Friday, May 5, 2017

Study: Could IV Acetaminophen Reduce the Need for Opioid Medication After Hip Replacement?

When considering joint replacement, many patients worry about how much pain they’ll experience after surgery. It’s a valid concern. Pain control is important not only to avoid discomfort. It’s also essential to get a handle on pain early on so patients can move around and engage in a physical therapy program.  

At Hospital for Special Surgery, we’ve studied pain control at length and have excellent pain management protocols for patients who have joint replacement.  We generally strive to lower patients’ use of narcotic medications known as opioids. Although these medications do a good job at controlling pain, they can have side effects such as nausea, vomiting, dizziness, drowsiness and constipation, which are not only unpleasant, but can make physical therapy more difficult.

At Hospital for Special Surgery, we just launched a study to see if intravenous (IV) acetaminophen can reduce the amount of opioid pain medicine needed after hip replacement surgery. Currently, joint replacement patients generally receive opioids along with the pill form of acetaminophen, commonly known as Tylenol.

We decided to undertake this study because research shows that giving acetaminophen in IV form reaches a higher peak concentration in the blood much faster than oral acetaminophen. Therefore, it may be better at reducing pain than the pill form. 

All study patients will receive the standard pain control protocol, with one group getting IV acetaminophen, while the other group receives the oral pill form. Our goal is to see if intravenous acetaminophen works better than the pill form and can lead to lower doses of opioid medication and more rapid attainment of physical therapy goals.

In addition to seeing if IV acetaminophen can reduce the need for opioid medication, we will be measuring sedation effects, length of hospital stay, and the achievement of physical therapy milestones in patients given intravenous vs. oral acetaminophen.  

Because of its efficacy, general safety and lower risk of adverse effects compared to other pain medications, IV acetaminophen could be an attractive component of the overall pain management plan. If we find that the IV form safely reduces the need for opioid medication, it would be advantageous for hip replacement patients.

For more information about Dr. Westrich and hip replacement, visit: www.westrichmd.com

© 2016 Geoffrey Westrich, MD. All rights reserved.  

Friday, March 10, 2017

Considering a Double Knee Replacement? Here’s What You Need to Know

Orthopedic surgeons perform almost 700,000 knee replacements in the United States each year. The procedure has a high success rate, alleviating pain and restoring an active lifestyle. It’s fairly common for patients to have arthritis in both knees, and they often decide to have both of them replaced. The dilemma many people face is whether to have surgery on both sides at the same time, a procedure referred to as “bilateral knee replacement,” or two separate operations.

I always advise people to carefully weigh the pros and cons of each option. Many people want to have a double knee replacement because they feel they can get it over with faster since there’s one surgery, one hospital stay and one course of rehabilitation. For the right patient, it’s a good option. However, double knee replacement is not for everyone, and people should be well-informed before making a decision.                

Studies show that bilateral knee replacement is a more risky procedure and the complication rate is higher. Rehabilitation is also much more demanding. Candidates must be in excellent physical condition, aside from the arthritis, with no underlying health problems.    

Not too long ago, people thought that if you had one knee replaced, the pain and rehab would be so taxing you wouldn’t want to come back for surgery on the other knee. But nowadays, with advances in surgical techniques, anesthesia and pain management, the recovery for a single knee replacement at a high-volume joint replacement center is much easier and faster than it was in the past. In our experience, virtually every patient comes back for the second knee replacement. Patients generally wait at least three months in between surgeries.
                                                               
Know What to Expect

Overall, the success rate is high for same-day double knee replacement, but patient selection is important. It should be out of the question for patients of any age with diabetes, heart or lung problems, or any other serious medical condition.

Patients who meet the criteria need to know exactly what to expect so they can make an informed decision about same-day double knee replacement. The recovery and rehabilitation after bilateral knee replacement are much more challenging because greater physical and emotional strain is placed on the body. The rehab is also much more difficult because patients can’t rely on a stable leg for support.

Another consideration is where an individual will receive physical therapy. Bilateral knee replacement patients almost always spend time in a rehabilitation facility after surgery, while those who have a single knee replacement often go straight home from the hospital and receive physical therapy at home.

Whether having two separate knee replacements or both sides replaced simultaneously, the orthopedic surgeon should have a detailed discussion with the patient about what to expect.

Because of the special considerations involved in double knee replacement, it's especially important to choose a highly experienced orthopedic surgeon who specializes in knee replacement. 

Patients should also choose a hospital that performs a high volume of joint replacements, such as Hospital for Special Surgery. The entire staff will be accustomed to dealing with the needs of double knee replacement patients before, during and after the surgery.©

© 2016 Geoffrey Westrich, MD. All rights reserved.  


Wednesday, March 1, 2017

Arthritis "Treatments" to Avoid

Advertisements for treatments claiming to cure or slow down arthritis can be found on the Internet, on television and in print ads. They include drinks, certain supplements and rubs. Most are a a waste of money. 
The ads target people in pain who want to avoid surgery. The problem is, the longer people wait, the worse their arthritis can get. In the beginning, even if these bogus remedies provide a false sense of security, people are actually worse off because they are not receiving the proper care.
The bottom line is that patients should be wary of any advertisement for a product claiming to cure arthritis.
Supplements such as glucasomine and chondroitin, more in the mainstream, are also purported to slow the progression of arthritis. However, in 2013, the American Academy of Orthopaedic Surgeons added these supplements to the list of treatments that provide little benefit.

Knee lavage or “washing out the knee” has also received a thumbs down from the American Academy of Orthopaedic Surgeons. The procedure has not demonstrated any benefit and should not be performed to relieve arthritis. People should be wary if a doctor recommends it.
Another useless “treatment” for arthritis is arthroscopic surgery, with tiny incisions and supposedly a quick recovery.  Although certainly much easier than joint replacement for both the patient -- and the surgeon performing the procedure -- studies show, and we know from experience, that arthroscopic surgery is of no benefit for arthritis and can actually make the pain worse. 
Arthroscopic surgery may be considered to fix a torn meniscus cartilage that is causing symptoms, such as locking or catching in the joint, that physical therapy has not helped. But for someone with arthritis, an arthroscopic procedure is of no benefit.
And not only is it useless, it often makes the condition worse. Every surgery carries some element of risk, so don’t be fooled by the words “minimally invasive.” Countless arthritis patients have come to me after arthroscopic surgery exacerbated their knee pain. One patient developed severe swelling and fluid in her knee after arthroscopy and needed to go back to the doctor every week to have it taken out with a needle, a very uncomfortable procedure.
Surgery is surgery, and all operations have risks and benefits. If an orthopedic surgeon tells you arthroscopic surgery will relieve arthritis pain or buy you time, find another doctor. In fact, if you’re ever unhappy with a doctor, go elsewhere. And it never hurts to get a second opinion, especially when surgery is being considered.
The only tried and true treatment for advanced bone-on-bone arthritis that's causing severe pain is joint replacement. Sometimes, if the arthritis is limited to just one area of the knee, we can do a partial joint replacement, and this is usually easier on the patient. The recovery is generally faster; plus, we preserve more bone.
It’s important to get the proper diagnosis sooner, rather than later. If people wait too long, the joint continues to deteriorate, and a partial knee replacement may no longer be an option. At that point, a total joint replacement will be necessary to relieve pain and restore mobility.©
© 2016 Geoffrey Westrich, MD. All rights reserved.  


Monday, January 30, 2017

Top Myths about Arthritis: Knowing the Facts Can Help You Manage it Better

Arthritis is a painful condition that can make activities of daily living difficult, if not impossible.  Osteoarthritis, the most common form of the disease, affects millions of Americans and is caused by wear and tear on a joint. It often affects the knee or the hip. 

Misconceptions about arthritis are prevalent, but knowing the facts can help people to better manage the disease.

Here are the top myths and facts about arthritis: 

1- MYTH: If you have arthritis, you shouldn’t exercise.
FACT: It may seem counterintuitive, but the appropriate exercise can help many people feel better. Certain exercises, such as swimming or the stationary bicycle, can help relieve stiffness and alleviate pain. Physical therapy or an exercise program to strengthen muscles around the joint can also be very helpful. 

2 - MYTH: Arthritis is a disease of the elderly.
FACT: About two-thirds of patients are under 65. In fact, increasing numbers of people in their 40’s and 50’s are feeling the aches and pains of the degenerative bone disease.

3 - MYTH: Cold, wet climates make arthritis worse.
FACT: There is no scientific evidence supporting the theory that a particular climate is better for people with arthritis. If a warm climate helped or prevented arthritis, then people who lived in mild-climate states such as Arizona or Southern California would not have arthritis. Adults all over the country experience arthritis pain.  However, inclement weather is associated with barometric pressure changes, and this may affect people with arthritis. It does not make the condition worse per se, but it may cause a change in someone’s level of pain.

4 - MYTH: There’s nothing I can do, so I’ll just have to live with the pain
FACT: People can take measures to alleviate arthritis pain. One strategy is to lose weight if one is carrying around excess pounds. Depending on the weight loss, it can take quite a bit of pressure off an arthritic knee or hip. Another recommendation is to avoid any activity, such as going up and down stairs, which may aggravate an arthritic knee or hip. Over-the-counter or prescription pain medication can help. No one needs to live with constant pain.  Joint replacement surgery is a tried and true way to eliminate arthritis pain once and for all. 

5 - MYTH: Supplements and drinks advertised on TV, in print and online can cure arthritis.
FACT: Many products purport to cure arthritis. Some of them are so bold as to claim they can regrow cartilage. Impossible. These unproven potions and pills are a waste of money.  The only way to eliminate advanced arthritis pain is with joint replacement surgery.

6 – MYTH: Arthroscopic surgery will relieve my arthritis.
FACT: Any doctor who says arthroscopic surgery to repair a torn cartilage or clean out a joint will relieve arthritis pain is doing a huge disservice to a patient. This type of minimally invasive surgery does NOTHING to relieve arthritis pain. Not only is it useless and unnecessary, but some patients are actually worse off because their joint becomes inflamed after surgery.

7 - MYTH: How can you have arthritis? You were fine yesterday, how can you be in so much pain today?
FACT: People who have arthritis can feel fine one day, and experience a flare up the next.

8 – MYTH: Even though I have painful arthritis that limits my activities, I’m only in my 40’s, so I’m too young for joint replacement.
FACT: Newer techniques such as minimally invasive hip and knee replacements, partial knee replacements and improved implant materials have made joint replacement a viable option for younger patients who want to alleviate pain and return to an active lifestyle.

For more information about arthritis, including videos, visit www.westrichmd.com.

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Wednesday, November 30, 2016

How Partial Knee Replacement Gave World Traveler a Leg Up


When it comes to joint replacement, each patient has his or her own set of circumstances and goals for surgery. David, who is from Alexandria, Virginia, not only wanted pain relief from knee arthritis. He was eager to get back to his active lifestyle. He has a fascinating job that takes him all over the world. So when unrelenting knee pain started slowing him down, he thought it was time to consider joint replacement. As a forensic psychologist with a PhD, he was accustomed to doing extensive research for his work. He explained that before scheduling surgery, he put his skills to use, setting out to find the best hospital and physician for the surgery. After consulting with a number of doctors, he decided to travel to New York City and made an appointment to see me at the Hospital for Special Surgery.  

David in Iraq

"I saw several different doctors in several different states before I made a decision, as I am very wary of surgeries, especially when it can hinder my work," David explained.  As a forensic psychologist, he designs personnel testing and other selection systems so private companies, public agencies, and even governments can find the best employees. His career has taken him to hot spots around the world, including Iraq, where he helped the country rebuild its police force and intelligence operations.

But in the past few years, his knee problems were slowing him down. He began walking with a limp and had trouble climbing stairs. Since he had no intention of giving up his work or his active lifestyle, he set out to find a hospital and an orthopedic surgeon with extensive experience in joint replacement.

"I know in my field it's all about experience, and I learned that's how it is in orthopedic surgery, too," David said, adding that the Hospital for Special Surgery and I came out on top in terms of sheer numbers. "Each knee reconstruction is probably unique in some way, and a surgeon who's performed many knee replacements will likely be able to deal with whatever challenge may come their way." 

David was a candidate for a partial knee replacement, which was just what he wanted to hear. He had learned from his research that the rehabilitation and recovery after this type of surgery is generally faster compared to a total knee replacement. The damage was limited to one area of his knee and did not affect the entire joint. 

Patients who qualify for a partial joint replacement generally experience less pain right after surgery and have a quicker recovery and rehabilitation. Yet the procedure completely relieves arthritis pain and allows patients to return to activities they were forced to give up. Another advantage is that it preserves the normal bone and cartilage in the rest of the knee that would typically be replaced in a total joint procedure."                  

The right diagnosis is key. To qualify for a partial joint replacement, also called a "unicompartmental" knee replacement, the arthritis must be confined to a specific area. The knee has three compartments – medial, lateral, and patellofemoral (kneecap region) – and arthritis can involve one, two or all three areas. One would be a candidate for a partial joint replacement if only the inner (medial), outer (lateral), or patellofemoral part of the knee is damaged, independent of the other compartments. Patients whose arthritis is widespread (in more than one compartment) would need a total knee replacement.

David says his recovery was everything he had hoped for. He had the surgery on a Thursday, left the hospital the next day, and by Monday attended a business meeting in New York. "It was like a miracle. I thought the recovery was amazing, it was so fast," he recalls.

Six weeks later, he traveled to Moldova, an Eastern European country, where he was invited to speak on how to strengthen that nation's internal security.  Now, less than five months after surgery, David, who is 71, says he has no intention of slowing down. "My travels are kicked back into high gear again." 


Monday, August 1, 2016

Olympic Buzz Has Weekend Athletes Jumping into Sports, But Doing Too Much, Too Soon Can Have Painful Consequences

As the upcoming Olympic Games shine the spotlight on sports and elite athletes, the excitement is enough to make many us get off our couches and jump into a sport or exercise program.  But anybody who's been inactive for an extended period of time should exercise caution. People who’ve been sedentary are at risk of injury if they don't take a few simple steps before starting a sport or an exercise program. 

You cannot overestimate the benefits of regular exercise for people of any age.  Exercise is good for the heart and lungs, it helps keep bones and muscles strong, plus, it can provide a psychological lift.  Strengthening muscles can also protect a previously injured joint from further injury.  And regular exercise can improve balance and mobility and even reduce the pain of arthritis.

But anyone who leaps into a sport or exercise program too quickly can suffer painful consequences, especially if over 40. As we get older, our bodies change, and we are more prone to injury.  Generally, people are not as flexible as they were in their 20's, response time is slower and we tire more quickly.

Weekend warriors, or those who try to cram all their exercise into one or two days a week, have a high rate of injury.  And many people over 40 have had a previous injury, which leaves them more susceptible to getting hurt again.  Even less strenuous activities such as golf can cause injury if people aren't properly warmed up.  Experts recommends balanced fitness program that includes cardiovascular, or aerobic exercise, such as bicycling, brisk walking or running; strength training; and stretching for flexibility.

Here are some tips for injury prevention:

  • Always warm up before any physical activity.  Warm up with stationary cycling or light jogging or walking for at least 10 or 15 minutes.
  • Try to engage in 30 minutes of moderate physical activity every day.  If you're pressed for time, you can break it up into10- or 15-minute segments.
  • Don’t overdo it.  Listen to your body and know your limits.  Stop if you're in pain or very tired.  Those who keep going when they’re exhausted are at greater risk of injury.  Running or playing a sport while having pain will only make an injury worse.
  • Take adequate time to rest in between exercising or athletic activities.  When strength training with weights, rest for at least one day in between workouts.
  • Swimming is good for people with arthritis or joint problems, but get out of the pool if you have a cramp and slow down if you become winded.
  • Use the proper protective gear, such as helmets and knee pads, and wear the right shoes for a particular activity.
  • For certain sports, consider taking lessons and invest in good equipment.  Proper form reduces the chance of developing an overuse injury, such as tendonitis or stress fractures.
  • When changing your activity level, increase it in increments of no more than 10 percent each week.  For example, if you normally walk two miles a day and want to get to four, slowly increase your distance each week until you reach your higher goal.  In strength training, increase your weights gradually.
  • Drink a lot of fluids, especially if exercising in hot weather.  Try to eat a balanced diet.
  • If you have had a previous sports injury, consult an orthopedic surgeon who can help you develop an exercise plan to accomplish your goals and minimize the chance of injury.

The key to injury prevention is taking it slow and steady, and some planning. Exercising good judgment now will ensure that people get the most out of their fitness program and see results later on. 

Friday, March 4, 2016

New Use for an Old Drug to Reduce Blood Loss in Joint Replacement Surgery

Blood loss and the need for a blood transfusion are concerns in joint replacement surgery, but a new use for an old drug is proving effective in reducing blood loss and transfusion rates, according to a study we conducted at Hospital for Special Surgery. The drug, tranexamic acid, or TXA, has been used for decades in heart surgery, to treat hemophilia and to stop excessive uterine bleeding.

After reviewing thousands of patient records, we found that TXA was safe and effective, reducing the need for a blood transfusion by more than 50 percent. The research was just presented at the annual meeting of the American Academy of Orthopaedic Surgeons.

TXA is classified as an “anti-fibrinolytic,” or blood clot stabilizer, whose mechanism of action reduces bleeding. TXA should not be used in patients who have a cardiac stent or in those who have had a previous blood clot.

We reviewed the records of 4,449 patients who had hip or knee replacement over a six-month period. There were 720 patients who received tranexamic acid topically, 636 who received it intravenously, and 3,093 patients who received no TXA.

We found that 9.7% of patients who received TXA received a blood transfusion, compared to 22.1% of those patients who did not receive it. Patients who were not given TXA received an average of 0.37 units of blood compared to 0.13 units for patients who received the drug.
 
At our institution, TXA in either intravenous or topical form was effective in decreasing the amount of blood transfusions, as well as the number of units of blood transfused in primary and revision hip and knee replacement. Furthermore, when safety was evaluated, there was no statistically significant difference in blood clots in patients who received IV or topical TXA, reconfirming its safety.

More studies are needed comparing various doses and combining IV and topical TXA to determine what would provide the greatest benefit to patients.