Trying to determine what works best

 Musculoskeletal Care of the Mature Patient 

 What’s the best hip or knee prosthesis? What about the type or length of that surgical incision? Is a 23-hour hospital stay for a joint replacement the best option?

 Does anyone really know the answers to these questions? In a health care system that spends $2.5 trillion a year, less than one-tenth of 1% is spent on research to determine what treatment option works best. Does Direct-to-Consumer advertising improve patient education or simply increase profits for those who pay to market? Until contracted health care, a patient would be referred to an orthopedic surgeon by a family physician, a family member or a friend. Then came the era of managed care and choices were based on third party payer pre-certification and approval. More recently, the patient has looked to patient information educational initiatives as found on the internet or in the media. But now it is direct advertising such as Direct-to-Consumer marketing to be found every year at this time in the non-professional magazines as the National Inquirer, for sale when you check out at your drug and grocery store.

 In April of 2009, an initiative was introduced within the American joint replacement community to create a United States total joint registry. Under development by the American Academy of Orthopedic Surgeons, surgeons will be provided with helpful implant survivorship data. It is important to be aware of the differences between clinical studies and registries. As compared to clinical studies, registries have the advantage of large patient populations, breadth of experience across large numbers of hospitals and surgeons; and immunity to the perception of bias resulting from investigators’ financial ties. On the other hand, registries are typically limited in their ability to measure endpoints beyond survivorship and to control for differences in patient population, patient risk factors and patient expectation.

 On May 11, 2010, the Food and Drug Administration (FDA) announced an outreach program to educate health care professionals (including physicians, nurse practitioners, and physician assistants) about the role they play in assuring that prescription drug advertising is truthful and not misleading. The FDA seeks to increase their surveillance effectiveness by curtailing inappropriate prescription drug detailing and drug-sponsored dinners and speaker presentations. According to the Congressional Budget Office (CBO), spending on advertising to health care professionals exceeds direct-to-consumer advertising (DCTA) by nearly 3 to 1. The program will be rolled out in three phases. In Phase 1, the FDA will engage health care providers at medical conventions and partner with specific medical societies to distribute educational materials. The latter phases will build upon the FDA’s, collaborative efforts with physicians and update educational materials developed during the first phase of the programThe FDA seeks to collaborate with health care professionals to address misleading drug promotion, wherever it may occur, including DTCA. Unfortunately at this time, the program does not target medical devices or biologics.

I have been involved in data collection and clinical studies for over 35 years. My many scientific outcomes, patient satisfaction, and prosthetic performance studies leading to publications after total hip and total knee replacement continually provides me with information concerning what works and what doesn’t work. Recently, other criteria for prosthetic performance have been established by way of Product Recall announcements from the several orthopedic manufacturers. The latter is a retrospective announcement when a prosthesis fails to perform after FDA approval and the company is sent a warning letter by the government agency. Until this year, orthopedic companies have been preempted from legal redress for product liability but that protection has taken away by the Congress.

 From the patient’s standpoint, be discerning about where you get your decision making input. A second opinion is worth the time and effort before deciding on the need for surgery, the surgeon and the type of implant.

Cycling medicine-“Big wheel keep on turning”

  

Musculoskeletal Care of the Mature Patient

 There are many claims for originally and orthopedic surgeons love to state that they were the first to introduce or invent a technique. Today, I am introducing my newest concept, cycling medicine. 

Certainly cycling enthusiasts, be it a century rider or those who ride rather than drive know the importance of a helmet. What about the proper fitting of a bicycle?  Are there forces in biking that are harmful to patients who have undergone hip or knee replacement surgery? I have included my particular research in forces across the hip and knee while biking before in my Blog so I will not repeat myself. Suffice it to say I am credentialed to comment on biking and forces across the implant. As well, I ride several thousand miles a year and have the acromio-clavicular deformities and residuals of a cervical spine fracture to prove it.

The three best activities, in general, you may safely enjoy after a total joint replacement or even beforehand include biking, swimming and Pilates. You may greatly enhance your biking enjoyment and effectiveness with a properly fit bike. The ultimate ”proper” fit is accomplished with a custom frame; but if the latter is not realistic, have your present bike properly fit by someone in the know.  The height of the seat, position of the saddle on the support post, and appropriate adjustment of the handle bar location make a big difference. So too is the nature of the pedal and type of clip on. The ability to change your foot position by slight rotary adjustments during the ride as important as your psychomotor agility in getting out of the clip on when needed.

Where does Pilates have a role for the biker? Strengthening the core will minimize the backache of the aerodynamic position and mobilizing your neck will allow for many more miles of comfortable riding. This past winter, I enrolled in a twice-weekly Comp train cycling program that helped me train during the off-season. The older you get, the less time you may take off from a specific sport. While general fitness training is great, with age, your training schedule need be sport specific. In addition to the attention you give to your orthosis (bicycle), pay attention to the proper glove and cycling wear so as to reduce the possibility of carpal tunnel injury or ulnar nerve compression. The split seat has not only made cycling more comfortable, it has diminished the potential for erectile dysfunction. If it rains, try a spin class. One last word of advice, never leave home without your butt butter.

 

 

 

 

Second Office – Northwest Suburbs

We interrupt the weekly Blog format with the following announcement:

In order to better serve his patient population, Dr Sheinkop has elected to establish a second office just North of the Lincolnshire Marriott off of Milwaukee Ave. Mitchell B. Sheinkop, MD will open a Northwest Suburban office July 20th, 2010 Adult & Pediatric Orthopedics, S.C. 555 Corporate Woods Parkway Vernon Hills, IL 60061 Calls will still be taken by Jennifer and appointments scheduled at 773 250 1000. The primary Chicago office location will remain unchanged.

Next week, we will resume the Musculoskeletal Care of the Mature Athlete format

Rehabilitation of hip injuries in athletes

Musculoskeletal Care of the Mature Patient

Most hip injuries are not recognized as the source of symptoms for an average of 21 months from the time of onset. The hip is part of the CORE and it becomes difficult at times to differentiate between referred pain from the back, the pelvis or the vascular system, a diagnostic dilemma In the differential diagnosis, it is helpful to be aware that hip injuries are common in specific sports such as ballet, running, soccer, golfing and contact sports.

 With the emergence of the MRI and more recently, hip arthroscopy, once the hip is recognized as the source if symptoms, it is possible to determine if the injury is extra-articular, chondral, capsular, bony, labral or systemic. The significance of the accurate diagnosis stems form the potential for non-operative rehabilitation of selected hip pathology.

 It is not possible in the available space to provide individual exercise programs for ITB, adductor sprains, snapping hip syndromes, etc. All hip rehabilitation though is centered about Pelvic/Hip/Core exercises. 

Stretching

 Strengthening

 Joint mobilization

 Core stabilization

 Functional drills

 Return to play

 The take home message, a well-designed rehabilitation program is essential to a successful outcome. The return to play criteria demands restoration of an acceptable range of motion, restoration of hip strength equal to the uninvolved side, the ability to perform sports specific drills at full speed without pain or compromise, and the completion of a functional sports test.

 My recommendation to patients who are interested in injury prevention is  cross training. Avoiding repetitive stress and cumulative fatigue will go along way to prevent injury. Equally important is to environ your self with skill matched competition and the setting of realistic goals. If injury should occur, head to the water. There is nothing better that water based aerobics and wet vest running in the deep end of a pool for keeping you in shape as you heal.

Sex after a total joint replacement

 Musculoskeletal Care of the Mature Patient

 Sports, exercise and sex after a total joint replacement

To burn calories and improve your performance get a new joint  -hip or knee that is. Sex after a total joint replacement, the ultimate athletic activity

 Sexual relations are a legitimate but often embarrassing subject so patients shy away from the discussion. I have decided to address Sexual Relations through the following question and answer format. The illustrations are available by contacting the American Arthritis Foundation

 Will I be able to resume sexual relations after joint replacement?

 The vast majority of patients resume safe and enjoyable post-operative physical intimacy.

Many patients experience impaired sexual function with the progression of arthritis because of preoperative pain and loss of joint motion. With the elimination of pain and restoration of motion following joint replacement, one may return to the thrilling days of yesteryear. 

When can I resume sexual intercourse?

 While we discourage postoperative, inpatient coitus, intimacy may be resumed (or initiated) when comfort and motion allow. Just as individual recovery times vary; desire, emotion and functional restoration is a special process in everyone.

 What positions are safe during intimacy?

 Total joint replacement precautions as introduced at preoperative joint camp, and re-enforced at the time of hospital discharge, need to be observed at all times. In general, follow the dos and don’ts and positions illustrated in the graphics available form the aforementioned resources. Patient on Top, Partner on bottom; Patient on the bottom, Partner on the Top; Patient on side, Partner on side; Standing position for both patient and partner.

Most postoperative patients, male and female, prefer “passive” intercourse in the bottom position. 

What should I tell my partner?

 Good communication is essential so be frank and openly discuss your desires or lack thereof. Sex after joint replacement is a very individualized matter since the postoperative medications or symptoms following removal of the urinary catheter may delay restoration of normal physiologic functions

What should I avoid?

 Basically anything that hurts or places your new joint in excessive flexion (knee toward chest), adduction  (leg toward center of body) and internal rotation (toes turned inward).

When your surgeon indicates that it is safe to return to work or to the workout, it is safe to fully enjoy the entire range of physical intimacy

Our final goal is patient satisfaction and we try

Golf medicine

 Musculoskeletal Care of the Mature Patient

There are many claims for originally and orthopedic surgeons love to state that they were the first to introduce or invent a technique. Hey, it attracts patients. Let me share with you the story of N.C, who had to give up golf during his Florida sojourn this past winter owing to a recurrence of low back pain. He first presented in my office in 2001 with an arthritic knee that had caused him to stop playing golf. To make matters worse, he had determined that his days of golf were finished and had put his condo unit in Southern California on the market. This very patient became the first recipient of an inlay unicompartmental total knee replacement through a minimally invasive incision and was discharged from the hospital on the same day as the surgery. What has followed thereafter in orthopedic surgery is now a well-established pattern, minimally invasive surgery for a joint replacement with a short hospital stay. Now in his early 80s with two artificial hips and having undergone a spinal decompression for stenosis five years earlier, he presents with disabling low back pain. My prescription, Pilate’s principles to help this golfer rehab and return to the golf course. This is just part of a new initiative, golf medicine. In my patient’s case, Pilates will be corrective of his symptom complex, for you it may prevent injury.

Pilates Principles

There are basically five principles that promote recovery from golf injury to the low back.

Alignment

Core Stability

Breath

Control

Strength with Flexibility

When you look at the nature of the golf injury, the dominant problem is a mechanical low back injury from hyperextension and torque although hip degeneration, shoulder tendinitis are quite common

You decide what makes the most sense. Either invest your money in a new fancy carbon-composite driver with an expanded “sweet” spot and in revolutionary golf balls engineered for longer and straighter flight or you may invest your time in Pilates rehabilitation to help you play and play to your potential

The known Science after a specific procedure

Musculoskeletal Care of the Mature Patient

Sports and exercise after a total joint replacement

Disclaimer-Despite improvements in implant materials, design and prosthetic technology; implant fixation remains a critical factor limiting athletic activity after total joint arthroplasty in patients over age 65. For those under age 65, increased activity may result in cycling of the articular bearing surfaces and a risk of loosening from articular wear and particle production. Sports may increase the risk of dislocation; implant failure, and peri-prosthetic/prosthetic fracture.

Total Hip Replacement

Hip Resurfacing

Total Knee Replacement

Unicompartmental Knee Arthroplasty

The issue is not whether you can return to sports but whether you may participate in sports without affecting the outcome and survivorship of the prosthesis. As I review all relevant science on the subject of sports participation for patients who have undergone a hip or knee replacement, it becomes apparent that the largest group of artificial joint recipients who return to high level athletics are recipients of hip resurfacing or unicompartmental knee prostheses. It also becomes apparent that sports participation after joint replacement is very much impacted by your level of preoperative sports participation as well as your body mass index. In general, 95% of joint replacement surgeons impose no permanent restrictions on swimming, golf, walking on level surfaces, cycling on level surfaces and stair climbing. Five to six years of follow-up after a total joint replacement is too short to allow me to evaluate implant survivorship. What is scientifically documented is that you will have less pain and better motion and function after a new hip or a new knee. What is clinically observed is that the majority of patients can return to return to most sports after a new hip or knee. The remaining unproven scientific question is not whether you can or will be able to but whether you should? In 1973, I helped pioneer knee replacement surgery in the United States. Earlier during my residency training, I partook in the introduction of hip replacement surgery here in the Midwest. In 1979, I was a member of the team of three who introduced cementless joint replacement in the U.S. Until, the early 2000s, our preoperative informed consent emphasized prosthetic survivorship and minimizing those activities that might or could result in premature failure of the prosthesis. It seems that sports after total joints is the demand of the maturing athlete but also the result of medical advertising to promote market share. It’s not the length of you hospital stay or size of your scar but the survivorship of the prosthesis that must influence your ultimate choices.

Musculoskeletal Care of the Mature Patient            

Sports and exercise after a total joint replacement

 

Athletics after total joints is controversial because of a paucity of scientific studies on the subject. Postoperative activity recommendation varies by geographical region, the comfort level of the surgeon, and the personal interests of the patient and physician. Furthermore, return to exercise does not necessarily imply a return to sports. The lesson here is the same I follow when trout fishing; pick a fly to match the hatch. If athletics and sports are important to you, pick a surgeon who understands your goals.

 One reason behind the paucity of data might be explained by the change seen in the United States of the past ten years wherein prior to the year 2000,  85% of hip stems were cemented. Since the change of the millennium, 85% of all hip stems are done cementless. This biologic ingrowth methodology decreases loosening with better impact tolerance. In 2004, highly cross-linked polyethylene bearing surfaces were introduced for the hip and the knee so we have only five years of data to scrutinize. At the same time, ceramic bearing surfaces were changed from alumina to zirconium and most recent to delta ceramic, a combination of alumina and zirconium. In general because of constant improvement in technologies, the outcomes data is insufficient.

The known Science of Specific Sports

Cycling:

 The studies in which I have participated indicate that the forces and impulses measured after a total joint are comparable to healthy subjects suggesting that after a knee replacement, the joint can be functionally restored.

 Golf:

  After a Total Hip Replacement, 87% of recipients have no pain while playing but 41% report mild pain or ache after the round. Average handicaps increase 1.1 strokes, the drive averages 30 feet further distance and plan to use a cart. After a Total Knee Replacement, 84% of respondents report no pain while playing, 35% had mild pain or ache after golf, the average increased handicap was 1.9 strokes, and the average drive increased about 30 feet. The targeted-side knee experiences significantly more discomfort. While the back-swing phase is slow and controlled, the downswing, impact and follow-through phases increase in speed but there is increased torque and shear on the targeted-side knee.

 Walking, Hiking and Jogging:

  In general, be aware analyzed forces across a hip joint indicate there is an increase of 2.5X body weight while walking and 5.2 X, while jogging. Instrumented implants indicate that the hierarchy of forces is stationery bicycle< walking<elliptical trainer<jogging. Peak shear stresses across knee prosthesis are measured at 40-60degrees flexion. The combinations of impact loading and shear stresses result in an increased subsurface polyethylene stress contributing to delaminating wear and destruction

 Skiing:

 The issue here is that skiers are a very physically active group in general. On the one hand, X-country classical skiing puts 4x body weight on the hip joint while skating places 4.6x body weight on the hip. In alpine skiing, long turns on a flat slope increase forces on the hip by 4.1x body weight while short turns on a steep slope concentrate forces to 7.8x.

 Tennis:

 The majority of joint replacement specialists allow the patient to return to tennis; but there is no agreement as to whether you should. Despite the popularity of tennis, there are no studies on the subject. About 16% of tennis players who have undergone a hip or knee replacement report some pain during or after a match. Anticipate increased court mobility but decreased speed.

 Swimming:

 There are no scientific studies on artificial hips and knees available for scrutiny. I have always counseled my patients to avoid breaststrokes and whip kicking, as those seem to result in the most complaints. 

The take home message, your return to athleticism may shorten the life expectancy and alter the outcome of your prosthesis. Most recommendations are judgmental rather than scientifically based. 

Hip Society:  basketball, football, jogging and soccer are NOT RECOMMENDED

Knee Society: jogging, soccer, basketball, football, and volleyball are NOT RECOMMENDED

 To be continued

Exercise after a total joint replacement

Musculoskeletal Care of the Mature Patient

 Sports and exercise after a total joint replacement

So you lost the battle and had a joint replacement, you can still win the war. In the 1960s through the 1980s, a total joint replacement was offered by an orthopedic surgeon to relieve pain, improve social mobility, provide functional independence, and to enhance psychological well-being. By next year, 2011, it is forecast that greater than 50% of total hip and total knee replacement recipients will be patients less than 65 years of age. This is a population being bombarded with information pertaining to the health benefits of exercise. The current population of joint replacement candidates is interested in a Return to Sports owing to the scientific evidence associated with increased physical activity, improved functional capacity, improved quality of life, and longer life expectancy.

Not to dampen sports after total joint enthusiasm, but first some words of caution. Just as your natural hip and knee were subject to wear and tear, breakdown and fracture leading to a joint replacement, so too despite improvements in implant materials, design operating technique and prosthetic technology do not eliminate the risk for a revision of that artificial implant. With excessive loading and high intensity activities such as high-impact sports (e.g. alpine skiing, running), there is a greater likelihood of revision surgery in 10 to 15 years after the index implant. Lower intensity, lower impact sports (e.g., golf and walking) should not contribute to early failure. Our problem is that there is very little scientific information on athletics after a total joint replacement. Because of my personal interest in this subject, in 2005, I co-authored an article presented at an international meeting, SICOT, and again in 2007 at the Scientific Podium of the Orthopedic Research Society during the American Academy of Orthopedic Surgery Annual meeting as well as a poster exhibit:

KNEE JOINT BIOMECHANICS DURING CYCLING IN PATIENTS WITH TOTAL KNEE ARTHROPLASTY

*Martin, A; ***Caglar, O; ****Mueller, M; *****Andriacchi, TP; **Sheinkop, MB; +**Wimmer, MA with the assitance of Langhenry,M

*Academic Teaching Hospital, Feldkirch, Austria +**Rush University Medical Center, Chicago, Illinois, USA.

So there you have it, a scientific basis for exercise after a total hip and total knee replacement. While our studies focused on forces around the knee, at the same measurement of forces at the hip were required.

Next week, the Blog focus on athletic activity after a total joint replacement will be sports specific:

Tennis, Golf, Walking, Hiking, Jogging, Cycling, and Skiing so be sure to return to www.sheinkopmd.com

Treatment of osteoarthritis of the knee without surgery

Treatment of osteoarthritis of the knee without surgery.

A clinical practice guideline.

Patients with symptomatic osteoarthritis of the knee as evidenced by joint pain, stiffness and functional deficit are encouraged to lose weight, engage in exercise and use physical therapy for quadriceps strengthening. Simple knee sleeves or taping helps with short-term relief of pain while analgesics and non-steroidal anti-inflammatories orally are the next level of approach. When the aforementioned are no longer helpful, intra-articular steroids and visco-supplementation are indicated. Needle lavage and arthroscopy with debridement is of no help. Patients may consider partial meniscectomy or loose body removal as conditions warrant.

Recommendations

1) Activity modifications

Walk, bike and swim instead of run

2) Regular contact with the health care provider or physician extender

3) Weight reduction

Reduce BMI to <25

4) Partake in low-impact aerobic fitness exercises

5) Partake in motion/flexibility exercises

6) Undertake a quadriceps strengthening program

7) Use patellar taping or a knee sleeve

There is no evidence that a brace or heel wedge is of value

9) There is no scientific evidence that acupuncture helps

10) There is no scientific evidence to support the use of glucosamine or chondroitin sulfate

11) Use analgesics for pain starting with acetaminophen (<4g/day) or nonsteroidal anti-inflammatories. The next level of intensity includes topical NSAIDs, nonselective oral NSAIDS plus a GI protective agent; or COX-2 inhibitors

12) The next level of approach is the intra-articular corticosteroid injection

13) When the need for intra-articular cortisone injection is too frequent, the intra-articular hyaluronic acid is indicated

14) Should the symptoms be of as mechanical nature, then arthroscopic partial meniscectomy or loose body removal is an appropriate option for limited indications

15) Realignment osteotomy in active patients with unicompartmental osteoarthritis of the knee especially for patients under 55

Not Recommended

1)Arthroscopy with debridement or lavage

2)Osteotomy of the tibial tubercle for patellofemoral osteoarthritis

3)Rigid Braces to redirect forces

4) Use of a free-floating interposition device

For more information, please go to www.drsheinkop.com.