Computer Knee Navigation
Jan,25,2010 12:17 Filed in: Knee
Replacement
I’ve always
been very skeptical of computer navigation in total
knee replacement. While it makes sense that computers
in the OR could help us place the parts more
accurately, in practice, these systems have been
cumbersome, time consuming, and haven’t been shown to
produce any improvement in outcomes. The extra
equipment is very expensive and required additional
pins to be put into patients bones to guide the
computer.
I’ve recently started using a system that produces custom molds made from an MRI scan of the knee. The molds are made before the surgery and guide the placement of the knee replacement. The molds are extremely accurate, require less time than a standard total knee and also allow us to place less instruments in the knee - not more. While the MRI and the molds are expensive, we do see some cost savings in less time in the OR and less instruments that need to be sterilized. The benefit to the patient is a custom fitted knee and less time in the OR. Not every patient is a candidate, and some insurers are resisting paying for the molds, I think this new procedure is going to be very helpful.
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Knee Resurfacing in the News
Oct,27,2009 20:57 Filed in: Knee
Resurfacing
Our Knee
Resurfacing patient J.E. who has returned to work as a
martial arts instructor after her surgery has been
featured on a number of local news stations. She is an
inspirational story for anyone who doesn't want to give
up the activity they love. See one of the stories at:
http://www.wkowtv.com/Global/story.asp?S=11139128
I’ve seen some pretty
dramatic improvements in patients who have had knee
resurfacing. Many of them were told that total knee
replacement was the only option for their arthritis.
Many are shocked to hear that there is an alternative
that not only preserves their bone and ligaments, but
can be done as an outpatient procedure.
German Surgeon Visit
Oct,27,2009 20:42 Filed in: Knee
Replacement | Hip
Replacement
We often
have visitiors from around the world at the Rubin
Institure. Recently, I had a group visit from Germany
to observe hip and knee replacement. They were very
interested in minimally invasive surgery and pain
management techniques. They also got to see a minimally
invasive hip replacement, revision knee replacement and
a hip resurfacing. I always have a great time showing
off what we are able to accomplish at the Rubin
Institure, but I also get to learn a lot myself. Out
visitors never fail to teach me some technique I wasn't
aware of or propose some improvement we can make. it's
this kind of interaction that forces me to always try
to stay ahead of our very knowledgable and experienced
visitors.
Progressive Knee Replacement
Now that we
have so many options for treatment of knee arthritis,
I’ve been trying to formalize an algorithm for
progressive replacement of the knee. I recently gave
grand rounds at Howard University on this idea. While
total knee replacement is a wonderful operation that
works very well, it does take a long time to recover
from. A great many patients can benefit from replacing
just the part of the knee that is worn out and not the
whole thing. These patients have a faster recovery,
less pain, and more natural feeling knees.
While this concept has been working very well for my patients, it’s extremely important to pick the right operation for the right patients, otherwise, they may continue to have pain. This algorithm helps to insure that treatment is as optimal as possible for each person no matter what their age, race or gender may be.
While this concept has been working very well for my patients, it’s extremely important to pick the right operation for the right patients, otherwise, they may continue to have pain. This algorithm helps to insure that treatment is as optimal as possible for each person no matter what their age, race or gender may be.
Parital Knee Replacement Around the World
I recently had the opportunity to give lectures in
Fukuoka Japan, and Vienna Austria on partial and full
knee replacements. It was a wonderful experience to
go to prestigious international meetings on almost
opposite sides of the world. I found it most
interesting that the attitudes toward partial knee
replacement are very different in these very
different countries. In Japan, surgeons tend to be
fairly conservative. They favor osteotomies or
realignment of the bones in younger patients who have
partially arthritic knees. In Europe, surgeons are
much more in favor of partial knee replacement,
because of the quicker and more predictable
recovery.My talk on partial knees was very well
received in Vienna, while it took much more
explaining and convincing in Japan. I think it’s very
healthy for surgeons to have different opinions and
attitudes about implants and operations. It
encourages us to constantly examine what we are doing
and make sure we know exactly why we are recommending
different treatments for different patients. I always
try to customize each patient’s treatment and not
just recommend the same total knee replacement for
every patient with arthritis. It’s nice to know that
there are so many surgeons around the world who have
the same attitude.
Trip to Japan
Jan,21,2009 10:11 Filed in: Knee
Replacement
More Knee Resurfacing
One of the big advantages of this procedure is the recovery time. Most of our patients are able to walk without a cane in just a few days and return to driving and exercising in about a week. It’s been so impressive, that I often have to get people to slow down, because they are feeling so much better. It’s really a dramatic difference from a total knee replacement. The xray to the left shows how small this implant is.
Knee Resufacing Update
I think this
procedure will be a major improvement for a number of
our patients. It can be done athroscopically with a
small incision for the femoral (thing bone) component
which allows most patients to go home the same day.
Pain is much less than with a total knee replacement
and the physical therapy is much easier. The parts are
so small that, if a patient needs a total knee
replacement someday, they will not interfere. Not
everyone is a candidate, but I think this procedure
will spare a lot of people from a premature knee
replacement
Hip Recalls
Sep,25,2008 08:21 Filed in: Hip | Hip
Replacement
As I’m sure
many of you are aware, there have been a number of
recalls of hip replacements, recently. The Zimmer Durom
cup and the Stryker Trident ceramic system have both
come under suspicion of causing problems. A number of
my patients have been calling with concern about the
hips that they have in place or are getting. I’ve been
very fortunate in that I’ve never used either of these
components. While it’s impossible to predict the
future, I try very hard to use proven technology that
has a long track record. Patients depend on us, as
surgeons, to pick an implant that works the best for
them, but will also last a long time. I take this issue
very seriously and my philosophy is always to use the
best implant available at any given time. I am always
open to discussion about the actual parts being used.
If something is going to be part of a patient’s body,
they should be very well informed about it
beforehand.
Arthrosurface
I very
excited about a new technology that we now have access
too. Called Arthrosurface, it’s an innovative new
approach to knee arthritis. Using an arthroscopicly
assisted technique, we can resurface small parts of the
knee that are worn our for arthritis. This is a much
smaller operation than a knee replacement, and patients
can go home the same day and walk on the knee
immediately. Physical therapy is much easier and the
time investment is much less. Not everyone is a good
candidate for this new procedure, but I think it will
save many patients from a much larger operation. We
don’t know the long term outcomes yet, but I’m very
optimistic about this technique’s future.
Gender Knee Update
Jun,16,2008 07:50 Filed in: Knee | Knee
Replacement
I still get
quite a few women asking about gender specific knees.
Most of them have seen television ads or a web site
promoted by an implant manufacturer. I think one of the
issues that has gotten lost amid all the hype is the
wide variarions that occur normally in human knees.
Knees vary not just by gender, but by age, race,
height, weight and the type of arthritis that the
patient is suffering from. Sometimes a “male” knee is
better for a woman or vice versa depending on the size
of the patients knee.
The most imporatant thing to focus on is the number of sizes available and picking the right knee for each patient. I try to pick the knee that is most appropriate for a specific problem, and then use the wide variety of differnent sized to get a perfect fit. In my experience, focusing on just the patient’s gender is too much of an oversimplification.
The most imporatant thing to focus on is the number of sizes available and picking the right knee for each patient. I try to pick the knee that is most appropriate for a specific problem, and then use the wide variety of differnent sized to get a perfect fit. In my experience, focusing on just the patient’s gender is too much of an oversimplification.
Birmingham Update
Jun,10,2008 21:51 Filed in: Hip | Hip
Resurfacing
We’ve been
using the Birmingham hip resurfacing for about a year
now. I think that overall, it’s been a great success.
The patients are very happy with their quick recovery
and we’ve have very few problems. I believe that the
most important key to success is picking the correct
patients for the surgery. The ideal patients are
younger, active, and have arthritis without a lot of
deformity. It’s also important to examine the bone for
cysts and other problems that might lead to early
failure. For younger patients who don’t fit these
criteria, they do extremely well with metal-on-metal
total hip replacement.
I’m going to be attending a meeting in August that will focus on some future possibilities with resurfacing. Hopefully, I’ll be able to post a new update then.
I’m going to be attending a meeting in August that will focus on some future possibilities with resurfacing. Hopefully, I’ll be able to post a new update then.
Deuce Knee Implant
May,15,2008 08:39 Filed in: Knee | Knee
Replacement
We have a
new knee implant available for patients with arthritis
of the knee. It's called the Deuce because it replaces
the inside of the knee and knee cap only.
The implant
can be put in with a minimally invasive technique and
retains all the knee ligaments, which isn't possible
with traditional total knee replacements. The thigh
bone side of the implant is made of a ceramic, called
Oxinium which may not wear out as fast as standard
metal implants. I think it may be a good choice for
younger patients who want to remain active. We can
determine if this is an appropriate choice by examining
x-rays and the arthritic knee.
Knee Tourniquet
Apr,23,2008 22:03 Filed in: Knee
Replacement | Knee
When a
patient undergoes a knee replacement surgeons almost
always use a tourniquet around the thigh to cut down on
blood loss and make it easier to see during the
surgery. The tourniquet is inflated to a pressure
of 250 to 350 mmHG, which cuts off all blood flow to
the leg and foot. As you can imagine, this puts
tremendous pressure on the thigh muscles. I've
long suspected that a lot of the pain and swelling
after surgery is related to the use of a tourniquet.
So, over the last year, we have been conducting a
formal study of patients who undergo knee replacement
without a tourniquet.
What I have found is that when a tourniquet is not used, patients have less pain, less blood loss, better range of motion and less swelling. The really dramatic difference is when patients return to the office, six weeks after the surgery, they are much more comfortable and much less swollen. It is now our standard form of treatment for both primary and revision surgery due to it's success.
There have been many studies published by The Journal of Bone and Joint Surgery that agree with these findings and I think a lot of surgeons haven't changed just because they are comfortable with the tourniquet. I plan to publish the findings formally fairly soon.
****Just to clarify, a tourniquet is placed on all knee replacement patients, it is just not inflated when there is adequate blood control.
What I have found is that when a tourniquet is not used, patients have less pain, less blood loss, better range of motion and less swelling. The really dramatic difference is when patients return to the office, six weeks after the surgery, they are much more comfortable and much less swollen. It is now our standard form of treatment for both primary and revision surgery due to it's success.
There have been many studies published by The Journal of Bone and Joint Surgery that agree with these findings and I think a lot of surgeons haven't changed just because they are comfortable with the tourniquet. I plan to publish the findings formally fairly soon.
****Just to clarify, a tourniquet is placed on all knee replacement patients, it is just not inflated when there is adequate blood control.
Gender Specific Knees
I've had
some questions recently about Zimmer's gender specific
knee, which is targeted at female patients. I am
actually pretty upset about what is a blatant attempt
to market unproven designs directly to patients. It is
true that femaie knees are generally smaller and have a
slightly different groove for the knee cap than men do.
However, most implants already take this into account
and have for years. There is no reason to label a knee
"specific to women" other than to steer them to a
Zimmer implant. I believe that my patients are smarter
than that and will see through what is basically
marketing hype. Unfortunately, we often spend a lot of
time talking about non-issues like gender specifics
rather than important things, like getting through the
surgery in the safest and smoothest fashion
possible.
Pain Control After Surgery
Controlling
pain is one of the most important areas of
postoperative care. It is usually the aspect of surgery
that scares patients the most and is most ignored by
doctors. We have tried to take a more comprehensive
approach. The most important principle is to treat the
pain with different modalities so that we have to use
the least amount of narcotics. Narcotics are the drugs
that make patients sleepy, constipated and unable to
cooperate well with their physical therapy.
We use local blocks, spinal anesthesia and injections around the incision to help control pain. By combining these methods with nonsedating drugs, we are able to keep patients very comfortable and use very little sedation after surgery. The nurses who take care of our patients after surgery have seen a dramatic difference in the amount of pain that patients report to them after surgery. I see this as one of the most important aspects of our care and does more to ensure rapid recovery than any other method we employ. If you have any specific questions about the exact methods we use, please email me any time.
We use local blocks, spinal anesthesia and injections around the incision to help control pain. By combining these methods with nonsedating drugs, we are able to keep patients very comfortable and use very little sedation after surgery. The nurses who take care of our patients after surgery have seen a dramatic difference in the amount of pain that patients report to them after surgery. I see this as one of the most important aspects of our care and does more to ensure rapid recovery than any other method we employ. If you have any specific questions about the exact methods we use, please email me any time.
Knee Implants
Apr,15,2008 08:40 Filed in: Knee
Replacement | Knee
Advertising Part II
Apr,15,2008 08:38 Filed in: Advertising
Every few
months, one of the major implant manufactures starts a
new marketing campaign. Recently, I've had a few
patients ask me about the J&J Rotating Platform
knee. It is advertised as "the only knee that bends and
rotates". This assertion is not only absurd, but
outright wrong. All knee replacements bend and rotate,
otherwise, our patients would be walking like
Frankenstein. This particular knee has been available
for many years and have never been proven to be
superior to other knees in any way. It does, however,
occasionally dislocate and require further surgery.
Another blatant attempt to mislead patients. If you are
considering any kind of knee surgery, discuss the
implant with your doctor until you both feel
comfortable with it. Try not to believe everything you
hear on TV.
Advertising
Mar,15,2008 08:43 Filed in: Advertising
I have been
very concerned about advertising on both TV and radio
being done by many surgeons and orthopaedic companies.
Much of the information is misleading or downright
wrong. One of the surgeons in our area is advertising a
procedure he's only done a few of, and some others are
promoting older technology as if it were invented
yesterday. Of course, it's important for patients to
discuss the type of prosthesis they may be getting, but
I think the advertising can interfere with that
process.
3D Knee
Mar,15,2008 08:42 Filed in: Knee
Replacement
We are
currently conducting a study of the 3D Knee. It's an
interesting concept that should work well for younger
patients who need a total knee replacement. By changing
the shape of the surface that the patient walks on, the
implant can compensate for the ACL, which has to be
removed during total knee surgery. This should provide
better stability and a more natural knee for very
active patients.
Tapered Titanium Stems
Mar,15,2008 08:41 Filed in: Hip | Hip
Replacement
We've been
using tapered titanium stems for total hip replacements
for many years now. They fit into the thigh bone and
require no cement. The bone grows into the roughened
surface plasma sprayed onto the titanium to make the
new part literally part of the natural bone. I recently
wrote a short monograph, along with some other well
know physicians, that was published in one of the
orthopaedic trade journals. If you would like some more
information, here is the
link. My article
is on pages 7-8.
Anterior Hip Replacement
Our anterior
hip project continues to progress well. We are able to
perform the hip replacement without using special
tables or x-ray machines, which makes it quicker and
easier to set up. There is also less uncertainty about
the placement of the components when I can see them
directly. Patients appear to have little to no pain,
although, I'll have to collect more data to know for
sure. Certainly, they are recovering their function and
ability to walk very rapidly.
Magnum Hip Replacement
Jan,15,2008 08:43 Filed in: Hip
Replacment
We've just
seen our 100th Magnum patient back for her 6 week
follow-up visit. So far we've been very happy with the
results. The patients say that they don't notice any
difference from their natural hip, other than it
doesn't hurt and can move much further. Have a few more
to do next week. Combining the Magnum with the minimal
incision, posterior approach has made for a very low
complication rate and no dislocations. The large head
size and metal on metal bearing are a great combination
and may result in a hip that lasts significantly longer
than the 10-20 years most patients can expect for a hip
containing plastic.
Birmingham Hip Resurfacing
May,15,2007 08:40 Filed in: Hip
Resurfacing | Hip
We are now
approved to do the Birmingham hip resurfacing at the
Rubin Institute. I've done a lot of very similar
surgery in the past, so this new prosthesis isn't much
of a change. I had to go through training with the
designer, Mr. Derek McMinn, from Birmingham, England,
before we could get the prosthesis at our hospital. The
big difference is that the Birmingham hip is FDA
approved. The other hip resurfacings in the US are
still being investigated and haven't been approved,
mostly due to the lack of good long term data. We are
very excited to have the ability to offer this option
to our younger patients. If you want some more in depth
information on hip resurfacing, take a look at
SurfaceHippy,
an independent site which had collected a lot of
excellent information on hip resurfacing.