‘Don’t let Arthritis keep you down: A Hikers Guide to Hip and Knee issues.’
Professor Brian Devitt

Good evening it’s a great pleasure to speak with you again, I’m going to speak on the topic of arthritis of the hip and knee and the title of my presentation is ‘don’t let arthritis keep you down, a hiker’s guy to hip and knee arthritis’, so my name is Brian Devitt so I’m going to start with a picture of a patient of mine, this is a lady I did a knee replacement on and we’re hiking here in Vietnam. There’s a couple of features first of all she’s smiling, so she’s pretty happy she’s also using a walking pole and she’s got the appropriate walking equipment including walking boots and her backpack and she’s willing to take the assistance of our guide, she is walking up quite a steep terrain. We see a lot of patients of ours who are interested in hill walking and hiking and it’s a fantastic pursuit it’s one I enjoy myself also but unfortunately they are afflicted by our arthritis which affects the knee and also the hip and our goal is to get them back on the mountain and allow them to continue their pursuits hopefully without surgery but occasionally we need to intervene.

While we were in Vietnam we learned about Confucius and he has a fantastic quote which I think really sums up this this talk and the treatment of arthritis in general “it doesn’t matter how slow you go as long as you do not stop” so that’s the key factor to keep our joints moving.

We all come in different shapes and sizes some of us have straight legs, some of us have bow legs, and some of us have valgus or Knock knees and it also is the same with the hips in terms of the shape of our hip joints and some of those people are more predisposed to getting arthritis particularly people with knock knees tend to get more arthritis in the front of the knee and they can particularly have issues walking downhills.

Long before we go into the surgical we speak to patients in our clinic and we find out what exactly is their issue. Our main goal with any type of arthritis is to try to keep people going as long as they can, but when people start getting a lot of pain within their knees particularly affecting them at night and affecting their sleep that really has an impact in their quality of life, so therefore there those type of patients are more likely to present for surgical opinion if they’ve exhausted all non-operative measures. For the most part GPS and physiotherapists are well able to manage mild arthritis symptoms and I’ll talk to you about the effective treatment in due course.

I wanted to start with just a few x-ray examples of those type of patients we see, so this is an x-ray of someone with bow knees, bow legs and severe arthritis of the inside part of the knee, you’ll see this on both sides, remember this x-ray I’ll show you a bit later how we manage this case. We also get other patients who have maybe knock knees and but if you look at the joint space here on the outside between the femur and the tibia, there’s plenty of space on the outside of the joint and also plenty of space on the inside and this is symmetrical so this person doesn’t have a problem with the inside or outside of the knee, but if you look at the knee from the side you see that they have lots of problems in the front of the knee, where the space between the kneecap and the front of the knee is quite diminished so this person is pain on the front of the knee or anterior knee pain as we call it. We do this other view where you see quite clearly that there is very little space between the kneecap and the front of the femur, so this person would have awful issues going down hills or going downstairs.

We then look at some people and they have asymmetrical arthritis, so this individual he has a loss of joint space on the inside of his left knee with his right knee is fine and the outside of the left knee is also fine so how do you manage these cases and we’ll see an example later on.  We look at the front of his knee and there’s plenty of space between the kneecap and the femur.

We also look at people with hip arthritis and I deal with many of these patients and we see quite clearly on the right hip that the hip is superiorly migrated so it’s moved up compared to the left hip which is a ball and socket joint but you see the ball here is has lost its position and you see the there’s lots of little cysts, these grey areas within the fermal head which is as a result of severe arthritis, so this individual is a keen mountain walker but couldn’t walk because his he had a marked limp on the right side and you can see why. Then we have individuals who have arthritis of both hips and really noticed that their stiffness is a big issue so really struggling to put his walking boots on or struggling to really just get up a hill because he can’t lift his or flex his knee because his hip is so stiff to get up those steep inclines.

I’m going to go back to school now for a bit of physics and you’ll see why Isaac Newton was so right and he wasn’t an orthopaedic surgeon but he knew a lot about gravity and the effect of gravity and we also know that when people have a lot of weight on or hiking that if the load going through their knees particularly going downhill tends to be a lot more. So, if we talk about the weight that goes through our knees or hips when we walk, so we’re just walking twice body weight goes through our knees on average. When we’re walking downhill that increases to four times so we often feel a little bit exhausted going uphill because of the physical demand but going downhill is what really hurts our knees, but if you’re running downhill or running on any surface it’s eight times your body weight so one of the first treatments of arthritis in individuals is to reduce your body weight and that reduces the load going through the knees and the hips so it’s a key factor to remember. Let’s just take a calculation of an example so 100-kilogram male so you imagine a little bit overweight, it’s 400 kg walking downhill that individual is putting through each knee. When we’ve talk about a 10 kg weight loss so it’s 10% body weight that’s 40 kg less per knee per step going downhill so it’s significant with the impact that this has on the treatment of people with arthritis.

Well let’s talk about specifically how do we avoid injuries while hiking. Well I think the key factor is knowing your limits so we’re not going to start off climbing Everest in terms of our pursuit, we’re going to do probably a more of a flat walk to initially and then increasing to an incline.

We also recognize we need to improve strength around the ankle and our general core and strength and our stability within our abdominal muscles, so I often recommend palates as a fantastic exercise particularly with former palates for holistic body approach to maintaining strength.

One of the simple factors using walking poles, so we’re able to dissipate the load going through our knees by helping our knees out with our arms and it adds to good balance so walking poles are fantastic addition when we when we hike to help our knees out. It’s also important to wear the appropriate footwear so we aren’t going to go walking with these type of sandals as you’ll slip or something for with a bit of ankle support is appropriate and it’s also appropriate that the rest of your clothing is correct, that if you’re if you’re walking on icy environments you need some type of crampon or something on the your feet so you can actually get some grip and just be cautious going out if it’s very slippery because you will injure yourself and sustain a fracture and also exacerbate arthritis on occasion.

It’s also really important to hydrate adequately because then you have better physical function you’ll be more equipped for the pursuits that you’re going to engage in.

So, let’s just look at the treatment that works with arthritis there’s a variety of treatments which people have been promoting over the years and this is a very famous quote from Macbeth “Eye of newt and toe of frog, wool of bat, tongue of dog, adder’s fork and blind worm’s sting, lizard’s leg and howlet’s wing, for a charm of powerful trouble, like a hell-broth boil and bubble”. I bring this up because it’s amazing how many people come up to me and have all these outlandish types of treatments and none of these work for arthritis by the way but it’s important just to stick to the tried and trusted in my mind.

If we look at just a Google search of arthritis you’ll find a whole array of different treatments and oftentimes it’s the sponsored ones are the more wacky ones with laser therapy, people suggesting stem cells, with no back up in terms of evidence. I really think it’s important that we stick to the tried and trusted.

Let’s look at the non-operative approach or conservative management some people call it, so keeping up your activity is really important, so by staying still as Confucius told us you’re really going to struggle so you don’t want to stop, keep active, you want to do exercise that is not going to affect you or going to you know give you those sleepless nights because of pain. As I mentioned and I showed you the equations that weight loss is really important probably one of the best methods of reducing the pain with arthritis, acupuncture you know hasn’t been found to be hugely effective but you know it doesn’t do any major harm but I wouldn’t spend a lot of money on it if it’s not going to do good. Massage can help out that sometimes if your muscles are bit crampy particularly around an arthritic knee that can be helpful, using braces provides a little bit of support but hasn’t been shown to reduce the progression of arthritis. Insoles likewise they make you kind of feel that you’re a little more secure in your footwear but haven’t been found to reduce arthritis. Glucosamine has not been found to be effective but it’s a cheap, easy medication to take and in my mind if people want to take it I don’t discourage them if they have the placebo effect at least, that’s good enough for me.

We look at the pharmacological treatment and we see anti-inflammatories and they’re very effective because anti-inflammatories reduce the fluid within the knee when you have fluid within your knee you’re more likely to have inhibition of the muscles particularly the quadriceps, the muscles at the front of the knee and they’re very active them were walking downhill so if you can activate those muscles, because when you fluid they don’t activate if you get rid of the fluid and can activate those muscles you tend to be much less symptomatic. Steroid injections can occasionally be helpful but they don’t alter the natural history of the condition they just give you a bit of pain relief and similarly with hyaluronic acid which is a chondroprotective jelly that can be helpful but only really in the early stages of arthritis, and it’s typically to give you enough pain relief that you can get on with your strengthening exercises. Platelet Rich Plasma once again the jury’s out in terms of its effectiveness but it has been shown to be effective in certain studies.

In terms of surgical treatment in the past people used to get an arthroscopic wash out when they had arthritis and we no longer do that because it hasn’t been found to be effective, occasionally if there’s a displaced meniscal tear with good joint space we can do an arthroscopy to remove a displaced tear but it tends to be not the gold standard treatment nowadays. We can change the shape of the leg if there’s too much load going through one side of the joint and this is typically reserved for younger patients, and this is a salvage procedure to offset or postpone a joint replacement later on but can be very successful in certain cases. Joint replacement therapy is extremely successful when needed and we try to push this down the road as long as we can but when we do it patients tend to do very well following joint replacement.

So let’s just revise or go back to some of the images we saw so this is the first case of bilateral so both knees affected with arthritis so in this individual they have arthritis particularly of the inside but also severe arthritis at the front of the knee and also arthritis towards the outside of the knee so in this case this individual got a bilateral knee replacement, so we actually did them both at the same time because she had um severe arthritis which affected both legs. Nowadays we’re more likely to do both sides, if both sides are affected obviously if only one side is affected we just do that side but it really stands to reason if you get reduce your rehabilitation, the risks aren’t significantly increased by doing both at the same time, but if one leg can’t achieve full extension or full straightening  and you’re doing a joint replacement on the other leg it really is hard to rehabilitate, so that’s why we do both together. If they’re both affected we tend to treat both at the same time.

So this the example of the patient who had the valgus knee with the arthritis under the kneecap, so in this case as we saw previously the joint space on the inside and outside of the knee was well preserved so we just did an isolated joint replacement of the kneecap joint and this was very effective for her. Her issue was walking downstairs and walking downhill and because she’d really no arthritis in the other side of the joint we did an isolated Patel thermal joint resurfacing. This is a very effective treatment for her and she did very well and got back on the hills.

This is the other example of the isolated unicompartmental knee arthritis so just the one side of the knee here on the left side the inside of the left knee and this gentleman we did a partial knee replacement of just the inside of the knee, and once again he got back to all his pursuits without any major issue. In this case his knee felt, really just back to normal because we hadn’t taken away any of the ligaments and we just resurfaced the side of the joint, so you see it quite clearly here and we’re just resurfacing that side of the joint and putting a metal resurfacing and then the plastic in between the two sides of the joint. So, one with the tibia with a tray and plastic which you can’t see in the X-ray lies in between the two joints.

In terms of your knee replacement what I always say is for knees in particular earn your knee replacement, the key factors are weight loss, modify your activity if possible if you need to use walking aids it’s really effective, maintain your strength and physical activity, and use anti-inflammatory medication. From my perspective there’s a limited role for arthroscopy and only seek to have a need replacement when you’re ready and your surgeon will speak to you about this and try to exhaust all non-operative measures before you go down the route of surgery. These are typically the indications, night pain and significant quality of life issues if it’s really affecting your ability to do things you want to do it’s really important.

The next question I ask is how active can I be with an knee replacement and nowadays we let people do whatever they want to do really in terms of getting back to their own activity you recognize that people aren’t probably going to run a marathon at that point, when they get arthritis they tend to be slightly on in years so it’s not in their interest to run marathon but a lot of people can get back on the mountain hiking, skiing, and really do whatever you want to do we’re not very particular in terms of limiting you but most people will be certainly limiting their own exercise tolerance but we definitely encourage to get back to most activities.

I want to share with you a quote I got from a patient of mine who’s a farmer and he misread the postoperative reviews instead of coming back at 6 weeks he came back at 6 months and I asked him did he have any pain and he said occasionally I get pain, I said when do you get pain and he said after sharing 50 sheep so he was a very active man with his knee replacement but he told me something very insightful and I share with a lot of my patients. He said “I quickly realized that it was a case of my knee getting used to me and not me getting used to my knee” and it was really interesting just to turn it that he wanted to get on with his pursuits and his knee just had to come along with him, he wasn’t going to sit down and mollycoddle his knee so it’s a very nice quote I think from his perspective and I think it sums up what we expect for patients after knee replacement.

Finally I just want to show you the other examples we started at the beginning of the talk and this is the example of severe hip arthritis and I do the hip through what we call an anterior approach so we divide between the muscles at the front of the hip, and this allows people to get back to the activities very quickly and this is an example of how we template the hip so we use the x-rays and we measure the appropriate size. The advantage of doing it this approach is I can x-ray during the surgery so I can try to mimic what I’ve templated and also ensure that we get the prosthesis in a good position.

This is the final product so this is a nice hip replacement so you see the hip is nicely balanced now and this individual is back to all his normal activities within 3 months of surgery. The advantage from my perspective with the anterior approach is that we don’t have as many precautions, so some people are you know restricted on how they lie in bed, we’re happy for people to get up and walk the same day of surgery and get back to their normal activities as quickly as they can.

Finally, the other example of an individual who has arthritis particularly infecting the right hip but also arthritis of the left hip where there’s extra bone forming here, so this is the man who really struggled to walk up hills because his hips were so stiff and couldn’t put on his walking boots. Well just like when you’ve arthritis of both knees we did a bilateral hip replacement in this individual so the combined procedures take less than 2 hours and he was up and walking same day of surgery, so he was back to all his normal activities as well. Certainly nowadays can manage most arthritic problems with ease but the key factor is when we choose surgery and the key decision maker in that is the patient. My objective is to get you back on the hills get you enjoying the outdoors for as long as possible.

Yeah that’s a very interesting question, I think in many respects people there’s a genetic predisposition to developing arthritis so we can’t really fight genetics but we can fight our environment and what we put into our bodies. I think you know really keeping fit as we age is so important, it’s important for our physical well-being, but also our mental well-being and I think moving as much as we can within reason is really important as we age but keeping your body weight down puts less load through your joints, so definitely keeping a really physical and active activity level is hugely important.

Yeah so a lot of the stuff which I kind of mentioned in my talk, kind of covers this point and really we want to look at the tried and trusted methods and one of the things that we’re very big on in UPMC SSC is using evidence-based practice, so you know supplements have not been shown to really reduce the rates of arthritis but they don’t do any major harm so if you feel it gets some effect and individuals can benefit differently I would have no problem recommending them. The key factors is keeping the muscles strong around the body and you know doing exercises to strengthen the quadriceps is particularly good for going downstairs, you can have minimally invasive procedures like injections can be helpful in the short term, but as I mentioned once the pain gets so severe that it affects your quality of life and particularly your sleep you’re looking at you know more invasive methods like joint replacement which are very successful.

I think you just need to be sensible regarding what to do afterwards and we recommend in the early phase that really the key focus is regaining range of motion and normalizing one’s gaze I think that’s really important so we walk before we run and I think you know doing the likes of hiking is a little bit more robust and it requires more energy and it puts the knees through a greater degree of load so we have to be prepared for that I think building up the strength in our lower legs is really important before we embark on a hike. I think then it’s also just listening to your body, I think in the early postoperative period there’s still a lot of swelling and I have a little phrase that with respect to the wound that, once the wound goes white there’s no pain at night, that once you see your wound whitening it means the inflammation has gone and you stop having discomfort in the evenings. That’s really a good phase where you get back into the more rigorous activities like hiking.

It’s hard to say I think the modern hip replacements really are fantastically manufactured and they can last for a really long time. I was at a conference recently and one of the presenters was asked that same question and they had a good answer which says that there’s a failure rate of 1% per year, that the hip replacement is in, so if you think about 20 years you have a hip replacement there’s an 80% chance that that hip is going to be functioning very well and that’s failure for all causes um so I think that kind of rule of thumb probably applies.

As I said that kind of fits into my phrase, no pain at night if the wound yeah so I think that you’d expect the pain to dissipate by probably 12 weeks so three months postop. A little bit of discomfort is no harm and I probably emphasized that she’s doing some good work as it sounds from her range of motion. So, really she can start integrating maybe some gentle inclines in her walks and definitely take some walking poles and really start getting back into it but start with small little you know hikes not too long don’t get stranded up a mountain and in pain and if there is a little bit of discomfort after hike there’s no harm at that stage taking some over the counter anti-inflammatories if it is a little bit painful. Although we’re very much of the opinion you need to use your knee and as I mentioned that quote don’t let your knee define your life you just go on with your life your knee will follow.

Yeah so, I think labral tears in in the hip an awful lot of times they’re precursor to developing arthritis I think you know if they’re very painful and you know there’s a lot of swelling in the hip, taking anti-inflammatories is very important. An injection can be helpful if there’s fluid in the hip and a lot of these label tears will settle down with time so it’s kind of avoiding any kind of deep flexion can be an issue, so if the individual is height and very steep inclines that might exacerbate the pain. So, building up the strength and just treating the inflammation is the key factor in managing label tears.

They can it relates to the posture, one has when they walk I think it’s really important if you can’t extend your knees you tend to walk with the more flex posture of your knees and if you try to walk with your knees flexed you’ll find your hips flex over and then it puts a bit more strain to your lower back. We often find people particularly with hips actually less so with knees, but do present with lower back pain and oftentimes when you resolve the contracture or stiffness within the hip, by a hip replacement the lower back improves, it doesn’t completely settle in all cases because you can have arthritis there too but it typically improves and likewise with the knees if you get the knees straight.

Yeah well I have no problem with people taking Difene provided there’s no contraindications in terms of other medications they’re taking but you know occasional Difene is not that harmful and if it’s taken as per the recommended methods, after food and if there’s any gastritis you can take some proton pump inhibitors to help the stomach but really occasional Difene is helpful if you have inflammation and in fact it’s very useful to reduce the inflammation in the joint and allow the muscles work so I’d say it can really treat a lot of problems very nicely. If you’re taking it on a daily basis that’s something that you need to look at and discuss that with your GP because it probably means that your joint is worse than you maybe think it is.