessels to deliver enough to blood to the bone cells. Injury: When a joint is injured, as in a fracture or dislocation, the blood vessels may be damaged. This can interfere with the blood circulation to the bone and lead to trauma-related avascular necrosis. Studies suggest that this type of avascular necrosis may develop in more than 20 percent of people who dislocate their hip joint. Steroid medications: Corticosteroids such as prednisone are commonly used to treat inflammatory diseases, such as systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, and vasculitis. Studies suggest that long-term, systemic (oral or intravenous) corticosteroid use is associated with 35 percent of all cases of nontraumatic avascular necrosis. However, there is no known risk of avascular necrosis associated with the limited use of steroids. Patients should discuss concerns about steroid use with their doctor. It is not clear exactly how the use of corticosteroids sometimes can lead to avascular necrosis. They may interfere with the body’s ability to break down fatty substances. These substances then build up in and clog the blood vessels. This reduces the amount of blood that gets to the bone. Some studies suggest that corticosteroid-related avascular necrosis is more severe and more likely to affect both hips (when occurring in the hip) than avascular necrosis resulting from other causes. Alcohol use: Excessive alcohol use and corticosteroid use are two of the most common causes of nontraumatic avascular necrosis. In people who drink an excessive amount of alcohol, fatty substances may block blood vessels, causing a decreased blood supply to bones that results in avascular necrosis. Other risk factors: Other risk factors or conditions associated with nontraumatic avascular necrosis Gaucher’s disease, pancreatitis, radiation treatments and chemotherapy, decompression disease, and blood disorders such as sickle cell disease. Who Is Likely To Develop Avascular Necrosis?   Avascular necrosis affects both men and women and affects people of all ages. It is most common among people in their thirties and forties.  What Are The Symptoms?    In the early stages of avascular necrosis, patients may not have any symptoms. As the disease progresses, however, most patients experience joint pain-at first, only when putting weight on the affected joint, and then even when resting. Pain usually develops gradually and may be mild or severe. If avascular necrosis progresses and the bone and surrounding joint surface collapse, pain may develop or increase dramatically. Pain may be severe enough to limit the patient’s range of motion in the affected joint. In some cases, particularly those involving the hip, disabling osteoarthritis may develop. The period of time between the first symptoms and loss of joint function is different for each patient, ranging from several months to more than a year.  How is Avascular Necrosis Diagnosed?   After performing a complete physical examination and asking about the patient’s medical history, the doctor may use one or more imaging techniques to diagnose avascular necrosis. As with many other diseases, early diagnosis increases the chances of treatment success. It is likely that the doctor will recommend a radiograph, commonly called an x ray. X rays can help identify many causes of joint pain, such as arthritis or a fracture. If the x ray is normal, the patient may need to have more tests. Research studies have shown that magnetic resonance imaging, or MRI, is the most sensitive method for diagnosing avascular necrosis in the early stages. The tests described below may be used to determine the amount of bone affected and how far the disease has progressed. X Ray An x ray is a common tool that the doctor may use to help diagnose the cause of joint pain. It is a simple way to produce pictures of bones. The x ray of a person with early avascular necrosis is likely to be normal because x rays are not sensitive enough to detect the bone changes in the early stages of the disease. X rays can show bone damage in the later stages, and once the diagnosis is made, they are often used to monitor the course of the condition. Magnetic Resonance Imaging (MRI) MRI is quickly becoming a common method for diagnosing avascular necrosis. Unlike x rays, bone scans, and CT (computed/computerized tomography) scans, MRI detects chemical changes in the bone marrow and can show avascular necrosis in its earliest stages. MRI provides the doctor with a picture of the area affected and the bone rebuilding process. In addition, MRI may show diseased areas that are not yet causing any symptoms. Bone Scan Also known as bone scintigraphy, bone scans are used most commonly in patients who have normal x rays. A harmless radioactive dye is injected into the affected bone and a picture of the bone is taken with a special camera. The picture shows how the dye travels through the bone and where normal bone formation is occurring. A single bone scan finds areas in the body that are affected, thus reducing the need to expose the patient to more radiation. Bone scans do not detect avascular necrosis at the earliest stages. Computed/Computerized Tomography A CT scan is an imaging technique that provides the doctor with a three-dimensional picture of the bone. It also shows “slices” of the bone, making the picture much clearer than x rays and bone scans. Some doctors disagree about the usefulness of this test to diagnose avascular necrosis. Although a diagnosis usually can be made without a CT scan, the technique may be useful in determining the extent of the bone damage. Biopsy A biopsy is a surgical procedure in which tissue from the affected bone is removed and studied. Although a biopsy is a conclusive way to diagnose avascular necrosis, it is rarely used because it requires surgery. Functional Evaluation Of Bone Tests to measure the pressure inside a bone may be used when the doctor strongly suspects that a patient has avascular necrosis, despite normal results of x rays, bone scans, and MRIs. These tests are very sensitive for detecting increased pressure within the bone, but they require surgery. What Treatments Are Available?   Appropriate treatment for avascular necrosis is necessary to keep joints from breaking down. If untreated, most patients will experience severe pain and limitation in movement within 2 years. Several treatments are available that can help prevent further bone and joint damage and reduce pain. To determine the most appropriate, the doctor considers the following aspects of a patient’s disease: The age of the patient.   The stage of the disease-early or late.   The location and amount of bone affected- a small or large area.   The underlying cause of avascular necrosis-with an ongoing cause such as corticosteroid or alcohol use, treatment may not work unless use of the substance is stopped. The goal in treating avascular necrosis is to improve the patient’s use of the affected joint, stop further damage to the bone, and ensure bone and joint survival. To reach these goals, the doctor may use one or more of the following treatments. Conservative Treatment Medicines – to reduce fatty substances (lipids) that increase with corticosteroid treatment or to reduce blood clotting in the presence of clotting disorders. Non-steroidal anti-inflammatory drugs may also be prescribed to reduce pain.   Reduced weight bearing – If avascular necrosis is diagnosed early, the doctor may begin treatment by having the patient remove weight from the affected joint. The doctor may recommend limiting activities or using crutches. In some cases, reduced weight bearing can slow the damage caused by avascular necrosis and permit natural healing. When combined with medications to reduce pain, reduced weight bearing can be an effective way to avoid or delay surgery for some patients.   Range-of-motion-exercises – may be prescribed to maintain or improve joint range of motion.   Electrical stimulation- to induce bone growth. Conservative treatments have been used experimentally alone or in combination. However, these treatments rarely provide lasting improvement. Therefore, most patients will eventually need surgery to repair the joint permanently. Surgical Treatments Core decompression – This surgical procedure removes the inner layer of bone, which reduces pressure within the bone, increases blood flow to the bone, and allows more blood vessels to form. Core decompression works best in people who are in the earliest stages of avascular necrosis, often before the collapse of the joint. This procedure sometimes can reduce pain and slow the progression of bone and joint destruction in these patients.   Osteotomy – This surgical procedure reshapes the bone to reduce stress on the affected area. There is a lengthy recovery period, and the patient’s activities are very limited for 3 to 12 months after an osteotomy. This procedure is most effective for patients with advanced avascular necrosis and those with a large area of affected bone.   Bone graft – A bone graft may be used to support a joint after core decompression. Bone grafting is surgery that transplants healthy bone from one part of the patient, such as the leg, to the diseased area. Commonly, grafts that include an artery and veins (called vascular grafts) are used to increase the blood supply to the affected area. There is a lengthy recovery period after a bone graft, usually from 6 to 12 months. This procedure is complex and its effectiveness is not yet proven. Clinical studies are under way to determine its effectiveness.   Arthroplasty/total joint replacement – Total joint replacement is the treatment of choice in late-stage avascular necrosis and when the joint is destroyed. In this surgery, the diseased joint is replaced with artificial parts. It may be recommended for people who are not good candidates for other treatments, such as patients who do not do well with repeated attempts to preserve the joints. Various types of replacements are available, and people should discuss specific needs with their doctor. For most people with avascular necrosis, treatment is an ongoing process. Doctors may first recommend the least complex and invasive procedure, such as protecting the joint by limiting movement, and watch the effect on the patient’s condition. Other treatments then may be used to prevent further bone destruction and reduce pain. It is important that patients carefully follow instructions about activity limitations and work closely with their doctor to ensure that appropriate treatments are used.
	What are symptoms of arthritis and how is it treated?
	Arthritis is an inflammation of the joints that is painful and can even change the structure of the joint. Though often considered a disease of the elderly, it can strike at any age. There are several types of arthritis, but the most common is degenerative joint disease or osteoarthritis. This disease affects more than 20 million people in the United States. Osteoarthritis is a joint disease that mostly affects the cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another easily. It also absorbs energy and cushions the ends of bones in joints. In, Osteoarthritis, the surface layer of the cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Bone spurs (small growths called osteophytes) may grow on the edges of the joint. Bits of bone and cartilage can break off and float inside the joint space. This causes more pain and damage. Osteoarthritis affects each person differently. In some people the disease progresses rapidly and in others slowly. People with osteoarthritis usually experience the following symptoms: Steady or intermittent joint pain.   Stiffness in a joint after getting out of bed or sitting for a long time.   Swelling or tenderness in one or more joints.   A crunching feeling or grinding sound with motion of the joint. Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees and hips. The cause of the disease for the most part is undetermined, but several factors may contribute including: Being overweight.   The aging process.   Joint injury.   Stresses on the joints from certain jobs and sports activities. Osteoarthritis of the knees: The knees is one of the body’s primary weight-bearing joints. For this reason, they are among the joints most commonly affected by osteoarthritis. They may be stiff, swollen and painful; making it hard to walk, climb, and get in and out of chairs and bathtubs. If not treated, osteoarthritis can lead to disability. Medications, weight loss, exercise, and walking aids can reduce pain and disability. In severe cases, knee replacement surgery may be helpful. Osteoarthritis of the hip: Osteoarthritis in the hip can cause pain, stiffness, and severe disability. People may feel the pain in their hips, or in their groin, inner thigh, buttocks or knees. Walking aids, such as canes or walkers can reduce stress on the hip. Osteoarthritis in the hip may limit moving and bending. This can make daily living activities such as dressing and foot care a challenge. Walking aids, medications, and exercise can help relieve pain and improve motion. The doctor may recommend hip replacement if the pain is severe and not relieved by other methods. Most successful treatment programs involve a combination of treatments tailored to the patient’s needs, lifestyle and health. Osteoarthritis treatment has four general goals: Improve joint care through rest and exercise.   Maintain an acceptable body weight.   Control pain with medicine and other measures.   Achieve a healthy lifestyle. Osteoarthritis treatment plans often include ways to manage pain and improve function. Such plans can involve exercise, rest and joint care, pain relief, weight control, medicines, surgery and nontraditional treatment approaches. Exercise is one of the best treatment options. Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general fitness. The amount and form of exercise will depend on the joints affected, their stability and whether a joint replacement has already been done.   Rest and joint care treatment plans include regularly scheduled rest. Patients must learn to recognize the body’s signals to stop or slow down. Canes and orthotics are used to protect joints and take pressure off them. Braces provide extra support for the weakened joints. They also keep the joint in proper position during sleep or activity. Splints should only be used for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness.   Pain relief can include nondrug and drug protocols. Warm towels, hot packs or a warm bath or shower can relieve joint pain and stiffness. In some cases, cold packs can relieve pain or numb a sore area. Always check with your physician or physical therapist what treatment is best. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress. For more severe pain, patients will often have to turn to pain medication. Physicians prescribe medicines to eliminate or reduce pain and to improve functioning. Physicians must consider the intensity of the pain and potential side effects of the medicine. The following types of medicines are commonly used in treating osteoarthritis: Acetaminophen: is a pain reliever that does not reduce swelling. It does not irritate the stomach and is less likely to cause long-term side effects than nonsteroidal anti-inflammatory drugs (NSAIDs).   NSAIDs: they fight inflammation and relieve pain. Some can be purchased over the counter and others require a prescription. Each is a different chemical, and affects the body differently. NSAIDs can cause stomach irritation and affect kidney function. The longer the person uses NSAIDs , the more likely they are to have side effects ranging from mild to serious. Always tell your health care provider what medications you are taking, since some drugs may interact with potentially dangerous side effects.   COX-2 inhibitors: Are a new class of NSAIDs that reduce inflammation with fewer gastrointestinal side effects. These medications occasionally are associated with harmful reactions ranging from mild to severe. Always consult your physician or pharmacists if you have any questions or concerns.   Other medications: Topical pain-relieving creams, rubs, and sprays, which are applied directly to the skin. Mild narcotic painkillers, which are very effective, may be addictive and are not commonly used. Corticosteroids are powerful anti-inflammatory hormones made naturally in the body or manmade for use as medicine. Corticosteroids may be injected into the affected joints for temporary pain relief. This is a short-term measure, and is not recommended for more than two or three treatments per year. Hyaluronic acid, a medicine for joint injection used to treat osteoarthritis of the knee. This substance is a normal component of the articular or hyaline cartilage. Surgery is often the last resort. For many people, surgery helps relieve pain and disability of osteoarthritis. Surgery may be performed to:   Bilateral Osteoarthritis  of the Hip   Remove loose pieces of bone and cartilage from the joint if they are causing mechanical symptoms of buckling or locking.   Resurface (smooth out) bones.   Reposition bones.   Replace joints.   Transplant cartilage or repair cartilage. Total Hip Arthroplasty   Surgeons may replace affected joints with an artificial joint called a prosthesis. These joints are be made from metal alloys, high-density plastic, and ceramic material. They can be joined to bone surfaces by special cements. Artificial joints can last 10 to 15 years or longer. About 10 percent of artificial joints may need revision surgery.    Failed Total Hip Arthroplasty Revision Total Hip Arthroplasty The decision for surgery depends on several things. Both the surgeon and the patient determine the patient’s level of disability by considering the intensity of the pain, interference with the patient’s lifestyle, the patient’s age, and occupation. More than 80 percent of osteoarthritis surgery cases involve replacing the hip or knee joint. After surgery and rehabilitation, the patient usually feels less pain and swelling, and can move more easily.
	What is the UniSpacer Knee System?
	The Unispacer was designed to slow the need for total knee replacement. The Unispacer is intended to restore stability and alignment for patients whose arthritis is primarily located on the inside half of the knee. It is inserted into the knee and provides a smooth surface for the bones to glide where the cartilage has worn away.  Typically used for younger patients who are not candidates for total knee replacement and are willing to live with incomplete pain relief. The UniSpacer is designed for people with arthritis in the medial (inside) portion of the knee. People with mild arthritis of the other compartments of the knee may get the UniSpacer, but if the arthritis in these other two compartments were severe, the Unispacer is not indicated. At the AAOS conference in 2002 they had 120 patients showing a 10% failure rate at the end of the first year. Since this procedure is relatively new, they lack any long-term outcome studies. Other considerations of this surgery:   Recovery and rehabilitation are slow.    Like any surgery, you must undergo anesthesia, which has risks.   Patients need extreme caution to avoid swelling in the knee.   Patients need to be diligent with their exercises to avoid stiffness in their knee.   Activities like running and tennis should be limited to short periods. The patient ultimately needs to decide if having a little less pain, enduring surgery and a slow recovery is worth the risk and effort.
	What is Ceramic-on-Ceramic Hip Replacement?
	Ceramic-on-Ceramic Hip Replacement is a new prosthesis that orthopedic surgeons can now offer to younger, more active patients whose mobility is limited by arthritis or joint injury. The new titanium sleeve increases the ceramic insert strength by 50%, and a peripheral rim protects the ceramic insert from impingement against the neck of the stem. The alumina ceramic bearing surfaces demonstrate significantly less wear than traditional systems in hip simulation testing because of an extremely low degree of friction. The components of traditional artificial hip replacements, which feature metal on plastic surfaces, can wear away over time, releasing debris into the joint and surrounding tissues. This wear debris, which may be higher in younger, more active patients, can cause a loss of bone called osteolysis, a leading cause of implant failures.  After 6 years of clinical trials, this prosthesis is now available for patients who are looking forward to a more active lifestyle. Patients can now benefit from hip replacement while they are young enough to enjoy their favorite activities, like golfing, biking or tennis. In the past, hip systems traditionally performed well for approximately 10-15 years. Many eligible patients put off the procedure to avoid the prospect of returning for revision hip surgery. This new ceramic-on-ceramic hip replacement may last 20-30 years.

Dr. LaButti is an orthopedic surgeon in Tulsa specializing in hip replacement,
 knee replacement, and revision surgery of the hip and knee.  Dr. LaButti practices with Central States Orthopedic Specialists, Inc.; the largest private group of orthopedic surgeons in Tulsa, Oklahoma.

Hipandkneedoc.com was designed as a resource for patients considering total hip replacement, 
total knee replacement or revision surgery to help them make an informed decision about surgery.

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