Dr. Mike (Host): Welcome to Meaningful Medicine, a Novant Health podcast. I'm Dr. Mike. And joining me today is Dr. Robert Hoffman. He's an orthopedic surgeon from Novant Health. Now, this episode, we're going to be talking about before the scalpel, helpful injections ahead of knee replacement. You know, we're going to explore nonsurgical treatments available to help with pain, enhance mobility, and maybe even delay the need for surgery. Dr. Hoffman, welcome to the show.

Robert Hoffman, MD: Thanks for having me.

Host: So, you have like a toolbox of things you can use that are non-surgical that may help some people. Can you just run through us what are some of those common treatments?

Robert Hoffman, MD: Well, we see lots of people with what we call knee osteoarthritis. So, wear and tear of the joint cartilage between the thigh bone, the femur; and the shin bone, the tibia; and under the kneecap. It's incredibly common and the overwhelming majority of people who have knee osteoarthritis or knee arthritis never end up needing any type of surgery.

And so, we treat patients-- without surgery-- who have knee arthritis all the time. In fact, most people don't ever need it. And we usually start easy. And so, we recommend things like exercise, maintaining good thigh muscle strength. Cardiovascular fitness helps patients who have knee arthritis. And so, that's always worth a try. We use a lot of things like medications, what we call the NSAIDs, the non-steroidal anti-inflammatory drugs. Things like Motrin and Aleve fall into those categories. Those are very helpful for patients who have arthritis. But not everybody can take them. They can harm the kidneys, they can harm the stomach. Some people just don't tolerate them well. And when those sort of simple treatments aren't working, that's usually when patients end up seeing us and that's when we start talking about sort of the orthopedic surgeons' non-operative treatments.

And I would say the most common treatment that we use is an injection. And so, everyone's heard of the cortisone injection or the cortisone shot, and we don't really inject cortisone. We use other steroids like Kenalog or triamcinolone, but they're in the same family. They're corticosteroids and they're potent anti-inflammatories. And so, I would say that that's often the first suggested injection treatment. It's been around for a very long time. It's safe, it's easy, it's inexpensive, and it often can provide a lot of pain relief. And so, that just involves coming to the office, having the area like around the knee numbed up and having a small shot and often can provide months of relief.

Host: When someone has that kind of procedure, that's quick, right? That's in your office, and then they go home, like same day.

Robert Hoffman, MD: Right. And it really doesn't require much modification of activities. And so, most patients maybe take it easy that afternoon, but you can go back and hit golf balls or tennis balls or ride your bike and those types of things the next day without any problem. And so, there's a reason that it's been around for a long time. It's pretty effective, very easy, and really doesn't interfere with your activities very much. And so, that's usually where we start.

Host: Okay. So, you start with the steroids. There must be some other options with injections as well. What are some of the other things you can use, medications you can use?

Robert Hoffman, MD: Well, the other one that's been around probably since early mid-'90s is what's called hyaluronic acid, or HA. We sometimes call it viscosupplementation. It is a jelly-like, viscous substance filled with hyaluronic acid, which is a protein found in your cartilage. And we usually will inject that in the knee as well. A lot of those types of injections, a lot of different companies make them. There's several different brand names that people have heard of like Synvisc, Hylan G, Supartz, Euflexxa, just to name a few of them. But many of those are done in a series of three injections done a week apart. There are some preparations that are a single injection. There are some that have been around that involve five injections. But I'd say typically those injections involve a series of three injections done a week apart, like on a Monday, then the next Monday and the next Monday. But again, super easy. Hyaluronic acid is a protein that's found in your cartilage anyway. So, there's really no downside to the injection at all, and they often provide several months of relief.

The downside of those injections, they're, a touch more expensive. Some insurance carriers. Don't fully cover them, so they can be a little more expensive. You often have to go to the doctor three times over a two-week period, which is a little bit inconvenient, but they're very, very safe and there's really no downside. The criticism of those injections is that they don't help everybody. And that is true, they don't. But the downside is minimal, if not almost zero. And so, it's often worth the try, especially in patients who really are eager to avoid any type of knee surgery.

Host: I want to get into to how some of those patients respond, good versus bad, and if you can predict that and all that kind of stuff. But before we do that, there's like a big movement in medicine to start doing everything at home. There's even at-home colonoscopy-type tests, and all this kind of stuff. Why can't these things be done at home, maybe to be a little more convenient for people, these injections?

Robert Hoffman, MD: Well, it's sort of important to get the substance into the knee joint. And so, injections can be harmful if injected in the wrong place, the big concern, the reason that we almost always do these in the office is out of concern for sterility. And so, maintaining a sterile injection so you don't introduce infection in the knee is very, very important. If someone who was sort of uninformed injected something into their own knee and created an infection, that would obviously be a disaster.

Host: It's not good, right? Not good at all. Like, people need to know.

Robert Hoffman, MD: It is not good. It's not good at all.

Host: If they're going to get injections, they're going to go see Dr. Hoffman. I mean, that's what they need to do, right?

Robert Hoffman, MD: Or at least somebody with experience doing injections. Obviously, there are nurses and other medical professionals that are very experienced and skilled doing injections. But if you're going to inject something into a major joint, you would want someone who's had some experience doing that.

Host: Of course. Yeah. Great response. So, we mentioned the corticosteroids, we mentioned the hyaluronic acid. For the most part, I think patients respond pretty good to this stuff, but how come there is a subset that doesn't? What's going on there?

Robert Hoffman, MD: Well, there's no question that, as the joint surface wear progresses and becomes more and more severe, a lot of the injection treatments, the anti-inflammatory treatments become less effective. And so, when you are being evaluated for the first time, your doctor can sort of give you an idea of where you fit on the spectrum. Clearly, patients with mild to moderate knee osteoarthritis tend to respond well to conservative treatments. The surgical options are presented more often to people with more severe osteoarthritis. Patients who have good knee range of motion tend to respond better to the injections. Patients who are in good physical condition tend to respond well, and patients who maintain a healthy body weight tend to have a little bit more favorable response to the non-operative treatment.

Host: So before we into the surgical part of this, besides the injections, right? So, what are some of the other lifestyle, exercise, physical therapy maybe recommendations you make to patients?

Robert Hoffman, MD: Well, there are a few things. The one injection thing that we haven't mentioned that's worth mentioning is what's called PRP or platelet-rich plasma Injections. Those things have really gained a lot of popularity over the past 15 to 20 years. Those are done by aspirating blood from a vein like in your arm and spinning off the red cells and injecting the remaining plasma into the knee joint. Those injections likely are even better than the hyaluronic acid injections. But those are also oftentimes not covered under insurance plans and can be a little pricier. Some of them cost $700, $800, $900 to do those injections. And so, those things have a very favorable response. Again, because it's your own material, there are really no downside to it other than the cost.

In terms of other non-operative treatments, things like physical therapy, there's no question that works. Maintaining good knee range of motion, maintaining muscle strength, maintaining a healthy body weight are critical. And oftentimes, those simple relatively simple things can really prevent you from needing knee surgery ever.

Host: Let's back up for a sec. What's going on there? So, you mentioned the red blood cells or the plasma injections. Why is that looking really effective? Is it doing something to stimulate repair? What's happening there in the joint?

Robert Hoffman, MD: That's a good question. And I would say that the answer to that is not completely known. It may have an anti-inflammatory effect. Those growth factors may help with repair of cartilage injuries in the knee. It does not appear that these injections allow you to grow new joint surfaces, but they do have a pain-relieving effect, an inflammation-reducing effect, and possibly a healing effect on areas in the knee. But the idea that you're squirting this stuff in there and new cartilage is magically growing in your knee, that is probably exaggerated.

Host: We don't have that research yet, right? No. That's not there.

Robert Hoffman, MD: As of the time of this broadcast, we do not.

Host: We do not. Yeah. But if something like that became more available, is this something you would recommend more?

Robert Hoffman, MD: I have been recommending it more in recent years. I think a number of us years ago were a little skeptical about how it would work, but I think the body of evidence is definitely increasing. And the number of studies that compared it to more traditional injections like steroid injections, hyaluronic acid injections, the platelet-rich plasma injections hold up pretty well. As it becomes more commonplace, it's undoubtedly going to become less expensive and more available. And I expect eventually, hopefully, insurance plans will cover it or at least allow patients to contribute towards their deductible so it becomes more easily available.

Host: One last question about the lifestyle physical therapies. I'm sure you talk to a lot of patients who, when you tell them about physical therapy, you tell them about exercise is good, it just hurts, and maybe they can't. How do you respond to that?

Robert Hoffman, MD: So, a lot of patients with severe knee arthritis who would like to be more active to lose weight and those types of things, telling them to take up running or running marathons is not going to happen. Their knees hurt. And so, we do suggest a lot of lower impact activities on the knee. So, things like swimming, elliptical trainers, exercise bikes, those types of things are very good ways for patients to get exercise and become more active without putting a ton of pressure on the knee. But, yeah, there's no question that exercise and maintaining good muscle strength is very important.

Host: So, you mentioned obviously that somebody with a bad knee, it hurts and they're overweight, they're not going to be able to get out there and jog and run marathons. And you did mention some great suggestions for low impact, but what about just walking?

Robert Hoffman, MD: Walking is great exercise. It's easy, anyone can do it. And walking on level ground, even for patients with knee arthritis is usually reasonably well tolerated. And so, I would encourage people walking not only helps keep a healthy body weight, it helps maintain bone density, it can be social. I mean there are lots of reasons to do that. But the non-pounding activities like walking, elliptical machines, bicycles are a good way to sort of stay active without really pounding on the knees.

Host: Yeah. Now, if somebody's doing injections, and they're doing their exercise, how often can that prevent going on to surgery or does it prevent? Is it just to delay?

Robert Hoffman, MD: Well, I think wear and tear of the knee joint over the course of your life is almost universal. And so, you can expect if you live long enough, except in rare circumstances, to develop some wear and tear. Clearly, the vast majority of patients, I would say more than three quarters who have knee arthritis, will never have any type of surgery at all.

And so, the odds are in your favor for sure. And as I tell patients all the time, your goal should be hold onto your original equipment as long as you can. If your knee is really ruining your life, a knee replacement is a very reasonable thing to consider. But if you're getting along without it, it's better to do that.

Host: So, that's interesting. So, like quality of life is a big decision-maker here, right? If somebody tells you, "I'm doing all this and I'm miserable. I still can't walk that well," that's probably time to move on.

Robert Hoffman, MD: If you are otherwise healthy without any significant severe medical problems, and your knee, despite all of your efforts, is still really keeping you from socializing, visiting family, exercising, doing the things you like, having a knee replacement is a good idea. I mean, you don't want your knee to take you down. If the knee is the main focal point of difficulty in your life, it can be a life-changing operation. I just think that for most people try the easy things first. And if they're not successful, you could consider the other options. The downside of the knee replacement, of course, is that it does take six weeks or so to recover from.

Host: Well, I want to talk about that, because I think that's one of the biggest issues that some people maybe have with moving from the non-surgical to the surgical therapy, is they've heard crazy stories. It's so hard, it's so painful. Recovery's bad. Sometimes you got to go back in for surgery. What do you say to that? Because overall, hasn't the technology gotten better, outcomes better? What do you think there?

Robert Hoffman, MD: I do think that knee replacement has improved. I do think that recoveries have become quicker over the last 20 years or so. Most patients are walking without assistive devices like canes or Walker within a week or two, but it's still a major surgery to have. There is no question. If you really step back and think about it, the worse your knee is going into the knee surgery, the more likely you are to be happy with your knee replacement. And so, that's another reason why we don't recommend knee replacement for patients who have minor degrees of arthritis. If your knee is making your life miserable, you will like your new knee even though you know the metal and plastic knee is not a perfect substitute for your original equipment. But the worse your symptoms are going in, the happier you're going to be.

In terms of having problems afterwards, the key to try avoiding problems after knee surgery is optimizing things before surgery. And so, having all of your medical problems controlled, not smoking, maintaining healthy body weight, all of those things can dramatically decrease your risk of having problems after surgery. And I think a lot of surgeons, especially over the last 10 years, have really tried to focus on trying to optimize patients before surgery to avoid problems afterwards.

Host: Dr. Hoffman, this has been. Fantastic. I know I've learned a lot. I think the listening audience got a lot of good tips in there. This is great. Any last words, like anything you want to say to the listening audience about kind of these non-surgical treatments?

Robert Hoffman, MD: Well, I guess what I would say is that the first thing you can do is try to take care of your knees and your body as best you can. There is no substitute for maintaining good strength and motion of your joints, maintaining a healthy body weight. There's nothing you can do to prevent having knee arthritis that works better than that.

If you develop knee arthritis, you should know that there are a variety of non-surgical options. If you go to the doctor, odds are one of those options is going to work for you. There is a small chance that your knee arthritis will progress and really give you trouble, and that you may end up needing surgery, but the odds of that are not very high.

Host: Dr. Hoffman, fantastic. Thanks for coming on today.

Robert Hoffman, MD: Oh, you're welcome. Thanks for having me.

Dr. Mike (Host): For more information, you can visit novanthealth.org. If you like this podcast, go ahead and share it on your social channels, and you can explore our entire podcast library for topics that might interest you. This is Meaningful Medicine. I'm Dr. Mike. Thanks for listening.