Treating OA Is a Journey

By Jill Tyrer

Travis Salmon wasn’t the type to let a little ankle roll knock him out of the game. When he twisted his ankle playing basketball in high school and college, he did what was expected: He iced it, popped an ibuprofen or acetaminophen, wrapped it up and got back in the game. And it served him well at the time. He earned a full college scholarship for basketball and played on a Division 1 team. He didn’t know the price he would pay for those repeated ankle injuries.

He was in his late 20s when his doctor diagnosed end-stage osteoarthritis (OA) in his ankle and pronounced that, at some point, Travis would need to have his ankle fused.

“I was young man. I was fresh out of law school, former Division 1 basketball player still playing multiple times a week at a high level,” says Travis, now 47. “That news hit me like a ton of bricks. I spent the next 15-plus years actively trying to prove that doctor wrong by looking anywhere and everywhere to avoid ankle fusion.”

Believing that fusion meant permanent loss of movement in his ankle, he became intent on finding a way of improving his pain and mobility — and quality of life — without fusion.

“Physical pain was always a huge part of my journey, but the mental and emotional aspects for me with OA was every bit as impactful and difficult as the physical part was,” he says. “It really limited what I could do with my kids and my wife. As an example, I would plan our family vacations around things that didn’t involve much walking. Those are big moments, but there were multiple small moments on a daily basis — grocery shopping and how am I going to carry my kids around? Walking my dog, getting up and down stairs.”

Surgery? No, Thanks

Travis’s reaction isn’t uncommon. OA has few effective treatments short of joint replacement or fusion in some cases, like ankles. Knee and hip replacements are now among the most common surgeries in the U.S., with mostly good results. But any major surgery has inherent risks, and joint surgery can involve an extended recovery period. Most people try other options before choosing surgery, a more permanent but potentially riskier solution.

“For some people, surgery [means] pain. There are potential complications. There’s the rehab time,” says sports medicine surgeon Scott Rodeo, MD, vice chair of orthopedic research and co-director of the orthopedic soft tissue program at the Hospital for Special Surgery (and head team physician for the New York Giants). And implants wear out over time, so younger patients often need a second surgery down the road. If they can get relief from a therapy that’s “quicker and simpler, that’d be the place to start,” Dr. Rodeo says.

When orthopedic surgeon Timothy Badwey, MD, first met with Travis in 2003, “He had had the types of ankle-rolling injuries that basketball players get. They roll their ankle, then they hobble off the court and get taped up and they’re back in the second half,” says Dr. Badwey, clinical professor of orthopedic surgery at University of Missouri, Kansas City, and associate program director for orthopedic education at St. Luke’s Hospital in Kansas City. It was Dr. Badwey who told Travis an ankle fusion was in his future, but he didn’t push it.

“From a surgical standpoint I tend to be very conservative,” he says. At the time, though, Travis had a bone spur that was impinging his ankle movement, which Dr. Badwey removed. “It’s addressing the symptoms of the arthritis because you can’t cure the arthritis. You’re basically buying him time before he has to have a bigger operation.”

Exploring Options

Over the next 15 years, “Travis would drift into my life and then disappear for sometimes years at a time,” while he tried other options, Dr. Badwey recalls. “At one point he went and saw a doctor in Iowa, who I know fairly well, who was doing a procedure called distraction arthroplasty, basically for people who are younger and trying to avoid something as limiting as fusion.”

That was in 2007 at the University of Iowa, Travis says. “I was part of a clinical study, and they put a fixator on my ankle —17 pins through my foot and ankle for three months to spread my joints out. When I got that fixator off, it actually did help alleviate the pain for maybe a year, year and a half,” he says, “but it eventually went back to getting worse.”

He also tried compression wraps, over-the-counter and prescription braces, shoe orthotics, physical therapy, massage, myofascial release, acupuncture, anti-inflammatory and pain medications, supplements and corticosteroid (steroid) injections. In 2016, he traveled to Washington state from his home near Kansas City, Kansas, to be fitted for and trained on an “ExoSym device,” he says, “this huge brace that fit underneath my foot and all the way up to my knee.” Also in 2016, he traveled to Philadelphia three times for a series of stem cell treatments. “That, unfortunately, didn’t help enough either.”

All along, he continued staying as active and healthy as possible, “because I knew that was one way I could combat arthritis,” he says. But instead of basketball, running and tennis, he walked, swam and rode his bike.

Travis finally concluded that he had exhausted his options. After more research into ankle fusion and speaking to people who had experienced it, he decided to move forward with the surgery.

“I realized there would be more movement than I anticipated, so I chose to do it. I had it done in September 2018, and it has changed my life for the better. I’m able to do things I haven’t been able to do for the last 20 years.”

It did involve a long recovery — about a year. “But I can walk, run, jog, I can do so many things,” he says. “There’s much more movement up and down and side to side than I thought there would be, and my gait has improved where people don’t even notice that there’s a limp. I actually think I walk very normally now.”

Doctor’s Advice

Travis’s journey to surgery might have been more complicated and expensive than others’ but it’s common for people with arthritis — osteoarthritis especially — to try other measures first. In fact, Drs. Badwey and Rodeo both encourage it.

“When I meet someone for the first time and we talk about surgery, I require they go home and think about it,” Dr. Badwey says. And he encourages them to get another opinion. “If a doctor gets upset because you go and get a second opinion, that doctor either has an ego problem or has something to hide.”

“The job of the surgeon is to explain the options for treatment after diagnosis, what to expect over time, and what the treatment options are and the pros and cons of each,” Dr. Rodeo says. “You have to go through all the conservative options and then the surgical — what we know, what we don’t know, risks versus benefits of each — so that they can participate in the decision. Eventually it’s a shared decision-making type of thing, an informed decision on the patient’s part.”

People considering knee replacement, for example, generally try oral anti-inflammatory medications, physical therapy, activity modification, weight loss, bracing, and corticosteroid or hyaluronic acid (HA) injections, Dr. Rodeo says. HA and/or steroid shots are very effective for many people. Although corticosteroid injections shouldn’t be given more than three times a year — and research shows they may accelerate arthritis progression in some cases — many people receive the shots periodically for years without joint replacement surgery.

Dr. Rodeo also discusses platelet-rich plasma (PRP) as an option, and some patients ask about other regenerative medicine techniques, such as autologous conditioned serum (ACS) or cell therapy, which are offered by some clinics in the U.S. even though they aren’t approved by the Food and Drug Administration.

“I tell them very honestly the degree and duration of relief can be unpredictable. This might not work,” Dr. Rodeo says of PRP. Still, some of his patients who don’t get adequate relief from steroid or HA injections try PRP, especially because the Hospital for Special Surgery offers it. “There’s a lot of regenerative medicine and cell therapy approaches that we study in our regenerative medicine center. Most are unproven. Most are generally safe, but the clinical data to support them is limited.”

Not all doctors advise regenerative medicine, including Dr. Badwey. “If somebody is really, really interested, we will sit down and have a discussion,” he says. “There are clinics that advertise to the public, and they have these seminars. And the problem is it’s a cash business — no insurance company covers them because none of these procedures are FDA-approved. And the reason they’re not FDA-approved is because no prospective blinded study has been done that shows PRP is better than a placebo.”

Should You Wait?

Joint surgery is typically elective. Ankle, hand, shoulder and other joint operations can be complicated. Even knee and hip surgeries, which are common and have high success rates, are not perfect.

“Complication rate is not zero,” says Dr. Rodeo, and surgeries don’t always live up to a patient’s expectation. “Up to 10% to 15% of [knee replacement] patients can be dissatisfied. They have some residual stiffness, soreness. They’re better, but they’re not perfect,” he says.

Delaying surgery is generally safe, Dr. Badwey says. “I tell people it’s going to be the same surgery, the same recovery time, the same success rate. You’re not doing any irreparable harm by waiting.”

That’s not always the case, though. Someone with a family history of diabetes, for example, may do well to have the surgery when he’s healthy rather than taking the risk of having it done with diabetes, which can lead to complications.

Putting off surgery also may be a mistake if arthritis progresses quickly or “to the point where it changes the joint alignment,” Dr. Rodeo says. “Rarely would I push someone toward surgery. But if I do see real change structurally that would potentially make the surgery more complex or would affect the outcome, then my job as a physician is to educate the patient about that so they can figure that into their informed consent.”

Another risk: Delaying surgery for an alternative treatment that doesn’t work. Dr. Rodeo tells of a man with end-stage knee OA who received cell therapy injections with umbilical cord blood formulation. When one of his knees became infected, he sought help from Dr. Rodeo. It required arthroscopy twice to wash it out, and antibiotics finally cleared up the infection. But his risk of post-operative infection at that point was too high, so even though he needed joint replacement surgery, he had to wait at least a year to make sure the infection was completely eradicated. “Not only did he not get better from the cell therapy injection, but now you’ve delayed his ability to have a replacement,” Dr. Rodeo says. “So, it’s a risk. It’s uncommon, but we’ve all seen cases like that.”

The Right Time

When is the best time to elect surgery?

When pain interferes with your life, Dr. Badwey says. “I tell them, ‘I don’t feel your pain, so I can’t look at you or your X-rays or examine your ankle or foot and say, you need to have surgery.’”

His advice? “When I’m experiencing pain every day that prevents me from doing the things I want and need to do, then I would do surgery.”

Now that Travis’s ankle is fused, he wishes it had been done years ago, but he had to try everything else first, just to be sure. “I still would have second-guessed myself if I hadn’t gone through those things,” he says.

There are some downsides: Because he is still young, the fusion may contribute to OA developing in surrounding joints, he says. But the surgery ultimately has changed his life.

For those facing a similar choice, he has this advice: “Staying diligent, patient and persistent: Diligent to try to learn as much as you can and not give up. Patient because there’s going to be bad days. And persistent, trying to find as much information to make as good a decision as you can, and trying to stay healthy as you’re doing that.”