Doctor Tarlow on Knees - The Lighter Side

Ice After, Not Before Sports Participation

2012-01-27T12:14:00.000-07:00

What is this ? Ice is, after all, the “I” in the acronym RICE (rest, ice, compression, elevation), which remains the standard first-aid protocol for dealing with a sports-related injury. Icing is also widely used to deal with muscles that twinge but aren’t formally injured.

Icing muscles significantly reduced muscle strength and power for up to 15 minutes after the icing had ended. It also tended to lessen fine motor coordination. Some of the reviewed studies found that people experienced impaired limb proprioception, or their sense of where their limb was in space after it had been iced.

The result was frequently, at least in the short term, poorer athletic performance. Volunteers were not able to jump as high, sprint as fast, or throw or strike a ball as well after 20 minutes of icing.

“The current evidence base suggests that the performance of athletes will probably be adversely affected should they return to activity immediately after cooling,” the authors conclude.

“The most likely reason is that ice reduces nerve conduction velocity,

That means for most of us, there may be times when it’s fine to ice sore muscles – like after a hard workout or when we experience serious injury — provided we do not jump back into the field.

Ice remains an accepted therapy for an acute injury and is popular with many athletes to help them to recover after exercise. But relying on ice to get you back into that senior-league basketball game or onto the running track when you’re already sore is inadvisable. “Athletes should consider that pain is usually a sign that something is wrong with your body.” Listen, and stay out of the second half of the senior-league basketball game or skip a day’s run. You have the rest of 2012 to fulfill your resolution.

Talk About Complications - Roadblock To Medicare Reform a Big Problem

2012-01-20T12:01:00.000-07:00

CRS report outlines hidden SGR roadblock.

"The Sustainable Growth Rate is an ineffective formula that has an pending, accumulated major decrease in physician payments something on the order of 30%. If these cuts were allowed to be enacted many anticipate a major exodus of physicians from the Medicare Provider panel. In other words, not many doctors would remain to provide services to Medicare recipients. This is a huge deal." ---Dr. Tarlow.

According to MedScape Today, a report compiled by the Congressional Research Service (CRS), a division of the Library of Congress, outlines a fiscal complication that works against legislative repeal of the Medicare Sustainable Growth Rate (SGR) formula. The Congressional Budget Office (CBO) has estimated the 10-year cost of SGR repeal to be $300 billion. Because the law requires beneficiary premiums to equal approximately 25 percent of the total cost of the Medicare Part B program, repeal of the SGR would pass the corresponding cost increases to seniors. Should Congress act to repeal the SGR and avoid the premium increase, the CBO-estimated cost of repeal would swell by an additional $75 billion. The U.S. Congress recently delayed an SGR-mandated 27.4 percent cut to physician reimbursement until March 1, 2012.

New Year's Resolution - Lose the Knee Fat !

2012-01-14T11:18:00.000-07:00

A New Year's resolution is a commitment that a person makes to one or more personal goals, projects, or the reforming of a habit. A key element to a New Year's Resolution that sets it apart from other resolutions is that it is made in anticipation of the New Year and new beginnings. People committing themselves to a New Year's resolution generally plan to do so for the whole following year. This lifestyle change is generally interpreted as advantageous.

Need motivation for your New Year's Resolution?

What better topic to discuss to start the New Year than body fat and the consequence of excessive fat on knees.

I would like to post this photograph as impetus for exercising, eating healthy and caring for our bodies. Excessive body fat invades and accumulates in every nook and cranny in your body, not just in the belly. This accumulation is unhealthy and is detrimental to healthy body functions.

What you are seeing is the accumulated fat removed from the knee of an obese man at the time of Total Knee Replacement surgery. For reference, a 5 inch pen is in the field.

In obese people the extra fat absolutely stuffs the inside and outside of a knee joint. This fat limits knee motion, probably causes pain, and certainly makes total knee replacement more difficult to perform.

So there you have it, a new wrinkle on how to motivate Americans to follow through on their New Year's Resolution. For the health and happiness of our country, let's hope this helps.

Ice/Compression Helps Knees Heal After Arthroscopic Surgery

2011-12-27T11:30:00.000-07:00

Everyone knows that icing the knee after injury or surgery helps with pain control, limits swelling and speeds recovery. This study identifies the chemical mechanism for these benefits. Perhaps these authors did this study to prove to Health Insurance Companies that the commercially available Ice/Compression devices are have a medical necessity and are worthy of being reimbursed when used after knee surgery - patients sometimes bear this cost as an out of pocket expense.

Local cryotherapy (cooling of the knee with "ice machine") - with devices such as Game Ready and Cryo Cuff - and compression after knee arthroscopy significantly lowered the temperature in the knee postoperatively, and the decreased inflammation in the knee (measured synovial PGE2 concentration was correlated with the temperature. Since PGE2 is a marker of pain and inflammation, the postoperative local cooling and compression appeared to have a positive anti-inflammatory effect. In summary, local application of a cooling and compression device after knee arthroscopy significantly lowered the knee temperature and maintained the low temperature during the initial postoperative period. This is the first study to demonstrate a correlation between the PGE₂ concentration in the synovium of human subjects and the temperature in the knee joint. Since PGE₂ is a marker of pain and inflammation, this finding implies that postoperative cooling and compression of the knee has a positive anti-inflammatory effect. The proposed protective effect of hypothermia on post-ischemic and hypermetabolic tissue is likely due to decreased metabolism and energy needs of the cells, as shown by the stability of the lactate concentration despite the decreased blood flow indicated by the increasing ethanol ratio.

Narcotic Pain Dependence Has Adverse Affect on Total Knee Replacement Results

2011-12-17T13:05:00.000-07:00

Background:

Chronic use of narcotic pain pills (opioid medications) leads to dependence or hyperalgesia, both of which adversely affect perioperative and postoperative pain management, rehabilitation, and clinical outcomes after total knee arthroplasty. This study evaluated patients who underwent total knee arthroplasty following six or more weeks of chronic opioid use for pain control and compared there outcome with a matched group who did not use opioids preoperatively.

Forty-nine knees in patients who had regularly used opioid medications for pain control prior to total knee arthroplasty were compared with a group of patients who had not used them.

Outcomes were worse in the narcotic pain pill group including Knee Society scores the opioid group had a mean of 79 points as compared with a mean of 92 points in the non-opioid group. A significantly higher prevalence of complications was seen in the opioid group, with five arthroscopic evaluations and eight revisions for persistent stiffness and/or pain, compared with none in the matched group. Ten patients in the opioid group were referred for outpatient pain management, compared with one patient in the non-opioid group.

Patients who chronically use opioid medications prior to total knee arthroplasty are at a substantially greater risk for complications and painful prolonged recoveries. Alternative non-opioid pain medications (such as Aleve or prescription NSAID) is preferred and more commonly taken preoperatively for patients with painful degenerative disease of the knee. A majority of patients with advanced knee arthritis do not regularly take narcotics prior to surgery. These people have two distinct and separate medical problems, one being knee OA and the other being Chronic pain. Both conditions need to be treated to obtain a successful outcome. The narcotic dependent patients need to have both their knee OA and their chronic pain conditions addressed by the orthopedic surgeon and the pain management physician in order to have a successful outcome after knee replacement surgery.

Pill Now Available to Prevent Blood Clots After Knee Replacement Surgery

2011-12-10T13:00:00.000-07:00

The Food and Drug Administration (FDA) has approved Xarelto (rivaroxaban tablets), a novel, once-daily, oral anticoagulant for the prevention of deep vein thrombosis which may lead to a pulmonary embolism in people undergoing knee or hip replacement surgery.

The approval of once-daily Xarelto tablets will provide a new option to help protect patients from developing venous blood clots following knee or hip replacement surgery. The use of a once-daily pill may play an essential role in helping to simplify clinical practice. The alternative has been the injectable medication, Lovenox, which is still used. However, now patients have the option of taking a pill instead of giving themselves an injection to prevent blood clots after knee replacement surgery.

The American College of Chest Physicians recommends the use of anticoagulants immediately following major orthopaedic replacement surgery and extended use post-discharge (at least 10 days for knee replacement) to help reduce such risks.

Xarelto tablet

“The use of blood thinners has been shown to safely and effectively help keep people from developing preventable blood clots,” said Alan Brownstein, CEO of the National Blood Clot Alliance. “The FDA approval of a new blood thinner, Xarelto, offers a new option for patients seeking knee or hip replacement surgery, and we encourage people to discuss with their physicians the risk of blood clots and which blood thinner offers optimal protection as part of their pre-surgical consultation.”

Knee Replacements Up Dramatically For Adults 45 To 64 Years Old

2011-12-07T10:30:00.000-07:00

The following confirms what we have been observing in our daily lives and reading about in the newspapers. More people than ever having knee replacement surgery, looking to improve their quality of life and return to a "normal" activity profile.

Women and men ages 45 to 64 were 2.5 times more likely to be hospitalized for knee replacement surgery in 2009 than in 1997, according to the latest News and Numbers from the Agency for Healthcare Research and Quality (AHRQ).

AHRQ's analysis of hospital stays for knee replacement surgery from 1997 to 2009 found that:

The rate for women ages 45 to 64 jumped from 16 to 42 stays per 10,000 people, while for men the same age, the rate climbed from 11 to 28 stays per 10,000 people.

The rates for women and men 65 to 84 rose from 72 to 122 stays and from 58 to 90 stays per 10,000 people.

Progress On Engineering Implantable Replacement Cartilage

2011-12-04T20:21:00.001-07:00

This is a recent news release out of Case Western Reserve University. This shows that scientists are closer than ever to discovering the key to regrowing worn out joint surfaces.

Engineering cartilage replacements

Spatiotemporal signals guide stem cell changes

A lab discovery is a step toward implantable replacement cartilage, holding promise for knees, shoulders, ears and noses damaged by osteoarthritis, sports injuries and accidents.

Self-assembling sheets of mesenchymal stem cells permeated with tiny beads filled with growth factor formed thicker, stiffer cartilage than previous tissue engineering methods, researchers at Case Western Reserve University have found. A description of the research is published in the Journal of Controlled Release.

"We think that the capacity to drive cartilage formation using the patient's own stem cells and the potential to use this approach without lengthy culture time prior to implantation makes this technology attractive," said Eben Alsberg, associate professor in the departments of Biomedical Engineering and Orthopaedic Surgery, and senior author of the paper.

Alsberg teamed with biomedical engineering graduate students Loran D. Solorio and Phuong N. Dang, undergraduate student Chirag D. Dhami, and Eran L. Vieregge, a student at Case Western Reserve School of Medicine.

The team put transforming growth factor beta-1 in biodegradable gelatin microspheres distributed throughout the sheet of stem cells rather than soak the sheet in growth factor.

The process showed a host of advantages, Alsberg said.

The microspheres provide structure, similar to scaffolds, creating space between cells that is maintained after the beads degrade. The spacing results in better water retention – a key to resiliency.

The gelatin beads degrade at a controllable rate due to exposure to chemicals released by the cells. As the beads degrade, growth factor is released to cells at the interior and exterior of the sheet, providing more uniform cell differentiation into neocartilage.

The rate of microsphere degradation and, therefore, cell differentiation, can be tailored by the degree to which the microsphere are cross-linked. Within the microspheres, the polymer is connected by a varying number of threads. The more of these connections, or cross-links, the longer it takes for enzymes the cell secretes to enter and break down the material.

The researchers made five kinds of sheets. Those filled with: sparsely cross-linked microspheres containing growth factor, highly cross-linked microspheres containing growth factor, sparsely cross-linked microspheres with no growth factor, highly cross-linked microspheres with no growth factor, and a control with no microspheres. The last three were grown in baths containing growth factor.

After three weeks in a petri dish, all sheets containing microspheres were thicker and more resilient than the control sheet. The sheet with sparsely crosslinked microspheres grew into the thickest and most resilient neocartilage.

The results indicate that the sparsely cross-linked microspheres, which degraded more rapidly by cell-secreted enzymes, provided a continuous supply of growth factor throughout the sheets that enhanced the uniformity, extent, and rate of stem cell differentiation into cartilage cells, or chondrocytes.

The tissue appeared grossly similar to articular cartilage, the tough cartilage found in the knee: rounded cells surrounded by large amounts of a matrix containing glycosaminoglycans. Called GAG for short, the carbohydrate locks water ions in the tissue, which makes the tissue pressure-resistant.

Testing also showed that this sheet had the highest amount of type II collagen – the main protein component of articular cartilage.

Although the sheet was significantly stiffer than control sheets, the mechanics still fell short of native cartilage. Alsberg's team is now working on a variety of ways to optimize the process and make replacement cartilage tough enough for the wear and tear of daily life.

One major advantage of this system is that it may avoid the troubles and expense of growing the cartilage fully in the lab over a long period of time, and instead permit implantation of a cartilage sheet into a patient more rapidly.

Because the sheets containing microspheres are strong enough to be handled early during culturing, the researchers believe sheets just a week or two old could be used clinically. The mechanical environment within the body could further enhance cartilage formation and increase strength and resiliency of the tissue, completing maturation.

Non-Verbal Clues Guide Doctor-Patient Relationships, Clinical Judgments

2011-10-15T14:09:00.000-07:00

Non-Verbal Clues Guide Doctor-Patient Relationships, Clinical Judgments

Subtle and unspoken clues exchanged by patients and doctors exert an influence on medical care, according to a new study by the University of Michigan Health System. Researchers analyzed video recordings of routine checkups and conducted follow-up interviews with participants to help elucidate signals sent and received on both sides of the examination table.
Tacit clues might include non-verbal behaviors such as body language, eye contact, physical appearance, and tone of voice.
The study found that patients relied on non-verbal clues to evaluate the doctor-patient relationship, focusing on whether the doctor seemed hurried or put them at ease. Doctors, on the other hand, reported that patients’ tacit clues influenced their medical judgments. The results were published Sept. 26 in the Journal of Evaluation in Clinical Practice.

“Our findings show that both doctors and patients identified tacit clues involving the behavior or appearance of the other, but they were not always able to articulate precisely how these clues informed their judgments and assessments,” says lead author Stephen G. Henry, M.D., a research fellow at the Veterans Affairs Ann Arbor Healthcare System and Department of Internal Medicine at the University of Michigan. “Not surprisingly, patients and doctors discussed these clues very differently.”

One doctor was particularly attuned to how non-verbal communication spoke to patients, the authors note. “I use my body a lot,” the doctor reported. “It’s nice to see that I don’t look rushed in the room. Although in my mind, I’m whirling. OK, so I sit down, I try to relax and look relaxed.”Patients, on the other hand, were mainly concerned with clues that indicated their place within the doctor-patient relationship – Did the doctor make them feel comfortable? Did the doctor seem like she was in a hurry? Did she put them at ease? Was the doctor a good listener? Did he make eye contact?
“Our findings are consistent with research from the social sciences suggesting that doctors’ and patients’ judgments in the examining room are often complicated and take into account many subtle, unspoken clues.

Two Arthritis Meds have Safer Cardiovascular Profile

2011-10-09T14:35:00.000-07:00

Naproxen (Aleve) and Ibuprofen (Advil) carry a lower cardiovascular risk compared to other NSAID (non steroidal anti inflammatory drugs). The highest overall risk was seen with Vioxx (taken off market in 2003) and Diclofenac (Voltaren or Cataflam).

The lowest risks are Naproxen at any dose and Ibuprofen below 1,200 mg per day. Other less frequently used NSAID were also studied but the ability to draw a conclusion regarding their safety is compromised due to lower confidence interval due to smaller numbers.

It is important to note that for people with no history of heart disease and are free of heart disease risk factors it does not really matter which NSAID is used because the risk between the different drugs is small. Additionally, any relative increase in risk is still only a small absolute increase.

This study was done by Dr. David Henry and Dr. Patricia McGettigan. This is a review of Observational Studies involving 2.7 million people and 184,946 cardiovascular events. This was not a controlled randomized study.

Patients at high risk, however, should avoid diclofenac and high-dose ibuprofen," Henry told MedPage Today.

Henry and McGettigan noted that the cardiovascular risks of NSAIDs have been highlighted in randomized trials, but doses are generally high and the settings are sometimes "atypical."

In addition, certain drugs tend to be "extensively" investigated while there is "little information on some widely available compounds, such etodolac [Lodine], meloxicam [Mobic], indomethacin [Indocid], and piroxicam [Feldene]."

Although indomethacin is still prescribed for gout, "it should be avoided by everyone," Henry said. "This new information on cardiovascular risk should consign it to history."

Diclofenac even in low doses carry a risk and should be avoided, as should celecoxib, Henry said. Ibuprofen dosage should be kept below 1,200 mg per day.

"Naproxen appears safe at higher doses, so it is the best drug for high-risk patients who need a strong anti-inflammatory effect," he concluded.

Systematic reviewers should consider all types of evidence in trying to build a complete picture of harms associated with drug treatments."

The editors praised Henry and McGettigan for analyzing "high-quality observational studies" and said that "passive surveillance is still crucial for providing early warning signals and generating new hypotheses about possible harms associated with specific approved drugs."

The study was limited by its observational nature and by not having access to certain information like smoking history and lab results.

PRP Update 2011

2011-08-20T11:07:00.000-07:00

Platelets are yellow, RBC's are red, Lymphocytes are purple

PRP (platelet rich plasma) use for ACL Reconstruction, Cartilage Restoration and Treating Osteoarthritis is an evolving technology that is in use in Orthopedic Surgery. PRP healing effects differ, depending on the musculoskeletal structure being treated and the composition of the PRP itself. The problem is that different procedures for producing PRP yield different concentrates and different results. There are several commercial product available with differing biologic properties. People also have variable concentration of platelets in their blood and the exact platelet count needed for obtaining the ideal concentration of growth factors is still being defined. Understanding how PRP affects the healing processes of various musculoskeletal tissues is critical to determining the appropriate type of PRP for specific injuries. The most effective application of this technology is the subject of clinical and laboratory studies. An expert panel reviewed the current state of PRP use in treating the knee. Stay tuned, this is an exciting and emerging biologic treatment.

ACL:
PRP has been proposed to augment reconstruction of the anterior cruciate ligament (ACL) in two ways. At the midsubstance of the tendon, PRP appears to harbor ACL cell viability and function in vitro, leading to enhanced histologic repair. When used to enhance bone healing at the graft-bone interface, however, PRP did not demonstrate any clinical or biomechanical effects at a 2-year follow-up in a level 1 randomized clinical trial. Whether these findings are applicable to other ligaments in the knee (medial or lateral collateral ligaments) is not known.

Knee Arthritis:
Studies of the use of PRP for cartilage degeneration have shown more consistently favorable results. The largest study (115 knees) found PRP injections effective at improving pain, function, and quality of life in patients with chondral injuries and early or advanced osteoarthritis, and a comparison of PRP and hyaluronan injections for osteoarthritis of the knee found improved scores with the use of PRP.Platelets provide an autologous source of growth factors for healing and tissue regeneration.

Knee Replacement Surgery:
One of the early uses of PRP in orthopaedics was the addition of a PRP fibrin sealant added to total knee arthroplasties. Both a retrospective chart review and a comparative study have found less postoperative blood loss, less narcotic use, and earlier hospital discharge with the use of PRP. A recent laboratory study has confirmed that PRP exerts an antimicrobial action against both gram-negative and gram-positive bacteria.

Knee arthroscopy and Blood Clots: The Risks are Minimal

2011-08-13T15:02:00.001-07:00

“Knee arthroscopy is the most commonly performed orthopedic procedure in the United States,” explained Diane L. Dahm, MD, at the annual meeting of the American Orthopedic Society for Sports Medicine.

Dr. Dahm and her colleagues conducted a case-matched, retrospective review of knee arthroscopies performed at a single institution over a 20-year period. They examined the records of 12,595 patients who underwent knee arthroscopy between 1988 and 2008. Overall, they identified 43 cases of symptomatic blood clots —35 cases of leg vein clots, 5 cases of lung clots, and 3 cases of leg clots that progressed to lung clots. The overall incidence of all blood clots was 3 1/2 cases per 1,000 arthroscopic surgery cases, or 0.34 percent, which is quite low. Serious lung clots only occurred in 1 in 1,500 cases.

Risk factors for the development of blood clots after knee arthroscopy include a history of cancer or prior blood clot or the presence of two or more of the following: age older than 65 years, Obesity, smoking, oral contraceptive or hormone replacement use, and chronic venous insufficiency.

This study shows that arthroscopy is a safe procedure and in most cases it is not necessary to use medication to prophylatically to protect against blood clots after knee arthroscopy.

Photo showing Patient positioned in operating room for knee arthroscopy, surgical leg in leg holder and healthy leg supported on cushion and using a sequential compression pump. These techniques employed by Dr. Tarlow can help lower the risk of blood clots.

3 Factors Associated with Better ACL Surgery Outcomes

2011-07-09T21:40:00.000-07:00

Conclusion: Six years after Anterior Cruciate Ligament Reconstruction (ACLR), patients could perform sports-related functions and maintain a high knee-related quality of life similar to their 2-year level, although their physical activity level (Marx) dropped over time. 3 factors were associated with better results: Choosing autograft rather than allograft, not smoking, and having normal body mass index are advised to improve long-term outcomes.

Methods: All patients with unilateral ACLRs from 2002 currently enrolled in the MOON (Multicenter Orthopaedic Outcomes Network) cohort were evaluated. Patients completed the validated outcome instruments preoperatively. Physicians documented intra-articular pathologic abnormalities, treatment, and surgical techniques used at the time of surgery. At 2 and 6 years postoperatively, patients completed the same validated outcome instruments.

The lead author is Kurt Spindler from Vanderbilt Sports Medicine, this study was presented at the annual meeting of AOSSM, Providence, Rhode Island, July 2010.

^†Vanderbilt Orthopaedic Institute, Vanderbilt University Medical School, Nashville, Tennessee.
^‡Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, Missouri.
^§Department of Orthopaedic Surgery, The Ohio State University School of Medicine, Columbus, Ohio.
^‖Sports Medicine Division, Hospital for Special Surgery, New York, New York.
^¶Department of Orthopaedic Surgery, University of Iowa School of Medicine, Iowa City, Iowa.
^#Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
^**Department of Biostatistics, Vanderbilt University Medical School, Nashville, Tennessee.
^‡‡Health Services Research Center, Vanderbilt University Medical School, Nashville, Tennessee.
^§§Department of Orthopaedic Surgery, University of Colorado School of Medicine, Denver, Colorado.
Investigation performed by the MOON Group
The lead author is Kurt P. Spindler, MD, Vanderbilt Sports Medicine.This study was presented at the annual meeting of AOSSM, Providence, Rhode Island, July 2010.

Depression Increases Likelihood of Knee Arthritis Pain Symptoms

2011-06-18T11:16:00.000-07:00

A Korean study published in March, 2011 concludes that depression is linked to knee arthritis symptoms. The authors evaluated 660 patients aged 65 years or older; severity of knee OA was assessed based on radiographs and symptoms and depression was assessed based on interviews and patient questionnaires. The presence of a depressive disorder was associated with increased risk of symptomatic knee OA among patients with a radiographic severity of minimal to moderate OA.

Mental well being and a positive outlook help people cope with and tolerate symptoms of disease. In this study, a person with minimal to moderate Knee Osteoarthritis was more likely to have moderate to severe symptoms, and the reason for the increased dysfunction was thought to be due to poor mental health, not poor physical health.

This is a good lesson for both patients and doctors. Always consider a person's overall health when formulating treatment plans. In some cases treatment should be directed at the cause of symptoms (treat depression, not knee arthritis) for the best outcome.

Oxford or Fixed Bearings for Uni Knee Replacement: Which is better?

2011-06-11T11:06:00.000-07:00

Specialty Day debate looks at clinical advantages in UKA

Do mobile-bearing designs -The Oxford Uni Knee- offer a clinical advantage over fixed-bearing designs-Most other brands including Makoplasty, Zimmer Uni, Stryker Uni, Smith and Nephew uni- for unicompartmental knee arthroplasty (UKA)? That was the debate between Craig J. Della Valle, MD, and Richard D. Scott, MD, during the combined Knee Society/American Association of Hip and Knee Surgeons 2011 Specialty Day program.

In expert hands, he concluded “both of these techniques work very well. There is nothing ‘magic,’ however, about a mobile bearing. Although wear is admittedly low, the surgical technique is more demanding, the risk of bearing dislocation is real, and all the other modes of failure are still possible. With a fixed-bearing design, particularly one that has a metal-backed tibial component, loosening is rare, reoperations for wear are present but infrequent, and survivorship is high.”

No clinical advantage found
“Although the idea of a mobile-bearing design is very appealing, I do not believe that it offers a clinical advantage over a fixed-bearing design,” Dr. Della Valle stated. “The mobile-bearing design has two important potential benefits—a decreased rate of wear as well as the promise of decreased stresses at the interfaces between the cemented implant and bone that could translate into a lower rate of prosthetic loosening.

“But the real question in my mind,” he continued, “is whether there is something magical about a mobile-bearing UKA that makes the outcomes better or in some way different or makes survivorship longer? And is there a clinical benefit that leads to better patient outcomes? I don’t believe there is; I think there are some real negatives to a mobile-bearing implant as well as advantages to a fixed-bearing design.”

Although Dr. Della Valle acknowledged that mobile-bearing UKAs have been shown to have very low polyethylene wear rates, the promise of decreased rates of prosthetic loosening has not been realized. “Almost every series in the literature includes tibial component loosening as a failure mode as well as problems with femoral component loosening,” he said.

According to Dr. Scott, the literature supports the concept that mobile-bearing UKAs offer excellent longevity, even in the middle-aged patient. His personal experience confirms that the early results of both mobile- and fixed-bearing UKAs are similar for both range of motion and pain.Dr. Scott identified poor patient selection, prosthetic design, and surgical technique as reasons for UKA failures, with wear, loosening, and degeneration of the opposite compartment as the modes of failure. “Wear is often design-related,” he explained. “The wear pattern of the prosthesis reproduces the preoperative wear pattern of the arthritic knee. Prosthetic designs, therefore, must accommodate this wear pattern.

Younger Patients Driving Increase in Total Knee Replacement Surgery

2011-06-05T11:06:00.000-07:00

From 1997 to 2007, the number of total knee arthroplasty (TKA) procedures performed annually in the United States doubled, with much of the increase taking place in younger patients, according to a study presented at the 2011 AAOS Annual Meeting. Data has shown that younger and healthier patients have better post-TKA outcomes, the indications for performing surgery have been expanded to include these patients. Keep in mind that more surgery in younger patients drives up the cost of US Healthcare, but better outcomes in young people justify the increase in costs. Treating severe knee disability increases the productivity of these working aged people and improves quality of life for 20-30 years.

During the study period, the overall U.S. adult population grew slightly (1.13-fold and the prevalence of obesity grew 1.12-fold). But the number of TKAs performed more than doubled—from 264,311 in 1997 to 549,707 in 2007. When researchers examined population growth, obesity rates, and number of TKAs performed by age group, they found the greatest growth in TKAs among those younger than age 65.

What is driving the increase?

Obesity and population size accounted for 22.6 percent of the approximately 100 percent increase in the number of TKAs performed,” said author Elena Losina, PhD, director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston.

The rapid expansion of TKA utilization can not be fully explained by increases in population and obesity prevalence.

Other factors that may be driving the increase in TKA include an increasingly active population and expanded indications for surgery among a younger patient population.

Previous studies have linked sport-related knee injuries and increased physical activity in younger people to an increase in early-onset osteoarthritis. Therefore, active lifestyle increases may help explain why rising numbers of younger patients are receiving TKAs.

Adolescent Knee Injuries - Patellar Dislocation

2011-05-16T21:59:00.000-07:00

Tear MPFL (white arrow), Patella partially dislocated

Loose body in Back of Knee, open growth plates

Patellar (Knee Cap) Dislocation is a common adolescent knee injuries. This injury can occur in children under age 10, but typically first occurs after age 12. The injury may be caused minor twist or a major event, such as a basketball or soccer injury. Girls are more likely than boys to sustain a patellar dislocation. Most cases are initially managed with rest, ice, bracing and physical therapy.

Best bracing options for patellar instability are the Breg PTO or the Bledsoe 20.50. Risk of recurrent dislocation after only one event is 1/3 (2/3 will not re dislocate).

This example case shown in the MRI pictures is of a first time dislocation treated with surgery because of the complete tear of the MPFL (medial patellofemoral ligament) and the associated osteochondral loose body. The ligament was surgically repaired via a small incision and the loose body removed arthroscopically.

Surgical intervention is often needed for recurrent dislocation injuries. Exact surgical options depend on factors such as bony alignment and whether damage has occurred to the joint surface of the patellofemoral joint. Physical exam, xray and MRI are all used to arrive at the best surgical treatment plan.

Arthrosurface Wave for Knee Joint Surface Defects in Knee Cap

2011-05-04T13:55:00.001-07:00

Patello-Femoral

The Arthrosurface HemiCAP® Wave system is a surgical method for the treatment of localized cartilage lesions in the patellofemoral joint (knee cap). This product is similar to the UniCAP in theory but has a different shape to match the femoral groove in which the knee cap tracks. The Wave can be used with or without a patellar (knee cap) resurfacing product. The HemiCAP® system is intended to provide an effective interim means for managing pain and disability in the middle-aged patient until a total joint replacement treatment option becomes more necessary, and is part of a clinical treatment strategy to help avoid early-age-revision scenarios. The HemiCAP® implants and instruments are designed to remove a minimal amount of bone stock, preserve functional structures and tissues, and allow for an uncomplicated removal in the event of revision. This system is comprised of three elements; a three-dimensional mapping technology, a set of instruments to map and prepare the damaged area and a cobalt-chrome and titanium implant.

There are 2 systems that comprise the Patello-Femoral Line. The first is the Classic Focal HemiCAP which is used for smaller, isolated and well contained lesions of the trochlea groove. This is not combined with a patellar resurfacing. The second system is called the WAVE and is used for those patients that have more diffuse or extensive damage to their PF joint. This may or may not be combined with patellar resurfacing using a UHMPE patellar implant, depending on whether the patellar joint surface is healthy or damaged. Both systems use the same proven intra operative mapping technology of all Arthrosurface systems.

Adolescent Knee Injuries - ACL tear

2011-04-29T14:09:00.000-07:00

Little information exists on the web regarding youth knee injuries. The explosion of participation in youth sports combined with the focus on year around training has resulted in an exponential increase in adolescent knee injuries requiring surgical treatment. Surgery in adolescents presents specific challenges because growing bones have to be treated with surgical methods that do not disrupt the normal growth of the joint. Despite this hazard it is usually better to treat the ACL tear in the adolescent surgically. Outcomes from growth plate sparing ACL reconstruction surgery are favorable and protect the knee from recurrent injury. In my experience the more serious risk is to NOT stabilize the ACL in a young athlete. The knee can not be stabilized with bracing and the damage that occurs from participating in sports with a brace (meniscal tears, recurrent knee instability) often dooms the youngster to a prematurely arthritic knee.

Future posts to address Patellar Dislocation and Osteochondritis Dissecans.

Anatomy of the ACL and Mechanism of Injury

The function of the ACL is to provide stability to the knee and minimize stress across the knee joint:

It restrains excessive forward movement of the lower leg bone (the tibia) in relation to the thigh bone (the femur).
It limits rotational movements of the knee.

A tear to the anterior cruciate ligament (ACL) results from overstretching of this ligament within the knee:

It's usually due to a sudden stop and twisting motion of the knee, or a force or “blow” to the front of the knee.
The extent of the tear can be a partial or a complete tear.
Individuals experiencing a tear to the ACL may or may not feel a pop at the time of the injury.
It is often injured together with other structures inside the knee joint.
After the initial injury, the knee may swell and become painful.
Instability or a sensation the knee is “giving out” may be a major complaint following this injury.

Arthrosurface UniCAP for Knee Joint Surface Defects

2011-04-21T13:52:00.000-07:00

Femoral Condyle Inlay Resurfacing

The UniCAP knee system is the first meniscus sparing implant designed specifically for the Sports Medicine surgeon. Articular cartilage is a thin, whitish, glistening layer of protective tissue that covers the joint surfaces of bones. Articular cartilage is composed of hyaline cartilage cells, which have many unique properties that allow it to function effectively as a smooth and lubricious load-bearing surface. Small defects in the articular surface can cause pain and restrict range of motion. Arthrosurface UniCAP is indicated for use for partial replacement of the articulating surfaces (femoral condyle) of the knee when only one side of the joint is affected due to the compartmental primary degenerative or post-traumatic degenerative disease. The system is comprised of the following elements: a 3-D mapping technology, a set of instruments to map and prepare the damaged area and a cobalt-chrome CAP mated to a Titanium post to fully cover the defect. The system precisely aligns the surface of the implant to the contours of the patient's articular cartilage surface, thus filling the defect and restoring a smooth and continuous articular surface. The best use is in the Millennium Patient with an intact meniscus and intact tibial articular surface that is "in between" options. These patients are too old or have exhausted the conservative and biologic treatments yet are considered too young for a total knee replacement. Ironically, this is one of the most effective uses of this product but is considered off label use by the US FDA.

Extra Weight Piles on Knee Arthritis Risk

2011-04-16T15:19:00.001-07:00

Doctors have few weapons to treat obesity. There are detrimental physical and mental consequences of obesity. Medications and surgery infrequently help. Self prevention of obesity is very important for improving the health of our country AND decreasing expenditures for health care. It is time people take ownership of their well being. Eliminating obesity is a mission of top priority.

Reuters Health summarized the findings.

Researchers calculate that as many as half of all cases of knee osteoarthritis could be prevented if obesity was eliminated. Being overweight (BMI 26-30) doubles a person's risk for osteoarthritis of the knees and being obese (BMI > 30) quadruples it, according to a new review of past studies that was designed to calculate how many knee arthritis cases would be avoided in a normal-weight world.

The researchers calculated that as many as half of all cases of knee osteoarthritis could be prevented if obesity was eliminated.

One in ten people over age 55 have severe knee arthritis, and many more suffer from chronic knee pain, researchers report.

Zhang and his colleagues reviewed 47 studies that compared the chance of developing knee osteoarthritis in normal weight, overweight, and obese people, including a total of almost 450,000 participants.

What is clear is that extra weight and arthritis are closely linked.

Extra weight can also increase a person's chance of getting arthritis in the hip, but the knee "is the joint where osteoarthritis causes the most trouble, (and) it's the one where obesity has its strongest effects."

Recovering in Style After Knee Surgery

2011-03-28T10:26:00.000-07:00

Distinguish yourself from the average joint replacement patient with the a high fashion cane. Limp in Style. Log on to http://www.royalcanes.com/. My special thanks to Carrie M. who brought this website to my attention.

2011-03-19T13:14:00.000-07:00

As the Presidential Guest Speaker at the Annual Meeting, legendary college football coach Lou Holtz gave an inspirational speech on ways a person can lead a rewarding and fulfilling life. The take home lessons for me is that most people lead good and blessed lives but do not realize how good they have it. Coach Holtz implored the audience to take a moment to reflect on how they live and use the power that resides inside your own mind to take control of how you view your life and focus on the positive events and relationships. He was also humorous at times, telling a few jokes that were truly funny. He had several witty lines. The coach spoke for 45 minutes, some 15 minutes longer than scheduled. He quipped " It is your (the audience) fault I went over my time limit. If some of you had stood up and left and others fidgeted and squirmed I would have stopped speaking sooner!"

Highlights from Coach Holtz address to the AAOS:

Three simple rule "I have only three rules: do what’s right, do everything to the very best of your ability, and show people you care.”

Your Attitude matters

The most important choice we can make is the attitude we’re going to have. “What is your attitude when you have adversity?” he asked. “When you’re down, you’ve got two choices: either you stay down or you pick yourself up. You can’t count on anybody else.

Four things in your life “You need four things in your life. Everybody needs something to do, something to love, something to hope for, and something to believe in. "

Two types of People “There are only two types of people. Those who lift up and those who pull down. You cannot lift other people up if you aren’t positive yourself."

Five Choices in Life “Life is a matter of choices. Point number one is the attitude you choose, Point number two is the passion to succeed. Number three, stay focused on your purpose. Number four, be a dreamer, and number five, build meaningful relationships with other people."

AAOS Position on Healthcare Reform/Other Ramblings on the Future of Medicine

2011-03-12T12:36:00.000-07:00

Response from the leadership of the American Academy of Orthopedic Surgery is summarized in this post.

Dr. Stuart Weinstein, MD-past president: All of us, consumers and providers, may see this Reform in a different light. The dichotomy comes from different perceptions of what healthcare reform was supposed to accomplish. Some experts were looking to improve quality and reduce costs, but President Obama's primary goal was to improve (expand) coverage. It is questionable whether the cost and quality issues have been addressed.

John J. Callaghan, MD - past president: Patient access to musculoskeletal care is our number one issue.

John Tongue, MD - First Vice President: Americans have an insatiable appetite for very expensive health care and an undeniable lack of resources to pay for this care in the future. All nations that control their health care costs have some sort of rationing.

Donald Berwick, MD - Head of Medicare: The r-word (rationing) is a very bad word politically in Congress, but we have to have this conversation because that is going to be how we prioritize getting value into health care.

Graham Newson, associate director government affairs AAOS: End of life issues are something the country will need to come together on to address effectively. Our Healthcare system is no longer sustainable as it is. Some changes do need to occur.

Another issue discussed is will private practice survive - the alternative is go to a Kaiser like model now being called ACO (accountable care organizations). Newly graduated Doctors will likely choose to work in an employee model, with the goal to reduce health care costs by limiting testing and limiting procedures unless there is proof of better quality by doing so. If your doctor is employed there is no financial incentive to perform procedures or order tests. In fact just the opposite - the corporation that is employing the physician will want less procedures done and less tests orders so that corporate profits can be maximized.

PRP Does Not Speed Recovery After Hamstring Injury

2011-03-05T12:24:00.000-07:00

In a small study of NFL football players Dr. Arup Bhadra found average time to return to play was 3 weeks. The five players treated with ultrasound directed Platelet Rich Plasma into the injured muscle had a similar recovery to players treated with rehabilitation only.