Below you can find information on Community talks, responses to medical articles, and video clips of treatments performed here at Essex Orthopaedics.

Upcoming Community Talks:  FREE LECTURE!

New Technologies in Hip, Knee and Hand Surgery

Dr. Thomas Hoerner
Dr. Sohail Husain

Tuesday September 13 - 6:00 - 7:00pm
at
Promises to Keep
Atrium Room
199 Rockingham Rd.
Derry, NH 03038

Watch Dr. Hoerner's Video on Joint Replacement:

Click here to see Dr. Hoerner's interview with Mary Richardson, formerly of Chronicle

Viscosupplementation….?Lube job for the Knee?

April, 2011  Dr. Arvidson's comments on these medications

You have been diagnosed with some arthritis in your knee.

You have had persistent pain in your knee or knees. You have tried weight loss (who hasn’t, but it’s hard, and frequently not effective/possible (the first, fifth, or 20th time). You’ve rested, you’ve tried increased activity. You’ve tried anti-inflammatories (if medically allowed), or Tylenol…you may have tried various rubs, nonprescription or prescription.

Possibly a “cortisone” injection has been tried, often with some long term, short term, or very short term effect.  You may have undergone arthroscopy of the knee, and during the follow-up, your doctor told you there is arthritis in the knee, some of the cartilage is worn. But you and your doctor don’t think you are a candidate for joint replacement…at least, not yet.

A suggestion has been made for another injection. You may have seen in written in magazines. Injection of something into the knee. Let me talk about this.

Why?-
What is it?
Where does this stuff come from?
How does it work?
Will it cure me?
What are the logistics?- How do they do this?

The normal joint produces fluid containing HYALURONIC ACID (HA). This helps the joint glide and move smoothly. The osteoarthritic joint produces lower quality HA, in addition to other effects on the joint .By improving the quality and quantity of the HA in the joint, we can often improve function and decrease pain.

BUT WHAT IF MY JOINT IS ALREADY SWOLLEN?
Don’t I have enough fluid? Pathologic joint fluid has lower concentration and lower quality hyaluronic acid, so this is actually largely removed before the new injections are made. By adding new joint fluid, this helps the remaining healthier cartilage in the joint work better. It seems to have other positive effects as well.

This is for patients with osteoarthritis; wear and tear type disease which often runs in families and worsens as we age.  The inflammatory types of arthritis, like rheumatoid arthritis, are less likely to be helped by the hyaluronic acid.

What is this stuff?
Surgeons and rheumatologists have known for years healthy joints contain small amounts of joint fluid (which contains the hyaluronic acid). It’s also found in other parts o the body. It’s slippery, and a little “sticky”- viscous – hence the term viscosity supplementation.

AND

People who KILL CHICKENS/ROOSTERS for us to eat have known for years that rooster combs (the thing on the top of their heads) contains a slippery substance. I don’t know if a very smart person realized from studying the topic, that rooster combs contained a high concentration of  HA, or if a sensible person who knew something about both human joints and rooster heads thought “Gee, I wonder if injecting this stuff would work if we put it in people’s arthritic knees?” Anyway……

Somebody purified the stuff even more, and started trials. It’s been found to work in racehorses as well (I don’t think I want to perform those injections). Although used in the rest of the world for a couple decades, the FDA let us start to use these injections since 1997. Most of the injections are made from purified rooster combs(so we can’t use these on people with egg/ chicken protein allergies) , and one type is made from recombinant DNA technology from bacteria (this is Euflexxa™)

Although not perfect, this group of injections seems to provide relief for many patients. Not just a mechanical improvement for the joint, the joints absorb the new fluid into the lining. This seems to decrease inflammatory compounds that the “angry” joint lining makes, and encourages the joint lining to make more native hyaluronic acid for the joint.

What Do I feel?

Usually not much at first. Most people (probably 9 out of 10) have very little discomfort with these injections. We freeze the skin, use local anesthesia, remove joint fluid if we need to, and inject the purified HA. There may be some achiness hours later, and I wouldn’t plan on heavy activity for about 36 hours. Occasionally, there is some swelling or inflammation associated with these injections, but less with the newer, more purified substances.

How Many Shots do I need to have?—I hate shots…

The number of shots varies the product being used. We use Hyalgan™ - typically 5 shots, although some new work is trying this with only three shots. Euflexxa™ is a series of 3 injections. Synvisc™ has a new prep with just one shot, but we are not regularly using this.

 WHY do you give 5 when you could give three shots? Or one?—each of these injections had original research work .The trials were done with different protocols, and we try to reproduce the techniques used in these original protocols, that seem to have the most lasting effect.

There are other types of injections out there- we’ve had good success with the Euflexxa and Hylagan.

Does this cure me?
No… no cure. But it does help symptoms in many people, AND can be repeated. Most insurance companies will allow us to do this every 6 months or so—if it works. OFTEN, it helps improve symptoms for longer than this.

Why not more cortisone?-
Cortisone was shown in the 1960’s to cause breakdown in cartilage, if frequently repeated. Therefore, we usually limit the number of injections given INTO joints. Hyaluronic acid doesn’t seem to cause this problem.

Why not just do this, and never operate?
With very arthritic joints, the injections are less likely to help. We hope that the injections slow the progression of the disease, but when the disease is advanced, the mechanical effects of bone rubbing against bone are unlikely to be improved with injection only. We also fear people missing their “window of opportunity” for joint replacement as they age. That is, at a certain point, a person’s age/health/mental status may prevent them from benefiting from joint replacement. The results of joint replacement are typically excellent (although there is post operative discomfort, some risk, and therapy required to benefit from any operation) so if a patient’s lifestyle is likely to benefit, we like to help our patients surgically when required.

My knees are ok, but my toe/ankle/hip/writst/shoulder has arthritis. Can we do something aobut that?
Each of the manufacturers have been trying hard to get injection of HA approved for other joints, especially the shoulder and the hip. The hip studies have been disappointing, and the shoulder studies also have not shown adequate improvement compared to placebo

I hope this answers questions you may have had regarding “viscosity supplementation”. Not exactly an oil change, we find it adds to the comfort of many (but certainly not all) patients with arthritis in the knee.