Friday, August 21, 2020

A Steroid Injection for Bone-on-Bone Arthritis? Not So Fast

When elective surgeries resumed in New York City in June, it was a relief for patients with severe hip or knee arthritis who had made up their minds to have joint replacement surgery. Many people needed to wait when the procedures, considered elective, were put on hold due to the pandemic. Some patients were in so much pain, they wanted to have the procedure as soon as possible.

But a number of them were surprised to learn they would have to wait, in some cases up to three months, because they had received an injection of a steroid or hyaluronic acid in their joint at another doctor’s office.

There are two issues for patients. First, the injections do nothing to relieve pain when someone has bone-on-bone arthritis and is a candidate for joint replacement, or if they provide any pain relief at all, it is very short lived. The other problem is that anyone who has received a steroid or hyaluronic acid injection must then wait approximately three months from the date of their last injection to have hip or knee replacement surgery. This is because studies have demonstrated an increased risk of infection in the first three months following these injections.

saw five patients over a two-week period whose joint replacement needed to be delayed due to an injection. All were understandably upset that the physician who ordered or gave them the injection did not inform them they would to wait three months to have a joint replacement. Two patients were in tears.

Hip and knee replacements are common and safe procedures that relieve pain and greatly improve quality of life. Overall, the risk of developing a joint infection is very low, but it is one of the most serious complications a patient can have following surgery. Studies show that as long as patients wait three months after receiving an injection, there is no increased risk at all.

An educated patient who takes an active role in his or her care and asks the physician good questions has the best chance to receive the right treatment for his or her condition.  

Monday, June 1, 2020

Tips to Manage Arthritis When Staying at Home

At the height of the pandemic, people displayed good judgment and stepped up to the challenge, staying at home to stop the spread of coronavirus. Although many locations are beginning to see a slow return to the “new normal,” many doctors’ offices are only open on a limited basis. Elective surgeries, such as joint replacement, are still on hold in New York City.

Since March, many people with arthritis have gone without physical therapy or injections at their doctor’s office to relieve pain. Those scheduled for joint replacement surgery had their procedure postponed. People with arthritis can adopt good practices to help lessen pain while they wait for treatment.

While staying at home, people may have gotten into the habit of watching a lot of TV or spending hours online. In the current pandemic climate, that’s understandable. But it’s good for those who have arthritis to engage in mild exercise or take a walk, if they can. If you sit around too much, your joints can become stiff and your muscles get deconditioned. This puts more stress on an arthritic knee or hip, and that can cause more pain.

For those binge-watching television shows or working in front of a computer most of the day, I recommend getting up every half hour and walking around for at least five minutes. In addition to helping to prevent stiff joints, it helps avoid back pain that comes from sitting too much.

Here are some more tips to help manage arthritis at home:
  • Be proactive. Do mild exercises to strengthen the muscles around an arthritic joint. For example, straight leg raises from a lying down or sitting position are a simple exercise that most people can do to strengthen the muscles around their knee.
  • Engage in non-impact activities, such as riding a stationary exercise bicycle or taking a safe walk outside.
  • Even at home, be careful not to overdo physical activities. People with less severe arthritis may want to go on a cleaning spree or declutter a closet, but too much bending, kneeling, and lifting could make joint pain worse.
  • If climbing up and down stairs causes pain, cut back. Be mindful of how you’re moving and take one step at a time if it helps.   
  • Take an over-the-counter pain medication unless it causes stomach or other problems. If you have a prescription, make sure you follow your doctor’s instructions.
  • Use cold or heat to make a joint feel better. However, if a joint is hot and swollen, make sure you use a cold pack.  Put a cloth or thin towel under the cold pack.  Never put ice directly on your skin. 
  • Use an aid, such as cane, when needed to relieve pressure on your knee or hip.  
  • Try to maintain a healthy diet. Keeping your weight down avoids stress on a joint. 
  • Try meditation, mindful breathing, or progressive relaxation to help relieve stress and feel better. A number of apps are available for this.
  • Make sure there are no hazards in your home that could lead to a fall. Use a cane if needed for better stability, make sure rugs are secured to the floor, maintain good lighting and be careful if you get out of bed in the middle of the night. Grab bars in the bathroom and other devices can make it easier to perform activities of daily living with an arthritic joint.
  • Try to maintain a positive attitude. Remember, we are all in this together. The pandemic will end eventually, and we will get through this.
To see a video I made with exercise tips, visit:        

Monday, May 4, 2020

Study Finds Good Outcomes in “Dual Mobility” Hip Replacement

More than 350,000 hip replacements are performed in the United States each year to relieve pain and restore mobility. Overall, it's a highly successful procedure and has given many people a new lease on life. However, as with all surgeries, the risk of a complication exists, and dislocation is one of the most common. At Hospital for Special Surgery, we conducted a study that found that an implant known as an anatomic dual mobility (ADM) hip replacement significantly lowered the risk of dislocation, reducing the need for a revision surgery.

My colleagues and I evaluated almost 200 hip replacements with the dual mobility implant and found no dislocations at follow-up of at least five years.The research appears online as an ePoster as part of the American Academy of Orthopaedic Surgeons Annual Meeting, which was transformed into a virtual experience due to Covid-19:

A hip replacement implant is a ball-and-socket mechanism, designed to simulate a human hip joint. Typical components include a stem that inserts into the femur (thigh bone), a ball that replaces the head of the thigh bone, and a shell that lines the hip socket. 

The dual mobility implant system was designed to increase range of motion and decrease the risk of a dislocation by increasing the size of the femoral head component. This leads to a hip replacement with increased stability, which is especially important for active patients who may put more demands on their new hip.

We designed our study to review hip replacements with the anatomic dual mobility acetabular cup to examine clinical outcomes after five years of implantation at Hospital for Special Surgery and three other hospitals.

We reviewed a total joint replacement registry for patients who had a total hip replacement with an anatomic dual mobility (ADM) cup from January 2008 to December 2012. A total of 144 patients who had undergone 199 hip replacements were included in the study. The mean age was 67 years, and patient follow-up was from 5 to 7.9 years. X-ray analysis showed no implant loosening, and there were no dislocations.

In addition to the stability provided by the dual mobility hip replacement, patient-reported outcome measures, including pain and function, also improved, making the dual mobility hip implant a good option for appropriate patients. 

Tuesday, April 28, 2020

Telehealth: How to Get the Most Out of Your Virtual Visit

During the coronavirus pandemic, many doctors’ offices are closed for non-emergency care and more patients are embracing telemedicine. Over the past few weeks, I’ve seen an increase in virtual consultations among both established and new patients.

One of my knee replacement patients had an in-office follow-up appointment on the last day it was open in early March, but given the choice, he opted for a telehealth consultation. He told me his online follow-up appointment after knee replacement was easy to set up, and it worked well. While consulting in front of his computer screen, he was even able to show me his knee. 

I’ve also had telemedicine consultations with several new patients seeking an orthopedic surgeon for a hip or knee replacement. Although they can’t have the surgery right away, they’ve already been told that the best option for pain relief is a joint replacement, and they’re planning ahead. 

Although elective surgeries, including hip and knee replacement, are now on hold in the New York metro area, patients can get the ball rolling by scheduling a virtual visit. In addition to being able to meet a doctor online and have a remote consultation, patients can send medical records, x-rays and MRIs to the physician.

In appropriate cases, patients can receive a tentative date for an in-office consultation once it reopens for non-emergency care. Many patients are relieved to know that once we start performing elective surgeries again at Hospital for Special Surgery, they will be at or near the top of the list.

For a someone considering surgery, a virtual consultation is also a good way to get to know a physician. A patient can see if the physician inspires confidence, takes the time to answer questions, and takes a genuine interest in the patient and his or her concerns.

Here are some tips to make the most out of a virtual medical consultation:
  •          Test the visual quality of your webcam and the sound quality of your microphone before the virtual visit.
  •          Make sure you have a good Internet connection.
  •          Plug in your computer or mobile device so it doesn’t run out of power.
  •          Set up the camera at eye level so it is easier for the doctor to see and engage with you.
  •          Close unnecessary programs. Having too many programs running on your computer or device can strain its memory and reduce the quality of your video consultation.
  •          Find a quiet space where you won’t be interrupted.
  •          Look into the camera and stay close to your device so the doctor can see and hear you.
  •          Before the consultation, write down your symptoms, any medications you are taking, previous consultations you have had regarding your health issue, dates and types of previous surgeries, and any prior hospitalizations.
  •          Write down your questions in advance. If you have a concern, don’t be afraid to discuss it with during the consultation.
  •          If the doctor gives you instruction, repeat them back to him or her to make sure you understand them.

Anyone who would like to set up a telehealth consultation me is invited to call my office at 212-606-1510. Stay safe and healthy!

Friday, November 9, 2018

Fall Prevention Measures Can Prevent Serious Injury

Supreme Court Justice Ruth Bader Ginsburg fell in her office this week and fractured three ribs. She was hospitalized, but fortunately, is now back home now and doing well, according to news reports.

Although the details of how the 85 year-old Supreme Court Justice fell have not been released, the mishap shines a spotlight on how serious a fall can be. It fact, a fall can be devastating for older adults in particular because their bones are more fragile. They often break a hip, sustain a severe head injury... or worse.

I would like to take this opportunity to wish Justice Ginsburg well and remind everyone that measures can be taken to prevent falls indoors. In your own home, or in the home of a loved one, these strategies can help prevent an accident and keep people safe. Some of these measures can be applied to the work environment, as well:

  • Ensure that the home is free of hazards such as slippery floors, rugs that are not secured and poorly lit areas.
  • Install handrails, grab bars and other safety devices.
  • Wear properly-fitting shoes with nonskid soles.
  • Engage in regular, moderate amounts of physical activity to maintain strength, coordination, agility and balance.
  • Get an eye examination and physical each year, and wear glasses if needed.
  • Check with your doctor about side effects of all your prescription and over-the-counter medications and take proper precautions.  Medications can cause drowsiness and interfere with balance.
  • Eat a nutritionally balanced diet with adequate amounts of calcium and vitamin D.
  • Avoid excessive alcohol intake.

Stairs and steps
  • Make sure light switches are at both the top and bottom of the stairs.
  • Provide enough light to see each step and the top and bottom landings.
  • Keep flashlights nearby in case of a power outage.
  • Install handrails on both sides of the stairway and be sure to use them.
  • Do not leave objects on the stairs.
  • Consider installing motion detector lights which turn on automatically and light your stairway.
  • Put nonslip treads on each bare-wood step.
  • Do not use patterned, dark or deep-pile carpeting. Solid colors show the edges of steps more clearly.
  • Do not place loose area rugs at the bottom or top of stairs.
  • Repair loose stairway carpeting or boards immediately.

  • Install grab bars on the bathroom walls near the toilet and along the bathtub or shower.
  • Place a slip-resistant rug adjacent to the bathtub for safe exit and entry.
  • Mount a liquid soap dispenser on the bathtub/shower wall.
  • Place nonskid adhesive textured strips on the bathtub/shower floor.
  • Use a sturdy, plastic seat in the bathtub if you are unsteady or if you cannot lower yourself to the floor of the tub.
  • Stabilize yourself on the toilet by using either a raised seat or a special toilet seat with armrests.
  • Replace glass shower enclosures with non-shattering material.
  • Keep a night light in the bathroom.

  • Clear clutter from the floor.
  • Place a lamp and flashlight near your bed.
  • Install night-lights along the route between the bedroom and the bathroom.
  • Sleep on a bed that is easy to get into and out of.
  • Keep a telephone near your bed.

Living areas
  • Arrange furniture to create clear pathways between rooms.
  • Remove low coffee tables, magazine racks, footrests and plants from pathways in rooms.
  • Install easy-access light switches at entrances to rooms so you won’t have to walk into a dark room to turn on the light. Glow-in-the-dark switches may be helpful.
  • Secure loose area rugs with double-faced tape or slip-resistant backing. Recheck these rugs periodically.
  • Keep electric, appliance and telephone cords out of your pathways, but don’t put cords under a rug.
  • Eliminate wobbly chairs, ladders and tables.
  • Do not sit in a chair or on a sofa that is so low it is difficult to stand up.
  • Place carpeting over concrete, ceramic and marble floors to lessen the severity of injury if you fall.
  • Repair loose wooden floorboards immediately.

  • Remove throw rugs.
  • Immediately clean up any liquid, grease or food spilled on the floor.
  • Store food, dishes and cooking equipment at easy-to-reach waist-high level.
  • Don’t stand on chairs or boxes to reach upper cabinets. Use only a step stool with an attached handrail so you are supported.
  • Repair loose flooring.
  • Use nonskid floor wax.

Monday, November 5, 2018

Study Finds “Dual Mobility” Hip Replacement Implant Reduces Risk of Dislocation

Hip replacement surgery is highly successful in relieving pain, restoring mobility and improving quality of life. More than 330,000 procedures are performed each year in the United States, and that number is expected to almost double by the year 2030. 

As with all surgical procedures, the possibility of a complication exists, and dislocation is the most common problem. The risk of dislocation is higher in patients who have had a second hip replacement, known as revision surgery. Some people need a revision surgery many years after their first hip replacement when the original implant wears out. Hip instability after joint replacement is another reason a patient might need a revision surgery.    

Research conducted at Hospital for Special Surgery, where I am director of research of the Adult Reconstruction and Joint Replacement Service, and other joint replacement centers indicates that a newer type of artificial hip known as a “modular dual mobility” implant could be a good option for patients who need a revision surgery. Our study was presented at the annual meeting of the American Association of Hip and Knee Surgeons in Dallas in November. 

Although the concept of dual mobility was originally developed in France in the 1970s, the technology is relatively new in the United States. Our study found that the newer technology with modular dual mobility components offered increased stability, lowering the risk of dislocation, without compromising hip range of motion in patients having a revision surgery. 

“Dual mobility” refers to the bearing surface of the implant - where the joint surfaces come together to support one’s body weight. A hip replacement implant is a ball-in-socket mechanism, designed to simulate a human hip joint. Typical components include a stem that inserts into the femur (thigh bone), a ball that replaces the round head of the thigh bone, and a shell that lines the hip socket.  

Modular dual mobility implants provide an additional bearing surface compared to a traditional implant. With the dual mobility hip, a large polyethylene plastic head fits inside a polished metal hip socket component, and an additional smaller metal or ceramic head is snap-fit within the polyethylene head. 

Currently, there are few large-scale outcome studies on the modular dual mobility device in revision hip replacement. We set out to determine the rate of dislocation and the need for another surgery following revision hip replacement using this implant and report on the functional outcomes.

The study included 370 patients who underwent revision hip replacement with the dual mobility implant between April 2011 and April 2017. The average patient age at the time of surgery was 65.8 years. Clinical, radiographic and patient reported-outcome information was collected. 

To be included in the final report, patients needed to be seen for follow-up for at least two years after their surgery, and the average follow-up was 3.3 years. At the latest follow-up, we found that surgery with the dual mobility implant resulted in a very low rate of instability for the revision patients, namely 2.9 percent, with good functional improvement and a low rate of reoperation. While longer-term follow-up is needed to fully assess the newer device, in our study there was clearly a benefit provided by the dual mobility implant in the first few years following revision surgery.

Monday, April 30, 2018

Study Finds “Dual Mobility” Hip Replacement Attractive Option for Younger Patients

More than 330,000 hip replacement surgeries are performed in the United States each year. Overall, it is a highly successful procedure. However, as with all surgeries, a risk for complications exists. 

Dislocation is one of the most common complications after hip replacement and the number one reason for revision surgery. A study we conducted at Hospital for Special Surgery (HSS) found that patients who received a newer implant known as a “dual mobility” hip replacement had zero dislocations.  In comparison, study patients who received a traditional fixed bearing hip implant had a dislocation rate of 5 percent.

The research, which focused on patients under 55 years old, was presented last month at the American Academy of Orthopaedic Surgeons Annual Meeting in New Orleans.  

We were especially interested in seeing how the younger patient population fared because they are generally more active and put more demands and stress on their hip after joint replacement, and this increases the risk of dislocation.

Although the concept of dual mobility was originally developed in France in the 1970s, the technology is relatively new in the United States. “Dual mobility” refers to the bearing surface of the implant - where the joint surfaces come together to support one’s body weight. 

A hip replacement implant is a ball-and-socket mechanism, designed to simulate a human hip joint. Typical components include a stem that inserts into the femur (thigh bone), a ball that replaces the head of the thigh bone, and a shell that lines the hip socket. 

Dual-mobility hip components provide an additional bearing surface. A large polyethylene plastic head fits inside a polished metal hip socket component, and an additional smaller metal or ceramic head is snap-fit within the polyethylene head. "Dual-mobility" means that there are two areas of motion, improving the patient's range of movement and reducing the risk of dislocation.

We compared the dual mobility system with the traditional fixed bearing system in two age-matched groups of patients who had a primary total hip replacement over the same time period. There were 136 patients in each group with a mean age of 48.

At three-year follow-up, the researchers found that the patients who received the dual mobility implant had no dislocations. In the group receiving the standard fixed bearing implant, seven patients, or 5.1 percent, had a dislocation and needed a revision surgery.

Total hip replacement is increasingly being performed in younger patients. The results of our study are encouraging for this active, high demand group of patients and may lessen concerns for dislocation. More research is needed to see how dual mobility implants perform over the long term.