Musculoskeletal Sunnybrook Magazine – Fall 2017

Determining the best treatment for hip & knee problems

Is operating always the best way to treat aging joints? Meet two patients who both have osteoarthritis but followed different treatment paths.

They awaken to stiff joints and spend their days fighting pain as they go through the usual motions of living.

An estimated 4.6 million Canadians suffer from osteoarthritis, a degenerative joint disease – and the most common form of arthritis – that starts with the breakdown of the cartilage that protects joints and keeps the bones from rubbing against each other. This chronic disease results in joint pain, stiffness and swelling, often becomes disabling, and is more prevalent among older people.

The implications are troubling for an aging country like Canada, where there are now more people over the age of 65 than there are children and where seniors will account for two out of 10 residents by 2024.

A number of studies in recent years have highlighted the growing prevalence of osteoarthritis among Canadians, and the greater burden this places on the country’s health-care system.

One study published in 2011 by the Arthritis Alliance of Canada – in a report entitled “The Impact of Arthritis in Canada: Today and Over the Next 30 Years” – predicts that by 2040, one in four Canadians will have osteoarthritis. With a new diagnosis of osteoarthritis every 60 seconds, almost 30 per cent of Canadian workers will have difficulty working because of the disease, the study’s authors wrote.

“Now more than ever, we need to look at how we can best serve the needs of Canadians with osteoarthritis in ways that will also be more optimal for the health-care system,” says Dr. John Murnaghan, interim medical director of the Holland Centre, part of Sunnybrook’s Holland Musculoskeletal Program.

Sunnybrook is leading the way in this effort. About 12 years ago, the Holland Centre introduced an innovative model of care for hip and knee arthritis. As part of its Hip and Knee Arthritis program, the centre pioneered a Central Intake and Assessment process that today continues to improve access and quality of care. Two patients from the Centre share their stories.

Mary Lou Nawrocki

For Mary Lou Nawrocki, it was a great relief to learn she didn’t need joint replacement surgery. (Photograph by Kevin Van Paassen)

Mary Lou Nawrocki: non-surgical treatment

Life changed the day Mary Lou Nawrocki’s knees buckled as she was walking about with a friend. Diagnosed shortly after with knee osteoarthritis, the retired elementary- school teacher could no longer take long walks or exercise because of the pain and stiffness in her legs. She became less active and gained weight, which put more pressure on her knees and added to her pain.

“I tried physiotherapy and then a chiropractor, but nothing worked,” recalls Mary Lou, who is 67 and lives in Toronto with her husband. “The osteoarthritis would just flare up and my knees would swell.”

Her life changed again last year, this time for the better, when her doctor sent her to the Holland Centre. Within the month of getting a referral, Mary Lou walked into the Centre’s Assessment Clinic.

A distinctive feature of the Holland Centre Assessment Clinic is that it is led by advanced practice physiotherapists (APPs) and advanced occupational therapists (APP/OTs) – clinicians with extensive credentials that include solid backgrounds in orthopaedics and specialized training from the surgeons.

Instead of immediately putting patients in a long queue to meet with an orthopaedic surgeon, the Holland Centre’s intake process connects them first with an APP/ OT, who works with them on a treatment strategy and, when needed, refers the patient on to an orthopaedic surgeon.

The process starts with a detailed assessment by an APP/ OT that includes a thorough clinical examination and a review of X-rays of the affected joints, as well as functional testing that gives information about a patient’s ability to carry out everyday activities. As part of the assessment, they are asked to do a six-minute walk test.

Using this information and a scoring system developed by the Centre’s experts, the APP/OT determines if the patient needs to see a surgeon about hip or knee replacement surgery or can carry on with non-surgical strategies such as exercises to strengthen weak muscles, weight loss to reduce joint loads, walking aids or other adaptive devices to help with everyday functions.

“Our APP/OTs give patients the tools, confidence and peace of mind to carry on with their daily activities,” says Susan Robarts, an advanced practice physiotherapist and team leader at the Holland Centre. “Many of our patients are pleasantly surprised to learn they don’t have to rush into surgery and that there’s a lot they can do to maximize their ability to move and function well.”

According to Dr. Albert Yee, chief of the Holland Musculoskeletal Program, the Central Intake and Assessment model provides a more efficient triage process because it ensures that only patients who need and want surgery are sent to an orthopaedic surgeon.

Today, about 30 per cent of Holland patients do not go on to see a surgeon. “Everyone’s immediate needs are addressed within a much shorter period,” says Dr. Yee. “Those who need surgery get to see a surgeon sooner and those who don’t need surgery can learn about their other options for treatment.”

Albert Yee

Dr. Albert Yee is the chief of the Holland Musculoskeletal Program. (Photograph by Kevin Van Paassen)

For Mary Lou, it was a great relief to learn she didn’t need joint replacement surgery. Instead, her advanced practice physiotherapist recommended a 12-week education and exercise program, which taught her movements to strengthen her damaged joints and muscles and lessen her pain.

“It’s all about strengthening the good muscles you have to support the bad joints,” explains Mary Lou, who signed up for physiotherapist-led education sessions at the Holland Centre. “At the end of the 12 weeks, I saw improvement. I could walk without pain, I had more stamina, I could climb stairs without apprehension. I was even doing knee presses on one of the machines at the Centre, and I was able to press a much greater amount of weight than I thought I ever could.”

Since it started collecting data in 2007, the Holland Centre has managed 20,000 patient visits using the Central Intake and Assessment model. Today it’s widely considered to be the gold standard in hip and knee arthritis care.

“We were the first Centre of Excellence in Ontario for hip and knee replacements,” says Dr. Jeffrey Gollish, a former Holland Centre medical director who was instrumental in the development of the Central Intake and Assessment model. “One of our first mandates was to develop a new model of care delivery to improve access to care for patients with hip and knee arthritis, so a group of us went to Glasgow and Edinburgh in Scotland to study what they were doing there, and we incorporated key elements of their model to form the basis for what we have at the Holland today.”

Jeffrey Gollish

Dr. Jeffrey Gollish was instrumental in developing the Central Intake and Assessment Model. (Photograph by Kevin Van Paassen)

Other health-care institutions in Canada have adopted similar models of care. Doctors and health administrators from other countries have also shown interest in the Holland Centre model.

“Our Central Intake and Assessment model functions very well,” says Dr. Murnaghan. “Going forward, our hope is to play a key role in working with Ontario’s health-system leaders to help other centres adapt it for their own settings, and to extend this model to other areas of musculoskeletal care, for example, for spine and for shoulders.”

Patricia Petersen: surgical treatment

Getting a referral to the Holland Centre also marked the beginning of the end of four years of pain for Patricia Petersen. In 2006, at age 66, she started feeling pain and tightness in her right leg and hip. Two years later, she was finally diagnosed with hip arthritis.

“I’ve always been very active. I used to hike, cross-country ski, kayak and do a lot of walking, until the pain began to limit my physical activities,” says Patricia, a retired University of Toronto professor and former director of the school’s Urban Studies Program. “Then in 2010, there was significant deterioration and my doctor looked at my X-rays and said, ‘You don’t have a hip joint there anymore.’ That’s when I was sent to Holland [Centre].”

A week after her doctor made the referral, Patricia got a call from the Holland Centre scheduling her for an assessment the following week. Within three weeks, she met with a Holland orthopaedic surgeon.

“I saw the surgeon in mid- May and they had a cancellation in June, but I was scheduled to teach in Germany, so the surgery was scheduled for my return in September. What I found so amazing was that within a month of seeing my own doctor, I had the assessment and was seen by the surgeon and could have had my hip replaced the next month,” Patricia recalls.

This optimal pathway from referral to surgery can be attributed directly to the intake process, says Dr. Richard Jenkinson, an orthopaedic surgeon at the Centre.

A study published last March in the international peer-reviewed BMJ (formerly the British Medical Journal) highlights the importance of joint replacement surgery for those who need it the most.

The study looked at about 4,500 patients in the U.S. between the ages of 45 to 79 and found that patients with severe knee osteoarthritis gained significant quality-of-life benefits from total knee replacement surgery, while those with less severe progression and symptoms of the disease experienced minimal improvement in quality of life after surgery.

“Now we’re only seeing patients who stand to benefit the most from surgery,” says Dr. Jenkinson. “At the same time, all patients are benefiting from a longer discussion about their options with an APP/OT, which typically takes more time than most orthopaedic surgeons are able to commit to in their clinic.”

Patricia Petersen


Patricia resumed hiking, kayaking and other physical activities after her hip surgery.

Last May, she returned to the Holland Centre, this time with a referral for her left hip. While she’s less than thrilled about having a second hip replacement, she’s happy her doctor once again sent her to the Centre.

Says Patricia, “Based on my experience with my right hip replacement and on my recent assessment, I know I’m in good hands.”

To operate or not to operate

Will I need a knee operation right away? Should I stop going to the gym? Patients who are diagnosed with osteoarthritis in the knee are often confused about what it means to have this degenerative joint disease. With so much information available online and through other sources, it can be hard to separate fact from misinformation. Dr. Richard Jenkinson, an orthopaedic surgeon of Sunnybrook’s Holland Musculoskeletal Program, discusses some of the most common myths around knee osteoarthritis.

MYTH: My osteoarthritis is bone-on-bone. I need a knee replacement.

FACT: Not necessarily. While the most reliable surgical treatment for bone-on-bone arthritis is a knee replacement, the key issue is the severity of a patient’s symptoms. Knee replacement is most beneficial for patients experiencing pain, stiffness and functional limitation that significantly diminish their ability to engage and enjoy their daily lives.

MYTH: Knee surgery is the only option.

FACT: Even if a person has severe knee arthritis, non-operative treatment can alleviate the symptoms. The most effective non-operative strategies to relieve symptoms include strengthening the muscles that support the knee joint and decreasing the forces across the knee through weight loss. A program of low-impact exercises, possibly including formal physiotherapy, can be very helpful. Medications, injections, braces and other treatments can also play a role in improving function.

MYTH: I’ve been told that I should have knee surgery now when I’m younger, so I can have a better recovery.

FACT: The time to have knee replacement surgery is when the symptoms are severe enough that a person cannot manage a regular lifestyle without severe limitation. Anyone considering a knee replacement should first make sure they’ve given non-operative strategies a full attempt. Weight loss and exercise can do wonders for knee symptoms. Surgery can be considered for younger patients, but only if their symptoms are severe enough to warrant a significant operation.

MYTH: Knee replacements only last 10 years. My surgeon says I am “too young” for the surgery.

FACT: The vast majority of modern knee replacements can be expected to last longer than 20 years. Surgery should not be rushed into, however, if someone has not fully explored nonoperative treatments and is having severe symptoms. On the other hand, they should not be suffering for many years, to the point where their function and mobility become severely limited before getting a knee replacement.

MYTH: If I can’t have surgery, I should just take pills for the pain.

FACT: Strengthening the muscles around the knee and adding even light physical activity to one’s routine can greatly improve knee arthritis symptoms. Medications such as acetaminophen and ibuprofen, which are over-the-counter drugs, can help manage arthritis symptoms. Stronger narcotic painkillers are not usually recommended to manage arthritic pain due to potential side effects and the risk of addiction. For the minority of those with inflammatory arthritis, like rheumatoid arthritis, medications are very effective and are an important part of the treatment. Injections, braces and other options can also help people manage their symptoms if surgery is not possible.