Dr. Karkare was the guest, on a local cable access show here in New York, discussing joint replacement options and techniques.
This is the entire episode as it ran in here in New York in mid October from our local PATV channel 20…
Video Transcription:
Host: Hi I’m Larry Mikorenda and welcome to this edition of Excelsior Forum. Continuing with our medical series and we’re really great and glad to have him on, is Dr. Nakul Karkare who is an Orthopedic surgeon and thank you so much for coming on the show.
Dr. Karkare: It’s great to be here Larry.
Larry Mikorenda: We have so many topics to go on because medical and technology seem to be merging and going on. Can you tell the audience a little bit about your background, yourself.
Dr. Karkare: Sure I’m a orthopedic joint replacement surgeon, so I have fellowship training in joint replacement surgery, metabolic bone disorders, sports and orthopedic trauma, but what I specialize in today and the focus of my practice today is joint replacement surgery, especially hips and knees.
Larry Mikorenda: I was gonna ask you one of our first questions, a lot of things going on with hips now especially when people get over 40 – 45 you hear all this stuff about osteopetrosis, calcium deficiency and everything like that, it could be a small thall, it could be a lot of things. How do people know when is it time to come and see a doctor about their hip?
Dr. Karkare: So what I tell my patients is, we want them to be active and pain free. It’s extremely important for patients to maintain that activity otherwise the muscles atrophy and it’s not good for them in the long term.
If a certain activity bothers, I ask them to slow down on that activity for some time, take over the counter medications but if the pain continues its very important to get an orthopedic evaluation so that the problem can be nipped in the bud.
Larry Mikorenda: Now what is some of the symptoms that you would have with hip pain, you know would it just be no more walking, you know other…
Dr. Karkare: So hip arthritis which is most of the problem that I deal with on a regular basis, presents as pain in the groin, its present as pain in the front of the hip. Patients have trouble with pain and stiffness. They have trouble getting in and out of the car, going up and down stairs.
When patients get into the car, they may need to lift their leg up with their hands because of the pain in the groin. It’s very important to differentiate pain that is coming from the back from the hip pain because it’s the same nerve that supplies the back and hip.
As a matter of fact, hip arthritis can sometimes present with knee pain because it’s the same nerve that supplies the back, hip, and the knee and that’s why a clinical examination is extremely important in the evaluation of patients with hip and knee pain.
Larry Mikorenda: Now people refer to sciatica, is that the sciatic nerve that you’re talking about?
Dr. Karkare: The pain of sciatic nerve, [inaudible 00:03:47] and the femoral nerve, but because it’s the same nerve that supplies the two joints, and the skin overline the joint, it sends a message to the brain that the pain is coming from all of the three places.
I do thorough clinical evaluation, now the clinical evaluation usually can differentiate back pain from hip pain, and knee pain. You also do other diagnostic tests like x-rays. If there is ever any confusion on where the pain is coming from then we may need a ration of investigations like an MRA.
There are very rare occasions that we cannot even differentiate where the pain is coming and under those circumstances we inject a painful joint with a numbing medication, something like Lidocaine or Marocain, and once that injection goes inside the joint that pain goes away so we know exactly where the pain is coming from.
Larry Mikorenda: So it helps you narrow it down. Now a lot of people hear hip replacement and they get scared and terrified, that might have been the case twenty thirty years ago. Now, we had talked before the show and you told me you have some patients who get the hip surgery. They are up and on their feet in no time. Can you explain a little bit about that?
Dr. Karkare: Sure, so today we have some fascinating technologies and that has allowed us to make remarkable changes in the way we treated people with hip and knee arthritis. Today we have newer designs, less invasive techniques, and better materials that have allowed us to do joints in very young patients.
Younger and younger patients also are now candidates because of these newer technologies. Most patients are able to get up and walk the same day of surgery, they can put as much weight as they want to on their leg, next day they’re walking with a walker then eventually with no support at all. Joint replacement surgery is one of the most gratifying surgeries in orthopedics today.
Larry Mikorenda: I would have to say that someone comes into your office, they’re on crutches, can’t walk or in a wheel chair and then after the surgery a day or two they’re walking into your office and talking to you like nothing happened at all, right?
Dr. Karkare: Orthopedic joint replacement surgery is very gratifying, it takes time for patients to get better. The pain that they had before the surgery is gone after the surgery, what they do have is surgical pain which gets better with time.
Hip replacement surgery is a little more gratifying than knee replacement surgery because the pain after surgery is gone within a few days. Knee replacement surgery involves a lot of rehabilitation and I tell my patients that they are not happy in four weeks, it takes about six weeks for them to light at the end of the tunnel –
Larry Mikorenda: Right.
Dr. Karkare: And at three months they are significantly better as against hip – hip replacement patients are doing pretty well within a few weeks time.
Larry Mikorenda: Now as far as prevention is concerned, is like walking good for people who have arthritis in their hips?
Dr. Karkare: So arthritis is more developmental, there are many reasons why patients develop arthritis, a big factor is genetics, your parents may have arthritis, your grandparents may have arthritis and that’s one of the reasons why develop arthritis especially as they grow older.
There are certain types of arthritis that are associated with certain disorders like a vascular necrosis or gout, rheumatoid arthritis, and we have excellent medications for that today to keep the patients joints healthy and active, and avoid the need for joint replacement surgery.
However, as I mentioned before we want patients to be active and pain free, walking typical is encouraged, what we don’t want patients to do is any impact type of activity because that’s going to increase the pain from the arthritis. Swimming is an excellent exercise.
What happens is even for patients who are not able to swim they can walk in the water and that off loads the weight of the joint and maintains muscle flexibility. So, swimming is an excellent exercise for patients who have arthritis and are trying to delay or are waiting for joint replacement surgery.
Larry Mikorenda: Now, how does obesity play into this with the hips because the extra weight to strain, now everybody knows when you’re in water you weigh like half the weight but obesity does that have a big play in, on your hips and knees.
Dr. Karkare: It does. Obesity has become an epidemic in the United States and more you weigh, more weight goes from the hips, through the hips and through the knees. And, the pain from the arthritis is more if you have a BMI of more than 35.
Additionally, if you’re is BMI is high, your risk factors are increased after surgery which means that the risk of infection is more after surgery for infection, for blood clots and many other risk factors increase due to obesity.
Larry Mikorenda: So that constant strain on the hips and the knees is not good. So, it’s best to keep your body mass index down. Try to keep your weight down. Not that everybody can be super thin all the time but, what is the average age for people that get hip replacements? Is it all ages or is just over forty or over sixty?
Dr. Karkare: So most hip and knee replacements are done in patients in their fifties, sixties, and seventies however there is no age that is exempt. I’ve done hips and knees in patients who are in their early twenties, and I’ve joint replacement in patients who are in their eighties.
I follow the three strike rule for anybody who is a candidate for joint replacement surgery and this is very important. The most important thing that I consider when booking a patient for joint replacement surgery, is are they able to do their activities of daily living without pain. That is the first and the most important strike.
So if they’re not able to do their activities of daily living then that’s a very important strike. The second strike is on examination I know that the pain is coming from that joint, and the third strike is if they issue with arthritis. Only if these three strikes come together do I discuss joint replacement surgery with the patient.
Larry Mikorenda: Alright, so if you have grandma and she can’t pick up the grandkids anymore or grandpa needs help getting dressed or getting his shoes on, things like this are the quality of life issues?
Dr. Karkare: Absolutely.
Larry Mikorenda: Those are major factors in going on, because a lot of people have asked me they say you know I’m pretty sure you hear this all the time, hey Doc I got a pain, right what does arthritis in the hip feel like, what is the symptoms, what should we look for?
Dr. Karkare: So arthritis presence has pain in the joint, it also presents as stiffness in the joint, people are unable to do their activities of daily living like going up and down stairs, getting in and out of the car, squatting, getting in and out of the chair is an issue in advanced arthritis.
They’re unable to walk. They walk with the cane or with crutches, or with the walker. Hip arthritis patients walk with the cane in the other hand, so if I have hip arthritis in the right hip I would be walking with the cane in the left hip, so there are many ways that arthritis presents to me.
Larry Mikorenda: And is it the redness, the swelling stuff like that that people would notice?
Dr. Karkare: Redness and swelling is a sign of infection, not a typical sign of arthritis. If you have redness and swelling associated with hip pain with high grade fever, it’s a sign of infection and that’s a reason for somebody to be evaluated immediately.
That person needs to probably go to the ER, if they have pain, redness, swelling, inability to move the joint, and high grade fever that’s a sign of infection.
Larry Mikorenda: And it can be some real nasty infections that once they get into your joints they do permanent damage, right?
Dr. Karkare: Absolutely and it’s very difficult to eradicate so if you go through extensive measures to prevent infection during surgery.
Larry Mikorenda: Now hip replacement, each individual each patient is different but I had one question from a woman was that are women more prone to getting hip arthritis than men, and you had answered this before the show but I’d like it if you could share that with the audience.
Dr. Karkare: Sure, so knee arthritis is more common in females than males. Hip arthritis is almost the same in males and females. There are certain conditions which make a patient more likely to have hip arthritis, as example there’s a condition called hip dysplasia in which the ball and the socket are not congruent so the ball is not completely covered by the cap.
What happens because of that there are increased stressors in the hip joint and make the hip more prone for arthritis. Similarly, you may have seen patients with bow legs or knobbed knees, because of the deformity more pressure goes from one side of the joint and that joint tends to degenerate, and arthritis happens in the joint.
Larry Mikorenda: Now we also had a question from someone who said, why is it when I go to sleep at night, my hip hurts but when I’m walking around during the day I’m fine, so that’s a big one for you.
Dr. Karkare: So we hear that all the time, with arthritis especially when patients are sleeping their muscles are relaxed, and when the raw part of the bone comes in contact with the raw part the patient suddenly gets pain and wakes up, this is a very common sign of arthritis, of the hips and of the knees.
Larry Mikorenda: So there’s no real quick remedy for that when you know, I mean would people take like a proximate sodium for something like that, cause that would be my next question, you know what is some of the treatments that are available until maybe the replacement is necessary that they can do, what’s some of the treatments that you might offer?
Dr. Karkare: So arthritis is the progressively deteriorating condition eventually when arthritis happens it progresses, so for patients if they consider how they were last year they would be worse, the year before that would be better than this year, but we have many ways to keep the pain down from the arthritis.
What we don’t want patients to do is take prescription pain medications for a variety of reasons. Intuitively it makes sense, I have pain take pain medications wrong answer because, again arthritis is a progressively deteriorating condition you can get hooked on to these pain medications, most certainly no narcotic pain medications.
The other medications can spoil the inner lining of your stomach, they can spoil your kidneys so we don’t want patients to be taking medications in the long time. Additionally, when patients need surgery, the pain threshold has already increased,
So after the surgery, they need even more pain medication than they are not able to cooperate with therapy and the risk of complication increases.
So for a variety of reasons, we don’t want patients to be taking prescription pain medication and so even over the counter medications, once in a while cheating with the over the counter medications is fine, but not on a regular chronic basis.
Larry Mikorenda: Yeah especially with the opioid crisis and everything else that’s going on, and like you said there’s a big trade off, a lot of people, there’s what they call opioid constipation, there’s the lining of the intestines, the stomach, the bowel, the colon like you’re saying.
Dr. Karkare: Absolutely. Larry this is a very common mistake even made by physicians. You have pain alright let me write you a script for pain medication, wrong answer but we have other methods to keep the pain and keep patient active.
One excellent option is a injection of cortisone, so patients can get an injection of cortisone inside the joint. I mix cortisone with a numbing medication so when the patient walks out of the door, they have no pain.
The numbing medication wears away and the cortisone kicks in a few days time, depending on how bad the arthritis is the cortisone can last for weeks to months to years sometimes. There are also other injections like these gel injections or these looser zone injections [crosstalk 00:17:27].
Larry Mikorenda: That was going to be my next question, they talk about collagen and chicken broth shots or something like that.
Dr. Karkare: That’s right. So that’s a different mechanism of action, there are also PRP and stem cells injections which is still under the research phase, but we do a lot of things to keep the pain down without giving them pain medications.
Larry Mikorenda: Now some of these like collagen they say it looks like the gelatin that forms on top of your chicken broth or something like, that there’s a purified form that you actually inject into some of these people that need problems solved.
Dr. Karkare: That is right, and if done for the right indication that gives relief for a really long time and can delay the need for joint replacement surgery by months and sometimes by years.
Larry Mikorenda: Now as we get to the hips a lot of people think oh it’s an old age disease there’s people over forty, you get into the knee that’s fair game for everybody and one of the questions that we had was about a torn meniscus in the knee, so what is the meniscus in the knee, what is it do what’s its function?
Dr. Karkare: So meniscus is the cushion between the two bones, and meniscal tears are a very common thing that I see in my practice. I solely get meniscal tear in a younger patient with no arthritis. it’s quite different from a meniscal tear in a older patient with arthritis.
So meniscal tear with arthritis is part of the arthritic process, the cushion wears down, the cartilage wears down and the patient has arthritis. We do not treat these meniscal tears for the reason that it’s part of the arthritic process, okay? We don’t do surgery on these meniscal tears for patients who have arthritis.
For younger patients where there is no arthritis and when there is a tear in the meniscus, we do surgery in which we removed the deceased part of the meniscus and the patients are good for a very long time. Most meniscal tears get better with pain pills like anti-inflammation medications.
Again for a very short time, with physical therapy, with rest and some time. Only if the meniscal tear does not get better do we consider surgery and we give many, many weeks for the meniscal pain to go away.
Dr. Karkare: Very interestingly, the meniscal tear does not heal but the pain goes away and that’s what matters.
Larry Mikorenda: Yeah, now I had been looking up some of the medical books and tell me if you concur with this that people understand when they say arthritis and everything.
When you take an x-ray of someone’s knee, you can tell right away if they have arthritis and what the doctor’s looking for.
And maybe you’ll explain this a little bit is that most joints are smooth and when you get arthritis it gets rough like sandpaper, and that is your pain and your problems would you say that’s pretty much accurate?
Dr. Karkare: That is right, so the most important thing that I want to drive home is that I treat patients, and not x-rays or MRIs.
Larry Mikorenda: Okay.
Dr. Karkare: And that’s really important. If a patient has arthritis on the x-ray, who cares if the patient does not have pain we go after treating the patient. We don’t get driven away by an x-ray report or by MRI report.
Sometimes the patient comes and shows me a report, oh this is what my MRI shows it shows a meniscal tear. Do you have pain? No.
Then forget about the report it doesn’t matter, and interestingly even if the patient has a big deformity, a deformity cosmetically may not need correction.
If there’s arthritis asscoiated with the deformity we don’t need to treat the deformity but when the patient does need joint replacement surgery we can fix any sort of deformity, the surgical exposion may be a little more the implants need may be a bit more, but what we treat essentially is the pain from the arthritis.
Larry Mikorenda: Now another common with the knee is cartilage damage. How can you tell if you’re a normal person that you have cartilage damage it’s not just a touch of arthritis or something else?
Dr. Karkare: So arthritis means that the cartilage is worn down, and the bone is rubbing on bone. The patients present with symptoms of pain, stiffness, on examination the range of motion is restriction, and there is tenderness on the join and on x-ray you can see that the join space has decreased.
In early arthritis the x-ray may not show arthritis, but if you get MRI it shows more clarity on how the cartilage looks, and that’s another way to know if the patient has arthritis.
Larry Mikorenda: Are there some other knee ailments that are caused, that just happen without being like a working out on sports, or a swimmer or a bowler or somebody who’s very physically active?
Dr. Karkare: Contrary to popular opinions [inaudible 00:22:41] don’t lead to arthritis. There’s a genetic predisposition that causes arthritis, there’s so many runners, so many active people who never develop arthritis over their entire lifetime.
And yet there are some very young patients who have arthritis in their twenties and in their thirties, so sporting activity does not necessarily correlate to having arthritis.
Larry Mikorenda: With, you were talking about the younger people and the knee, besides surgery the other treatments that you mention you were talking about shots and stuff to the knee, are there other treatments available, I know they’re doing a lot of stuff with electronics now and stuff like for pain. Is this something that you see in the future with medicine going that way?
Dr. Karkare: What I see in the future is a big use of stem cells for regenerating cartilage, we’re not yet there. In the lab we’ve been able to regenerate cartilage, there are certain substances which regenerate cartilage in the lab however, when you take orally how much it affects the cartilage in the joint is yet to be resolved, but I see stem cells coming up in a very big way in the next several years and decades.
Larry Mikorenda: What would cause knee pain without injury?
Dr. Karkare: There are many reasons for getting knee pain without injury, one could be a meniscal tear like we discovered before. Other reasons could be what we call a vascular necrosis which means the blood supply to the part of the joint is cut off and that can happen because of many genetic disorders.
It can happen also due to chronic alcoholism, or it could happen without any reason so if the blood supply to the joint is cut off it’s called a vascular necrosis, and that can give rise to sudden bouts of pain in the knee joint.
Larry Mikorenda: How would you know that you’re a good candidate for knee replacement surgery?
Dr. Karkare: I follow the three strike rule.
Larry Mikorenda: Again back to the three strikes, okay.
Dr. Karkare: The most important thing is pain interfering with activities of daily living, second strike on x-ray we see arthritis, and the third strike is on examination I know the pain is coming from that joint. Only of these three strikes come together I talk about joint replacement surgery.
Larry Mikorenda: Here’s one of the most biggest one that people should pay attention to, what can we do ourselves to help prevent hip and knee damage?
Dr. Karkare: The most important thing that patients can do is keep their weight down. Maintain a healthy lifestyle, keep your muscles strong, do stretching on a regular basis, if the pain continues to bother you, you stop that activity and get yourself evaluated. If there’s a problem nip it in the bud.
Larry Mikorenda: My next question before we wrap up here is people say diet has a lot to do with it, and constantly on the T.V. you’re seeing these joint pills, and seaweed, and eaten the bark off a tree is gonna help you with your joints and stuff, is this true about the diet? Are there some things that will help your joints or is just old wives tales?
Dr. Karkare: I’m not paid by any pharmaceutical companies so, I’ll be honest with you. [inaudible 00:26:13] sulfur and MSN are the most common supplements available in the market for arthritis. They worked well in the lab in a Petri dish, but the literature is not very strong when you take it orally for hip and knee arthritis.
Some people swear by that and I get it but many trials have shown that the pain and the decreasing pain that happens from the arthritis, when you compare just over the counter and doctor recommended medications to [inaudible 00:26:46] it’s almost the same, and these medications can cause problems some patients may be allergic to it.
Larry Mikorenda: Yeah I was gonna say allergies.
Dr. Karkare: And they’re costly, so it hasn’t really panned out very well, might as well take some anti-inflammatory medications, and going back to our conversation before we don’t want patients to be taking medications at all when there are excellent options like injections that will keep the patient pain free for a very long time, sometimes for months and sometimes years.
Larry Mikorenda: Well Dr. Karkare we’re basically out of time, but I’m hoping you’re gonna come back and do a part two with us –
Dr. Karkare: I look forward to that.
Larry Mikorenda: And tell us all about more of these things that are going on, we didn’t get to touch on the advances in medication and all these other treatments that are now available, but I did want to thank you for coming on.
If you have any questions or like to know a little bit more about Dr. Karkare, you’ll see his website at the end of the program. And probably during the program too we’ll sneak it in there, and he’ll be more than happy to answer any of your questions. Till then, I’m Larry Mikorenda we’ll see you right back on this channel.
