Ask the Doctors December 2018 Issue

Ask The Doctors: December 2018

Q: I’m 80 years old and I have terrible osteoarthritis in my knee. I can’t go up and down stairs, and the pain keeps me awake at night. Am I too old to get a knee replacement?

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Arthritis Advisor Editor-in-Chief Steven Maschke, MD, Department of Orthopaedic Surgery, Cleveland Clinic Orthopaedic & Rheumatologic Institute.

A: Your overall health is more important than your age. There’s no upper age limit for joint replacement surgery. Talk to an orthopaedic surgeon to see if you meet the criteria.

Osteoarthritis occurs when cartilage, which covers the ends of bones in joints and allows bones to glide smoothly against each other, wears down. The space between bones narrows and the surfaces of the bones change shape. This can lead to inflammation and pain. Eventually, bone can rub against bone. Osteoarthritis is always treated with nonsurgical measures first, including physical therapy, medications, use of a brace and maintaining a healthy weight.

When arthritis worsens to the point where these are not effective and the pain and disability seriously limit your daily activities, it’s time to think about surgery. Your age doesn’t disqualify you. In fact, having the surgery can have positive effects. Your mobility, including walking and climbing stairs, should improve after surgery and rehabilitation, allowing you to be more active.

With a knee replacement, the cartilage and some bone are removed. An implant made of metal and plastic replaces these. Like all surgery, it involves some risks, including blood clots and infection. But these are rare. Your surgeon will assess your general health and ability to withstand surgery. He or she will consider all past and current medical issues, as well as the medications you are taking.

Knee replacement won’t give you the knee you had when you were young. But it can dramatically reduce pain and improve function.

Q: I was treated for melanoma, and I am now cancer free. But I have arthritis as a result of the treatment. Why is this? What can I do about it?

A: New drugs called immune checkpoint inhibitors have revolutionized treatment for certain cancers, including melanoma and Hodgkin lymphoma. They are showing promise for other cancers as well. Examples of these drugs are pembrolizumab (Keytruda®), atezolizumab (Tecentriq®), ipilimumab (Yervoy®) and nivolumab (Opdivo®). These powerful drugs fight cancer by boosting the body’s own immune system. Cancer cells send out signals that block the ability of immune system cells to recognize and kill them. The new drugs inhibit these blocking signals, thus unleashing a stronger immune system response.

This has worked well for many people with cancer, including former President Jimmy Carter, putting them into remission. But these drugs may have unintended consequences. As immune checkpoint inhibitors have become more widely used over the past few years, physicians have noticed a growing number of their patients developing an inflammatory type of arthritis that resembles rheumatoid arthritis.

An overactive immune system is behind autoimmune diseases, such as rheumatoid arthritis. With rheumatoid arthritis, the body’s own immune system attacks healthy tissue, mostly around joints. It seems that enhancing the immune system response with the new cancer drugs may have a similar effect.

Not everyone who uses an immune checkpoint inhibitor develops arthritis, and it's not known how common it is. Treatment may include a powerful anti-inflammatory drug, such as prednisone, and other drugs commonly used to treat rheumatoid arthritis.

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