What to do when waiting for joint surgery

If you’re waiting for a knee or hip replacement, what can you do now about pain?

Joint pain often results from osteoarthritis, the most common type of arthritis. It injures cartilage, deforms bone and affects other tissues in joints, and causes inflammation, according to the Arthritis Foundation. This incurable condition worsens with time, and risk factors include injury or overuse of a joint, having a family history of the disease, and being older, female or obese, according to the Centers for Disease Control and Prevention.

Falmouth orthopedic surgeon Paul Dimond, MD, said treatment for osteoarthritis and results vary with the individual, but he prefers to try a conservative approach first. Pain can be managed for years for most osteoarthritis patients without resorting to joint replacement, he said, estimating only 5-10 percent of his patients require it.

“If they have an acute flareup of pain, I typically use ice,” said Dr. Dimond, who practices at Total Orthopedic Care, located within the Falmouth Orthopedic Center, and serves as director of rehabilitation at JML Care Center, both in Falmouth. “When the flareup is past, warmth can limber up the joint.”

Patients may also use over-the-counter rubs containing anti-inflammatory ingredients. “It does get into the bloodstream,” he said.

Physical therapy can both keep patients moving before surgery and help them recover afterward.

“Conditioning the muscle around the joint can be very helpful,” Dr. Dimond said. “It’s a good way to delay things. Plus, it gets them stronger.”

The American Academy of Orthopedic Surgeons (AAOS) recommends patients avoid activities that cause pain, like climbing stairs; employ walking aids, such as canes, crutches or walkers; take nonprescription NSAIDS (nonsteroidal anti-inflammatory drugs), including aspirin, ibuprofen and naproxen; and exercise to maintain range of motion. If you’re overweight, shedding some pounds can be beneficial.

If ice, heat, anti-inflammatory rubs and exercise haven’t provided enough pain relief, Dr. Dimond said other measures can be tried.

• Injections of the corticosteroid cortisone into the joint can reduce inflammation and pain for weeks, he said. Cautionary note: Doctors limit use of corticosteroids, as regular intake may cause side effects, including raised risk of infection, mood changes, increased blood pressure, disruption of your hormonal system and thinning of bones (osteoporosis). Repeated injections into joints can weaken cartilage, according to the Arthritis Foundation.
• Hyaluronic acid can be injected into the knee where it acts as a lubricant. This treatment is not approved for hip joints, Dr. Dimond said. Osteoarthritis patients have lower levels of this gel-like substance in the synovial fluid that bathes the inside of joints, according to the AAOS. Results vary, and more research is needed to support the use of for mild to moderate osteoarthritis, when proponents say it is most effective, the AAOS says.

The Next Level

If a patient doesn’t respond to these treatments, more advanced options include:

• Injection into the knee of Zilretta, a slow-release steroid (triamcinolone acetonide) that’s effective for months at a time, as opposed to weeks of relief offered by cortisone shots. This method of drug delivery reduces corticosteroid side effects, according to a 2019 article in Drugs.
• A nerve block by injection of an anesthetic administered in the thigh or back of the knee. Done on an out-patient basis at the hospital, so the patient can recover at home.
• A nerve block via freezing of nerves surrounding the knee, effective for about three months, according to Pacira Biosciences, maker of the iovera system. Dr. Dimond said he hopes this will soon become available locally. “It’s an exciting thing coming down the pike to us,” he said.

Dr. Dimond said his office also offers two biologic injections into knees that use a patient’s blood or stem cells and are not covered by insurance.

• PRP, or platelet-rich plasma, takes blood from a vein in a patient’s arm and separates out the platelets (cells important for clotting) and plasma (liquid portion). The idea is to “change the chemical environment of the arthritic knee,” he said, adding that it “calms down inflammation,” but does not build cartilage, as some proponents claim. The cost is $750.
• Stem cells, taken from bone marrow in the iliac crests of the pelvis and separated out by centrifuge. Stem cells have the potential to become specialized cells that form the tissues inside the joint. “In my mind, slightly better than PRP,” Dr. Dimond said. He charges $2,500 for the procedure.

Biologics hold a lot of promise, but the effectiveness and safety of these treatments has not been determined, according to the American Association of Hip and Knee Surgeons, which urges more research be done and does not now support their use.

If a knee or hip causes pain, Dr. Dimond urges patients to first talk to their primary care doctor and begin exploring what can be done.