Knee image

Minimally Invasive Knee Replacement: Pros and Cons

Over the past 10 years, there has been a lot of discussion and advertising of “minimally” invasive knee replacements as an option for those with end-stage knee arthritis.  Our last blog post talked about “minimally” invasive hip replacements and it’s pros and cons ( https://wordpress.com/stats/day/nwomedicine.wordpress.com ).  We’d like to direct attention a little south (or distally in medical terms) of the hip to the knee.

With a lot of attention to advertising the minimally invasive procedures, one is likely to wonder how much is real and how much is just that, advertising and marketing.  On paper, it sounds great so let’s review both the Pros and the Cons of this procedure.

First, what is a minimally invasive knee replacement?  This type of surgical procedure uses smaller incisions and utilizes less cutting of the tissue surrounding the knee.  Intuitively, this sounds good.  Let’s compare and contrast the pluses and minuses of the traditional total knee replacement (TKR) with minimally invasive.

A traditional TKR requires an incision approximately 8-10″ in length vs. that of minimally invasive at 4-6″.  Therefore, there is less damage to the skin and surrounding soft tissue, including muscles, ligaments and tendons.  In the short term, it makes sense that there’s less immediate post-operative pain.  There is less blood loss in surgery from the smaller incision and, of course, a smaller residual scar.

However, The Cleveland Clinic orthopedic surgeon, Carlos Higuera, MD, describes the minimally invasive procedure like this:  “Minimally invasive knee replacement is like repairing a car engine via the muffler rather than opening the hood — it might be possible, but it is more difficult.”  Visualization of the joint and surrounding muscle, tendon, nerves and blood vessels is more difficult and can lead to complications.

Medical literature shows that like the minimally invasive hip replacement, risk of complications can be higher and the procedure may take longer, which is detrimental for the final outcome of the surgery.  Minimally invasive total knee replacement is not suitable for all patients. Your surgeon will conduct a thorough evaluation and consider several factors before determining if the procedure is an option for you.

Generally, candidates for minimal incision procedures must be thinner, younger, healthier and more motivated to participate in the rehabilitation process, compared with patients who undergo the traditional surgery.  There are many limitations to qualify for this procedure to start.

Therefore, minimally invasive surgeries are less suitable for patients who are overweight or who have already undergone other knee surgeries.

An additional limitation is for patients who have a significant deformity of the knee (very knock-kneed or bowlegged), those who are very muscular, and those with health problems such as slow wound healing may be at a higher risk for problems from minimally invasive total knee replacement.  Most surgeons advise against the procedure with the above limitations or complications.

Although minimally invasive total knee replacement sounds good, there are many limitations that are sometimes difficult to meet.  Some potential complications may make traditional TKR a more attractive or even necessary option for those with severe knee osteoarthritis.

The discussion to this point has been on the surgical side of TKR.  But, timely and quality physical therapy for rehabilitation is a big factor in achieving a positive outcome even given a good immediate replacement.

If you or someone you know is looking into procedures or therapy to address knee arthritis and are looking for experienced professionals, give us a call at:  419.427.1984 and check out our website at:  http://www.nwomedicine.com

 

Is Minimally Invasive Hip Replacement for You?

Hip joint

There has been a lot of buzz over the last several years about what has been termed “minimally invasive” hip replacement surgery.   “Minimally invasive” generally refers to a hip replacement involving about a 5″ incision or two 2″ incisions instead of the standard 8″.  Richard A. Berger, MD from Rush-Presbyterian-St. Luke’s Medical Center in Chicago refined the technique.  He touts that through less tendon and muscle disruption, patients have less pain and a quicker recovery.   The name itself and these stated benefits makes it an attractive alternative to the tried and true hip replacements that are still being done by the majority of orthopedic surgeons.  However, there may be some complications that are often understated by those surgeons performing the “minimally invasive” procedures.

Critics of this method state that the benefits are often overstated and under proven.   Why risk additional complications to achieve a slightly smaller incision?  It turns out that indeed, there is a relatively high learning curve by the surgeon and higher complication rates.

In a recent meeting at the American Academy of Orthopedic Surgeons, researchers from the Mayo Clinic  performed two-incision operations on 10 cadavers. The surgery “cut or damaged measurable amounts of muscle or tendon in every case,” they concluded.  They attribute some of these complications to a lesser ability to visualize or see what they’re doing.  Now, these were cadavers and not live subjects. Can this very simple lab translate into a reason to go forward or not with the minimally invasive method?  No.  However, a couple other studies may bolster the critics complaints of the procedure.

Two studies at the AAOS meeting provided some areas of concern about complications with two-incision operations. In one series of 80 patients from the Mayo Clinic, 14% of patients suffered complications.  This rate is nearly four times higher than normal. Problems included the major complication of seven fractures of the femur and one deep infection.  The deep infection, although very serious, may not necessarily be due to the type of method of joint replacement surgery as are the seven fractures.

A second study at the University of Missouri at Columbia suffered a similar fate. Nine of 87 patients or 10% required a second hip operation within six months and 22 or 25% suffered nerve injury.  This is three to four times the normal rate of problems.

Every technique has its own learning curve.  Most residents learn the traditional method while in their residency program.  However, some seek a total joint fellowship AFTER residency giving them further expertise in most methods of joint replacement.  Allan E. Gross, MD, professor and chairman of orthopaedic surgery at the University of Toronto suggest that for the two incision method, surgeons should do 50 per year to be and stay proficient.  This many hip replacements in a year is a lot for a smaller practice as it averages over one per week of this method alone.

Some other research shows that the advantages of this technique is well overstated.  Graham Bailie, MD, a co-researcher states there’s no difference in recovery time between the minimally invasive method and the traditional.

Overall, although there seem to be advantages to the minimally invasive technique, one should be careful choosing a surgeon with advanced training and with vast experience to solve the increased learning curve.  Also, if one is considering it, ask the surgeon for a handful of patient references who have released their information stating they’d discuss it with future patients.  Future studies are necessary and, perhaps, perfection of the technique to reduce some of the increased complications that arise from minimally invasive hip replacement.

If you suffer from hip pain, NWO has the only orthopedic surgeon in the region who is fellowship trained in total joint replacement.  Dr. Brian Hecht is proficient and an expert in this field and will be glad to help.  You can call for an appointment at:  419.427.1984.  Our website is:  http://www.nwomedicine.com

Ice, Ice Baby

Slippery when Icy

Slippery when Icy

Winter has finally hit en force to our northern climate.  With it comes cold, snow, and ice.  At NWO, we don’t have to look outside to know there’s ice on our roads, sidewalks, driveways and parking lots.  We can tell by an uptick in the broken bones we see this time of year.  It’s like clockwork.  Ice coats these surfaces and our schedules start filling up wrist, ankle, elbow and hip injuries or fractures.  Because we have a couple more months of winter left (and really, weather-wise, it’s just begun), let’s look at some ways to PREVENT these slips and slides.

  1.  It may be obvious, but worth saying anyways.  If there is suspected snow or ice outside, minimize your exposure to it and only go out when you need.  Sometimes we don’t consider altering our plans based on weather or conditions when waiting just a day or even a few hours might cause enough melt to make footing better.
  2. If you must go out because, you know, work or school is pretty important as well as trips to the grocery, pharmacy or other appointments, where appropriate footwear.  Sneakers and rubber-soled boots are better than dress or hard-soled shoes.  There is no crime in wearing these shoes but carrying your dress shoes in a bag to change later.  You’ve seen those New Yorkers or Chicagoans do this for comfort alone.
  3. It sounds lazy or wasteful but if you have a sloped or slippery driveway, a car in the garage   and have to get the mail or newspaper, you can drive down and thereby avoid exposure to a possible fall.
  4. There are several kinds of “spikes” or the like that can be slipped over your shoes like the old style galoshes.  Yaktrax, Kahtoola and several other companies make these which consist of a webbing of rubber that goes over the shoe or boot but have soles of spikes or the like.  Some of these can be purchased for as little as $10-$15 but they go up from there.  Here’s an example of spikes that add traction in slippery conditions:

Ice falls-spikes

5.  Remember the old Aesop’s Fable of the Tortoise and the Hare?  There is no need to race or rush when conditions don’t warrant it.  The tortoise was deliberate but steady and he won the race.  The alternate ending of that fable is the hare slipped on ice, injured his paw and had to see the orthopedic vet thus disqualifying him from the race.  Take short, quick steps maximizing the time spent on both feet.

6.  Walk near the edge or even on the edge of the walkway.  If you have one foot in the grass or berm, it’s likely your footing will be enhanced than both on ice.

7.  Have your charged cell phone with you.  It may sound odd but if unfortunately, you DO fall and DO sustain a significant injury, you want a way to contact help.  Just be sure to keep from getting distracted with Facebook, Twitter or Snapchat while you’re walking..

If you have fallen and could or couldn’t get up, but feel you have injured something, we are happy to help get you back to where you want to be.  Just contact your partner in healing at NWO at:  419.427.1984.  Check out our Facebook page at:  https://www.facebook.com/NWOmedicine or website at:  http://www.nwomedicine.com

Mishaps and Mistletoe

Clark Griswold hanging from roof

This is a special time of year spending time with friends and family celebrating traditions and religious milestones.  There are some time-honored traditions of trees, shopping, baking and decorating that make the season more memorable.  This is also a season of Doctor and emergency room visits from mishaps under the mistletoe.  Injuries and mishaps don’t only happen to Clark Griswold and cousin Eddie and a little prevention can go a long way in keeping this time of year jolly.

We’ve heard a lot about issues that can occur with a live Christmas tree and know it’s important to keep it watered and as fresh as possible throughout the holidays.  A dry tree can go up in flames in a few seconds given the right spark.  Similarly, throw out damaged lights cords or anything that looks like it could spark or short out from damage.

However, a lot of the more orthopedically related injuries happen while installing and removing Christmas lights and decorations.  Visits to the ER go up this time of year from just falls from ladders.  Often, these injuries are more major for the older individual than their younger counterparts.  Patty Davis, from the Consumer Product Safety Commission, states “About 200 people a day suffer decoration-related injuries this time of year.”   Injuries range from bumps, scrapes, and bruises to life-altering injuries like spinal cord or brain injuries.  Most of these can be prevented with careful planning.

Anecdotally, Ball adds that when he talks to people about hanging Christmas lights, he frequently hears tales of “near misses” that didn’t require an ER admission or involve severe injury, but very easily could have. Though not covered in the Injury study, he says these close calls further highlight the dangers. “I think without question this issue … is a lot more common than the paper would elucidate.”

So how can you safely install and remove your lights and decorations without a visit to the hospital?  Below are a few helpful tips.  Some may be obvious but often in the heat of decorating or removing lights, we rush without much thought.

  • Hire out if you can afford it. This is cost prohibitive for many but if you’re planning an over-the-top, Griswoldian array of holiday illuminations, think about hiring a pro to do it.  A big difference between you and a professional doing it is they have the proper equipment and safety harnesses.
  • Assess your physical abilities and limitations. Or, maybe a significant other should assess your limitations as they are often give a more honest assessment.  Anyone with vertigo or balance issues should avoid climbing ladders. Individuals with such risk factors should also avoid working at heights, including on roofs.
  • Scan the weather. Do you really need to install lights when it’s 0 degrees below and icy? Even if the weather is dandy when putting up the lights, they must come down and that weather can turn at any moment in the winter.  You should be flexible when putting up or taking down decorations so you reduce the icy, wet, cold or slippery conditions as best as possible.
  • Be sure you have firm footing. Falls can occur from roofs, trees and railings, but commonly involve a slip from a ladder. So, ladder safety is a must:
    • First, use a ladder that’s tall enough for the job.  A ladder should extend at least 3 feet over the roofline or working surface.
    • Put the ladder only on level, firm ground, and make sure it can support your weight.  Loose stones, sand, mud or uneven ground opens the door to a mishap.
    • Set up the ladder at a 75 degree angle away from power lines.  More vertically placed, you can fall backwards while on the ladder and if more horizontally placed, the ladder can slip out from underneath you.
    • Have a helper hold the ladder.  This is very helpful even under the safest of conditions.
    • Don’t reach.  The tendency to save time moving the ladder to safer positions is to reach causing it to slide from one side or the other.
    • Wear appropriate footwear not slippers (just the name sounds like an accident waiting to happen), sandals or flip-flops.

Besides the potential for broken bones or other injuries when decorating, lifting decorations can cause back or shoulder injuries.  Use proper lifting mechanics and get help if the box is too heavy for one person.  Carrying heavy weight up or down stairs may also call for getting another helper.

Most importantly, put thought into and be safe this season.  A little planning and follow through goes a long way in avoiding mishaps under the mistletoe.  Be safe and Merry Christmas and Happy Holidays from your family at NWO!

A: It Goes, Snap, Crackle and Pop: Q: What is Knee Cartilage?

snap crackle pop

Sometimes, or even many times, we hear some snapping, crackling and popping going on in our knees.  Often, cartilage in the knee joint is the culprit of noisy knees.

There are a few different types of cartilage in the human body.  There is articular cartilage found on the ends of bones in joints, fibrocartilage found in the knee meniscus and neck and back discs and elastic cartilage found that helps make up the ear.  The knee actually has two of these types:  articular and fibrocartilage.  Let’s take a closer look at these two commonly injured types of cartilage in the knee.  We’ll start with articular cartilage.

Articular cartilage lines the entire ends of bones that come in contact with one another in a joint.  It can be thought of as a thin shock absorber and is low friction allowing one bone to slide on another during our daily activities.  It is a living tissue and can get damaged either through wear and tear or some sort of trauma.

In general, cartilage has a fairly poor blood supply.  It gets its nutrients from the underlying bone and through the fluid in the joint.  In wear and tear of the articular cartilage, there is a progressive loss of cartilage and roughening over time.  This is one of the characteristics of osteoarthritis.  Causes of this kind of arthritis is poorly understood except that there is a genetic component to it.  Normal daily activities don’t increase the risk of this whereas heavy and repeated loading of the knee, twisting, etc. can increase that risk.  Other risk factors are muscle imbalances or weaknesses, joint instability and abnormal joint shape.

Trauma may damage the articular cartilage and/or the underlying bone.  This may result in a piece of cartilage loosening and floating in the knee and may cause catching or locking in the knee.

Besides joint pain, catching or locking, other signs of cartilage damage is in or around the knee.  X-rays can show arthritis but not cartilage injury.  An MRI may be helpful in this diagnosis.

At times, the inflammation caused by wear and tear can be reduced with relative rest and therapy to address muscle weakness and imbalance.  More advanced or deep, smaller defects of the articular cartilage can be helped with surgical drilling of the defect.  The resulting cartilage growth is less strong than the original but can help delay a joint replacement.

The fibrocartilage, or meniscus, in the knee is made of two parts:  medial and lateral meniscus.  Often in sports or deep squatting, this is the kind of cartilage involved.  These two menisci are rubbery and C-shaped and attached to the top of the tibia (shin bone) in the knee.  They also help in cushioning the knee and providing some stability to the knee.  They are prone to injury in twisting or pivoting on the knee with it bent.  With age the meniscus become worn and more fragile.

Small or minor meniscal tears may pose little trouble after the initial inflammation settles down.  Moderate or severe tears will likely cause, well, moderate to severe problems.  Intermittent to common locking or catching are common.  Pain at the joint line and swelling are also present.

Menisci also don’t have a good blood supply and with the larger tears, may require surgical intervention.  An MRI can assist in making the diagnosis.  In some cases, a surgical repair may be possible but often, trimming of the torn fragment is necessary.  This results in losing some of the cushioning that the meniscus provides but with poor blood supply, may be needed.  Rehabilitation after a partial removal or meniscectomy can be fairly fast for an otherwise healthy individual.

If you suspect a cartilage injury or any knee injury, give us a call.  NWO specializes in all knee injuries and has a team of specialists to help get you back on your feet.  Our number is:  419.427.1984 and website is:  http://www.nwomedicine.com

Collateral Damage

Collateral Ligaments

The collateral ligaments are two of the four major ligament stabilizers of the knee.  Most people familiar with athletics have heard of the Anterior Cruciate and Posterior Cruciate Ligaments (ACL and PCL, respectively).  The two others are the Medical Collateral and Lateral Collateral Ligaments (MCL and LCL, respectively).

Unlike some “ball and socket” joints in the body, the knee joint does not have great stability in and of itself.  It depends largely on its ligaments for stabilization.  Generally, side to side stability of the joint is derived from the MCL (on the inside of the knee) and LCL (on the outside).  Injury to these ligaments is common and, in fact, the MCL is the most commonly injured ligament of the knee.

Injuries occur to these two ligaments usually by direct blows to  the inside or outside of the knee.  The MCL is often damaged by contact to the outside of the knee pushing it to the inside.  The LCL can be stressed and damaged by a direct blow to the inside of the knee as well as over-rotation of the knee.  Signs of a torn MCL or LCL is pain and tenderness directly over the ligament, localized swelling and instability in that direction with weight bearing or in stressing the knee in that manner.

Diagnosis of the injury involves the history and manual exam.  Although x-ray is indicated to rule out a fracture, it doesn’t help with soft tissue injuries such as these.  Your sports medicine therapist or doctor may order an MRI that will confirm the damage and may even tell how severe of a tear was sustained.

Injuries to the MCL rarely require surgery. If you have injured just your LCL, treatment is similar to an MCL sprain but, if your LCL injury involves other structures in your knee, your treatment will address those, as well.  LCL injuries sometimes do require surgical repair and subsequent rehabilitation.

 

Ice. Icing your injury is important in the healing process right from the start. The proper way to ice an injury is to use crushed ice directly to the injured area for 15 to 20 minutes at a time, with an hour or so between icing sessions.

Bracing. Your knee must be protected from the same sideways force that caused the injury as this would keep the ligament loose and not allow it to “tighten” back up while healing. Your doctor will recommend a brace to protect the injured ligament from stress. To further protect your knee, you will likely be given crutches to keep you from putting weight on your leg.

Physical therapy. Your doctor will suggest strengthening exercises. Specific exercises will restore function to your knee and strengthen the leg muscles that support it.

If the collateral ligament is torn in such a way that it cannot heal or is associated with other ligament injuries, your doctor may suggest surgery to repair it.  This occurs more often with the LCL and its associated structures than MCL.  Physical therapy is an important component after surgery as well.  Gradual motion and strengthening exercises to resume activities are critical.

Once your range of motion returns and you can walk without a limp, your doctor may allow a functional progression. This is a gradual, progressive return to sports activities.  For example, if you play soccer, your functional progression may start as a light jog. Then you progress to a sprint, and eventually to full running and kicking the ball.  Your doctor may suggest a knee brace during sports activities, depending on the severity of your sprain.

If you think you have injured your MCL or LCL or have any other knee injury that you are concerned about, give us a call at:  419.427.1984 so we can help you get back into the game.

 

Ligament Injuries of the Knee- The PCL

Ligament Injury-us women soccer

In our last post, we covered the Anterior Cruciate Ligament (ACL), it’s injury, diagnosis, surgery and rehabilitation.  Now, we’ll touch on the Posterior Cruciate Ligament (PCL) while next post will cover both the medial and lateral collateral ligaments.

The cruciate ligaments which cross over in the middle of the knee (behind the kneecap with the knee straight) are the anterior cruciate ligament which prevents the shin bone popping out forwards and the posterior cruciate ligament prevents the shin bone or tibia moving backwards with respect to the thigh bone or femur.  The PCL is often injured from a blow to the front of the knee or upper shin while the knee is bent. This can occur in automobile crashes and sometimes sports-related contact.  PCL tears tend to be less deleterious to sports participation than the ACL tears.

Symptoms of a PCL injury typically include pain at the time of injury which may also be felt in the calf region down the road. There will likely be swelling, although this may be minimal. The athlete may complain of instability of the joint, perhaps associated with the feeling of the knee giving way.

Injury to the PCL sometimes have other injuries associated with it.  These include damage to the meniscus (cartilage) and other ligament structures.

Initial treatment should include the principles of PRICE. Protection, rest, ice, compression and elevation. Ice and compression should be applied as soon as possible after injury for 10 to 15 minutes every hour to help reduce pain and swelling over the acute stage. There are cold therapy wraps specifically designed for the knee that combine cold therapy and compression, but any kind of cold treatment will help (ice or ice pack). This should be continued for 24 to 48 hours or longer depending on how bad the injury is. Ice should not be applied directly to the skin as it may cause ice burns. Wear a knee support or elastic wrap to support the joint and crutches as needed.

If the knee is initially pretty painful and swollen it is unlikely that a full examination is possible. Once the pain and swelling has settled down to the point where it can be examined, contact your orthopedic or sports injury professional.  Our skilled physicians and therapists at NWO are experts in evaluating and treating PCL and knee injuries.  They will likely order x-ray and possibly an MRI scan to assess the extent of the damage. Once the injury has been properly assessed and diagnosed, there are two directions of treatment that may be recommended, conservative treatment or surgery.

Conservative treatment for PCL injuries or tears is everything short of surgery. This is the usual recommended approach for most posterior cruciate ligament injuries.  This will include physical therapy to address the symptoms of pain and swelling but also include the progressive strengthening and neuromuscular reeducation required after this injury.

Advise on a specific rehabilitative exercise program which may include quadriceps and hamstring strengthening, gait re-education and balance training using wobble boards or foam matting. A knee support or brace can be used in the early to mid stages. Hinged knee braces will provide the most support for knee ligament injuries to help prevent the shin bone from sliding back on the thigh bone.  This will help prevent premature stresses on the under surface of the kneecap.

Surgical intervention in PCL injuries are much less common.  But, in more severe cases and especially in cases where other ligaments have been injured besides the PCL, surgery may be indicated.  Surgery may also be indicated if the conservative management has not aided the stability of the knee sufficiently over a period of time

Generally, people who have suffered a PCL injury have very good recovery rates and outcomes, with most being able to return to sporting activities at the same level as before the injury. However, full recovery from PCL damage is highly dependent on the ability to adhere to a strict rehabilitation program.  This is where the teamwork of the orthopedic physician, the physical therapist and the patient is so important to achieve that outcome that we all desire.

If you think you may have injured your posterior cruciate ligament or any other structure in the knee, give us a call.  NWO would be glad to partner with you for your road to recovery.  Call us at:  419.427.1984.  Our website is:  http://www.nwomedicine.com  You can also find us on Facebook.