Dual Pivot Hip
Jan,13,2012 16:39 Filed in: Hip Replacement | Total Hip Replacement
I’ve mentioned metal on metal hips a few times in past posts, and as many people are aware, there has been a great deal of concern about the long term effects of this type of hip. While I am convinced that only a few of these designs are a problem, it’s important to understand the benefits and if there are any other ways to achieve the same results. Recently, we have had great success using a dual pivot design for hip replacement. This design provides all the benefits of metal on metal - the large head and wear resistance - without an actual metal on metal surface. The dual pivot design employs a smaller ceramic head, embedded into a large plastic head that is placed into the same socket we used for metal on metal. The plastic is very thick and wear resistant and the dual pivoting surfaces should result in less wear over time.
For younger patients who have concerns about metal on metal and need the range of motion and durability, I think this represents a great option.
For younger patients who have concerns about metal on metal and need the range of motion and durability, I think this represents a great option.
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Epoly
Sep,21,2011 16:37 Filed in: Total Knee Replacement | Total Hip Replacement
Many of my patients have been asking about concerns related to metal on metal hip implants. While we have had tremendous success with metal on metal, but the feature that I feel is the most beneficial is the large ball and socket that make dislocations less likely. Metal on metal also has less wear than traditional plastic. However, during the last ten years, plastic technology has caught up in many respects. We are now able to use cross linking techniques to make the plastic stronger and use vitamin E to prevent the plastic from getting brittle while it is cross linked. I am happy to report that we have ePoly available for both hip and knee replacement . It should provide us all the benefits of metal on metal without the worry about metal ion generation. While we can never promise, I think we are getting closer to lifetime joint replacements with each new innovation.
iTotal Knee
Jul,29,2011 13:50 Filed in: Total Knee Replacement | Computer Navigation
Conformis has been working on a CT guided, custom knee replacement for a number of years now, using the same technology we are using for their uni knee replacement. Unlike other systems, this is a true custom knee unique to each patient. it should allow a more accurate knee without giving up the benefits of a total knee replacement. We should be able to start our first cases in the fall. I’m really looking forward to offering this to our knee arthritis patients.
Newest Television Appearance
Apr,29,2011 12:38 Filed in: Uni Knee Replacement | Knee Replacement
Dr Waldman discusses custom knee replacement.
http://www.bmorehealthyexpo.com/interactive/health/videos/vid_34.shtml?sms_ss=email&at_xt=4dbae9fd13b0e550%2C0
http://www.bmorehealthyexpo.com/interactive/health/videos/vid_34.shtml?sms_ss=email&at_xt=4dbae9fd13b0e550%2C0
Corin Minihip
Apr,29,2011 12:33 Filed in: Hip Approach | Hip Replacement
The anterior approach can have advantages for early recovery. Many patients are able to go home in one to two days. However, it often requires a complex table or forceful manipulation of the leg during surgery. The Corin Minihip allows us to preserve bone and perform anterior surgery much more easily due to it’s shape and small size. it has been an excellent alternative to resurfacing in patients who want to preserve bone, have a mini incision, and have a full active lifestyle.
Custom, Navigated Unicompartmental Knee Replacement
Feb,12,2011 09:15 Filed in: Uni Knee Replacement | Knee
It’s a very exciting time to be an arthroplasty surgeon. As computer technology improves, we’ve been able to get a lot of the cumbersome planning and navigating steps out of the OR and into our preoperative planning. The more we can do a head of time, the less time the surgery takes which should lead to fewer complications and more accurate surgery. Below is the plan for an upcoming uni knee replacement. A preoperative CT allows us to make custom cutting blocks and custom implants that come in a small, sterile package, all ready to go. Each implant is made specially for each patient and perfectly matches their anatomy.
Bilateral Total Knee Replacement
Jan,27,2011 21:52 Filed in: Knee Replacement
I get a lot of questions about bilateral, or both at the same time, knee replacement. Doctors have really struggled with this concept because doing both at the same time can result in a much more difficult operation. It obviously takes twice as long, can result in more blood loss, more stress on the heart and lungs, and a longer anesthetic. Doing both knees together takes some surgeons three to four hours and can get very tiring. Because of these added complications, many surgeons severely limit the number of bilateral knee replacements they will do - if they will do any at all.
At the Rubin Institute, we have been able to minimize these problems by combining several techniques. The first is the computer navigation I discussed in an earlier post. By doing all the calculations using custom molds before the surgery, we can speed up the measuring process for both knees. Combining this with some innovative, uncemented knee technology, we can eliminate cementing, which can take 15 - 30 minutes per side. These techniques, I believe, have resulted in better alignment and a much quicker procedure. We are able to do both knees in about 90 minutes with a spinal anesthesia, which is generally safer for the patient.
Our early data show better results, in less time, with fewer complications. It’s allowed me to open up this procedure to far more patients than in the past because of the reduction in risk. While doing both knees at the same time does result in more time in the hospital, many patients recover just as quickly from two knees as one. I always caution that this is still major surgery, and can certainly have complications, but it is a much more reasonable option than it was in the past and can benefit a lot of patients.
At the Rubin Institute, we have been able to minimize these problems by combining several techniques. The first is the computer navigation I discussed in an earlier post. By doing all the calculations using custom molds before the surgery, we can speed up the measuring process for both knees. Combining this with some innovative, uncemented knee technology, we can eliminate cementing, which can take 15 - 30 minutes per side. These techniques, I believe, have resulted in better alignment and a much quicker procedure. We are able to do both knees in about 90 minutes with a spinal anesthesia, which is generally safer for the patient.
Our early data show better results, in less time, with fewer complications. It’s allowed me to open up this procedure to far more patients than in the past because of the reduction in risk. While doing both knees at the same time does result in more time in the hospital, many patients recover just as quickly from two knees as one. I always caution that this is still major surgery, and can certainly have complications, but it is a much more reasonable option than it was in the past and can benefit a lot of patients.
Minimally Invasive Hip Replacement Video
Dec,06,2010 11:00 Filed in: Hip Replacement | Hip Approach
Television Appearance
Dec,06,2010 10:52 Filed in: Hip Resurfacing | Knee Resurfacing
Visiting Japanese Surgeons
Dec,04,2010 09:20 Filed in: Knee Replacement
We recently had the pleasure of hosting a group of surgeons from Japan. I presented some of our research on total knee replacement and they shared a great deal of information about joint surgery in Japan. They visited the Rubin Institute the next day and witnessed a few 3D knees. Hopefully, I’ll be able to go back to Japan for a visit in the near future.
Trip to Italy
Jun,28,2010 20:45 Filed in: Hip Revision | Hip Replacement
I recently had the incredible opportunity to travel to Italy and operate with a number of surgeons who perform hip revision surgery. I was helping DJO Surgical evaluate a revision hip made by Lima - an italian company that has created some very impressive technology to deal with difficult revision surgery. I learned a lot of interesting techniques and got to eat some incredible food. Hopefully, we will be able to import some of these innovative implants to help patients here in the states.
Uderzo, Italy
Knee Resurfacing
Jun,28,2010 20:41 Filed in: Knee Resurfacing | Knee Replacement
We continue to see great successes with knee resurfacing. I have treated a number of patients who were told that their only option was total knee replacement who have been very happy with the more minimal procedure. Here is video story on WebMD starring one of our most impressive patients:
http://www.webmd.com/video/arthritis-epidemic
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.
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.