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Osteoarthritis (transcript)
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(Dr. Peter Salgo) 
Welcome to Second Opinion, where each week our healthcare team solves a real medical mystery.  When we close this file a half an hour from now, you'll not only know the outcome of this week's case, but you'll be better able to take charge of your own healthcare.  I'm your host, Dr. Peter Salgo, and our story today concerns Arthur.  More about him in a minute.  You've already met our special guests, who are joining our cast of regulars, primary care physician Dr. Lou Papa, and bioethicist expert Dr. (Glenn).  No one on the team knows this case, so let's get right to work.  Now, let me tell you a little bit about Arthur, shall we?  Arthur is 66 years old.  He's five foot eleven.  He weighs about 212 pounds, and he comes to his primary care physician's office - Lou, it's always the primary care physician who sees these people, right?
 
(Dr. Lou Papa)  
So it should be.  Right.

(Peter) 
... complaining of knee pain. His right knee is worse than his left, and he's been dealing with this for about ten years.  He's tried self-medicating, and that says here he's been using Tylenol.  Then the word in the chart is he's moved up to Advil. But now he just doesn't think he can take the pain anymore.  He's in your office right now.  Lou, what are you going to do?

(Lou)  
Well, first, I want to identify what the cause of his knee pain is.  You say that it's been going on for awhile.  That's helpful.  Some other information is helpful.  Does it ever swell or become red?

(Peter) 
It's not swollen.  He doesn't complain of redness, and it's very painful.  He actually gives an estimate for how painful it is in the sense that he can only walk about a thousand feet, maybe a quarter of a mile before he's got to stop.  He's been taking the over-counter painkillers every day, all day, around the clock, he says.  He can't carry heavy weight anymore.  He's a cabinetmaker, he says.  He has problems getting his work completed.  Any other history you want?

(Lou)  
All right.  Is there any family history of...

(Peter) 
Nope.

(Lou)  
joint problems?

(Peter) 
No family history of joint problems, specifically denies a family history of rheumatoid arthritis, and there's also no history of major trauma to the joints.

(Lou)  
Okay.  I would like to examine him.  You know, osteoarthritis comes to mind.  He's in the right age group.  You know, the - the symptom complex is consistent with that, but there's a lot of other things that can cause joint pain that would be treated very differently.  So

(Peter) 
All right.

(Dr. Lou Papa)  
my examination would help with that.

(Dr. Peter Salgo)
I can tell you that they got some lab tests.

(Lou)  
Okay.

(Peter) 
There's a - there's a battery of lab tests.  Of course, he went to a doctor's office.  So they got his blood count, his sedimentation rate, a CRP level, a rheumatoid factor, ANA, uric acid, calcium -

(Dr. Mark Hyman) 
What do they show?

(Peter) 
phosphorous.  Nothing.

(Lou)  
Right.

(Peter) 
Every last -

(Lou)  
Right.  Right.

(Peter) 
one of these tests was -

(Lou)  
Right.  Right.  Right.

(Peter) 
unremarkable.

(Lou)  
Well, I think as part of the rationale of doing some of that, I guess, depending on the - the clinician's suspicion, is is this a - more of an inflammatory arthritis or rheumatoid arthritis?  It should be treated very differently and can be very destructive quickly.  So -

(Dr. Peter Salgo) 
Guys, what is this?  Is this arthritis?

(Randy) 
Well, arthritis is, you know, an inflammation of the joint and a - and a deterioration of the gliding surface of the joint, the articular cartilage, and that's a common feature of every kind of arthritis.

(Mark) 
I want to know what's the cause of this.  You have any other health issues that may be contributing to this joint inflammation?

(Peter) 
Why?

(Mark)  
Why?  Because, you know, the knee's connected to the rest of the body.  It's not -

(Peter) 
The knee bone's connected to the hipbone.

(Laughter)

(Mark)  
That's right.  That's right.  So what's going on in the knee may be a reflection of other factors that are affecting that person's health, what they eat, stress levels, activity levels, and those all influence inflammation in the body.  And we actually, you know, know that arthritis is not just - Osteoarthritis is not just a wear and tear phenomenon, which we thought it was once.  It's actually an inflammatory process in the joint as well.
 
(Peter) 
Anybody want any other studies, any other tests?  We had a lot of blood -

(Mark)  
X-rays -

(Peter) 
You would order an x-ray?

(Mark)  
- for - yeah.  Maybe an MRI.
-
(Peter) 
You would order -

(Dr. Mark Hyman)  
Absolutely.

(Dr. Peter Salgo) 
So did Arthur's doctor, and I can tell you what it shows.  The x-ray shows some thinning of the joint cartilage, some roughness of the bone, and what is called on the - on the chart here, not the official read, wear and tear in the joint. 

(Dr. Fredereick Buechel, Jr.)  
I think we -

(Peter) 
What kind of arthritis does he have?

(Dr. Fredereick Buechel, Jr.)  
I think we - we need to understand what that x-ray reading actually means, and that x-ray reading is telling us that the - the surface, the gliding surfaces on the ends of the bones, are starting to thin.  There's not as much joint surface there anymore, and so it's rough.  And when they move it, it hurts.  It grinds, it scrapes, and it causes more and more inflammation.

(Peter) 
But when you say the - the gliding surface -

(Dr. Fredereick Buechel, Jr.)  
That's the cartilage.

(Peter) 
Okay, there's cartilage on top of the bone, and it's kind of the Teflon -

(Dr. Fredereick Buechel, Jr.)  
It's the cap on the end of the bone, like on the end of a chicken leg.  It's that white surface.  That's the easiest way to understand it.  It's that white surface that wears down.

(Peter) 
Can we tell from these x-rays, from these studies, from the blood work, from his history what kind of arthritis it is?  I think, you know, the - the two words that are out there, right, and we've even mentioned them, osteoarthritis and rheumatoid arthritis, two big categories.  What are they and can we make that distinction?

(Dr. Fredereick Buechel, Jr.)  
I think we can make that distinction because we have a battery of lab tests, as you said, and it really has so far ruled out the inflammatory process of rheumatoid arthritis, and the x-rays are leading us towards the osteoarthritis, the wear and tear arthritis, because we've lost our space.

(Peter) 
Is everybody agreeing from the lab tests that it's osteoarthritis -

(Dr. Fredereick Buechel, Jr.)  
Osteoarthritis.

(Dr. Peter Salgo) 
not rheumatoid arthritis?  That being said, taking all of arthritis together, how big a problem is arthritis in the United States?

(Dr. Randy Rosier) 
It's a huge problem.

(Mark)  
It's an enormous problem.

(Dr. Fredereick Buechel, Jr.)  
It's a huge problem.

(Peter) 
Can anybody put in numbers here?

(Joanne Insull)  
Seventy million people, I think -

(Peter) 
Seventy million people?

(Joanne)  
It's about one in four.

(Peter) 
One in four people, that's huge.

(Joanne)  
One in four people, yes.

(Randy) 
It increases exponentially, the incidents does with age.  So as the population ages, the number of patients that have osteoarthritis is dramatically increasing --

(Dr. Fredereick Buechel, Jr.)  
With our aging population, the numbers are going to be astronomical in the future.

(Lou)  
And our growing population in weight with respect, as well.

(Peter) 
If you had to - I'm sorry, go ahead.

(Glenn):   
From a public policy point of view, and from the standpoint of just being a person who's thinking about, "Do I have arthritis?  What will it mean for me?" that explosion of the population that might be diagnosed with this, it has huge impact.

(Mark)  
Absolutely.

(Glenn McGee):  
The cost for this is amazing, and you - the first thing you focused on was what happens to this guy, right, what does he do?  So part of the question isn't are there more people with arthritis; it's are there more people, and what's it going to do to them and our economy as we try to figure out how to cure them.

(Peter) 
Our population is aging, right?

(Lou)  
Yeah.

(Dr. Peter Salgo) 
And as we grow older, more people are - fall victim to this disease.  Let me - let me put this in - in perspective.  All comers, all causes of disability in the United States, where does arthritis rank?

(Dr. Frederick Buechel, Jr.)  
I'd say arthritis is one of the - is the leading cause of disability in the United States.

(Peter) 
Number one -

(Joanne)  
Yes.

(Peter) 
all comers?

(Joanne)  Yes.

(Peter) 
That's huge.  Huge.  Millions and millions of folks.  All right.  What I want to do now is - is pause for just a moment, sum up what we've been discussing, and then we'll pick it up from there because we got more to talk about about Arthur.  Arthritis, huge problem in the United States.  It is expensive.  Lot's of people suffering with it.  In fact, it is the leading cause of disability in this country.  Fair enough?  Fair enough.  I got buy-in from everybody?

(Joanne)  
Yes.

(Frederick)  
You got it.

(Peter) 
Good.  Let's go on.  You know, Arthur is diagnosed with osteoarthritis.  They've looked at his x-rays.  Primary care physician made this diagnosis -

(Dr. Lou Papa)  
Sure.

(Peter) 
I'm pretty sure.  What's in store for him next?  Therapeutically, what's his doctor going to do, Lou?

(Lou)  
Well, I mean, some of it relates to, you know, pain control and maintaining a functional level, which you very often start with ways to reduce that with very often start with acetaminophen or Tylenol first.  It's a good first line agent for pain control.

(Dr. Peter Salgo) 
Joanne, you've been down that road.  What's it like?

(Joanne Insull)  
Well, it - you tend to put it off, and you tend to self-medicate for a period of time until it - it gets to the point where it's not tolerable anymore or it's affecting you functioning.  Then - then you say, "You know, I think I better have something done about this."

(Peter) 
Your problem is where?  It's not in your knees?

(Joanne)  
No, it's in my hip.

(Peter) 
Why did she get osteo?  Why does Arthur have osteoarthritis?  I guess what I'm asking is what causes this thing?

(Lou)  
Well, you know, it's - the cause of this is not completely understood.  It's multi-factorial.

(Randy) 
An injury to a joint can cause osteoarthritis.  There are genetic factors that are starting to be identified, and then environmental things, activities, deformities.

(Mark)  
Diet.

(Randy)
Diet, weight.

(Lou)  
Many, many factors.

(Peter) 
At this point, Arthur has been self-medicating with over-the-counter medications for ten years, and he's running out of rope on these things.  Clearly, he's gone to his doctor.  It doesn't work.

(Lou)  
Right.

(Peter) 
Right now, what are you going to prescribe, if anything, for him?  Lou, can you start us on that?

(Lou)  
Yeah.  Going up to the nonsteroidals is a reasonable approach.  There's down sides to that.  Nonsteroidals are not benign drugs.

(Peter) 
So what nonsteroidals?  What are you talking?

(Dr. Lou Papa)  
Oh, you know, the ibuprofen, the naproxen, the nabumetone.  There's a host of nonsteroidal -

(Dr. Peter Salgo)  
COX-2's?

(Lou)  
COX-2's, we'll get to that.  COX-2's - COX-2's, to be offered, that has to - the - we have to engage in a significant discussion about going to COX-2's.  I don't take that off the table.

(Peter) 
Just for the record, those are also nonsteroidal -

(Lou)  
Right.

(Peter) 
anti-inflammatory -

(Lou)  
Nonsteroidals with special - with, you know, a special feature in them that provides some GI protection.  But what you find with a lot of patients is everybody's different.  You know, some people will respond incredibly to this one drug and not so much to another drug.  So it's a lot of trial and error.

(Peter) 
What's a downside of a COX-2 inhibitor?  It's a pill, right, that - that sort of - super aspirin.

(Dr. Randy Rosier) 
Yeah, one of the big downsides is expense.   These drugs are expensive.

(Mark) 
They also may cause blood clotting -

(Randy) 
Right.

(Mark) 
and heart attacks and strokes.

(Lou)  
Which I'm getting at here is discussion of quality of life.

(Dr. Mark Hyman)  
Right.

(Lou)  
There are some patients, when the COX-2 issue came out, and those drugs were yanked from the market, I had several angry patients -

(Mark)  
Yes.

(Dr. Lou Papa)  
because -

(Mark)  
It worked.

(Lou)  
it was controlling their pain, and they felt, "That's a decision for me.  That's my decision."

(Peter) 
But the - the FDA said, "There's a chance you could have a heart attack."

(Lou)  
Right.

(Mark)  
Correct.

(Peter) 
And so they yanked the drug.

(Lou)  
Right.

(Dr. Peter Salgo) 
Or at least warned you about the drug.

(Lou)  
Right.

(Peter) 
Are you telling me that patients have a right to make a risk benefit analysis on these drugs?

(Lou)  
They do it every day.

(Mark)  
They do every day.

(Dr. Lou Papa)  
They do it every day.

(Peter) 
Tell me about that.

(Lou)  
Well, whenever - there is no such thing as a perfectly safe drug or surgical procedure, right?  There's no such thing as walking safely up and down the stairs or getting in your car.  There's a risk with everything.

(Frederick)  
Every choice you make has a risk benefit ratio to it.

(Lou)  
Absolutely.

(Frederick)  
Every single choice we make, and the different medications, some of them may be touted as much better than others.

DR. LOU PAPPA:  
Right.

(Frederick)  
But every person may react differently to it.

DR. LOU PAPPA:  
Right.

(Dr. Frederick Buechel, Jr.)  
And so you may feel great with acetaminophen and you may feel great with ibuprofen and it's not that one's better than the other.

(Mark)  
It's true. 

(Frederick)  
It's just it works well for you.

(Dr. Mark Hyman) 
It's true, medications can be helpful.  You know, patients may need more advanced therapies, joint replacement, and so forth, but the question is are there first steps you can take that are going to help the patient recover function, reduce pain - improve the quality of your life without necessarily having to go to medications and surgery.

(Peter) 
Now, the traditional thought, in the past, has always been let's give something to ease the pain and reduce the inflammation, a drug.

(Mark)  
Right.

(Peter) 
And I know from knowing you that might not be the way you'd get into.

(Mark)  
Well, I - I mean, don't take me wrong.  I mean, I want people to feel good and reduce suffering, and if they need a drug, I'm going to give them a drug.  If they need surgery, I'm going to recommend surgery, but there's a whole host of other options that people have they can explore.  Arthritis is an inflammatory condition.  Like other inflammatory conditions, it responds to our diet, and - and our diet contains inflammatory compounds, which is, you know, commonly called the standard American diet, the SAD diet, S-A-D, and that's, you know, processed food, junk food, trans fats, sugar, all promote inflammation.  Some - some foods, particularly gluten, some of the selenosis family, like the night shades, may affect some people, and so there's a way of using diet as a trial to reduce inflammation.  And that can be dramatically effective, and I've seen it over and over again in my practice.  Then there's other substances, like glucosamine, we haven't talked about -

(Joanne)  
Mm-hmm.

(Mark)  
but that's been studied and doesn't just reduce the pain.  For example, the anti-inflammatories actually will allow joint destruction to occur and progress.  So the pain may be better, but the joint continues to deteriorate.  In glucosamine, they actually found that the joint structure, the cartilage may actually improve, and you get better cushioning effects.  And - and so that may be a first step, and it also can be very effective in reducing pain and inflammation.  There's herbs that may be helpful - and there's also acupuncture that's been shown in trials from the NH to be effective.  Exercise is very powerful because building muscle around the joints will protect and - and - and reduce pain in the joints.

(Peter) 
Stabilize it.

(Frederick)  
Stabilize it.

(Mark) 
Yeah, stabilize and also reduce inflammation because exercise is a great anti-inflammatory.  So there's a whole host of choices that you have to - to go through and then offer people before you actually get to drugs and surgery.

(Peter) 
Well - go ahead.

(Glenn):  
I just - you know, I - I - I want Mark to be my doctor, but but there's a - a fact here that we've talked about.  It -

(Dr. Peter Salgo) 
He has a card.

(Laughter)

(Glenn):  
it's - that's right.  There's expense and it's important.  That long list, if I find the right person, I might be able to get into eliminating nitrates and doing these things that are actually less expensive to do.  If I can't find that doctor, if my insurance won't pay for it, I don't get it.  So part of defining what's available is defining what I can get.

(Mark)  
You don't need a doctor to eat better and exercise.

(Glenn):  Right, but - you -

DR. LOU PAPPA:  
You don't even need to have arthritis to do that.

(Glenn McGee):  
Right.

DR. LOU PAPPA:  
I mean, you're supposed to eat better and exercise and do these things anyway.

(Peter) 
Well, let me tell you what Arthur does.  Arthur asked for COX-2's, but his doctor did take a history Lou and found out that he had a strong family history for heart disease.  And so they discussed that, and that wasn't going to go.  Then Arthur asked about something called MSM injections.  What the heck is that?

(Dr. Mark Hyman) 
MSM is a - is a sulfur molecule, and sulfur is one of the building blocks of cartilage, and there's some, I think, kind of weak evidence that it may help with arthritis and it may help some people.

(Peter) 
There's a whole list of things that he did bring to his doctor's office.  Let me just rattle this list off.  Maybe you could address some of them for me.  Cortisone was one, viscosupplementation was another.

(Joanne)  
Mm-hmm.

(Peter) 
He wanted to know about acupuncture, massage, physical therapy.

(Joanne)  
Mm-hmm.

(Peter) 
Anti-depressants.

(Joanne)  
Mm-hmm.

(Peter) 
I mean, any of this stuff make sense to you guys?

(Frederick)  
Well, let's - let's touch on a couple of those.

(Dr. Peter Salgo) 
Please.

(Frederick)  
Injectable medicines, the - the two common that you touched on, are the cortisone preparations and the viscosupplements.  Cortisone is a very, very strong anti-inflammatory drug.  Unlike the pill prednisone, that you take by mouth, this is something you can inject directly into the joints that helps reduce the inflammatory process.  There are many side effects to taking a cortisone-type medication, and our family doctors can tell us a whole lot more about the side effects.  The other one that was viscosupplements, with less of a side effect profile than the cortisones, and these help lubricate the joints.  We're not exactly sure how they work, but they - they sort of simulate your own joint fluid, help add cushion to the fluid in your knee joint, and they produce - they provide a reduction in inflammation, also.

(Lou)  
There's nothing unreasonable on that list, and even the anti-depressants are interesting because -

(Peter) 
Why?

(Lou)  
Well, as folks get older, the incidence of depression goes up, as well.  When you're depressed your threshold for pain drops.

(Peter)  
His doctor says to Arthur, "Look, you're going to have some pain, but let's see what we can do to keep you mobile."  And so he sends him out on glucosamine, some viscosupplementation, and he started him on Motrin and asked him to take that.  Does this regimen sound at least reasonable for now?  He's going to go out in the real world -

(Mark)  
Yes.

(Dr. Frederick Buechel, Jr.)  
Mm-hmm.

(Peter) 
and that's what he's going to have.

(Lou)  
I would add one thing.  Especially in an older person, especially knowing now the risk factors, you may want to provide some GI protection, if they're going to be taking the Motrin ibuprofen regularly, and there's some studies to show that giving somebody a PPI, a proton pump inhibitor, reduces the risk of ulceration in the stomach.

(Peter) 
Are you convinced of that?

(Mark) 
You know, that has other complications and problems.  I - I agree, you don't want people to bleed to death.  You want to protect their stomach.  There's other ways, but, you know, for me the most important thing is - is - is a trial of diet.  I mean, you know, I found, for example, in one study that 11% of people with osteoarthritis were found to have antibodies to gluten in their joint space.  So not everybody responds to a dietary trial, but by simply giving people an anti-inflammatory diet for a week or two, you'll often see dramatic changes in their pain level.

(Peter) 
Let's sum up where we are just now.  There are many effective treatments for arthritis, that you don't have to live with arthritis pain really is the point, certainly not chronic, horrible pain.  If you do this right, you can probably help yourself in a variety of ways.  Well, let's go back to Arthur here because, actually, he did fairly well.  Arthur, for the next six years, was followed by his primary care physician, he was treated with this regimen, and Arthur was able to - to manage and get along, but the pain got worse.  And now Arthur comes back to his doctor, and he says, "Look, I've - I've been a good soldier here.  You actually have helped me, but I've tried everything.  My life now is just almost unbearable.  I have trouble walking."  He says, "I have trouble standing.  My sleep is interrupted by pain," and - and I was taught in medical school that's a biggie.  I want to talk about that.  He has loss of his joint function.  He just can't bend -

(Mark)  
Mm-hmm.

(Peter) 
his knee anymore, and he's gained weight, Mark -

(Mark)  
Mm-hmm.

(Dr. Peter Salgo) 
because he can't move.

(Mark)  
Right.

(Peter) 
His doctor takes some new x-rays, and on these new x-rays it now shows that his knee joints are bone on bone.  Now what, guys?

(Frederick)  
Well, now you're into a whole nuther area.  You've - you've passed the - the diet, the exercise, the supplementation, the injections.  Well, maybe not the injections.  You - you now have somebody that has no surface left on the end of their bone that prevents that pain.

(Peter) 
That's what bone on bone means.

(Frederick)  
Bone on bone means that white cap, like on the end of a chicken leg - that's your cartilage, again, okay?  That white cap has totally worn off, and the bone underneath is rubbing against the bone - on the other bone.  And when that bone is rubbing it hurts, and so now we have to do something to resurface that end of the bone.

(Peter) 
When you say resurface, I'm hearing surgery.  Is that what you're suggesting?

(Frederick)  
In some people, yes.

(Peter) 
Arthur.

(Frederick)  
Arthur.  Arthur?  Well, it depends on how bad Arthur's -

DR. LOU PAPPA:  
Right.

(Dr. Frederick Buechel, Jr.)  
pain is and how bad his disability is and his function and his lifestyle.  If all these things have changed, and we've tried all these other ways besides surgery, that's when surgery comes -

DR. LOU PAPPA:  
Right.

(Frederick)  
into the picture.

(Peter) 
All right.  Lou, you're the primary care physician.  You're on the hot seat.

(Dr. Lou Papa)  
Mm-hmm.

(Peter) 
He's given you this story -

(Lou)  
Right.

(Dr. Peter Salgo) 
the pain waking him up from sleep, all of this.

(Lou)  
Right.

(Peter) 
Are you going to recommend surgery?

(Lou)  
I'm going to recommend he speak to an orthopedic surgeon.

(Peter) 
Joann, you had this conversation.

(Joanne Insull)  
Yes, I did.  I had the conversation -

(Peter) 
Tell me about it.

(Joanne)  
twice.  I went to see an orthopedic surgeon, and he said, "I would do it -" you know, he said -

(Dr. Mark Hyman)  
In a heartbeat.

(Joanne)  
"In a heartbeat," yes so to speak and I said, "Well, I - I don't think I'm in that much pain yet," you know.  So we elected to put - put it off, come back in six months, come back whatever.  I went again and the orthopedic surgeon said, "If you would like, we could do it this summer," and I said, "Well, will I be ready to go to Italy in September?"  And he said, "Oh, yes, you know, we'll get you."  And I said, "You know something?  I'm really nervous about that.  Let's postpone it 'til after I come back, and then I'll have the - I'll have the surgery at some point probably in the fall or winter."

(Mark) 
I think it's really important.  I mean, I - I'm all for alternative treatments and natural therapy, but when you need a joint replacement, it's one of the greatest advancements in modern medicine, and I - and I often see patients waiting too long and the quality of their life decreasing and they're not being able to enjoy their lives the way they should.

(Peter) 
Tell me what the surgery is all about because these appliances, I must tell you, are just beautiful.  Look at these things.

(Frederick)  
Well, this is - this is a knee replacement, and a knee replacement is basically made up of three different parts.  The bottom part has two here.  There's a tibial component.  That goes into the top of your shinbone, and then there's a plastic bearing that's on top of the tibial component, and then there's a cap that goes on the end of your femur.  And these components, these three components work together to resurface your joint.  If you look at it from the side view here, this component goes on the end of your thighbone.  It gives you a nice, new, metal surface.  There's a metal surface that goes on the top of the shinbone with plastic between, and now it's smooth.  It rotates again and moves, and you can turn with this.  And now you don't have that debilitating scraping, scratching, grinding feeling that you had anymore.  You have a nice smooth joint.  So that's what a knee replacement looks like, and these can be put on either using a bone cement that kind of glues them onto the end of the bone, or they can be press fit onto the bone, and your bone will grow right into the back of the implant.  So this is a standard appearing, fixed bearing, total knee replacement, and these have a very good life span.  Our knee replacements nowadays can last 20 years and more, if you're using the proper designs.

(Peter) 
And it's worth noting that that bottom part with the spike does get hammered in.

(Frederick)  
It gets - well, you actually have to - you have to use a knife.  You have to open up the skin.  You have to remove the ends of the bone with a saw, so this is - this is serious surgery.  And that brings up a good point, though.  One of the things our - our public hears all the time is its minimally invasive or minimal incision surgery, and that's a whole nuther topic, but joint replacement is not minimally invasive.  You are cutting the bone with saws, and you're using hammers to put these on, so this is big time stuff, and we - and - and this is not a thing to think of lightly.

(Peter)  
This is remarkable.  I can remember when these things, A, didn't exist and, B, were not like this.  What's coming up, anything new?

(Randy) 
Well, a couple of things.  One is that one of the problems with all of these types of joint replacements is that they generate particulate debris.  Any bearing, any machine generates little particles, and in a small percentage of patients, those can cause an - an inflammation that leads to bone reabsorption and loosening of these.  So new materials, new types of surfaces are being developed to try to deal with the wear debris problem.  That's one area of research.  The longer bigger - bigger picture types of research are to try to prevent this in the first place or intervene at an early stage, when the cartilage is starting to deteriorate, do something to stimulate regrowth of the cartilage.  That has a long way to go.

(Dr. Peter Salgo)  
I was going to say, is that coming on -

(Randy) 
No.  There -

(Peter) 
coming soon to a pharmacy near you?

(Laughter)

(Dr. Randy Rosier) 
You know, it - it is possible -

(Frederick)  
Probably ten to twenty years away from that.

(Randy) 
Yeah.  There's a lot of exciting research, but it's a long ways off. 

(Peter) 
All right.

(Glenn):  
A long ways off or not, though, it's really important to say, I think at this point, that thing, it's not just beautiful.  It's cyborg.  That's the future.  When we talk about this stuff, we're talking really not just about the future of treating Arthur.  We're talking about the future of treating all of us and all of our having some parts and pieces that are like this.  It will extend the quality of our lives.

(Dr. Frederick Buechel, Jr.)  
The beauty of these joint replacements, though, are they put people back in the workforce, as well.

DR. LOU PAPPA:  
Right.

(Mark) 
Mm-hmm.

(Peter) 
But the bottom line in human terms is that pain -

(Frederick)  
You get your life back.

(Peter) 
You get your life back.  Let's pause for just a moment and sum up where we are.  I think it's fair to say that when all else fails in the treatment of osteoarthritis tremendous progress has been made and is continuing to be made in joint replacement surgery.  You can actually have one of these put in, and you're going to feel better in all likelihood.  Well, Arthur - let me tell you about Arthur.  He had joint replacement surgery.  He had a total knee on both sides.  This thing was put in on both his left and on his right.  What is the follow-up for Arthur like now?  It's not get out of bed and go play tennis, right, or is it?

(Frederick)  
Oh, no.  No, it's a - it's - it's a - it's a - it's a several month process, and actually, over the first year and a half people progress until they're going to be where they're at.  They work with physical therapists right there the day after or the day of their surgery.  They work with physical therapists when they go home.  They work with physical therapists outside of the home for months afterwards developing their muscle strength back, their balance back, and their confidence back.  So it's - it's a - it's a process.

(Peter) 
We know that Arthur was a motivated patient before.  I can tell you he was a motivated patient after.  He's doing really well.  You haven't had your joint surgery yet.

(Joanne)  
No, I've not.

(Dr. Peter Salgo)  
Enjoy Italy.

(Joanne)  
Thank you so much.

(Peter) 
How are you doing now, and are you looking forward to the surgery?

(Joanne)  
Looking forward is probably not the correct term.

(Laughter)

DR. LOU PAPPA:  
The hammer.

(Joanne Insull)  
No.  I - I am looking forward to not having the pain, hopefully, but I - I also feel that part of the responsibility falls on me to make sure I'm the healthiest patient there is to go into that surgery.  So, in terms of maintaining my exercise program, being as healthy as I possibly can be to get ready for that, so that I will rehab faster.

(Peter) 
You know, I haven't heard a patient say that in a very long time.  Preoperative prep is really key.

(Mark) 
Oh, yeah.

(Peter) 
I mean, the healthier the patient is going in, the healthier you're going to be coming out.

(Joanne)  
Right.

(Peter) 
Thank you -

(Joanne)  
Right.

(Peter) 
so much for joining us.

(Joanne)  
You're welcome.

(Peter) 
A great, great discussion.  Thank you, all.  Of course, we're out of time, as usual.  All right.  We've covered a lot of ground today, so let me just sum up the key things to remember.  Arthritis is a huge problem in the United States.  It is expensive, and many people suffer with it.  Osteoarthritis is the leading cause of disability in this country.  There are many effective treatments for arthritis.  You don't have to live with chronic, grinding arthritic pain.  And when all else fails the treatment of osteoarthritis, tremendous progress has been made with effective joint replacement surgery and research is ongoing.  Our final message is this; taking charge of your health means being informed and having honest communications with your doctor.  I'm Dr. Peter Salgo and I'll see you next time on another Second Opinion.

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