Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we are highlighting non-operative options for arthritis. And in the case of refractory options that don't work, we're going to talk about preparing for total joint replacement.

Joining me is Dr. Andrew Waligora. He's an orthopedic surgeon with AHN Orthopedic Institute, specializing in adult reconstruction. Doctor, thank you so much for joining us today. I'd like you to start by giving us a little bit of a table setting. Tell us about joint pain and inflammation, the prevalence, and really the impact on the patient's quality of life, and what is different now about what we know about arthritis, rheumatoid, osteo, and what is different for you, doctors, about what you're seeing when you're working with patients.

Andrew Waligora, MD: So, thanks for having me, first of all. I think as far as the prevalence of arthritis and arthritic pain, I think the stats say that anywhere close to 50% of all adults are experiencing some kind of musculoskeletal element at all times. And that includes back pain, hip pain, knee pain, shoulder pain, elbow pain, wrist pain.

So, the orthopedic surgeon, our job first and foremost is to keep people moving. I liken people to boulders that are moving. It's very easy to keep a boulder moving if it's rolling already. But to initiate it from the start when it's not moving, it is hard. So, we want people to continue moving.

I think a lot of our colleagues and other specialties, you were talking a little bit about different types of arthritis, particularly in the inflammatory arthropathies, the rheumatoid, the Sjogren's, the lupus, our disease-modifying antirheumatic drugs have done wonders. I remember being even in residency and looking at folks who had rheumatoid arthritis. And the number of people coming in with the typical rheumatoid stigmata of the hand deformities and just the bad erosive joint disease-- that, for the most part, it's almost completely disappeared. My old attending in residency, I mean, he made his way in taking care of people with complex rheumatoid hand and foot deformities. And I think if he tried to do that now, he wouldn't be able to do it. So, these medications are very helpful and our rheumatology colleagues are working very hard. They're so successful, and we're finding out more about these inflammatory arthritis issues. I think there's actually even a greater demand for rheumatologists now than there ever have been. We need more of them.

As far as the other types of arthritis, I mean, you kind of break it down into the post-traumatic arthritis, so the injuries that happen or the arthritis that happens from injuries, and then the wear and tear arthritis. And I think we're seeing basically an escalation in both that require treatment for a multitude of reasons. So, the advent of the increase in youth participants in sports over the last 20 or 30 years has led to more ACL injuries, more hip injuries. And what we do know is that despite our best efforts at performing ACL reconstruction, there are still a vast majority of folks who go on to developing post-traumatic arthritis in their knee. And typically, these symptoms can show up anywhere between 15 and 20 years from the time of the injury. Sometimes a little bit longer, but we do know the older you are, the more likely that arthritis is to show up earlier. And we've seen people trying to maintain a very active lifestyle well into their 30s, 40s, 50s, and 60s. And so, the incidences of ACL tears in that age group are also going up. The unfortunate thing is if you tear your ACL in your late 40s, that onset of arthritis, a lot of the times happens much sooner. So, we see that post-traumatic arthritis. But people are trying to stay active longer. We're living longer and the quality of our lives are longer, we're working longer. And so, we want to maintain a nice functional status. And so, those arthritic ailments that really inhibit people's ability to enjoy not only typical things, but also their activities. Golfing, tennis, pickleball has become huge in the last two decades. People want to keep doing those things, and we have to figure out a way to keep them moving.

Melanie Cole, MS: So while we're looking at joint wear and tear today, and that's pretty much-- I mean, post-traumatic for sure, whether reconstruction is needed, we'll get into that. But as we're looking at joint wear and tear and the things that happen, and I'm in my 60s, so I know how that goes. First line of defense when we are looking at knees and hips, what are you talking to your patients about? And, you know, Ortho is not always the first person to see. So, primary care might be the first person. And so in that case, what are we looking at as far as first line of defense? Do we start right with meds, physical therapy? There's a lot of tools in your toolbox now.

Andrew Waligora, MD: What's the old saying? An ounce of prevention is worth more than a pound of cure. And I think the biggest thing that we need to do is really start identifying people that might be at risk for having these issues. And the obesity epidemic in this country, it's unbelievable. It's showing no signs of stopping. So, I think anything we can do on the forefront to try to prevent obesity or work on people with obesity, I think that's huge. If you take a look at the number of, for example, knee replacements that get performed in the country every year, it seems to be climbing at almost a linear rate that follows that of the obesity epidemic. So, there's certainly a degree with that.

I think the second part is really talking to patients even from a young age about maintaining a healthy, active lifestyle. Just because you have arthritic changes in your knee does not mean that you're going to develop significant symptoms and therefore even talk about needing a joint replacement. People who seem to go on to need further interventions are the ones that typically develop loss of motion, feelings of arthritic instability. A lot of this is coupled to weakness, deconditioning, and lack of activity. So, I think the biggest thing is just trying to prevent that. Weight loss and maintaining healthy, active lifestyle. So, that's the first part.

The second part is you look at the very easy things we can do. Ask them: Are they having pain? Or is it an instability? Or is it a combination of both? A lot of the times, pain, you can start with simple things. And the people who can take medications, the anti-inflammatories are a great first line of defense for people who are having an arthritic flare. And a lot of the times those people, especially if they're not active, I mean, I think that's a good indication to maybe get into some physical therapy a little bit early and then have that physical therapist really help to transition them to a nice home exercise program that they can eventually take and do a normal addition to their life. They don't have to exercise every day, but a couple times a week might be reasonable. That's the first line.

Then, you can start jumping up to the next lines. So, anti-inflammatory therapy is not working, they're still having pain. One of the hallmark things we've done for years that seems to be very beneficial are steroid injections. And there are different formulations of steroid. There are different types of steroid. The jury's out there as to whether or not these newer medications that come as suspensions that have delayed releases are any better than the time-true, just true cortisone injection essentially. But that's a great next line of defense.

After that, you've got the viscosupplementation injections, which some people try. Our academy has been indifferent about whether or not these are great things. They don't really recommend their use or they don't make a strong recommendation for their use. But that being said, I think any one of us will tell you that it's about a 50/50 chance that it'll help with arthritic symptoms.

Outside of this, getting back to some of the other symptoms, so particularly those with instability, bracing for a short period of time is not a bad thing. I'm not a big fan of keeping people in braces forever unless they're extenuating circumstances. But getting them into a brace and then getting them into a physical therapist to work on some functional rehabilitation, I think is very beneficial. And particularly if the patients are older, getting them to work with a therapist and to help with those stability things can help falls and other injuries.

Melanie Cole, MS: So, Doctor, you mentioned obviously injections, which is just a huge field right now, really burgeoning field. I'd like you to just expand a little bit more for us because we're hearing about PRP. And, obviously, you mentioned steroid injections. Where do you see that field going as a less invasive form before total replacement?

Andrew Waligora, MD: I think what it's going to come down to is the insurance coverage's ability, or want to include this as a covered option. Currently, the biologics, PRP and stem cells, they're not covered by insurance. They're out of pocket. And depending on where you live, the prices can vary. I believe in the city of Pittsburgh, I believe that PRP is about $500 an injection out of pocket. And I think stem cells can reach about $10,000 out of pocket. So, they're pretty expensive.

The problem is, if you look at the data about them, they don't really show to be that much more beneficial than either steroids or even the viscosupplementation I talked about. And I think that's been part of the insurance program's hesitancy in covering them because there really hasn't been a lot of established benefit. From how they do and what they do for people, these do not-- and again, I have to emphasize that this is related to arthritic change-- this isn't isolated cartilage injury. This isn't like an acute injury where you have a torn ACL and a piece of the cartilage. It covers the bone. The articular cartilage is torn off with what we call an osteochondral defect. This is for arthritic change-related to degeneration. There is no evidence that PRP or stem cells helps to regrow cartilage or reestablish joint lines. It just does not happen. But what it probably does is it acts like an immunomodulator where it kind of modifies how the inflammatory process works in the knee with the arthritic changes, and it may modulate that and help reduce symptoms.

Melanie Cole, MS: So now, we're looking at any patients who have tried all of these things, and as you mentioned, the obesity epidemic is contributing to that pressure on knees and hips, and we're seeing just so much more of it. If the patients have tried therapy and injections, even weight loss as a tool, all of these things, activity modifications, whatever it is, now, their pain is still substantial, what are the indications for replacement? Are we doing partial or full repair? What are we doing? What's exciting in your field and the indications for someone to come see you for that?

Andrew Waligora, MD: So, I think we have to divide that into hip and knee arthritis. So, we'll start simply with hip arthritis. I think that the way that surgical techniques have evolved, particularly over the last 10 years with a change in the approach to hips, so how we get to the hip joint. Most people, they'll refer to it as basically the minimally invasive or muscle-sparing approach. We call it the direct anterior approach. And first thing I tell people is I don't think that there is anything that is minimally invasive about doing a surgery in which we're actually running power tools and using hammers. So, I try to be very clear about that. But the combination of the direct anterior approach, our current anesthesia modalities, and the way we do rapid rehabilitation has really led to a profound improvement in people's immediate postoperative outcomes. So, people are getting to points at six weeks that it took them previously, I mean, three months essentially. We don't put them on restrictions. They don't have to worry about how they sleep in bed. The biggest thing I tell people, honestly, Melanie, is like, "Please don't fall after surgery." If they don't do that, 99% of the time, things end up perfect.

There has been some consideration into the use of robotics and technology in joint replacement. And hips, we're not really clear where we're going with this. So, there was a lot of talk within the last few years about spinal-pelvic relationships and how there's a higher incidence of hip dislocations in some individuals. And so, maybe we need to be a little bit more specific about how we place the implants. And I don't know if there's been a preponderance of data that has really pushed and shown that doing things routinely with robotics for the hip has really done anything.

I think robotics serves a great place in people who have really complex bony deformities or atypical anatomy. I think it'd be helpful for that. It can make the outcomes maybe a little bit more predictable by being able to fine tune exactly where you put their implants. But I think it's maybe a little bit more exciting down around the knee side. And we've been implementing robotics for both total knees and partial knees, and that includes the replacement of medial compartments, lateral part compartments, and patellofemoral joints.

If you look at the information about robotics as a whole for knee replacement surgery, I would say that the data is kind of all over the market as to whether or not robotics is absolutely necessary or useful. I think that if you narrow down the data and you look, individuals who are younger have greater deformity as well as have higher demands immediately after surgery tend to recover maybe a little bit quicker. I think that's where we found it with the totals. I think as far as partials, I think this is the one indication where I would say if the robot had to go away forever for primary joint replacement, I would say we would definitely want to keep it for the partials.

Partial knee replacement is basically reserved for individuals who have a situation where we can essentially resurface the knee. So, they've got either a bow leg or a knock knee deformity that is correctable. They've got reasonable range of motion. They have, for the most part, an intact MCL, LCL, intact posterior cruciate ligament. There's some thoughts that doing partial knees and ACL-deficient people is probably okay in some situations. But partial knees, if you're going to do them, they are a very technically demanding procedure where perfection is a must. Anything less than perfection would lead to earlier failure or lack of improvement in symptoms. So, I think the robotics have helped us really key in and put these implants in a very specific position. But also, being able to run intraoperative analytics by looking at the three-dimensional mechanical functioning of the partial knee will a lot of the times let us know if it's going to work by helping us to define those who have maybe some very subtle instability that would not be conducive to a partial knee that we may not be able to pick up if we were to do it manually.

Melanie Cole, MS: That's really interesting and this is such an exciting time in your field. And when we think of better outcomes and improved recovery. What do you recommend patients do? Are we looking at ERAS? What do you tell patients to do before surgery so that they do have better outcomes?

Andrew Waligora, MD: Yeah, I think the big thing is preoperative optimization, and that's something that was preached to me very heavily in my fellowship by my mentors. It was preached to me very heavily in residency by my mentors, and it's something that I preach very heavily to the fellows. And essentially, what that means is taking all of your medical comorbidities and making sure that they are optimized. If you have thyroid issues, make sure they're controlled. If you're diabetic, make sure it's controlled. If you have a history of any heart issues, you make sure it's controlled, making sure that you see your dentist preoperatively to make sure you don't have any active dental issues. If you are overweight, trying to make sure that you obtain a body mass index that's maybe a little bit more conducive to better longevity of implants, but also lowering the risk of infection and other complications. So, that's first and foremost.

Secondly, we're always trying to push the envelope on this rapid recovery, and I think we've done a very good job by doing a couple things. So, first of all, you're right, using like an enhanced recovery protocol where we're really pushing people to make sure that they're maintaining appropriate hydration before surgery, making sure that they discontinue with the appropriate medicines prior to surgery. Everybody gets a preoperative cocktail before surgery. That is, for the most part, tailored to make sure it doesn't interfere with their comorbidities. Everybody for the most part are getting regional anesthetic and as a recipient of regional anesthetic myself, I tell all my patients that it's probably one of the best things that you can do. You don't have that hangover from general anesthesia. You wake up a little bit crisper and cleaner with a spinal. And then, you go home with basically an extended recovery, a nerve block, that really helps you to get moving in those first 48 hours, which is very important.

I also think the very act of, trying to get people home early on has actually helped because people are now at home. They're recovering in their own home. They're eating their own food. They're with their loved one. I mean, watching your own TV is better than a hospital TV for sure. But that's also making sure that you're up and moving. And I think just the act of making people get up and move and act more like themself and less like a patient has really helped.

Melanie Cole, MS: Now, what makes AHN's total joint replacement capabilities so unique? I'd like you to speak about your team. What's exciting that you're doing there, and the multidisciplinary factor that comes into play for these patients. That's so important.

Andrew Waligora, MD: So, every member of our adult reconstruction program is a member of the American Association of Hip and Knee Surgeons. We all do everything we can to either make the meeting every year or we watch it virtually. We're involved with a fellowship. And a lot of people get very concerned when they hear that we train fellows.

 And quite honestly, I think it should provide them a breath of fresh air, because we literally have to stay up with all of the current literature at all times to make sure, A, that we're educating these orthopedic surgeons that want to become specialists, but also we're able to answer their questions. And it constantly makes us question what we're doing. Are we doing the right thing? Are we not? All of us are allowed to practice essentially independently. So, we can do our own thing. And I think the thing that's really reassuring is that the stuff that is important, we all come to the same conclusion that it's the right thing to do and the right way to do it.

We have at least twice a month meetings with the fellows where we go over difficult preoperative and postoperative cases. We all share our ideas. And I think that helps a lot. And when we have complex cases, we can share it with one another. And we can act as a team to come up with a great treatment plan for the patient.

I think the other part is that we have a lot of guys that are appropriately pushing the envelope to newer technologies. So, we have several members of our team that are heavily involved in the development and the teaching of robotic surgery. We're soon going to be getting a newer rendition of one of the robots that's going to allow us to begin applications for revision surgery, which is something we've been doing for a little while. And I think all of this lets us stay on the forefront of technology while maintaining an appropriate check on each other to make sure that we're doing things safely and we're doing it for the best of our patients.

Melanie Cole, MS: Certainly a comprehensive approach. And, Doctor, as we wrap up, what would you like other providers to take away, the key takeaways about what you're doing there at the Allegheny Health Network? Why it's so important and when they should be referring their patients?

Andrew Waligora, MD: I would say, when to refer a patient-- anytime a patient has any questions about, "Is this time to get my joint replaced?" Who better to ask than the surgeon? And we are truthful and we're honest. And so, if it's time, we're happy to tell them it's time. If it's not time, it's not. But I think the biggest thing is is just kind of like I said, ensuring that these folks, they're optimized medically, that their comorbidities are taken care of. And again, I always tell people to practice within a scope of your comfort.

 If you get to a point where the arthritic symptoms, you don't think you're doing a good job with them, or you think they need a second set of eyes, I mean, send them over. If I have a patient that submitted to the hospital, I don't manage their diabetes, I have the medicine doctor do that because that is their profession. That is their specialty. Don't have your plumber check your electrical work.

But again, all of the stuff we talked about, the American Association of Hip and Knee Surgeons and the American Academy of Orthopedic Surgeons, they have a very good outline on the current consensus for treatment of these arthritic elements that are readily available online. I mean, you can literally Google it, AAOS Recommendations for non-operative treatment for hip and knee arthritis, and same thing with AAHKS. And they provide a very good comprehensive review of things that they provide for which they have strong recommendations for, strong recommendations against, or weak recommendations for or against. And all that is based off of literature and a very good comprehensive analysis.

Melanie Cole, MS: Thank you so much, Dr. Waligora, for joining us today and sharing your incredible expertise. And to learn more or to refer your patient, please call 844-MD-REFER, or you can visit find care.ahn.org/andrewwaligora. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.