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In Motion December 2013


Advances in Joint Replacement Implants

By Michael Bloomfield, MD

There are currently about one million total hip and knee replacements done annually in the United States. With joint replacements being done in younger and more active patients, surgeons and implant companies continue working to improve the implants and techniques used in joint replacement surgery.

Advances in many aspects of joint replacement implant technology have occurred over the past several years. Historically, the lifespan of a hip replacement has been limited by wear of the plastic weight-bearing surface of the prosthetic. The effect of this was twofold. First, the wearing down of the implant could cause hips to start dislocating many years after surgery. Second, the microscopic particles emitted would cause the body to react and reabsorb bone around the implant (a process called osteolysis), which would often lead to the need for a replacement of the prosthesis (revision surgery).

Over the past 10 years, changes in the methods by which the plastic prostheses are manufactured and processed have resulted in considerable improvements in surgery outcomes. This new class of plastic, called highly cross-linked polyethylene, has reduced wear rates to a fraction of what they were and has virtually eliminated osteolysis (at up to 10 years after surgery). Laboratory studies using hip simulator models have shown that these materials could last for decades.

Revision surgery

Another major advance has been the development of highly porous metals for use in revision/ replacement surgery. Revision surgery is more difficult than first-time joint replacement because there is bone missing due to the failed prosthesis. This can make it challenging to get good fixation of the new implants to the patient’s bone. These new materials have greatly enhanced the ability of the remaining bone to grow into the implants to form a secure bond that will last for the long term. These metals can also replace large sections of missing bone and reduce the need for complex bone grafting.

However, not all new technologies have been positive. Metal-on-metal hip replacements are having higher rates of revision surgeries and Cleveland Clinic orthopaedic surgeons are experienced at performing these.

Today, several emerging trends in joint replacement continue to be developed. In total knee replacement, manufacturers are introducing technology that produces personalized patient-specific instrumentation. Further improvements to the metal bearing surfaces are also being studied, with the use of advanced ceramic and oxidized zirconium.

At Cleveland Clinic, we are heavily involved in conducting research on joint replacement implants and techniques to continue to improve the safety and outcomes of joint replacement.

Michael Bloomfield, MD, is an orthopaedic surgeon specializing in primary and revision hip and knee replacements. To schedule an appointment with Dr. Bloomfield or another one of our adult reconstruction surgeons, please call 440.312.6242.


Using NSAIDs to Relieve Inflammation Pain? What You Need to Know

By Linda Mileti, MD

Nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most commonly used medications to relieve pain and decrease the inflammation associated with arthritis. When other treatment options are not effective enough--such as physical therapy, weight loss or simple analgesics (i.e., acetaminophen)— NSAIDs can be very helpful to reduce pain. They can also decrease swelling that occurs with many types of arthritis.

There are several types of NSAIDs, many of which are available over-the-counter. They include:

  • Aspirin
  • Ibuprofen (i.e., Advil®, Motrin®)
  • Naproxen (i.e., Aleve®)

There are many more available by prescription. When one NSAID does not work, another may be helpful. There also are several generic options, making them cost effective. In addition to pills, there are other formations, including gels and patches.

These medications sound great, right? They decrease pain and inflammation. There are many available options, and most are inexpensive. However, as with all medications, there are potential side effects. NSAIDs can affect the cardiovascular system, gastrointestinal system, kidneys and liver. It is important to be aware of these effects, particularly in patients with certain medical conditions such as heart disease, peptic ulcer disease or kidney problems.

NSAIDs have been associated with an increased risk of heart attack and stroke. The risk appears to be greater when these medications are used at higher doses for a longer duration, particularly in patients with a known history of cardiovascular disease. Naproxen may be the safest NSAID for these patients. These risks are much lower in patients taking NSAIDs in lower doses for a short duration without a history of cardiovascular disease.

NSAIDs also are associated with an increase in blood pressure and water retention. The recommendation is to use NSAIDs at the lowest dose possible for the shortest duration possible. This recommendation does not apply to people taking aspirin at low doses per a doctor’s recommendation to prevent heart attacks and strokes. Other NSAIDs may reduce the cardiovascular benefits of low dose aspirin.

Another concern with NSAID use is the increased risk of stomach upset and bleeding from the stomach (peptic ulcer disease). The risk of ulcers is higher in patients taking NSAIDs long-term and in patients over the age of 65. This risk can be decreased by taking an acid blocker such as famotidine (Pepcid®) or omeprazole (Prilosec®) along with the NSAID.

NSAIDs can worsen kidney function and long-term use, particularly in high doses, can harm the liver. Most patients with chronic kidney disease or cirrhosis should avoid taking NSAIDs. And they are generally not recommended for pregnant patients, particularly in the third trimester, but they are safe to use during breastfeeding.

Although NSAIDs have some potential side effects, they are a very effective class of medications to treat pain and inflammation. When used for a short duration in the lowest dose necessary to control symptoms, most patients do just fine with NSAIDs and have no problems at all with them. Before taking NSAIDs, consult your healthcare provider to find out which one would be best for you.

Linda Mileti, MD, is a rheumatologist who specializes in arthritis, lupus, osteoporosis and other rheumatic conditions. To schedule an appointment with her or any of our rheumatologists, please call 440.312.6242.


Winterizing Your Diabetic Feet

By Georgeanne Botek, DPM

Facing Northeast Ohio winters can be a challenge for all of us who seek to stay active outside the confines of our warm homes. For people who have diabetes mellitus, facing the elements can be especially challenging and should be approached with increased caution.

Here are some important things you can do to keep your feet healthy if you have diabetes:

  • Protect your feet from extreme temperatures (cold or hot) by wearing socks that fit well and have soft elastic at the top. When active, consider wicking socks that will keep the moisture away.
  • Make sure that your winter boots and footwear fit properly so they don’t constrict the blood flow to your feet. With a loss of protective sensation, cold weather can inhibit a person with diabetes from knowing when they are at risk for developing frostbite or when a pair of boots is too tight fitting and narrow.
  • If your feet get wet from slush, rain or snow, immediately remove your shoes and socks and dry your feet.
  • When you are sitting for prolonged periods—which we tend to do during the winter months—put your feet up and give your feet a workout by doing circular motions with your ankles and wiggling your toes.
  • Our skin tends to get dry in the winter, which can lead to cracked skin. Be sure to keep your feet moisturized by applying good skin lotion, but be careful not to leave any between your toes.
  • As always, wash and dry your feet every day and examine the tops and bottoms of your feet for cracked skin, blisters, sores and redness or tenderness. If a problem persists, see your doctor.
  • Cut your toe nails after bathing when they are soft. Cut them straight across and use an emery board to smooth them. Don’t let your nails dig in to the foot.
  • As always, eat a healthy diet and keep your blood sugar in your target range.

As with most medical problems, prevention is the best medicine. People with diabetes have different categories of risks to their foot health and having an annual diabetic foot exam has proven to reduce diabetic foot complications according to many studies.

A person who is categorized as Category 0 has a low risk diabetic foot with intact sensation and no signs of poor circulation. A person in Category 2 or 3, has poor blood flow and has loss of feeling in their feet, known as peripheral neuropathy. If you are a person with diabetes, know your risk Category and follow the above preventive care practices.

By participating in an annual diabetic foot exam, you will know if you need to take special precautions for wintery weather, or if you are safe to play in the snow without extra precautions.

Georgeanne Botek, DPM, is the Medical Director of Cleveland Clinic’s Diabetic Foot Clinic. To schedule an appointment with Dr. Botek or any of our podiatrists, please call 440.312.6242.


Understanding Sciatica and its Treatments

By Garett Helber, DO

It is important to recognize that the term “sciatica” describes a symptom, or group of symptoms, rather than a specific disease. These symptoms include pain in the lower back, hips and/or buttocks and may involve pain, numbness or weakness in various parts of the leg and foot. Patients also often report a “pins and needles” or tingling sensation.

Typically, these symptoms happen on one side of the body and may be aggravated by coughing or sneezing and prolonged sitting. Difficulty with controlling the limb and walking are not uncommon, but could be the sign of a more serious condition that should be evaluated by a physician.

Causes of pain

Sciatica can affect anyone, but it is more common as we get older due to age-related changes affecting the spine. Sciatica most commonly happens as a result of compression or irritation involving one of the five spinal nerves that combine to form the sciatic nerve. A herniated lumber disc pressing on one of the lower back or sacral nerve roots is the primary cause of this nerve compression. Severe pain can result from not only direct nerve root compression, but also from release of inflammatory chemicals.

Lumbar spinal stenosis, a narrowing of the spinal canal resulting from bone spurs or spondylolisthesis (shifting of one bone on another), may also cause irritation of these nerves. Less common causes of sciatica include pregnancy, tumor, direct trauma to the area (i.e., from a motor vehicle accident or fall on the buttocks), and prolonged inactivity such as a lengthy surgical procedure.

Treatment

While the pain associated with sciatica may seem unbearable, most cases can be resolved with conservative measures over a period of days to several weeks. With a physician’s help, medication therapy can be initiated that may include a combination of anti-inflammatories, muscle relaxants, opioid analgesics and/or membrane stabilizers.

In addition to medications, a rehabilitation program with a physical therapist may be recommended to help with severe sciatic pain and to prevent recurrent injuries. This program will incorporate exercises to help correct posture, strengthen the muscles supporting the back and improve overall flexibility.

For symptoms that do not respond to these conservative treatments, a spinal injection may be recommended. This involves injection of corticosteroid medication into the area with the goal of reducing pain by suppressing inflammation around the irritated nerve.

In more serious cases when treatment isn’t working or symptoms are getting progressively worse, surgery may be considered. Surgery may also be warranted when the compressed nerve causes significant weakness and/or bowel or bladder dysfunction. Surgeons can remove the herniated disc or arthritic bone spur that is irritating the nerve and alleviate any ongoing sciatica symptoms.

If you are experiencing sciatica symptoms, be sure to talk to your primary care provider for advice on your treatment options.

Garett Helber, DO, is a specialist within Cleveland Clinic’s Center for Spine Health. To make an appointment with a spine specialist, call 440.312.6242.


Not Quite Lupus, Not Quite Rheumatoid Arthritis -- Diagnosing and Treating UCTD

By Matthew Bunyard, MD, FACR

In the field of rheumatology, we have defined several systemic rheumatic diseases. They are referred to this way because they typically involve multiple organ systems of the body, including the connective tissues, such as our joints, muscles and skin. These defined diseases include:

  • Rheumatoid arthritis—inflammation and swelling of the joints
  • Lupus —a chronic disease caused by an overactive immune system that can affect almost any organ in the body
  • Sjogren’s syndrome—an autoimmune disease that causes dryness of the eyes and mouth
  • Scleroderma—a rare disease that involves thickening of the skin and internal organs
  • Polymyositis/dermatomyositis—a disease characterized by inflammation of the muscles causing weakness

A large group of patients have some features of these autoimmune diseases, but not the full blown disease. In these cases, we call the condition an undifferentiated connective tissue disease (UCTD). We do not know what causes UCTD, but it is also referred to as an autoimmune disease—which means the body’s own immune system breaks down in such a way that it attacks its own tissues. UCTD is a very diverse disease by nature, with varied signs and symptoms that can include:

  • White color to the fingers and toes in the cold (known as Raynaud’s phenomenon)
  • Joint pain and swelling
  • Rashes

When tests are done, there may be some abnormalities, but they are not specific enough to categorize the patient into one of the defined diseases. This is not uncommon, with up to 25 percent of patients with rheumatic diseases being undifferentiated. This is different from what we call overlap syndromes, which means the patient truly has two or more of the defined diseases noted above.

The first step toward receiving a diagnosis of UCTD is having a rheumatologist perform a history and physical examination followed by a select set of testing, depending on the symptoms. Treatments are generally to use medications to suppress the immune system.

There is not one treatment for UCTD, and some patients may simply require observation.

Rheumatologists will follow patients with UCTD over time. Fortunately, most patients with UCTD can manage their symptoms and will not progress into one of the defined diseases.

Matthew Bunyard, MD, FACR, is Director of Clinic Operations for Cleveland Clinic’s Department of Rheumatic and Immunologic Diseases. To make an appointment with Dr. Bunyard or any of our rheumatologists, please call 440.312.6242.

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This information is provided by Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

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