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.

Thursday, January 7, 2016

New Year, New Knee

Knee pain is a very common problem. If your knee has been bothering you for a while or keeping you from activities you enjoy, the new year is a good time to take action. I encourage you to resolve to get the right diagnosis; resolve to take action to relieve the pain; resolve to live life to the fullest, life pain-free.

For some people, strategies such as physical therapy and weight loss may bring so much improvement, they will feel like they have a "new" knee. For others with severe arthritis and constant pain, a "new knee" in the form of a joint replacement may be the best option to eliminate the pain once and for all.

Basically, there are two types of knee pain. "Acute" pain is what we experience after a sudden knee injury. When this happens, people are advised to follow the regimen known as RICE:  Rest, Ice, Compression and Elevation. They should rest their knee, apply ice on and off, and keep the joint elevated over the level of their heart. They may consider using a compression bandage, as well. However, if the injury is really bad and one cannot put weight on the joint, it is advisable to go to the emergency room or see an orthopedic surgeon sooner rather than later.

The other kind of knee pain is called "chronic" because it doesn't go away. It may be worse on some days, but the discomfort is generally ongoing. The most common reason for this type of pain is arthritis, which results from wear and tear.

As the joint damage progresses, it can become increasingly painful, but some simple strategies and good practices could help you feel better.

The first step is to see a doctor for the proper diagnosis. Anyone who has pain, stiffness or swelling in or around a joint for more than a couple of weeks is advised to make an appointment with an orthopedic surgeon. 

When someone is diagnosed with arthritis, the following strategies may provide some relief:

           Be careful not to overdo physical activities, and avoid any action, such as climbing up and down stairs, that may aggravate an arthritic knee.

           Try to keep your weight down to avoid stress on the joint, or lose weight if you are overweight.  Losing weight takes pressure off the knee and may slow the progression of arthritis.

           Take over-the-counter or prescription pain medication, and follow your doctor’s instructions.

           Start physical therapy or an exercise program to strengthen muscles around the joint.  Good exercises for people with arthritis include using a stationary exercise bicycle and swimming or even walking in a pool. Exercises should be low-impact.

           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 thin towel under the cold pack.  Never put ice directly on your skin. 

           Rest a joint until it feels better. 

           Use an aid, such as cane, to relieve pressure on your knee when needed.

A doctor may recommend steroid injections into the knee joint to reduce inflammation. This may provide temporary relief, but can only be used on a limited basis. Another procedure called viscosupplementation entails injecting a substance called hyaluronic acid into the knee to provide lubrication. This procedure may benefit people with mild to moderate arthritis, but studies have not shown it to be useful for those with advanced arthritis.

When to Consider Knee Replacement

If someone has severe arthritis and conservative measures no longer help, knee replacement surgery is often the best option for permanent pain relief and restored mobility. Major advances over the past decade have revolutionized the way we perform the surgery, and nobody should live with unrelenting pain.

More than 700,000 knee replacements are performed in the United States each year. After the procedure and recovery, most patients say you cannot put a price on what they gained. 

Advances in implant design mean a knee replacement could last 25 to 30 years. Nowadays, most major joint replacement centers use regional anesthesia, eliminating the need for general anesthesia. The patient is still asleep during the surgery.

Minimally invasive knee replacement with much smaller incisions generally means less pain and a faster recovery. The procedure entails a three- to four-inch incision instead of the standard 10- to 12-inch incision.

Some patients may qualify for a less extensive surgery called a "unilateral" or partial joint replacement.  A smaller incision, less pain after surgery and a quicker recovery are potential advantages of a partial joint replacement. Many patients say their knee feels perfectly natural after the procedure.

For the best outcome, people are advised to carefully choose their orthopedic surgeon. Indeed, when considering any type of surgery, it is extremely important that people do their homework. Individuals should choose a surgeon with extensive experience in the procedure they are having, with whom they feel comfortable, and who takes the time to answer all of their questions. It is also advisable to select a major hospital in which a high number of joint replacement surgeries are performed.

If conservative measures fail to provide arthritis relief, joint replacement can eliminate pain and restore quality of life. For those able to get back to activities they once loved, it can change their lives dramatically.