Gout

Overview

Gout is a common condition that causes sudden severe joint pain, usually affecting the big toe, feet, ankles, knees, hands, and wrists. It can be treated effectively, and if necessary, there are medications that can help to prevent frequent attacks. Lifestyle changes may also prevent or reduce episodes. We will work with you to find the best approach to treatment and prevention.

Gout occurs when uric acid, a waste product of the body, builds up in your blood. This happens if your body produces extra acid or doesn't eliminate enough, or if you eat or drink too many foods with purines. Purines are found in anchovies, sardines, shrimp, and organ meats such as kidneys and liver. Beer and other alcoholic beverages may also elevate uric acid levels.

Normally, uric acid dissolves in the blood. It passes through the kidneys and out of the body in urine. But when uric acid builds up, it can form crystals that lodge in the joints and cause intense pain.

The initial gout attack can last several days to 2 weeks unless it is treated. Some people will only have one attack. In others, attacks can recur from time to time in the same joint.

Gout is more common in males, women after menopause, and people with high blood pressure. Heavy alcohol use, diabetes, obesity, sickle cell anemia, and kidney disease also increase the risk of a gout attack

Symptoms

The primary symptom of gout is sudden onset of severe pain in a joint and red or purplish skin, swelling, and tenderness. Gout attacks are often followed by periods of no symptoms in the affected joint or joints

:Other symptoms may occur and can include the following

The big toe, ankle, and knee are most often affected, but gout may affect the fingers, especially if you have osteoarthritis. You may also experience limited movement. Some people may develop symptoms in more than one joint

With chronic gout, there is pain in the joints that may go on for long periods of time

In people with untreated high uric acid levels, uric acid may collect in the joints. If large amounts of uric acid build up, it may cause lumps or nodules to form. These are called tophi. These tophi may also cause damage to the joints and subsequent deformities

Diagnosis

Gout may be difficult for us to diagnose because the symptoms may be indistinct and can mimic symptoms of other conditions
:Most of the time, however, the diagnosis is made by using a combination of criteria
Your history of pain and swelling of one joint at a timeLack of symptoms between attacks

Blood test showing high levels of uric acid

Rapid improvement after anti-inflammatory medication

f the diagnosis is unclear, then we can perform a joint aspiration. As little as 1 drop of fluid can reveal the presence of uric acid crystals (monosodium urate), confirming the diagnosis

Risk Factors

:There are several factors that can increase your risk of developing gout; including

Advanced age. Gout usually occurs in middle-aged men who have certain health issues like obesity, high blood pressure, unhealthy cholesterol levels, or heavy alcohol use. After menopause, the risk increases in women. At age 60 the incidence is equal in men and women, and after 80, gout occurs more often in women

Family history. About 20 percent of people with gout have a family history of this condition

Obesity. Researchers report a clear link between body weight and uric acid levels

Foods and alcoholic beverages. Eating a lot of purine-rich food like meat and seafood, or drinking a large amount of alcohol, particularly beer


Exposure to lead

Use of hydrochlorothiazide, a medication used to treat high blood pressure

Various surgeries and illnesses. People who have had organ transplants or who have thyroid problems, leukemia, and lymphoma are at higher risk

Prevention

:Lifestyle changes may help to prevent gout. There are a number of steps you can take, including

Lose weight by eating fewer calories and increasing your activity levels each day

Avoid foods high in purines such as organ meats like kidneys or liver as well as anchovies, sardines, and shrimp

Choose low-fat foods and complex carbohydrates, such as whole grains and foods high in dietary fiber
Avoid red meat and fish and eat more low-fat dairy foods like low-fat or skim milk, low-fat or nonfat yogurt, or low-fat cottage cheese

Avoid sugar-sweetened drinks like soft drinks and fruit juice high in fructose

Avoid alcoholic beverages, especially beer and hard liquor

Medication

Medications can be given to prevent gout in patients who develop frequent or severe attacks. Usually more than 2 or 3 attacks a year are a reason to start medication to prevent gout. The goal of treatment is to lower the concentration of uric acid in the blood

Preventive Medications


Uricosuric drugs, which increase the excretion of uric acid via the kidneys. The most common drug in this group is probenecid

Losartan (Cozaar), commonly used for hypertension treatment, may lower uric acid

Allopurinol reduces the formation of uric acid. It is usually recommended if you have tophi development or if you are more than 60 years old

Combinations of these medications may be used in some patients

Oral colchicine in low doses has been used in the past for prevention of gout but is used less now because of long-term side effects to muscles

We may need to change or adjust the medications you take for other chronic conditions. Medications commonly used for hypertension like hydrochlorothiazide or chlorthalidone may cause uric acid levels to increase in the bloodstream

Medications for Acute Gout Attacks

:Other medications are sometimes used, including the following

For pain relief, nonsteroidal anti-inflammatory drugs such as naproxen 500 mg twice a day or indomethacin 50 mg three times a day are most commonly used. You should not use them if you have problems with stomach or intestinal bleeding, kidney disease, or allergy to these medications. Other nonsteroidal anti-inflammatories like nabumetone may be used for patients with gastrointestinal problems



Colchicine can be very effective if taken soon after the attack starts. Oral colchicine is mainly used as bridge therapy. Gout can flare with the addition of medications like allopurinol. Maintaining twice-daily colchicine can minimize this risk. This type of treatment, known as bridge therapy, is often continued for 3 to 6 months. It has the disadvantage of causing diarrhea, nausea, and vomiting in a number of patients



Glucocorticoids (cortisone) may be injected into the affected joint or may be given orally in a pill form in patients who cannot take nonsteroidal anti-inflammatories or colchicine. Prednisone is a common form of oral glucocorticoid we use for this purpose

Remember that if you are already on treatment for gout, it is important to continue taking the medication as prescribed even during an acute attack

Osteoporosis

Overview

Osteoporosis is a condition that weakens bone. Healthy bone is very dense and has high concentrations of minerals like calcium and phosphate that keep your bones strong. However, people with osteoporosis, which means "porous bones," have low bone density. Over time, the loss of bone density and essential minerals makes the bones brittle, weak, and more likely to fracture easily.

Osteoporosis and the fractures that result from it are a major public health concern. More than 1.3 million people experience an osteoporosis-related fracture every year in the United States. Early diagnosis and treatment of bone loss can reduce or eliminate the risk of fractures.

:It's important to know that

Women 65 and over and men 70 and over are at high risk for osteoporosis, and they should talk to us about bone mineral density testing

Women are at higher risk, especially just after menopause when estrogen levels begin to decrease with time

Osteoporosis is under diagnosed. Since osteoporosis can be prevented and treated, it is important to talk to your personal physician or Ob/Gyn about it

Fractures, especially of the spine and hips, often lead to loss of quality of life and permanent disability for elderly women and men

You can reduce your risk of developing osteoporosis and fractures by improving your diet, especially by increasing your calcium and vitamin D intake. Regular exercise and avoiding or quitting smoking also reduce your risk of fracture

Symptoms

People with osteoporosis often have no visible symptoms, until they fracture a bone. The condition has a

number of symptoms that include

Fractures
If you have osteoporosis, a minor fall can cause a bone to fracture
Fractures of the vertebrae, the bones that make up the spine, are the most frequent type of fracture, but fractures in the hips and wrists are also common

Vertebral fractures might not cause any pain, though sometimes curvature of the spine may result in a loss of height. Sometimes we find these fractures when we order X-rays to evaluate another problem, like a cough or abdominal pain

Loss of height and spinal changes
Fractures of the vertebrae can cause you to become shorter and may lead to an increased curvature of the spine, known as kyphosis

Pain

Pain at the site of the fracture is often the main symptom. However, vertebral fractures do not always  cause pain, and so they are often not diagnosed

Causes and Risk Factors

Causes

Osteoporosis is characterized by bone loss and subsequent bone weakness. There are several reasons why you may lose bone 

Aging
Insufficient calcium, phosphorus, or vitamin D in your diet
Decreased or abnormal production of the hormones that control bone formation

Your bones grow the most during your teens and your 20s. After age 30, that growth slows down and your body begins to absorb more bone than it produces, making your bones thinner. If your diet did not include enough calcium and vitamin D to support healthy bone growth during your teens and 20s, you are at increased risk of developing osteoporosis later in life

Bone thinning occurs in both men and women. However, bone loss in women accelerates in the years after menopause because women stop producing estrogen, a hormone that protects against bone loss. This means that women are more likely to develop osteoporosis than men

Risk Factors
Age is the primary risk factor for osteoporosis. Women who are 65 or older and men 70 or older are at risk for osteoporosis. Other factors that increase your risk for developing osteoporosis
include

Gender. Females are 4 times more likely than males to have osteoporosis
Race. Northern European Caucasians and Asians are at higher risk
Body size. Small bones or low body weight. Weighing less than 127 pounds or having a body mass index (BMI) of less than 21
Family history. Having a parent, brother, or sister with history of hip fractures and/or osteoporosis
.Lack of menstruation

History of injuries. Prior fracture due to fragile bones or having a history of falls
Certain medications. For example, use of oral corticosteroid drugs like prednisone at doses 7.5 mg/day or greater for more than 3 months increases your risk of developing osteoporosis

Lifestyle. Smoking, excessive alcohol use, and lack of exercise also seem to increase your risk of developing osteoporosis. Being hit, hurt, or threatened can also seriously affect your health. There is help if this is happening to you
If you have two or more of these risk factors and are a woman younger than 65 or a man younger than 70, talk to us about early screening and other ways to reduce your risk for developing osteoporosis. A man or woman with risk factors may be screened as early as age 50; we can discuss the screening plan that's best
for you

Screening and Diagnosis

We recommend that women 65 and older and men 70 and older get screened for osteoporosis. During screening, we evaluate your medical history to assess your risk factors. We may recommend a bone mineral density test to evaluate the thickness of your bones or use a tool called a FRAX calculator that can help in predicting your individual fracture risk.

If you're at a higher risk of developing osteoporosis, we may recommend that you begin screening earlier than 65 or 70 years. If you're uncertain if you are at higher risk, talk with us about whether you need a test

Bone Mineral Density (BMD) Testing
A BMD scan is a type of X-ray of your skeleton. The scan measures the density of your bones, which is reported as a number called the bone mineral density or BMD. Your BMD is used to calculate your T-score

The T-score indicates whether your bone density is above or below the average reading of a healthy person of your gender at age 35. According to the World Health Organization, T-score results indicate

	Fracture Risk Assessment We use the results of the BMD test along with other risk factors in a Fracture Risk Assessment Tool (FRAX*) to guide your treatment and recommend the best way for you to prevent osteoporosis and fractures *FRAX is a tool developed by the World Health Organization to help people determine their risk of bone fracture in the next 10 year Frequency of Screening We recommend that women come in for an initial screening at 65 years of age and that men begin screening at 70 years of age. Certain men and women should begin screening at a younger age if certain risk factors are present Men and women who have sustained any kind of bone fracture after the age of 50 should be screened as soon as the fracture occurs Men and women who take regular oral glucocorticoid medication should have early screening to check for bone loss :If the results of your first BMD scan are normal and You have other risk factors for osteoporosis, we will discuss a schedule for screening that's best for your health You have no other risk factors, we recommend that we revisit the subject of screening again in 5 years, or sooner if you develop risk factors Prevention There are many things you can do to prevent or slow the development of osteoporosis. They include improving your diet, adding more calcium and vitamin D, exercising, minimizing your risk of falling, quitting smoking, and reducing alcohol intake Increase your calcium and vitamin D intake Men and premenopausal women need 1000 mg of elemental calcium and 800 to 1200 units of vitamin D daily. Postmenopausal women need 1200 mg of calcium and 1000 to 2000 units of vitamin D daily. Here are some tips for adding vitamin D and calcium to your diet Eat 3 to 4 servings of calcium-rich products every day. Milk, cheese, and yogurt all contain lactose, which enhances calcium absorption. If you are counting calories, choose low-fat or skim milk Drink vitamin D-fortified milk and get some exposure to the sun. Use a good sunscreen to avoid skin damage Avoid a diet high in fat and protein, as excessive fat and protein can interfere with calcium absorption in the intestine Limit caffeine. Caffeine in coffee and in sodas has been implicated in calcium loss, so limit or avoid these beverages Eat a nutritious, balanced diet. You may need a protein supplement if you are not eating enough, especially if you have suffered a fracture Drink alcohol in moderation. It may affect your balance and make you more likely to fall Even with a healthy diet, many people do not get enough calcium. It's a good idea to take an over-the-counter calcium supplement twice a day with meals. If you cannot tolerate milk or dairy products for any reason, supplements are particularly important. Follow these guidelines          Vitamin D is necessary for calcium absorption and is available in our pharmacies without a prescription. You can safely take up to 2000 units per day You should not take more than 500 mg of calcium at one time since your body cannot absorb higher doses effectively. Your body cannot absorb calcium without vitamin D, so take your vitamin D supplement at the same time Calcium carbonate is the most effective and least expensive form of calcium. Take it with a meal and be aware that it may cause constipation or gas Calcium citrate is easier on the gut and may be taken on an empty stomach Common acid-blocking medications like famotidine (e.g., Pepcid) or omeprazole (e.g., Prilosec) affect the absorption of calcium carbonate. If you are taking these medications, use calcium citrate instead of calcium carbonate Exercise Regularly Daily activity helps keep your bones strong and makes them less likely to break if you fall. Weight-bearing exercise (walking, jogging, dancing, or lifting weights) is the best way to build strong bones and muscles Weight-bearing exercise. If you spend less than 4 hours per day on your feet, we recommend that you do some form of daily weight-bearing exercise, like walking, aerobics, or dancing, to make your bones stronger and denser and to reduce bone loss Strengthening exercise. Increasing your muscle strength will also help you prevent falls. We can help you develop an appropriate exercise program. Exercises that involve strength and balance, such as T'ai Chi, have been shown to help reduce the risk of falls Stop Smoking and Limit Caffeine, Salt, and Alcohol Smoking reduces bone strength and is a major risk factor for heart disease and cancer. Ask your physician or other health care professional for help quitting Caffeine, salt/sodium, and alcohol can all reduce bone strength. Experts recommend that women reduce caffeine and salt intake and drink no more than one alcoholic beverage each day to prevent osteoporosis Prevent Falls :You can protect yourself from injury by preventing falls
	Remove throw rugs, electrical cords, and items left on the stairs that may cause you to trip and fall Make sure that your home is well-lit, including stairwells and entry ways Do not walk on ice, polished floors, or other slippery surfaces Avoid walking in unfamiliar places Use a cane or walker regularly if your balance is poor and install grab bars (e.g. in the bathroom) to keep you safe at home Wear low-heeled shoes with good arch supports and rubber soles Check your vision and get new glasses if you do not see well Medications Bisphosphonates We typically use a class of drugs known as bisphosphonates, such as Fosamax or alendronate, to treat osteoporosis. These medications decrease the breakdown of bone and are used to prevent and treat osteoporosis in postmenopausal women. We will talk with you about which specific medication may be best for your individual situation How to take your medication Bisphosphonates need to be taken first thing in the morning with 8 ounces of clear, still (not carbonated) water You need to remain sitting or standing for half an hour before eating or taking any other medication to reduce the chances of food-pipe irritation or pain Common side effects Stomach upset can be a common side effect of bisphosphonates. Please tell us if you have stomach or chest pain when taking this medication Rare side effects Osteonecrosis of the jaw. This is a rare side effect that has been seen in some patients receiving high doses of bisphosphonates during treatment for cancer. However, this side effect is very rare in patients being treated for osteoporosis Atypical fractures of the femur may be a side effect of treatment. However, the benefits of treatment far outweigh the risk of this unusual and very rare fracture Other drugs Other drugs for treatment of osteoporosis include Parathyroid hormone Calcitonin used nasally Combinations of estrogen and bisphosphonates Selective Estrogen Receptor Modulators  SERMS If you cannot tolerate bisphosphonates or can't take them for another medical reason, we will prescribe another class of medicines known as selective estrogen receptor modulators (SERMs). SERMs produce estrogen-like effects on bones and reduce the risk of vertebral fractures. They are less effective than bisphosphonates, but they can still be helpful. Choices include Raloxifene (Evista). This is the most commonly used SERM for osteoporosis Tamoxifen. This is not commonly used to prevent osteoporosis. It is used to prevent and treat breast cancer. However, researchers have observed that breast cancer patients who are taking tamoxifen may also be getting some bone protection Treatments Estrogen/progestin therapy (HRT therapy Hormone therapy (estrogen alone or estrogen and progesterone) is also very effective at reducing fractures. If a woman is taking hormones to relieve menopausal symptoms, she will also have the benefit of bone protection for as long as she takes the medication. We no longer recommend HRT therapy to prevent osteoporosis because studies found that in some cases it has been associated with an increased risk of breast cancer, stroke, blood clots, and heart attacks Complementary/alternative treatments A number of alternatives are available to treat osteoporosis. For example, isoflavones, plant estrogens with properties similar to estrogen, have been shown to prevent bone loss in some women and to increase bone density in others. Isoflavones are found in high concentrations in soybeans, chickpeas, and lentils. These effects are more pronounced when taken in combination with calcium and vitamin. It is important to talk to us before using alternative therapies, as they may affect medicines that we have prescribed for you

Knee Osteoarthritis

Overview

The knee joint is the meeting point of 3 bones – the femur (thigh bone), tibia (shinbone), and patella (kneecap). Each of these bones is covered by articular cartilage, the hard, slippery tissue that covers the ends of the bones where they meet to form the joint. Cartilage protects the joint from the impact of everyday movements by allowing the bones to glide over each other smoothly. Osteoarthritis of the knee is caused by the gradual loss of the cartilage in your knee joint.

When enough cartilage wears away, the bones rub against each other, causing pain, swelling, loss of motion, and joint changes.

The body responds to the loss of cartilage by producing more fluid in the lining of the joints to cushion it. However, the additional fluid can cause the joint to swell, limiting motion and causing pain. This is called an effusion, or fluid on the knee.

Friction between the bones may cause small deposits of bone called bone spurs to form on the edges of the joint. Cartilage can also break off and float around inside the knee joint, causing more pain and damage

Symptoms
The primary symptom of knee osteoarthritis is pain in the knee joint that gets worse when you are active and gets better with rest. If you have advanced osteoarthritis, you may also experience pain when you are resting. Symptoms usually progress gradually over time, although your symptoms may suddenly get worse if you aggravate your arthritis by doing too much or you injure your knee. Other common symptoms include

Stiffness It is very common to feel stiff, especially first thing in the morning. Stiffness usually lasts for about 30 minutes after you get up and can recur during the day if you are inactive for a while. Stiffness can make it difficult for you to go about your usual daily routine. For example, you may have difficulty

Walking
Climbing stairs
Squatting or kneeling
Standing up after sitting on a chair
Getting out of a bathtub

Tenderness. Touching the knee joint can be painful. Your knee may hurt to the touch even if there is no visible evidence of inflammation

Swelling. Your knee joint may swell with fluid, as your body attempts to make up for the loss of cartilage. Sometimes there is so much fluid that it begins to build up in the back of the knee, a condition known as a Baker’s cyst
Crackling or grating. You may feel a crackling or grating sensation when you move the joint. This is thought to be caused by roughening of the normally smooth cartilage inside the joint

Bone spurs. You may be able to feel bone spurs under the skin near the affected joints. These get larger over time

Causes and Risk Factors

There are a number of factors that may increase your risk for developing osteoarthritis in any joint. Risk factors that make it more likely that you will develop osteoarthritis in the knee specifically include

Kneeling and squatting. Work that requires frequent squatting and kneeling, such as construction and housework, may be a cause

Stress on the knee. This can be caused by

Heavy work. Carrying heavy items (tool belt, briefcase, purse, etc.) puts extra stress on the knees and hips, which causes more wear and tear on your joints

Being overweight. Carrying extra weight on your frame also places extra stress on your knees, and it can cause you to develop arthritis at a younger age and worsen your symptoms if you already have arthritis

Diagnosis

We evaluate the results of a physical examination and your description of your symptoms in order to diagnose osteoarthritis of the knee
Medical history

We will ask you a number of questions about your symptoms

?What kind of work do you do? What kind of work have you done in the past? What sports and other hobbies do you participate in

؟Have you ever injured your knee

?When and how did your symptoms start, and how have they changed over time

?How much pain are you having, and does it come and go, or is it constant
?When do you feel pain or stiffness, and how long does it last
?DOyou feel a grinding or grating sensation when you bend or straighten your knee
?Do you have family members who have experienced joint problems

?What medications are you taking now? What medications have you taken in the past

Physical examination
During the physical examination, we will examine your knee and look for
Swelling or fluid around, or behind, the knee joint

Tenderness over your knee

Bony enlargement of the knee joint

Any redness or warmth over the knee, which may indicate infection

Loss of ability to fully bend or straighten your knee

Imaging studies

We will look at X-rays of your knee in order to determine how severe the osteoarthritis is. An X-ray can reveal a number of knee joint characteristics that can help us confirm osteoarthritis. These include

The space between the thigh bone and shin bone is narrowed due to the loss of cartilage

Bony spurs, also called osteophytes

Cysts on the bone

Treatments

Our goals for treatment are
To decrease your pain and minimize swelling

To improve the function of the knee

To help you maintain a healthy body weight

To improve your quality of life and help you achieve a healthy lifestyle

There are a number of ways to treat osteoarthritis including exercise and physical therapy, weight management, medication, joint injections, and, in severe cases, surgery. We recommend a combination of treatments specifically for osteoarthritis of the knee joint
Limit the activities that may aggravate your knee; for example, running, fast walking, carrying heavy items, and standing for extended periods of time

Exercise and physical therapy

A combination of body-strengthening and aerobic exercise has been shown to reduce pain and improve quality of life. Gentle midrange movement makes arthritic joints feel more comfortable. Inactivity can make joints feel stiffer. Exercise can also improve your mood, energy levels, quality of sleep, weight control, heart health, and muscle tone and strength. It is important to choose the right kind of exercise and to limit activities that aggravate your knee. Running, fast walking, carrying heavy items, and standing for extended periods of time can all increase stress on the knee. We can help you choose the most appropriate form of exercise

Physical therapy

Physical therapy may improve the flexibility of your knee joint and strengthen the muscles that support the knee. As part of your physical therapy, we will teach you exercises that avoid hurting the joint or causing you more pain. It is important that you continue these exercises at home to maintain your progress. A physical therapy plan for the knee usually includes

Exercises to strengthen the quadriceps, or main thigh muscles. For some individuals, this increases the stability and mobility of the knee joint and reduces pain

Aerobic exercise. We can help you choose the most appropriate form of exercise. For example, if you are a runner, we may suggest that you try swimming or cycling on a stationary bike instead to reduce impact on your knee

Steroid injections

If oral pain medications are not effective, we may consider injecting the knee joint with steroid medication. Steroid injections can provide short-term improvement, usually for a few weeks to several months. We may repeat injections about every 6 months if they remain effective for you. Side effects of joint injections include pain and swelling after the injection

Surgery

We may recommend surgery if less invasive treatments have not been effective. Surgical procedures for osteoarthritis include knee arthroscopy, total joint replacement, partial joint replacement, and osteotomy

Arthroscopic Surgery

In many cases, we can evaluate and make some repairs to an arthritic knee joint using an arthroscope. This approach avoids the need for a large incision. An overview of this procedure includes the following
We make 2 or 3 small incisions in the knee joint

We then insert an arthroscope – a lighted device with a camera and surgical instruments attached – into the joint itself

The scope allows us to see the structures inside the knee and any debris, such as bone spurs and loose cartilage that have collected in the joint

We insert small instruments into the other incisions and use them to trim torn articular cartilage and/or remove debris that may be causing pain

Total Knee Replacement Surgery
We may recommend replacing your knee joint entirely if your osteoarthritis has not responded to other medical treatments and is so severe that it is affecting your ability to perform everyday activities

Total knee replacement is a very successful procedure that significantly reduces pain for many people and enables them to get back to the activities they enjoy. Replacement knee joints can last 15 years or more. How quickly they wear out will depend on the amount of pressure you put on your knee and how active you are

Not everyone is a candidate for knee replacement surgery. We will consider a number of factors while evaluating you for this type of surgery. It is crucial that you, and your joints, are healthy enough to recover from surgery and participate in a comprehensive rehabilitation program

The replacement knee joint is usually made of metal and/or plastic and has 3 components

A femoral component that attaches to the femur. This is usually made with polished metal

A tibial component. This is the part that is attached to the top of the tibia. It is usually made of plastic and metal

Kneecap – or patellar – component

The surgery
Knee replacement surgery takes between 1 and 3 hours. We usually perform the procedure using spinal anesthesia. You will be awake but numb from the waist down. Alternatively, we may recommend a general anesthetic


During the procedure, we make a vertical incision along the kneecap. We then prepare the bones so that the replacement implants fit well. We do this by removing some of the bone from the ends of the tibia and the femur and then drilling small holes into the ends of those bones. Next, we install the replacement knee. We use a special bone cement to attach the joint. Finally, we close the incision with stitches or staples, which we usually remove 2 to 3 weeks after the surgery

Recovery and rehabilitation


We will work with you to develop a graduated exercise program to restore mobility to your knee and to strengthen the muscles that stabilize the knee. We can advise you how and when to resume normal activities such as sitting, standing, and climbing stairs and discuss the most appropriate place for you to begin your rehabilitation. If you do not have anyone at home who can help you, we may recommend that you stay at a skilled nursing facility to begin your physical therapy. If you do go home, a physical therapist will visit for 4 to 6 weeks to make sure that you are progressing well. We will also talk to you about preventing falls. This is particularly important, as any fall can damage your new knee and require more surgery

Partial Knee Replacement

We may recommend a partial knee replacement if osteoarthritis has damaged only one area, or compartment, of your knee. During surgery, we replace only the damaged compartment of the knee – the medial, lateral, or patellar (kneecap) compartment. 
Partial knee replacement is a simpler and less invasive surgery that requires a smaller incision. You may recover and get back to your normal activities much more quickly than you would after a total knee replacement. We don’t usually recommend this procedure for younger, active patients as they are likely to put too much stress on the replacement, causing too much wear and tear. A partial replacement may be a good option for older slim patients who have less active lifestyles

Osteotomy

We may recommend a different procedure known as an osteotomy if you are young and not yet ready for a total knee replacement. Delaying a total knee replacement is particularly valuable for younger people because replacement knees tend to last, on average, about 15 years. Replacing your knee earlier in life may mean that you have to have knee replacement surgery several times during your lifetime.
During the procedure, we remove a section of bone from your knee. Removing bone from a specific area of your knee pushes your weight onto an area of the joint that does not have osteoarthritis damage. For example, if you have lost more cartilage in your inner knee, we may remove bone from the outside of your tibia, closest to the knee. The resulting unevenness tips your body weight toward the outer knee, which has healthier cartilage

Prevention

Although you can’t prevent osteoarthritis, you can decrease your risk of developing severe problems in your knee. A few things that you can do are
Maintain a healthy weight. Carrying excess weight places extra stress on your knee. Talk to us about weight management resources and classes

Exercise. Regular exercise will keep your muscles strong and your ligaments flexible. Try exercises that do not stress your knee like swimming, stationary bicycling, elliptical machines, or water aerobics

Wear shoes that support and cushion your feet

Avoid falls at home by keeping your home well lighted, using handrails on staircases, and using sturdy ladders or foot stools if you need to reach for items on high shelves. Do not use a chair or step on the counters

Avoid prolonged and repetitive kneeling, squatting, or frequent knee bends

Use walking sticks if you have to walk up and downhill

Psoriatic Arthritis

Overview

Psoriasis, a common skin condition, is characterized by itchy, scaly rashes. Some 10 to 30 percent of people with psoriasis can develop psoriatic arthritis. This is an inflammatory condition that caused joint pain, stiffness, and swelling.

It may affect any joint in the body, though most commonly it appears in the fingers. It can affect just one joint, or several joints throughout your body. Like psoriasis that affects the skin, psoriatic arthritis tends to flare up episodically. Symptoms can range from mild to very intense pain. In its most severe forms, psoriatic arthritis can cause joint damage, deformity, and disability.

Psoriatic arthritis usually occurs in people between the ages of 30 and 50. Although there is no cure, psoriatic arthritis can be effectively treated with medications, exercise, physical therapy, lifestyle adaptations, and, in some cases, surgery

Types

:Psoriatic arthritis may take one of the following forms

.
Distal interphalangeal predominant (DIP) affects the small joints of the fingers and toes
Symmetric affects the same joints on both sides of the body. Multiple sets of joints are affected, and this
condition can be progressive. This pattern may resemble rheumatoid arthritis
Asymmetric usually affects 1 to 3 joints, and does not necessarily involve both sides of the bospondylitis involves inflammation of the spine and results in pain and limitation of normal movement of the back. It can affect any part of the spine, from the sacrum to the neck
Arthritis mutilans affects a small percentage of people with psoriatic arthritis and causes damage and deformity of the joints of the hands and feet

Symptoms

Common symptoms of psoriatic arthritis include pain, swelling, and stiffness in the joints. Other possible
manifestations of this condition are

Cracking, discoloration, or separation of fingernails or toenails
Swollen, painful fingers and toes, commonly called "sausage digits"
Pain or swelling in tendons and ligaments
Pain, tenderness, inflammation, and redness of the eye, called iritis

Causes and Risk Factors

Psoriatic arthritis is a disorder of the body's immune system, which means that the immune system inappropriately attacks healthy tissue, causing inflammation and swelling. This type of disease is also known as an autoimmune disease.
Autoimmune disorders may have genetic or environmental causes. For example, you are at a much greater risk of developing psoriatic arthritis if you have a close relative with the condition, or if you have had psoriasis. Physical traumas or infections (viral or bacterial), such as a streptococcal throat infection, may trigger the development of psoriatic arthritis, particularly if you have a genetic predisposition

Diagnosis

There is no single test for diagnosing psoriatic arthritis. If you have symptoms characteristic of psoriatic arthritis, we will explore your medical and family history. After a thorough history and physical examination, we may request one or more of the following tests:

• X-rays can reveal inflammation and changes in the joints
• Blood tests can help us check levels of inflammation in your body and help us to rule out other conditions, such as rheumatoid arthritis
• Joint fluid analysis can identify gout or another infection that may be causing inflammation

A diagnosis of psoriatic arthritis can usually be confirmed once we have evaluated your symptoms and ruled out other possible causes. If the skin rash is not typical of psoriasis, we may refer you to a dermatologist for additional tests

Treatments

Psoriatic arthritis is normally treated with a combination of medication and lifestyle adaptations including exercise. Most people with psoriatic arthritis will experience a marked reduction of symptoms and a
significantly improved quality of life with proper treatment

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) or aspirin may be recommended to control pain. Corticosteroids such as prednisone (Deltisone, Meticorten) can help reduce inflammation. At times, cortisone joint injections may be recommended to relieve particularly troublesome joints. Other types of medicines can help reduce inflammation and the risk of joint damage

Disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine (Azulfidine) and methotrexate (Rheumatrex). These agents have been used for psoriatic arthritis for many years. The benefits of these medicines may take weeks to appear

TNF-alpha inhibitors (also known as anti-TNF agents) such as etanercept (Enbrel), infliximab (Remicade), and golimumab (Simponi) all have been approved by the FDA for this indication


These are very potent medicines to reduce inflammation and can be given only as an injection or an intravenous infusion. They can increase the risk of infection while you are taking them, so we will monitor you closely

Other immunosuppressant drugs such as azathioprine (Imuran) and cyclosporin (Neoral, Sandimmune) are used less frequently but are effective in many cases


Any of these medications may have side effects, some of which can be serious. We will prescribe medication for you based on your symptoms and degree of inflammation. If you experience side effects, please discuss this with us so that we can adjust your medication accordingly. We may also recommend vitamins or supplements if they are appropriate for your condition. We will make sure that this treatment does not interfere with any other health issues you may have

Surgery

Joint surgery may be recommended to relieve pain from severely involved joints that do not respond to medical treatment. Types of joint surgery include joint fusion or replacement

Other treatments

Physical therapy, yoga, and range of motion exercises can help to improve mobility and relieve pain and stiffness. Hydrotherapy or water therapy done in a pool can also help increase range of motion in the joints.

Heat and cold therapy can be done either on your own or with the help of a healthcare professional. The application of a hot towel (or simply a warm shower or bath) can relax muscles and relieve stiffness. Applying an ice pack can reduce joint inflammation

Lifestyle Management

Self-care is very important to managing psoriatic arthritis. Activities you do and habits you maintain on your own are essential for controlling your symptoms.
Daily exercise – including aerobic, range of motion, and strength-building exercises – will help relieve stiffness and pain, preserve mobility and flexibility, and improve joint function. It is important to have an exercise routine that works for you and your needs. We can help you create an appropriate exercise program. Improper or overly strenuous exercise may make your condition worse.
Maintaining a healthy weight will help to reduce pressure on your joints. A healthy diet of fresh fruits and vegetables, whole grains, legumes, and lean meat will boost your energy and improve how you feel. You should also consume alcohol and caffeine in moderation

Body mechanics

Reduce stress on your joints by changing your body position often and not sitting in one position for a long time. In addition, you may consider

Taking frequent breaks when performing physical tasks, particularly repetitive tasks

Using your bigger stronger joints instead of smaller joints whenever possible, such as carrying a shoulder bag rather than holding a briefcase or pushing doors open with your shoulder rather than your hand

Using both hands to lift heavy objects

Using assistive devices, such as canes or grab bars

A physical therapist can coach you in the techniques of proper body mechanics. An occupational therapist may help you select assistive devices

Pacing yourself

Your condition and your medication both may contribute to fatigue. Do not push yourself to the point of exhaustion. Staying active is healthy, but it is equally important to respect your body's need for rest. For example, you may wish to perform tasks in short segments. Take naps and, in general, make sure you are getting plenty of sleep. Set a schedule of weekly activities, prioritizing the activities that matter most, including spending pleasurable time with loved ones

Coping and Support

Psoriatic arthritis is a stressful and sometimes debilitating condition. It is not something you have to cope with by yourself. It is best if you have a strong support system of family and friends, people who can help care for you and with whom you can express your feelings. Consider getting counseling or joining a support group.
Maintaining your emotional health is as critical to your well-being as your physical health. If you are feeling depressed, we can assist in finding counseling resources. Joining a support group of people with psoriatic arthritis can also be helpful. Regular exercise will reduce your stress. Stress-reduction techniques such as meditation, yoga, and listening to soothing music are also effective.

Learn everything you can about your condition, the latest treatment options, and your prognosis for the future. The more you know, the more empowered you will be to make the best decisions for yourself and the more in control you will feel