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Melanie Cole (Host):  Are you one of the millions that suffer from knee pain? Well you're not alone, and you know if you have knee pain, it can be debilitating and keep you from taking part in the activities that you enjoy. Welcome. My guest today is Dr. Steven Dellose. He's an orthopedic surgeon with Christiana Care Health System. Dr. Dellose, let's start with the current state of knee pain and injuries today. What do you see and what is the prevalence and what do we know about knee injuries today that maybe we didn't know ten or twenty years ago?

Dr. Steven Dellose, MD (Guest):  Mostly my focus is in the treatment of osteoarthritis, and the prevalence of osteoarthritis is great. The economic impact is great, and there's millions and millions of people who suffer from osteoarthritis of the knee.

Host:  Tell us a little bit about osteoarthritis. People hear rheumatoid and osteo, and they don't know the difference.

Dr. Dellose:  That's a great question. There's a lot of different types of arthritis. The joints, they include osteoarthritis, which is your basic wear and tear arthritis, and osteoarthritis is basically the disease of cartilage. You were born with a certain amount of cartilage in each joint, and over time that cartilage breaks down and you become osteoarthritic. Rheumatoid arthritis is a systemic type of arthritis. We classify those as inflammatory types of arthritis, that's more of a systemic problem. Most of these function as an autoimmune problem, where your body attacks itself, will become an autoimmune synovitis, which is basically inflammation of the joint, and therefore you'll get secondary destruction of the cartilage from that disease process. 


Host:  How and why does osteoarthritis start and progress in the knee?

Dr. Dellose:  There's many factors that contribute to the development of osteoarthritis, so we call that multi-factorial. Hereditary components certainly have a place, but we do define osteoarthritis as the wear and tear arthritis. Basically from the time you were born until the time we get older, there basically is a destruction of cartilage, the molecules of the cartilage change, and they start to disintegrate down to the level of bone on bone. 

Host:  Dr. Dellose, how does excessive weight affect your joints, and especially your knees? 

Dr. Dellose:  So excess weight puts a lot more stress across the cartilage surfaces, therefore if you have any destruction or disintegration of the cartilage, it's going to exacerbate the development or the degeneration of the cartilage, and therefore you'll develop more arthritis faster. Also your symptoms will increase in terms of the amount of inflammation that develops. It's very easy to consider that as more weight would be going through the joint.

Host:  Tell us about some of the risk factors for osteoarthritis. Is there a genetic component or is it mostly wear and tear?

Dr. Dellose:  So there is a genetic component and obviously you can't do a lot about that. There are things that you can do to help decrease your symptoms with osteoarthritis and also decrease the osteoarthritis degeneration, including weight management. I think that is the biggest thing that can contribute, that is a controllable risk factor for the development of arthritis. So weight and keeping your weight down is probably the biggest thing that a patient can do. It's also related to age, female gender, and those we can't control. Also keeping your muscles and tendons and ligaments strong around the joint can help offset some of the force going through the joint itself. 

Host:  What do you do when somebody comes to you at the beginning, and they've got knee pain, maybe they're a weekend warrior, maybe they're an athlete, maybe they're just somebody who likes to exercise. What's the first thing you do in the clinical history that you take?

Dr. Dellose:  Well, we certainly talk to them about their history and their desires. We talk about the symptoms that they have and our goal is to keep them as active as possible. So we will talk to them about different exercises and things that they can do whether it's a stretching program, strengthening program to help keep their joints healthy. 

Host:  Dr. Dellose, before we talk about some of the first lines of defense for knee pain, how important are shoes? As we've learned the base, our feet, are such an important part of the rest of our body - our knees, our hips, and our back - where do shoes fit into the picture of good knee health? 

Dr. Dellose:  Shoes can have some efficacy in terms of treating knee pain. Wearing certain soles can change your foot position, such as a lateral heel wedge may produce a different stress across the knee. Also soft shoes, in terms of walking shoes, may be beneficial for some patients. So shoes can make a difference in terms of the symptoms of your osteoarthritis. 

Host:  If someone comes to you, they've got pain, you're diagnosing it as osteoarthritis, what do you recommend as far as first line defense? Is ice, bracing? Do you recommend they wrap their knee if they're somebody who likes to go on the treadmill or play tennis? What do you recommend at the beginning?

Dr. Dellose:  So almost all the things we do are symptomatic treatments for the osteoarthritis as we have very little that we can do to affect the disease process. So we do recommend, as a first line treatment, anything that decreases the symptoms. That does include medicine, such as over-the-counter medicines, or prescription medicines. It does include exercise and stretching. It does include weight loss. We do recommend bracing or wraps for some patients. There are some issues that can occur with those wraps. We also use topical treatments for some patients as well, and those are sort of the first line treatments for patients with osteoarthritis.

Host:  Let's start with exercise, Dr. Dellose. When you're recommending that they begin an exercise program, sometimes with arthritis, certain exercises certainly can help as they could learn in physical therapy, and other exercises might hurt them if they feel like they're going on the treadmill at an angle. How do you recommend that they begin an exercise program walking that fine line, as it were, between something that could damage more their arthritis and something that really could help.

Dr. Dellose:  Yeah, and not every recommendation we give to every patient is the same. And some patients may respond very positively to certain exercises while other patients may not. And so this is sort of an exploratory type of thing. A patient has to explore what exercises are good for them, and what exercises may be bad for them. In general, we like lower impact exercises, as they seem to produce less symptoms. But as you mentioned, sometimes a patient will do very well on an elliptical exercise machine, and others will not. So the patient really has to explore what is the best for them.

Host:  When it comes to medications, over-the-counter NSAIDs certainly, when does it become a prescription medication, and what are some of the latest medications you might use? 

Dr. Dellose:  So in the first line of treatment, we do use over-the-counter medicine. My philosophy is to take the least amount of medicine as possible to help treat the symptoms. You certainly don't want to take a full prescription if you don't have to. So we start with over-the-counter medicine including Tylenol and anti-inflammatories, and then we progress to a prescription strength of anti-inflammatories down the road. But keep in mind that we try not to treat osteoarthritis as much with anti-inflammatories as we used to, as there are a lot of side effects from systemic medications. 

Host:  What an interesting point, Dr. Dellose. So when is the discussion about injections? I'm sure the patients have so many questions, they hear about cortisone injections in the knee, and HCL, and all of these interesting new injection therapies available. Talk to us about the injections, when you would use them, how often they can get them, and what kinds that you would be looking to. 

Dr. Dellose:  Yes, I like the use of injections to help treat the patients with symptoms. Injections are localized treatments, so we do think of them as safer than using a systemic agent. I usually start with a cortisone injection, which is a steroid, and that steroid is purely an anti-inflammatory. It decreases inflammation in the joint, it usually has a very quick onset of action within a couple hours to a couple days, and usually lasts three to six months. Literature says that you can really inject the patient every three months, but keep in mind that there's a decreasing efficacy as the patient's arthritis progresses. A lot of people talk about cortisone or steroid injections as being bad for the joint, but most of the time when we're using them, the joint has already shown significant signs of osteoarthritis. We then move on to polyuronic acid injections, which is something called visco supplementation. That's usually a series of injections, whether it's three, four, or five, but now comes in a series of one. This is something that we call visco supplementation because it supplements the viscosity of fluid within the knee joint, it's a very thick clear material, mixes with your normal fluid, and hopefully makes things slide a little better in terms of lubrication. It also has some other effects in terms of decreasing inflammation, and hopefully symptoms. This has a much slower onset of action, and sometimes takes up to six weeks to fully kick in, but hopefully if it works for the patient, then it works for about six to twelve months’ time. 

Host:  And Dr. Dellose, there are some other ones; stem cell injections, and platelet rich plasma. Tell us about some of the other ones people might have heard of.

Dr. Dellose:  So about ten years ago or so, platelet rich plasma became popular, and what that was, is we would take some blood from the patient, and we would centrifuge that down and separate it into different types of factors, and these factors were basically looked at as growth factors, and we would inject these factors back into the knee itself, and hopefully that would have an effect. Stem cells, we actually take mesenchymal undifferentiated cells from bone marrow, also spin that down, it's also treated with some other medicine, and then we inject that into the knee. Unfortunately these types of treatments really haven't shown a lot of promise. Actually, the American Association of Hip and Knee Surgeons just came out with a position statement on the use of them and cannot recommend their use period. They also have significant costs with them, as they're not covered by insurance, and so I don't use them in my practice at the present time.

Host:  Well, thank you for clearing that up for us. As people have so many questions about their knees, when does the discussion of a knee replacement or a surgical intervention? I know you've got a lot of tools in your toolbox, Dr. Dellose. When does that become the discussion?

Dr. Dellose:  So I'm a very conservative practitioner, and I usually use all conservative management that I can that have had some proven benefit to them, and only when they fail conservative management is when we start talking about surgery. In terms of surgical management, arthroscopy is a possibility for someone who has mild to moderate changes of osteoarthritis and degenerative meniscal pathology. We sometimes will use that and that may help, and when we do that, we perform something called a chondroplasty, and we'll actually take areas of rough cartilage and make them smooth using an arthroscopic technique. But ultimately the only cure for osteoarthritis or solution for osteoarthritis of the knee would be knee replacement surgery, and that is a last resort in terms of my arsenal of treatment. But unfortunately as osteoarthritis progresses, a lot of people progress on to knee replacement surgery.

Host:  Then tell us about that. How have joint replacement surgeries advanced in recent years? What's changed with the replacement implants, or as far as recovery times; tell us about what that looks like.

Dr. Dellose:  In terms of joint replacement surgery, I think everything has changed in the last fifteen to twenty years. Both implants themselves have changed, the materials are definitely better, the implant in terms of sizing has increased which makes it easier. Some of the techniques for implanting knee replacements have changed, become more tissue friendly. You can consider that less invasive, although joint replacement is a highly invasive surgery. Some of the rehab protocols have changed for the better, which makes the recovery quicker. Pain management has also improved significantly in terms of treating the post-operative pain so the patient can participate in physical therapy more effectively, and all of these things change the outcome and make the recovery faster. We've also therefore decreased our length of stay in the hospital, and this is considered just an overnight or outpatient surgery in the near future. And so it used to require a three-night stay in the hospital, and now 95% of our patients go home just the day after surgery.

Host:  What can a patient expect as far as that recovery and return to function, range of motion, even getting back to the activities that they like. What is that whole recovery process for someone?

Dr. Dellose:  So most of the time when people have failed all the conservative management, they usually are very limited in the activities that they can perform, and therefore that's what drives them to have their joint replacement surgery. Joint replacement is a good operation, it usually restores function by giving the patient pain relief so that they can have the opportunity to engage in the activities that they would like, and that's really the important concept. Knee replacement will not change your life in terms of making you feel younger, it will just give you the opportunity to do things that you may not be able to do if you didn't have the knee replacement surgery done. 

Host:  What's the rehab process after a surgery like this? Do they go to physical therapy? How long do they have to do this kind of thing? And how do you pain manage for them after a surgery such as a knee replacement? 

Dr. Dellose:  So a lot of the rehabilitation or work that has to be done after surgery is really on the patient's back. The patient must participate in physical therapy, they must do their exercises to ensure a good result. And we try to manage their pain the best we can so that they're able to do that, and we use a multi-modal pain approach nowadays that includes pre-operative medication, that includes certain things we do intraoperatively, and then post-operatively we place them on a lot of different pain medicines that treat their pain in different manners so that they are not exposed to as many narcotics going forward. Narcotics usually tend to slow patients down in the long run as it is a fairly big depressant and has a lot of side effects itself. But really it comes down to the patient owning the surgery. It takes a long time to recover from it, and our job is to prep the patient in terms of telling the patient about the expectations of surgery, how long the rehab takes, and it does take a long time to recover from knee replacement surgery. I usually tell my patients it's about a three-month to six-month recovery fully to recover from a knee replacement, and they'll be better at twelve months than they will be at six months. It's sort of a process that continues to improve, although the patients are moving much faster, I tell my patients they'll be in the hospital just overnight. At that point they'll go home, a lot of patients will go directly to outpatient physical therapy, although some will have therapy at their house, and they usually can drive between one and three weeks, and usually return to work between four and six weeks. 

Host:  Wow, isn't that amazing? And what about the implants that you use, Dr. Dellose? Do they have to have some sort of card at the airport? Is this anything that's going to set off the security alarms? Tell us about those implants, and also while you're telling us about those, how do you fit implants into someone of different sizes? Are these knee replacements one size fits all, or are they different for each person?

Dr. Dellose:  Yes, they're certainly not one size fits all, and that is one of the advancements that has really taken off in the last couple years. All the new knee replacements have specific sizes for female anatomy because they were basically made in that manner. There are a lot of different options to choose from in terms of the different sizes. Originally when knee replacements came out, they had small, medium, and large, and now we have ten or fifteen sizes of femoral components, and ten sizes of tibial components, and a lot of different pieces of polyethylene that fit different sizes. So we can do a better knee replacement because of sizing. Knee replacements are made out of metal, and basically when we do the surgery, we are resurfacing the ends of bone with metal, and putting a plastic spacer in between. We realign the knee and balance the knee when we do the knee operation, and hopefully that will restore their mechanics from their very osteoarthritic poorly performing knee. The metals that we use are basically cobalt and chromium on the femoral side. That is the top bone. The piece of plastic in between is purely just polyethylene, although it is a highly cross-linked polyethylene that gives us better wear characteristics and decreases the wear. And then on the tibial side, which is the bottom bone, we can use either cobalt chromium or titanium. And so there's advantages to each, and that's a surgical preference. There are other knee replacements with different types of materials, but a standard knee replacement is basically what I described.

Host:  Tell us a little bit about your best advice. When somebody asks you how they can keep healthy knees, what do you tell them about weight loss, weight-bearing exercises in general, and the types of strength training, whether it's for their quadriceps or hamstrings, what you like them to do to try and keep those good healthy knees. Give us your best advice, Dr. Dellose.

Dr. Dellose:  Yeah, so we really do emphasize a stretching and strengthening program for every patient to their tolerance. As you become more and more osteoarthritic you may be less able to do certain activities, and certainly we counsel everyone on weight loss. As we can see, we do have an obesity problem, and that has its long-term effects on our joints, and also on the implants. Even after we implant a patient, if their weight is very high, the success rate of the implant goes down because of their weight, and the revision rates then go up. And so we counsel them even pre-op and post-operatively in terms of weight management.

Host:  Tell us what you love about working at Christiana Care and about your team there, and your multi-disciplinary approach.

Dr. Dellose:  So we have a multi-disciplinary approach to joint replacement. We have an entire team of both physicians, physical therapists, nurses, and administrators that work with every single patient that goes through our center and our process, and we set up a totally comprehensive type of system in terms of modifying the risk factors for our patients, and trying to optimize these patients so that they have no complications post-operatively. So when you sign up for surgery at our center, and we operate nearly 3,000 joint replacements a year, you will go through an entire streamlined process. You'll get your medical clearance, risk assessment, and optimization done by our internal line of physicians, and they will make sure that your risks are as low as possible. And then on the day of surgery, we can accomplish doing a lot of surgeries during the day. Sometimes our surgeons may do fifteen up to thirty cases a day on some days, and our staff of dedicated teams - we work with the same people all the time in the operating room - manage these patients extremely well and efficiently, and then they go up to the floor and we have a confined type of unit in terms of these are all orthopedic patients that have been through the process. Most of them are joint replacement patients and our nursing staff and physical therapy staff and administrative staff on the floor do a phenomenal job, as this is what their specialty is. And so we're a very efficient system, and very successful system because of what we have put together in terms of the way our system is managed.

Host:  As we wrap up, Dr. Dellose, what would you like listeners to take away from this episode, and why they should come to Christiana Care for their care?

Dr. Dellose:  So I think our approach is very solid. We have a lot of different surgeons doing these cases. We've tried to streamline it in a way that makes it the best experience for the patient, and it shows in what we're doing. Our patient satisfaction rate historically has been in the high nineties for years, and we have received a lot of different accolades because of the production of our numbers in terms of our low complication rates and problems. But it really goes back to the patient has to be ready to have joint replacement. We try to prepare the patient the best we can so they'll have the best outcome that they can have. 

Host:  Thank you so much, Dr. Dellose, for coming on with us today and sharing your expertise and explaining to so many people who are suffering from knee pain all of the treatment options that are available, and your best advice for keeping good healthy knees. For more information on the latest advances in medicine, please visit www.ChristianaCare.org/nomorepain. That's www.ChristianaCare.org/nomorepain. This is Melanie Cole, thanks so much for tuning in.