Sunday, October 30, 2011

Better alignment could cut need for hip replacements

By Dr. Lou Pack, Special to CNN  October 28th

Editor's note: Dr. Lou Pack practices in the Atlanta area, is a founding fellow of the American College of Rheumatology, a former clinical instructor of medicine at Emory University School of Medicine, a board-certified foot and ankle surgeon and the author of, "The Arthritis Revolution: Latest Research on Staying Active Without Pain Medication or Surgery," available on

(CNN) -- On October 4, Brian Williams continued his "NBC Nightly News" report on the "Largest Medical Device Failure Ever," involving "metal-on-metal" hip replacements manufactured by DePuy, a subsidiary of Johnson and Johnson.  (Click here to get to the Video: )

Originally reported in The New York Times on August 28, 2010, the story says 93,000 of these implants were recalled because of fracturing, dislocations, pseudotumors and metal particles flaking off and entering the bloodstream.

With all the recalls on our parts, you would think we were cars. And much like our motorized counterparts, this recall was not issued until more than two years after the Food and Drug Administration received complaints. Williams said that "so far this year, the FDA has received nearly 11,000 such complaints about metal-on-metal implants." By far, this is not the only recall. In July 2008, Zimmer Holdings issued a similar recall on its Durom Hip Cup, which had been used in 12,000 patients.

According to the National Center for Health Statistics, in 2004, there were more than half a million hip and knee replacements in the United States, and the numbers are growing. Researchers have predicted that if current trends continue, total knee replacements will increase 525% by 2030, and annual costs for knee and hip replacements will reach $62.5 billion by 2015.

Often, these prostheses don't last either, many needing replacement in 10 to 15 years. Although there are implants that have helped people regain active lives, obviously what we are doing is not working. Even though I was trained as a surgeon, I learned long ago and still believe that the best surgery is the one you can avoid.

So why are all these implants needed? By far, the largest numbers are utilized for those with osteoarthritis, the most prevalent form of arthritis, and now the No. 1 cause of pain and disability in the United States.

The National Institutes of Health, Arthritis Foundation, Centers for Disease Control and Prevention, and other reputable sources consistently list age, followed by weight, as the leading cause of osteoarthritis: Live long enough, and we will all get it. And despite the introduction of many new drugs and advanced surgical procedures, misunderstandings regarding the true cause of this disease have resulted in medicine's inability to prevent or stop it. This has led to an epidemic number of arthritic patients.

Indeed, some of what we have learned about osteoarthritis truly makes no sense, and one does not have to be a physician to come to that conclusion. It seems we are confused about the difference between a correlation and a cause.

We could say for example, that heart disease is also caused by age, since far more older people have it than do younger ones. Yet age is not a cause, but rather a correlation. In both heart disease and osteoarthritis, the pathological process actually begins in childhood, but it takes years before symptoms and tests can confirm the diagnosis.

In almost all cases of osteoarthritis, one knee or hip joint begins to hurt a patient first. Sometimes, that joint is the only one that ever shows symptoms. Certainly, one knee is not younger than the other. And in cases where both knees and hips are involved, the onset of one most always precedes the onset of the other and is more severe. If age is the primary cause of osteoarthritis, why do some 90-year-olds have no arthritis of their knees or hips, while some other far younger people have severe arthritic changes in these same joints, even in cases where there is no history of prior injury?

This logical fallacy is true of weight as well. As is the case in older people, many overweight people only have one knee or hip joint involved. Is all their weight on one side? Some significantly overweight people have no joint problems, whereas others, weighing far less, have arthritic joints. And why, if someone loses that excessive weight and has a joint replacement that is stronger than the original, does that same joint often have to be replaced again? There must be other causes.

Although many factors are involved, the average car's tires will wear out in about 40,000 miles. It can also be assumed that if you live to 80 or 90 years of age, some of your cartilage will also wear out. So age certainly is a factor. But you also know that you can drive just 10,000 miles in poor alignment and get far greater wear than you may have at 40,000 miles with properly aligned tires. That's exactly what happens to us: We get osteoarthritis of a particular weight-bearing joint because of improper alignment, which increases friction and pressure on a localized area of that joint, causing it to wear unevenly and prematurely.

Carry extra weight on that poorly aligned joint and yes, weight, too, is a factor. But make no mistake; it is the abnormal alignment that precipitates the process. And my work of 40 years shows that the correction of these misalignment issues has a very positive, often immediate effect on eliminating the symptoms of this disease, at times, even in very severe cases.

Medicine is traditionally very slow to change its thinking. Yet there is a wealth of credible data based on reliable studies to validate my premise that hips.

Sharma and colleagues published their findings in the prestigious Journal of the American Medical Association in 2001. They found that abnormal alignment of only 5 degrees from the ankle to the hip increased the progression of osteoarthritis three to four times and concluded that osteoarthritis was therefore a result of local mechanical factors. In 2008, researchers at the famed Mayo Clinic confirmed the results of this and a number of other previous studies and found that there was a 55% increase in the risks of arthritis of the knee for each degree of bad alignment from the ankle to the hip and stated that "age was only weakly associated with an increase risk."

You may have heard stupidity defined as "doing the same thing over and over and expecting a different result." We must begin to realize that the very same laws of physics apply to us as they do to all other things in the universe. The accepted science of biomechanics, i.e., the application of physical laws to human motion, is based on this and is something that must always be considered in those with osteoarthritis of their weight-bearing joints.

Abnormal alignment, such as a longer leg or flattened foot, primarily aligned by optimizing the position of our feet, the foundation of our entire skeletal system, is the root cause of osteoarthritis, and until we accept this, we cannot prevent or stop this disease. It is high time we focus on this, instead of continually trying to produce a better run-flat tire.

[ Connie's comments:  The idea that alignment might be the primary cause of these hip and knee problems is a really interesting proposition which  I had not heard before.    I wonder if the old adage is correct:  If you seek advise from  a surgeon, "the problem" will always be solved by cutting.  If you seek advise from an internist, they will investigate non surgical solutions first.  Just a thought.]

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