JOINT DISEASEHIP AND KNEE

Scott Kelley MDNorth Carolina Orthopaedic Clinic

919-471-9622

(updated May 19, 2006)

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INTRODUCTION..................................................................................................3

JOINT ANATOMY................................................................................................5

JOINT PATHOLOGY...........................................................................................9

SPINE....................................................................................................................15

PAIN.......................................................................................................................17

NONSURGICAL TREATMENT OF ARTHRITIS..........................................21

SURGICAL TREATMENT: HIP.......................................................................26

SURGICAL TREATMENT: KNEE...................................................................31

PRE-ADMISSION INFORMATION.................................................................39

HOSPITAL OVERVIEW:...................................................................................41

GOING HOME AND RECOVERY (FIRST 6 WEEKS)..................................51

ACTIVITIES (AFTER RECOVERY)................................................................54

RESULTS AND COMPLICATIONS.................................................................55

MEDICAL MANAGEMENT..............................................................................62

EXERCISES.........................................................................................................63

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INTRODUCTION

The purpose of this educational video is to provide you with basic information about our approach to

joint replacement. Our approach is based on the background and training of my team.

I am a third generation surgeon, born and raised in Iowa. My grandfather and father both attended

medical school at Northwestern in Chicago. My grandfather graduated from there in 1907 and

practiced General Surgery at Iowa Methodist Hospital in Des Moines. My father returned to Des

Moines after serving as a medic in World War II and completing his training in Orthopaedic Surgery at

the Mayo Clinic.

I grew up with Medicine and Surgery. Even before I started high school, my father would take me

with him on the weekends, to a small county hospital outside of Des Moines. Helping manage

Orthopaedic cases was a service he provided these small communities. One such hospital, in Madison

County allowed me to watch him in surgical cases. In high school, I worked as an orderly in the

operating room, performing jobs ranging from scrubbing floors to helping position patients for surgery.

Both my father and I were born and worked in this same hospital, Iowa Methodist Hospital.

After graduating high school, I attended the University of Iowa for both undergraduate and medical

school. I did my surgical internship and Orthopaedic residency at the State University of New York,

Upstate Medical Center in Syracuse. I was recruited to this residency by Dr. David Murray, who was a

former president of the American Academy of Orthopaedic Surgeons and one of only two Orthopaedic

Surgeons to serve as President of the American College of Surgeons. He was a founding member of

the knee society and inventor/developer of a knee replacement prosthesis call the Variable Axis Total

Knee Replacement.

Following my general Orthopaedic Training, I did an adult hip and knee reconstructive fellowship at

the Mayo Clinic. After my fellowship, I returned to Des Moines, just as my father was retiring from

Surgery. I joined a partnership with Dick Johnston called Joint Replacement Surgeons. Dick was one

of the founding members and past president of the Hip Society.

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One of the highlights of my time back home was the opportunity to operate on many of the same

patients that both my grandfather and father had performed surgery. One such patient was Don

Gardner, whose life my grandfather had saved at age 16. In 1932, my Grandfather performed an

emergency appendectomy on Don. Years later, my father performed a left hip replacement and in

1988, I performed a right total hip replacement on Don. This story was picked up by the Des Moines

Register and Tribune – the only paper with statewide distribution.

Shortly before Dick Johnston retired from Surgery, I joined the faculty of the University of North

Carolina at Chapel Hill.

I was recruited by Frank Wilson. Dr. Wilson was the past president of the American Orthopaedic

Association and a founding member of the Knee Society. During my eleven years at the University of

North Carolina, I saw the transition from a division of surgery to a Department of Orthopaedic Surgery,

where I served as Vice Chairman for the remaining five years of my tenure.

In 2003, I joined with a group of four other academic physicians and formed the North Carolina

Orthopaedic Clinic. Our reasons for the change were simple; we needed more control of our practice

in order to deliver a higher quality of medicine.

Dr Joe Minchew is our spine surgeon, Dr. Louis Almekinders is our Sports Medicine Surgeon, Dr

David Thompson is our Hand/Upper Extremity/Foot Surgeon, and Dr. Paul Tawney is our Physical

Medicine and Rehabilitation Physician.

Many of the North Carolina Orthopaedic Clinic patients are from outside the Research Triangle, often

from out of state and sometimes from outside the United States. Almost 50% of my patients live

outside the four counties that make up the Triangle (Durham, Wake, Orange, and Chatham). While

managing patients from a distance has its difficulties, we have over time adapted our system to

accommodate the situation.

As we review our surgical results later in this program, it should become clear that our high rate of

success (and low complications) should significantly reduce your chance of having more than one

operation per joint in a lifetime. Unquestionably, the surgery I later describe can be performed very

successfully in many hospitals throughout the country, but the key question is, “what are their

published results?”

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I cannot guarantee that you will get a good result in my hands. I cannot guarantee that you will not

suffer complications… but I can tell you what the odds are.

The key to our success is the word “our”. Your care will be delivered by a team approach. What that

means, is that I will be involved with every aspect of your care, either visibly or behind the scenes.

My focus will be on your actual surgery and the identification and management of any adverse

outcomes. Specifically this means - I personally will be doing your surgery.

I will not be primarily responsible for the majority of the communication between you and our team.

In order for me to maintain my focus, I have organized a team to “field” your questions and concerns.

While this approach may give you the impression I am not involved, it allows me to give more

attention to the key elements of your care, including the technical aspects of your surgical

management. The key is that you trust our team concept by trusting the members of my team to handle

their assigned jobs and alert me when appropriate.

This team approach will be most apparent during your postoperative management. I will see you,

during this period, but my visits will be direct and system orientated. I will leave my team to gather

and present your concerns.

I feel strongly, it is only by such a team approach, such a system, that I am able to almost eliminate

your chance for failure.

As the patient, you are also a member of the team managing your care. We will need your help, not

only in following the treatment plans but in and helping make the plans.

My ten year data for knee replacement and our publication of the 20 year results from the Iowa Hip

experience will be reviewed. The data I will present for both hips and knees is as good as, or better

than, any previously (or subsequently) published results in the Orthopaedic literature. My success is

based on a team approach focused toward reducing your chances for future surgery on the same joint.

Or simply worded - My primary goal is to do only one operation on your joint.

The rest of this DVD will review all aspects of lower extremity disease, including anatomy, pathology,

nonsurgical and surgical treatment modalities, risks and complications and finally recommended

exercises.

JOINT ANATOMY

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INTRODUCTION

Wherever two bones meet, it is called a joint – the significance of this relationship is highlighted by the

name of the most important orthopaedic journal, “The Journal of Bone and Joint Surgery” with a

worldwide distribution of over a 130 countries.

The normal anatomy of a joint includes:

HARD TISSUE: bone, cartilage, and

SOFT TISSUE which includes

meniscus & labrum,

the ligaments & associated capsule,

synovium & bursa and

lastly, muscles & tendons.

HIP AND KNEE

The Hip Joint is made up of two bones: the pelvic bone AND THE femur (also known as thigh bone).

The hip is often described as being a ball and socket joint. Let’s take a closer look at the hip joint by

removing the capsule and dislocating the hip. The socket (also known as cup or acetabulum) is a part

of the pelvic bone and the ball (also known as the femoral head) is a part of the femur (thigh bone).

The bones of the knee joint include the lower end of the thigh bone (femur), the top end of the calf

bones (tibia and fibula), and the knee cap (patella).

The knee joint is really two joints:

The Femoral-Tibial Joint (which consists of two distinct compartments: one on the inner and one on

the outer half of the knee) and the

Patello-Femoral Joint: which is the weight bearing joint with climbing stairs.

CARTILAGE:

Cartilage is the key structure within the joint. Cartilage is the bluish-white shiny material you

see on the end of a chicken bone, when you break it open at the joint. Cartilage does not have any

nerves in it.

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Pictured on the left is the blood supply to a normal hip and on the right is a close up of the

cartilage and its relationship to the blood supply.

All of the nutrition to the cartilage comes from the joint fluid, as cartilage does not have a

blood supply.

MENISCUS/LABRUM:

In addition to cartilage covering the bones, there are soft tissue fillers, called the meniscus and

Labrum. In the hip, there is only one labrum…

and in the knee, there are two menisci. To some degree, they function as shock absorbers, but

they also increase the surface area of the joint.

LIGAMENTS & JOINT CAPSULE:

Ligaments hold the bones together in the same way that a hinge holds a door to the door

frame.

The knee relies heavily on its ligaments for stability. There are four main ligaments in the

knee: collateral ligaments on each side of the knee, and posterior and anterior cruciate ligaments,

which are inside the joint.

The collateral ligaments stabilize the knee with side-to-side stress. The anterior cruciate

ligament prevents the tibia from moving forward on the distal thigh bone or femur and the Posterior

Cruciate ligament prevents the tibia from moving backward in relationship to the distal femur or thigh

bone. Ligaments are confluent with the joint capsule and in some cases; the ligament is just a

thickened portion of the capsule.

SYNOVIAL LINING (Joints and Bursa):

The inside of the joint capsule is coated with synovial tissue, which secretes fluid to lubricate

and give nutrition to the cartilage. To illustrate this, a picture of the hip and its capsule are shown.

With only the capsule removed, the synovial lining is now shown in blue. Outside the joint is another

structure lined with synovial tissue, called Bursa. Bursa help lubricate the edges (or corners) of bone,

so that the soft tissue can glide over the bone as you move your joints.

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In the hip joint, bursa is located around the part of the thigh bone called the Greater Trochanter.

The knee joint has many more bursa. The bursa are located around the patellar tendon, the patella, and

the hamstring tendons – in particular a bursa called the pes anserine bursa.

MUSCLES & TENDONS:

The muscles cross the joints and attach to bone by tendons, as seen here in the diagram of a

musculotendon unit. The muscles pull on tendons and provide what is called “active” motion – they

power joint movement.

In the hip there are multiple muscle groups that function in an extremely complex fashion – the

most important muscle group are the abductors. The abductor muscle performs two important

functions: 1) keep your body level when standing on only one leg (by pulling the body in the direction

of the arrows and 2) they lift or move the leg outward sideways

There are two main groups of muscles about the knee.

The Hamstrings flex the knee from the back side of the joint. The quadriceps extend (or

straighten) the knee on the front side.

The quadriceps muscles are attached into the top of the kneecap or patella. The patella is then

attached to the tibia by the patella tendon. As mentioned earlier, the patella is part of the patello-

femoral joint.

PATELLA FUNCTION

What is the function of this joint? The quadriceps (and its tendon) travel around the end of the

femur and attaches to the tibia by the patellar tendon. When the Quadriceps contracts, it pulls on the

tibia to straighten the knee.

If you ran a rope around a corner and pulled back and forth from both ends, it would abrade

over time. By running the rope around a pulley, function is improved. The patello-femoral joint acts

as part of a pulley system for your quadriceps muscle. Just as a rope sits in the groove of a pulley, the

patella (or kneecap) sits in the groove of the femur. While this pulley, improves the mechanical

function of your quadriceps, enormous forces are transferred to this small joint.

The forces are greatest when climbing stairs or sitting. The forces are so great at times; the

question should be “why doesn’t everyone’s knees hurt?”

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JOINT PATHOLOGY

We will divide our discussion of Hip and Knee Disease into Hard Tissue Disease (Bone and Cartilage)

and Soft Tissue Disease (Meniscus, Ligaments, Muscle and Synovium).

HARD TISSUE

BONE Abnormalities and Disease:

There are many problems that occur in bones. … The two most frequent problems in the knee

and hip are fractures and avascular necrosis (otherwise know as osteonecrosis). Fractures or breaks

involving bones need little explanation. Osteonecrosis is less frequently encountered. …..

Osteonecrosis is death of the bone and results from a reduction in the blood supply to the bone. This

condition may lead to a painful collapse of the dead segment of bone and subsequently the cartilage,

which it supports. When this process occurs, arthritis usually follows.

CARTILAGE & ARTHRITIS:

As previously discussed, cartilage does not have any nerves in it, so you can move bone against

bone without feeling any pain (when you have normal cartilage).

If you have a hole or defect in the cartilage, then bone (which has nerves) can rub against bone

and you will have pain. A fracture hurts for similar reasons: there are two bones rubbing against each

other without any protective surface in between. Nerves are similar throughout the body. If you had a

hole in your tooth down to the nerve, it would hurt in a similar fashion. The pain might vary during the

course of the day, throbbing at night, sharp pain when biting, or radiating pain throughout the jaw.

There are three main categories of arthritis. The first is Degenerative Arthritis, which is also

known as Osteoarthritis or “wear-and-tear” arthritis.

The second category of joint arthritis is caused by inflammatory disease. The most common

disease in this category is rheumatoid arthritis. This is a systemic (throughout the body) disease. The

basic problem in rheumatoid arthritis is that the body’s immune system begins to attack normal joints

causing inflammation and eventual destruction of the joint. Other forms of inflammatory arthritis are

associated with Lupus (SLE), psoriasis, inflammatory bowel disease, ankylosing spondylitis, Reiters

and Gout (to name a few). One of the more severe forms of destructive inflammatory arthritis is the

result of joint infection.

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When cartilage damage is caused by (or is secondary to) structural changes of the joint; we call

this ‘Secondary Arthritis. Causes of secondary arthritis include:

congenital (birth) abnormalities such as joint dysplasia,

childhood disease (such as Blount’s, slipped epiphysis or Perthes) or from

trauma (joint fractures, meniscal / labral injuries or ligament injuries).

We diagnose the loss of cartilage by your history of progressive pain with activity, by your

exam – often showing swelling, warmth, loss of motion and deformity AND FINALLY, by x-ray.

X-rays help diagnose arthritis – but we do not operate on x-rays, we operate on people and their

symptoms – no matter how bad the x-rays look – whether any surgery is recommended or not is

determined by your pain and your level of function.

SOFT TISSUE DAMAGE/DISEASE AND INJURY

Soft tissue damage can occur in two basic forms: NonSurgical and Surgical. NonSurgical Soft

Tissue damage occurs with either minimal or no trauma, often overuse type syndrome from repetitive

activities. The damage is often similar to a deep blister and is characterized by local inflammation.

Surgical Soft Tissue Damage usually occurs with significant trauma and when the soft tissue

tear is completely through and through; only surgery will bring the tissue together so that it can heal.

The different types of soft tissue involved are listed (Meniscus, Ligaments, Muscle and

Synovium). Some have such poor blood supply, that inflammation does not occur and healing is

unlikely – such as meniscal tears.

When soft tissue is irritated or inflamed, it has the suffix “-it is” attached. While the meniscus

does not have enough blood supply to become inflamed, the other tissue types are all susceptible and

are given such terms as capsulitis, tendonitis, synovitis and bursitis.

Since all these tissue types are close to each other, sometimes it can be difficult to differentiate

which tissue type is injured and to what degree. Often it is best to treat the inflammation and observe

the problem – improvement suggests non-surgical damage/inflammation and persistence of the

problem suggests a potential surgical problem.

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MENSCUS/LABRUM TEARS:

Meniscal problems usually involve tears of this piece of the cartilaginous-like substance. Fresh

(acute, traumatic) tears are treated more aggressively than degenerative tears. Acute, traumatic

meniscal tears can displace and become wedged between the joint surfaces causing the knee to lock.

Treatment for this condition involves removing the torn portion of meniscus or repairing it, which can

often be done by arthroscopy.

Degenerative tears occur concurrently in knees developing degenerative arthritis of the

cartilage. Arthroscopic surgery rarely provides long term relief for patients with degenerative tears.

Shaving frayed meniscus and cartilage does no more for the knee, than trimming a frayed edge of your

clothing. The trimmed edge continues to fray at the same (if not accelerated) rate. Degenerative

meniscus tears are often associated with Baker’s cysts in the knee. These large cysts occur in the back

of the knee when joint fluid is pumped out of the knee through meniscal tears.

These tears act like valves, letting fluid out the back of the knee, but blocking the flow back in.

While these Baker’s cysts are often more symptomatic than the causative degenerative meniscus,

treatment should be directed towards the meniscal tear, rather than excising the cyst. This is one

instance where debriding a degenerative meniscal tear may help.

CAPSULE and LIGAMENTS – SPRAINS / TEARS:

Since the ball and socket joint of the hip provides significant stability, the ligaments of the

normal hip are infrequently injured. If they are injured, surgery is rarely required.

If the ligaments of the knee are torn, the joint may become unstable. Ligament injuries often

require operative treatment in the form of repair or reconstruction. Surgery is commonly performed for

tears of Cruciate ligaments, inside the knee – especially in young athletes. Often when ligaments are

torn, other structures such as cartilage and meniscus are damaged, such that the joint is more likely to

develop arthritis.

MUSCLES AND TENDON INJURY (STRAINS):

Injury can occur to either the muscles or tendons around any joint. Incomplete tears of

muscles and tendons are treated with rest and should heal with time. Muscle tears (also called strains)

are usually incomplete with portions of intact muscle. Tendons are more likely to be completely torn

and may require surgical repair. The most frequent tendon tears that require surgery in the knee

include patellar tendon below the kneecap and the quadriceps tendon above the kneecap.

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A more common problem than muscle tears is muscle spasm. Muscle spasm occurs for many

different reasons, but commonly is seen after minor joint injuries as a protective mechanism to prevent

further joint movement and reduce the chance of further injury.

SYNOVIUM AND BURSA (synovitis & bursitis):

Inflammation of the lining of a joint or bursa is extremely painful, since this lining is well

innervated. Any type of trauma, even minor trauma or overuse can cause this tissue to inflame.

Inflammation inside the joint is called Synovitis and inflammation of tissue outside the joint is called

Bursitis.

Trochanteric Bursitis is among the most common forms of this problem. As previously

mentioned, the knee has many more bursa. The two most common areas for bursitis are around the

patella and the pes anserinis.

Symptoms associated with synovitis and bursitis are the same as any inflammatory condition.

The onset of pain is infrequently caused by trauma – but is related to activity, especially a change in

activity. Generally treatment involves modifying your activity and some form of anti-inflammatory

medication – either taken orally (by mouth) or as a cortisone injection – the most important part of

treatment is to give it TIME to heal.

PATELLO-FEMORAL DISORDERS:

The complexity of this joint has led to the creation of a unique diagnosis (chondromalacia patella) and

numerous operative procedures to re-align the tracking of the patella. I personally, do not believe there

are many (if any) surgical options for patients with anterior knee pain unless:

1. there is a history of acute (recent) dislocation or

2. evidence of significant arthritis on x-ray.

I do not believe that arthroscopic procedures (such as debridement and chondroplasty) works

for more than 3-12 months. The symptoms almost always return with minor injuries – often when

symptoms return, the patient is worse.

Patients with evidence of sufficient cartilage space and pain of recent onset, the following list

will usually help alleviate your pain:

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activity modification,

anti-inflammatory medications (either oral Naiad’s or a joint injection with cortisone)

And most importantly terminal extension exercises (as described towards the end of the last

chapter).

DIAGNOSTIC STUDIES

The diagnostic tests commonly used by Orthopaedic Surgeons include X-ray, Blood tests, Bone Scan,

Joint Aspiration, CT scan and MRI.

XRAY

X-RAYS give an excellent picture of bone and prosthetic implants. The soft tissue, including cartilage

is almost invisible; however cartilage can be evaluated by the space between bones. Arthritis leads to a

loss of cartilage, which results in a decrease in the space, seen on x-ray, between the bones.

On normal x-rays there is a space between the bones as seen on this x-ray of normal hip joints – you

can see the ball and socket – with a normal space.

Now shown is a degenerative hip with the loss of this space.

On this x-ray of a normal knee you can see the space between the thigh bone (or femur) and the shin

bone (also known as the tibia) Now shown is a degenerative knee with the loss of the space between

the bones.

The condyles of the femur have a groove in them for the patella. – which as discussed earlier is known

as the patello-femoral joint.

This joint can best be x-rayed by shooting the x-ray beam at the angle shown in the picture. This gives

us a picture like the one shown to the right. The two most important things to look for on such an x-

ray, is 1) the alignment of the patella in the groove and 2) the space between the patella and femur – a

space that should normally be filled with healthy cartilage.

Blood Tests

The most common blood tests performed for evaluation of joint diseases include what is called a CBC

with Differential. Basically this test looks to see if the inflammatory white blood cell count is elevated.

Such an elevation may suggest an infection. Likewise there are other tests evaluating inflammation in

your body such as C-reactive protein and Sed Rate (ESR).

Bone Scan

Bone scans involve a small amount of radiation, less than an x-ray. A radioactive marker is injected

into your blood and will then stick to bone that is actively remodeling (being broken down and

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healing). Since your bone is continually remodeling at a low level, your entire skeleton will light up

when scanned. Areas where the bone is abnormal will either brightly light up, or not at all.

Joint Aspiration

Once it has been determined there is inflammation in a joint, analyzing fluid removed with a needle

(aspiration) is the most reliable method of determining the cause. Of most concern is infection. If

infection is found, the aspirated fluid may allow us to identify the bug and to test which drugs will best

kill the bug.

CT Scan (Computerized Tomography)

In the simplest terms this is a sophisticated x-ray machine hooked up to a computer that can give 2-

dimensional cross sections of the body and 3 dimensional reconstructions. Like x-rays, CT Scans best

visualize bone. While x-rays usually will give us all the information needed, sometimes the extra

detail obtained with this study is helpful. Like x-rays, CT scans are not very helpful in evaluating the

soft tissue around your bones and joints.

MRI (Magnetic Resonance Imaging)

In the simplest terms, this is a giant magnet hooked up to a computer that can produce images of your

body. At first glance, the images from this study look similar to those produced by a CT Scan. The

difference is the MRI best shows the soft tissue and the CT scan best shows the bone. The MRI is also

useful for evaluating the blood flow inside the bone.

MRI is especially helpful for evaluating spinal disease, including the lower back. The MRI is rarely

helpful in the evaluation of joint arthritis. MRI’s are helpful in evaluating ligament, meniscal, tendon

and muscle injuries. An experienced physical examiner can usually make the soft tissue diagnosis

without this time consuming (and expensive) test. However, just as a car mechanic often needs to look

under the hood to diagnose engine problems, sometimes an MRI allows the physician to “look under

the hood”.

Surgery is the traditional method of “looking under the hood”. In cases where surgery is inevitable, the

MRI may not be necessary.

Hopefully this section has helped you better understand the anatomic structures that make up your hip

and knee joints. Patients with disease in these joints often have associated spine disease. The anatomy

of the lower back (also known as the lumbar spine) differs significantly enough, that it will be

discussed separately in the next section.

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SPINE

While this DVD is not geared toward lower back problems, often back disease either contributes to the

problem or adds confusion to the diagnosis and treatment.

The lower back anatomy connects the upper body to the lower body and consists of five lumbar

vertebrae. Let’s look at a smaller segment of the spine. These vertebrae connect to each other by 3

joints: Between the vertebral bodies there is one disk, in front of the spinal canal and behind this canal

are two facet joints.

Almost all back disease starts in one of these joints. Younger people tend to have disease in the disk

and older patients tend to have the disease in the facet joints, called spinal stenosis. As patients age,

they tend to evolve from the younger disk disease to the older facet (spinal stenosis) disease. Here is

how this sometimes happens.

STRAINS/SPRAINS:

Patients in their 20’s might suffer multiple injuries including muscle strains and joint sprains. The

pain at this stage is mostly due to muscle spasm trying to protect the patient from further injury.

DISK DISEASE:

The Disk is continually being loaded when bending forward. In some patients this Eventually results

in the soft disk breaking down and extrude (or slip) back and pinch individual spinal nerves, as they

exit the spine. This can cause severe leg pain, especially when bending forward. In some patients

surgery is required to prevent permanent nerve injury, but for most patients these slipped disks will

eventually heal and the pain will go away. Because the pain can be quite severe and prolonged, many

patients will elect to undergo disk surgery to speed the recovery.

INSTABILITY:

The disk contributes to spinal stability and the loss of normal disk function leads to the loss of spinal

stability – this results in increased motion (or shucking) at the involved level. Usually aggressive

physical therapy can strengthen the muscles and help provide stability. In some cases spinal fusion is

required.

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SPINAL STENOSIS:

With loss of stability provided by a normal disk, stability becomes dependent on the facet joints. This

increased stress often leads to arthritis of these small joints. Part of the arthritic process is the

hypertrophy (meaning thickening or enlargement) of these joints. The increased size can crowd the

same nerve roots pinched by slipped disks.

The symptoms are different from disk disease for three reasons: 1) the arthritic facet joints are hard and

boney, 2) the compression involves the entire canal (rather than just one nerve exiting the spine) and 3)

the compression is from the back where the facet joints are (rather than from the front where the disk is

located). Disk disease is aggravated by leaning forward and loading the disk. Facet disease is

aggravated by leaning back (extending the spine).

The symptoms of spinal stenosis are: buttock pain with standing or walking – and improves when

leaning forward such as pushing a grocery cart, unlike disk disease which is made worse by leaning

forward. Spinal stenosis can usually be managed with aggressive physical therapy, but sometimes

requires spinal decompression surgery.

At almost any age, the most painful aspect of lower back disease is the protective muscle spasm that

occurs when the body senses that more back movement may cause more damage. This spasm can be

so severe that it can tilt the pelvis, making the legs feel like they are different lengths.

Anyone who has experienced a ‘charley horse’ in the calf muscles knows how painful muscle spasm

can be. Unlike the calf, it is very difficult for a patient to stretch and massage their own lower back

muscles.

This back muscles are among the largest in the body and effectively connects the upper body to the

lower body. They are constantly in use. When they go into spasm…it is the body’s attempt to treat

itself by having the muscles go into spasm to splint and protect the back – a classic case of the

treatment being worse than the cure.

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Often there is a single trigger point in a location called the posterior superior iliac spine (PSIS), where

the majority of the muscles attach. If the stimulus in the trigger point is turned off then the muscle

spasm will release. This can be turned off using muscle relaxants, stretching, injection (with cortisone

and Novocain-like numbing medicines), acupuncture, massage or some types of chiropractic

treatments. Sometimes mobile fatty nodules can be felt in the region of the trigger point.

REFERRED PAIN

One of the most confusing aspects of back disease is when the pain radiates into the hip and sometimes

the knee. When it gives the sensation that the pain is really in the hip or knee, it is called referred pain.

Referred pain also occurs when hip disease causes knee pain instead of hip pain.

Another confusing aspect of the relationship between the back, hip and knees is when joint

contractures of one joint, put increased strain on the other joints. The most common pattern is with

flexion contractures of the hip in patients with spinal stenosis.

When examining the hips, the back should be flat against the table. When one hip is flexed or bent up,

the other hip should lay flat. IN patients with severe hip arthritis, the other hip often has a contracture

such that it will not lay flat. When these contracted hips are forced flat, this will cause the pelvis to

rotate and lift or extend the back off of the table.

As mentioned before, patients with spinal stenosis are more painful when the back is extended – so that

hip contractures and stenosis do not go well together. This is one situation where hip surgery can help

back disease.

SUMMARY

In closure, back disease often progressed throughout life, from a normal spine (with a normal

canal) to disk disease compressing nerve roots and causing leg pain, to spinal stenosis,

where all the nerve roots in the canal are compressed, causing bilateral buttock pain. Hip

and knee disease makes the situation even worse.

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PAIN

Introduction: Orthopaedic disease presents with either:

Pain (sometimes described as tired, tight, sore, ache)

Loss of Motion (stiffness)

Weakness

Instability

Deformity resulting in problems like leg length differences

Presentation

My patients almost always present with pain. This symptom is the most confusing of all the

above symptoms, because it is the only one that cannot be measured by the Physician. There is a great

deal of pain we humans cope with. Often this pain is not amenable to surgery. Often this pain is not

amenable to any known treatment.

There are many different types of pain. While I don’t buy the concept that “the pain is

in your head” it remains true that your brain filters all painful signals – your brain is the judge and jury

as to how severe the pain is.

In the simplest of terms, there is both ‘good’ pain and ‘bad’ pain. I would define pain as

bad when a destructive process is occurring. I would describe pain as good, when it is the result of the

healing process, or giving a warning to the patient.

We learn about injury to the skin early in life. The simple type of low-grade skin injuries

(burns, blisters) rarely make it to the Dermatologists office the way a sprain (or muscle pull) might.

The difference between breakdown of the skin versus deeper musculoskeletal tissue is VISUAL. The

next time you overdue a new activity and cause yourself pain, think of the injury as a deep blister. It

will heal with time, if you don’t irritate or rip open the blister.

The two most common forms of “bad” pain are:

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1) The Acute pain that occurs in direct relationship to a traumatic event (like a blister or a burn). It

comes on quickly and usually goes away. What is the message your body is sending your brain

with Acute Pain? Don’t aggravate me! The body is having a tantrum and it will only calm down

over time. Your response or attitude towards pain will affect the outcome.

2) Chronic pain that persists years after an injury and occurs almost constantly.

The bad pain, associated with chronic pain is much more difficult to understand. Chronic pain

occurs in two forms:

1. Normal physical exam: Often this pain occurs with low-grade repetitive (or prolonged)

trauma. In other words – you hurt, but you don’t stop the activity (that is hurting you). The painful

tissue looks normal and often the physician cannot find abnormalities.

2. Abnormal Physical Exam: Here the patient may present with scarred, stiff joints. Often

the patient has had multiple previous surgeries. There are obvious abnormalities, but the patient has

been told there is nothing surgical that can be done. There is a reason for this. Trauma causes scar,

Surgery is Trauma, more surgery will cause more scar, and make the process progress.

If your pain has been present for over one year and it occurs almost constantly and you have

normal exam and normal x-rays, you most likely are dealing with a chronic pain issue. If you have a

chronic pain problem, you most likely have an incurable disease. Possibly controllable, but incurable

none-the-less.

A patient with “bad” pain must stop aggravating their problem by doing things that cause pain.

Sounds simple. Then why don’t patients figure this out on their own? Often they do, but when they

don’t, there can be many reasons:

1. They don’t want to give up the activity that is hurting

2. They haven’t been able to pin down the activity. They know they have pain, they just

don’t know what activity is involved.

3. To the patient, all pain signifies something is broken that requires a medical fix. They

push for surgery and start down a path that only aggravates the problem. Trauma causes pain, surgery

is trauma, and more trauma causes more pain.

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4. Patients may look for an easy solution, almost like magic wand that will wipe out their

pain – not a change in activity. Chances are patients have heard about new treatments before their

doctor has and will keep trying alternatives to activity modification.

5. Their pain almost goes away, but then comes back when they try and resume certain

activities. I call such patient ‘Testers” and this requires more discussion.

There is one unrecognized pattern of destructive behavior that causes damage and pain to our

bodies. The people who exhibit this behavior, I call Testers. These are intensely driven individuals,

highly successful at their individual endeavors. They don’t accept failures. They may be runners, they

may be CEO’s, and they may be soccer moms. They play to win. When their bodies fail, it is not

easily accepted.

When a plan for healing is laid out – they take the exercise, the therapy, the medication –

anything and everything that may help – and attempt to maximize their treatment. They overdo all the

treatments prescribed. Just as medications can be overdosed, so can therapy and exercise.

Just as the patient is close to healing, they begin testing the problem to see if it has “healed”.

What they often do is rip the blister open and start the entire process over again. Call it impatience or

just a drive for excellence, this behavior must be suppressed until the body is fully healed. Our bodies

are programmed to heal at a certain rate and that rate changes as we age. Frustration with this process

is a significant cause of chronic pain. Once you think you are done healing – give yourself another

couple of weeks. Rarely does a significant painful condition heal in less than 6 weeks.

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NONSURGICAL TREATMENT OF ARTHRITIS

INTRODUCTION

There are many options for managing the pain previously discussed. The type of

treatment chosen depends on many factors, including age, physical condition, needs of daily

living, and the severity of the disease.

This section focuses on the non-surgical methods for managing arthritis or (loss of

cartilage and the) pain associated with it. Arthritis, whether rheumatoid or degenerative, can

usually be treated non-operatively during its early stages.

Nonsurgical treatment modalities include:

Medication

Physical Therapy: Stretching and Muscle Strengthening

Activity Modification and Weight Reduction

Ambulatory Aids (such as cane or walker)

Alternative Medicine

ORAL MEDICATION:

No medications are without side effects and most have adverse interactions with other

drugs. For this reason we only prescribe medications for short periods of time.

Medications can be classified in many different ways based on their properties. Patients with arthritis

may require medications for the following:

analgesia (pain control)

anti-inflammation

muscle relaxants

sleep

The list of potential pain and anti-inflammatory medications is too long for this DVD but generally is

grouped as follows:

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Acetaminophen

Steroids

Non-Steroidal Anti-inflammatory

Traditional (Ibuprofen, indomethacin, naproxen)

COX 2 Inhibitors

Narcotics

And combinations of the above.

While COX2 inhibitors reduced the effects on the stomach, but there are increased side effects on the

heart, such that Vioxx was recalled, followed by others. While the long term use and availability of all

these drugs will continue to evolve – the take home message is that: There is risk involved with

depending on drugs for long term control of any Orthopaedic disease including arthritis.

Modern Health Care at times is a bit cavalier with its use of medications, well illustrated by a cartoon,

which reads: The top prescription is for your arthritis, but it may cause a heart attack, the second

prescription should prevent a heart attack, but it could damage your liver, the third should prevent liver

trouble, but it may destroy your spleen and so on…

All medications should be used with caution

PHYSICAL THERAPY:

Stretching and muscle strengthening exercises can maintain motion in the joint and give added strength

to a joint, which often helps protect it from further damage.

ACTIVITY MODIFICATION:

Often pain in the joint is brought on by certain activities, which can either be modified or stopped,

depending on the patient’s situation.

AMBULATORY AIDS,

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such as the use of a cane, can reduce pressure on the joint by as much as 15%. When using a single

cane or crutch, it is usually best to use it with the arm opposite the involved joint and should move

simultaneously with that extremity.

WEIGHT LOSS:

Each pound of weight lost diminishes pressure in the joint loading (the force placed on the joint) by

over three pounds. However, it is difficult to lose weight when it is too painful to exercise or remain

active.

KNEE SUPPORT:

There are two types of external support for knee arthritis; compression wraps and stabilizing braces.

Compression wraps are made of a stretch fabric or rubber (like a scuba wet suit). The pressure from

these devices gives some support and probably diminishes the swelling, giving the patient a sense of

protection. These devices are inexpensive and are available over-the-counter.

Stabilizing braces are more expensive and available by prescription. The braces need to be

custom fitted and often are custom made for each patient. They function by stressing the leg in the

opposite direction of the patient’s deformity. This means for patients who are “bow-legged”, the brace

forces the knee towards a “knock-knee” position. The goal is to take the pressure of the painful portion

of the knee.

SHOE LIFTS, SHOE INSERTS AND HEAL WEDGES:

Often adjustments in your shoe wear can benefit other joints in your body such as your back,

hip and knee.

If there is a difference in your leg lengths a shoe lift may be of benefit.

Shoe inserts that add a cushion with each step can cushion the forces on these other joints

too. Patients interested in giving this a try will need to individually experiment with different inserts,

usually sold in most pharmacies.

If your leg is out of alignment – either knock knee or bow legged – wedges can help shift the

weight back to a more comfortable position.

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While these adjustments to your shoes can sometimes have dramatic effects on your pain – the

effect is often short lived. However, we do not discourage our patients from experimenting with such

modifications. For the majority of patients, shoes comfortable to the foot, are the best shoes for the

other joints.

INJECTABLE MEDICATION:

We do not recommend many of the injectable drugs, such as Prolo or Hyaluronic Acid. Prolo comes

in many forms and is an irritant that is supposed to stimulate healing.

Hyaluronic acid (sold as Synvisc, Hyluronate):

is supposed to regenerate cartilage, but the evidence is very weak. This is not surprising since

Hyaluronic Acid is a soft tissue lubricant, not a cartilage lubricant. Since these drugs require three

injections with similar results to saline (a salt-water solution), we do not recommend them.

The most important form of lubrication is called boundary lubrication – which is when

the lubricant actually binds (coats) the surface it is lubricating. The (boundary) lubricant for

cartilage is a material called Lubricin and is not available in an injectable form.

Cortisone (steroid)

One of the most effective treatments for an arthritic joint is an injection directly into the joint with a

numbing medication (Novocain, Marcaine) combined with a Cortisone (steroid) in preparations such

as Celestone and Kenalog.

The injection serves two purposes. The numbing medication will take effect within 15 minutes

and usually last for many hours. This time period is important in determining whether surgery might

eventually help. Joint Replacement Surgery will only help the pain in the joint, not the pain in the

surrounding tissues. If the injection initially takes away 100% of your pain, it is likely surgery will be

of benefit.

The cortisone will probably not take effect for 3-7 days, sometimes longer. It functions as a

form of treatment and may relieve your pain for weeks, months or in some cases, years. While

repeated (weekly) injections of cortisone are bad (as any overdose of medication), 2-3 injections a year

can actually be good for a joint, by decreasing the destructive inflammation.

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While knee injections can be performed in our office, hip injections are more complicated. The

hip joint is located deep within the pelvic area and is most safely injected under x-ray guidance. For

this reason, your injection will be scheduled with another physician (either a Radiologist or a Physical

Medicine &Rehab Doctor) with access to a fluoroscopic-guided X-ray machine that can help guide this

injection.

ALTERNATIVE MEDICINE:

Massage therapy has similarities to some physical therapy modalities and may be effective when

muscle spasm is a significant component of the pain.

Many nontraditional (holistic, herbal) treatments may provide significant relief for some patients.

Most successful have been the oral proteoglycans (chondroitin sulfate, Glucosamine Sulfate 500mg

3x/day). These drugs should be used cautiously with Diabetics, Pregnancy, children, blood thinners,

shellfish and sulfa allergies. Some of my patients have reported relief with some of the other

modalities listed here (magnets, acupuncture, Fish oil, SAM-e.

We will not make any recommendations regarding alternative modalities. Most medical

physicians are not trained in most of these modalities any more than holistic medical practitioners are

trained in surgery. None-the-less, we recognize that many non-traditional modalities provide

significant relief for some patients.

NON OPERATIVE WRAP UP

None of the treatment options will rebuild the cartilage and there is little scientific evidence any

will slow degenerative arthritis from progressing. Treatment is focused on reducing pain while

maintaining strength and joint motion

Long term management with oral medication should be used cautiously. In many cases,

symptoms will best be managed with cortisone joint injections one to four times a year. Consider also

trying a Chondroitin Sulfate preparation, but be prepared for any positive benefit from this medication

to last only about 6-12 months.

Beware of controlling your pain by reducing your activity. When your joint pain begins to

make daily decisions for you, as to what you are going to do that day – then your joint is making

decisions for your heart, your lungs, your mind, and the rest of your body as well. Eventually

decreased activity levels will have an effect on your overall health. When you reach this point it may

be time to consider surgery.

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For many patients, -- non-operative modalities offer only short term relief. If it is determined

that your disease may benefit from surgery – that is not necessarily bad news. As you will see in the

sections that follow, the results are excellent. In many circumstances, it is actually worse news to hear

that there are no surgical options.

SURGICAL TREATMENT: HIP

Options include arthroscopy, osteotomy, fusion, girdlestone and joint replacement.

ARTHROSCOPY

Arthroscopy is a technique well suited to most joints. It involves the placement of a tube or

arthroscope through a small incision into the joint. The surgeon can visualize inside the joint to guide

the use of surgical instruments. The best indications for arthroscopy are localized problems such as

labral tears and loose bodies (or loose fragments sometimes called joint floaters), and in some cases

small cartilage defects.

Unlike with the knee joint (to be discussed) there are rare indications for arthroscopy on the hip

joint. In part this is due to the tight fit between the ball and socket. This tight fit makes it difficult to

tear and displace soft tissue. The tight fit tends to keep out loose bodies and also makes it difficult to

insert arthroscopic surgical instruments.

None-the-less, occasionally, localized problems with the hip joint can be treated with

arthroscopy. The long term results of such treatment are not known.

OSTEOTOMY

Osteotomy means to cut the bone and either rotate or realign the bone next to the joint in order

to improve joint contact. Once re-aligned or reoriented, the bone must heal in the new position.

Osteotomy can be considered when the joint surface remains relatively normal (which means there is

good cartilage space between bones), but the joint is either incompletely formed from birth (congenital

deformity) or) or its bone development is abnormal during growth.

In the hip joint, the osteotomy usually involves rotating the joint into an improved position (in

contrast to the knee where the bone is usually re-aligned). The most common osteotomy in the hip is

called a Ganz osteotomy, which is done on the acetabulum (pelvic bone). In some cases, the

osteotomy is best performed on the femoral side (thigh bone) and in rare cases, both sides.

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The care and therapy following a Hip Osteotomy is similar to that after a Hip Replacement.

However, Osteotomies of the hip are significantly more complicated than hip replacement and the

recovery time is much longer.

Rather than a few months of recovery (with a total hip replacement) the recovery is more like 6

months. The risks associated with osteotomy are the same as those with hip replacement, with the

additional risk of failure of the cut bone to heal.

HIP FUSION

Rarely is there an indication for fusing the hip joint. One of the few remaining indications for

this procedure is for single joint arthritis in the very active young, such as post-traumatic arthritis as

opposed to multi-joint inflammatory arthritis.

GIRDLESTONE (or flail hip)

Removing the hip joint or prosthetic implant without inserting a new prosthesis has been

traditionally called a girdlestone operation.

Currently the main reason for removing the hip joint is for infections of previously replaced

joint. Usually, after the infection has been cleared up a new replacement can be performed at a second

stage, but sometimes this is not possible and the joint is allowed to fill in with scar forming a

pseudojoint. While it may not seem possible patients are able to function fairly well with this

disability, despite the need for cane, crutches or a walker, to ambulate.

TOTAL HIP REPLACEMENT

Total hip replacement is an operation that was developed in England in the early 1960’s, in which the

diseased ball and socket of the hip joint are replaced with an artificial device.

Many patients (and doctors) mistakenly think that Hip Replacements only last 10 years. This has been

shown to be false. A study I co-authored, evaluated the results of surgical techniques developed at my

former practice in Iowa.

We study the success by Survivorship Analysis. We can demonstrate how well hip replacements hold

up, by make a Survivorship Graph. Here is how that is done. We graph Percent of Success versus

Time in years.

If hip replacement only last ten years, the trend would look something like this (graph). This graph

shows that initially 100% of the patients are doing well (another words 100% initial success), but by

ten years have all failed.

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We would prefer to have the trend line have a flatter slope such as the graph now shows. Nationally,

the best reports looked more like this – at twenty years the procedure was successful for 80% of

the patients.

Ideally, you would like to see a graph that is more like this.

At a minimum of 20 years follow-up we reviewed 322 hips, performed by my now retire partner,

Dick Johnston. We documented results unsurpassed in the hip literature. An editorial written by the

head of hip surgery at Harvard, preceded our publication, stated that the excellence of the results set

the standard of what can be achieved by an experience skilled total hip replacement surgeon.

Our study showed that 90% of the patients never required further surgery.

The results are shown in this survivorship graph of percent success, defined as no re-operations over a

20 year period. The goal is to have as close to 100% success as possible. The re-operation rates we

reported were much lower at 20 years than had previously been reported in other studies at 10 years.

In an attempt to further improve on these results; our technique has evolved.

Continued study has allowed us to significantly reduce many of the previously reported complications,

such as infection. I have sufficient data on my own surgical population to confirm that I have been

able to improve upon the techniques I bring from my former practice.

If performed correctly, there is a very low chance that you will ever need to have repeat surgery on

your total hip.

The pictures/figures illustrate a normal hip appearance with normal joint space, an abnormal hip

appearance showing the loss of space between the bones, and finally an x-ray of a hip replacement.

You can see the acetabular cup and the femoral component going down the thigh bone.

Total Hip Replacement is performed as follows:

First the Hip is exposed

Then the femoral neck is cut and the femoral head is removed

The acetabulum or cup is then shaped with reamers, followed by placement of the actual prosthesis

The acetabular prosthesis is usually placed without cement

The metal shell is porous and allows bone to grow into it

Usually two screws are then place to hold the cup while the bone ingrowth is obtained

Finally, the plastic liner is placed

Attention is turned back to the femur or thigh bone

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The femur is prepared by reamers followed by rasp which match the geometry of the prosthesis

The femoral component is then placed

The choice on the femoral side is either with or without cement

Once the femoral component is fully seated, the femoral head is placed on to it and then the hip is reduced into the acetabular cup and brought through a range of motion to check hip stability

The operation is essentially done

The muscle and soft tissue are closed and the dressing is placed

There are many options for attaching the prosthetic joint to the bone. The operation with bone cement

has been performed in the United States since the early 1970’s and the operation without bone cement

since the early to mid 1980’s. When cement is not used, fixation of the components to bone relies on

the bone growing into the rough surface of the prosthesis – often called bone ingrowth.

The word “hybrid” means a combination of fixation techniques, cement, and bone ingrowth. Cement

is used to fix the femoral component to the thigh bone and bone ingrowth fixation is used for fixation

of the cup socket to the pelvis.

Younger patients have been found to have higher loosening rates than older patients when using

cement fixation. The reasons for this are complex, but are related to the higher activity levels in the

younger patient. Therefore, for younger patients, it is recommended to have Bone Ingrowth fixation

only, for both the femur and acetabular cup. Earlier designs for Bone ingrowth had the disadvantage of

thigh pain associated with strenuous/high level activities, which may have limited patients’ activity and

protected the joint replacement. Newer designs have almost eliminated thigh pain and can now be

considered for older patients.

Surgical Approach:

Traditionally, the debate regarding surgical approach was limited to

(Anterior (entering the joint from the front) vs. Posterior (entering the joint from the back),

Recently, new terms have been added to the debate: mini-incision, 2 incision, noninvasive and

muscle sparing. Of all these new terms, the only one of importance is muscle sparing, which means

not cutting muscle to expose the hip. This approach decreases recovery time and improves function.

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All surgery is invasive – there is no such thing as completely non-invasive surgery. While I

believe it is good to minimize the invasiveness of operative procedures, by minimizing incision length

and surgical dissection – I think the most important aspect of any surgery is the following:

Patients should be more concerned about how their joint is doing 10-20 years after the surgery,

rather than how they are doing 10-20 days after the procedure.

When possible, our preference is to use an ‘anterior’ approach through a recently developed

muscle sparing approach. This technique was made possible by the introduction of a modification of

the operating table by removing a section.

. The anterior approach is associated with a lower dislocation rate and muscle sparing is

associated with shorter incisions and quicker recovery rates. While we can usually avoid cutting

muscles, there are many cases where smaller incisions are not possible (for example: severe deformity,

previous surgery). Frequently in heavier patients, the incision needs to be extended. The most

important aspect of your incision is this: The incision is long enough to reduce your chances of having

your joint replacement fail and need revision.

Trochanteric Osteotomy

Often in Revision Hip surgery, we need to improve our surgical exposure by making longer

incisions and performing a trochanteric osteotomy. A trochanteric osteotomy involves cutting through

the bone of the greater trochanter, keeping the abductor muscle attachment. This allows us to enlarge

our exposure without damaging muscle.

When we are finished, the trochanter is wired back down into place with 2 to 4 wires. These

wires are strong enough to hold the trochanter down while it heals back into place. By the time the

wires break, they have done their job. Usually they stay in place without irritating the surrounding

tissues, but in about 5% of the cases, may be removed with a simple outpatient procedure.

Prosthetic Materials

The materials used in joint replacement include metal and plastic. The outer surface of the

socket and ball and the attached femoral stem components are made of metal, currently combinations

of Titanium and Cobalt-Chromium Alloys. We use a highly cross-linked polyethylene for the cup liner

or joint surface. There is some controversy regarding what is the best joint (or bearing) surface.

Joint Surface Materials:

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(Metal – Plastic, Metal – Metal, Ceramic –Plastic)

The recent popularity of metal and ceramic surfaces is making way for even newer technologies with

highly cross-linked polyethylene. Our preference is this new variation of Metal on Plastic. This

plastic, made of highly crossed linked polyethylene is the newest technology. It has been shown to

have the best wear characteristic with the least loosening, fracture and tissue reaction. There are

reports of >25 years of clinical experience with variations of this plastic material.

While the risk of metal sensitivity is extremely low, with metal deep in the body, the potential

for metal sensitivity is more likely to occur with metal-metal bearing surfaces. This is especially true

for resurfacing hip replacement, where the surface area of articulation is large and the potential to

generate metal debris is higher. Here is an x-ray of such a hip resurfacing prosthesis. I have concerns

regarding the use of such metal bearing prostheses, especially in light of the excellent results reported

for highly cross linked polyethylene.

TESTIMONIALS…

COST OF PROCEDURE

While we try to focus on the medical issues related to joint disease, cost increasingly is an issue

in medicine today. While insurance plans differ significantly, the total costs with and without

insurance can be provided to you by a member of my team.

SURGICAL TREATMENT: KNEE

As with the hip, options include arthroscopy, osteotomy, fusion and joint replacement. The

counterpart to the hip girdlestone, creating a flail knee is almost never a viable option. Unlike the

reasonable function obtained with a flail hip, a flail knee functions so poorly that a fusion or even an

amputation will more likely be a better option.

ARTHROSCOPY

Arthroscopy is useful in many joints, but its best use has been in knee, especially for conditions

resulting from injuries. It is not usually helpful for advanced arthritis of the knee. Arthroscopy

involves the placement of a tube or arthroscope through a small incision into the joint. The surgeon

can visualize inside the joint to guide the use of surgical instruments.

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The best results from arthroscopic procedures is in the treatment of localized problems such as

meniscal tears and loose bodies (or loose fragments sometimes called joint floaters), and in some cases

small cartilage defects.

Unlike with the hip joint, there are frequent indications for arthroscopy on the knee joint. In

part, this is due to the loose fit between the bones of the knee. This makes it easy to injure and easier

to fix problems in the knee. This loose fit makes it easy to tear and displace soft tissue. The loose fit

allows loose bodies to catch in the joint and likewise makes it easy to insert arthroscopic surgical

instruments.

Although rarely indicated, the arthroscopic procedure most often performed for knee arthritis

involves shaving and clearing out of the damaged parts. Essentially, the rough surfaces of the joint are

smoothed down. Often surgeons add to this type of treatment with techniques designed to stimulate

formation of cartilage. The cartilage that forms is more like fibrous scar than like cartilage and is

called Fibrocartilage. It does not have the mechanical properties of normal (hyaline) cartilage, usually

does not integrate well with the cartilage, and is usually a short term solution.

Frequently patients improve initially after this surgery, only to have their arthritis progress at a

faster pace. This might occur if the procedure enlarges the area of damage. Unless a patient comes in

with a sudden onset of pain related to a new injury in an arthritic knee, arthroscopy is rarely

recommended for arthritis.

Regardless of age, patients with recent injury and persistent pain, often do well with

arthroscopy, to repair or remove damaged structures. Its best use is for new tears in the meniscus. The

recovery is in days to weeks rather than months, as seen with joint replacement.

OSTEOTOMY

When there is abnormal shape or alignment of the knee, such as knock-knees or bow-legs, the

forces across the knee are concentrated in one place, causing increased wear of cartilage in that area.

The pain caused by this cartilage wear can be decreased by straightening the bone (osteotomy) to

restore normal alignment.

Although the long-term results of this operation are less predictable than those of joint

replacement, 70% of patients have some relief of pain and improved function for up to ten years

following the operation.

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Its best use is in younger patients with high activity levels, such as heavy labor (frequently

lifting greater than 50 pounds). It is still possible to perform a knee replacement after an osteotomy

(although the operation is a bit more difficult). Hopefully, the osteotomy will delay the need for knee

replacement until the patient reaches an age with lower physical demands.

KNEE FUSION

Like the hip, rarely is there an indication for fusing the hip joint. Because knee motion is

critically important to the function of the lower extremity, even young active patients with single joint

arthritis would rarely to consent to having their knee fused. However, because of the poor function

seen with a flail knee, knee fusion is the procedure of choice with severe joint infections where it will

not be possible to implant a new replacement. If the destruction from the infection is so severe that a

fusion is not possible, unlike the hip an amputation will usually be preferable to the creation of a flail

joint.

JOINT KNEE REPLACEMENT

We will now discuss joint replacement beginning with unicompartment followed by total knee

replacement.

UNICOMPARTMENTAL KNEE REPLACEMENT

Partial knee replacement is similar to total knee replacement (discussed next, in more detail).

The differences are few, but significant. Uni-compartmental replacement uses a smaller prosthesis

than a total knee and is a smaller operation, with shorter recovery. However, it has not been shown to

be as long-lasting as Total Knee Arthroplasty. About 10-20% of patients having the partial procedure

require re-operation within10 years, for either loosening or for progression of disease in the rest of the

knee.

Rather than the 6-8 week recovery seen with total knee replacement, there is a 3-6 week

recovery with uni-compartmental knee replacement. It must be emphasized that only the most

significantly diseased portion of the joint is treated with this procedure, and that in many cases there

remains mild disease in the part not replaced.

The two complications that that relate specifically to partial replacements, are: 1) progression

of disease (arthritis) in the rest of the knee (which doesn’t occur when the entire knee has been

replaced) and 2) higher loosening rates seen with the smaller components, that are harder to obtain

good fixation with, compared to the larger total knee replacement.

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PATIENT DISUSSING PARTIAL (UNI-COMPARTMENT) KNEE REPLACEMENT VS.

OSTEOTOMY

TOTAL KNEE REPLACEMENT

Total knee replacement, in its current design, has been widely used for almost twenty years and

is one of the most successful operations performed in medicine. The purpose of this operation is not to

give you a normal knee but to relieve pain and improve function in the knee.

TWO MISCONCEPTIONS ABOUT KNEE REPLACEMENT

There are two misconceptions regarding knee arthroplasty. The first, misconception is that it is

truly a knee replacement – where we remove the entire knee joint and replace it with a hinge. This is

not true – the knee is still there after the procedure; including the ligaments, tendons, skin, muscle, and

most of the bone. What is replaced is the damaged cartilage. The cartilage surface is replaced with a

metal and plastic surface.

Holes in cartilage are similar to a hole in a tooth. The treatment for such a situation in the tooth

is to cap the tooth and cover the nerve. The treatment for a hole in cartilage down to the nerve is to cap

the knee to cover the nerve. Same idea. Although we will continue to call it a ‘knee replacement’, a

better description would be to call this operation knee resurfacing.

The second misconception is that they only last ten years. A knee replacement will last much

longer in most cases. We study this by Survivorship Analysis. We can demonstrate how well knee

replacements hold up, by make a Survivorship Graph. Here is how that is done. We graph Percent of

Success versus Time in years.

If knee replacement only last ten years, the trend would look something like the graph below.

This graph shows that initially 100% of the patients are doing well (another words 100% initial

success), but by ten years have all failed.

34

We would prefer to have the trend line have a flatter slope such as the graph now shows.

Ideally, you would like to see a graph that is more like this.

This graph is from a study reviewing my first 101 total knee arthroplasties in Des Moines,

Iowa, was published in December of 2002. There are not any previous studies of total knee

arthroplasty reporting such results.

This study is unique because:

All surgery was performed by one surgeon, myself, and

All of the procedures were performed at the start of my career.

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Other surgeons provided subsequent care for the patients.

A third team of surgeons from the University of Iowa investigated the long term results.

Information was available on 100% of the patients at 9.8-14 years after the procedure.

There were ZERO failures in the first 10 years and no reoperations. By failure, I mean

reoperation for any reason such as infection, loosening, or dislocation of the implant. Any

problems that resulted in a failure of the knee replacement.

Total knee replacement, in its current design, has been widely used for almost twenty years.

The purpose of this operation is not to give you a normal knee but to relieve pain and improve function

in the knee. When performed correctly, one operation should last the rest of the patients life in >90% of

the cases. Failure of the prosthesis, requiring reoperation is devastating to patients and their families.

This risk can be minimized by knowing the true prosthetic survivorship of the individual surgeon.

Let’s review the basics of the surgery…

The incision is made in the front of the knee, through the skin and soft tissue down to the knee

joint. After adequate exposure has been obtained, the top of the tibia is cut to accommodate the tibial

component. Followed by cuts on the distal thigh bone or femur to accommodate the femoral

component. Finally the undersurface of the kneecap to accommodate the patellar component. All

three components are then secured to the bone with acrylic bone cement.

CONTROVERSIES

There are numerous debates in joint replacement over minor preferences from one surgeon to

another. Research studies often show superiority of one technique over the other, but sometimes

differences are not found

As I discuss some of the controversies listed below, the important take home point is this – I

stand by my ten year data.

Surgical Approach and Incision: All surgery is invasive – there is no such thing as completely

non-invasive surgery. While I believe it is good to minimize the invasiveness of operative procedures,

by minimizing incision length and surgical dissection – I think the most important aspect of any

surgery is the following:

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Patients should be more concerned about how their joint is doing 10-20 years after the surgery,

rather than how they are doing 10-20 days after the procedure.

PCL retaining vs. Posterior stabilized

My philosophy is to keep anything that is still functional. Saving this ligament makes the

operation more difficult, but in most cases, keeping this ligament will create more anatomic function.

The posterior cruciate ligament functions to roll the femur back on the tibia as the knee bends.

There are studies to suggest keeping this ligament improves the mechanics of the kneecap. The

data is not strong, such that it is acceptable to remove this ligament, provided the prosthetic design is

slightly altered to substitute for this ligament. The two options are shown in this figure, to the left is a

cruciate preserving diagram and to the right a cruciate sacrificing design.

Rotating Bearing:

One issue worth discussing is the controversy regarding bearing surface. There are two

options: Fixed bearing and Mobile or Rotating bearing surfaces. The Mobile bearing has movement at

a second location – under the plastic. The metal on this side is as smooth as the femoral component.

The older style fixed components had slightly rough surfaces under the plastic and probably

contributed to some of the wearing, we saw in my study after ten years. The tibial component now has

a smooth surface under the plastic, just like the rotating bearing prosthesis, only the plastic doesn’t

move. I like these new fixed bearing prostheses, because the address the wear problem, while

maintaining more anatomic function. My problem with the rotating bearings is that this is not how the

normal knee functions. Here you can see they both have the same surface finish to the trays.

Bilateral (Both) Knees:

Often patients present with severe arthritis in both knees, which raises some questions such as:

1. Which knee should be replaced first?

2. Can they both be done at the same time?

They can be done at the same time and we often perform bilateral knee replacement. However,

studies have shown that medical risks are very high for patients over age 70. Patients who are 60-70

are at moderate risk and for those under 60 the risks are acceptable.

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If both knees need replacement, but are not done at the same time, the second knee can be

replaced as early as 8-10 weeks after the first knee.

If one knee is significantly worse than the other, most patients should consider doing only that

knee. If both knees are similar in pain and for reasons discussed it is decided to do one at a time, go

with your gut feeling as to which knee is more often the problem and which knee do you favor. In the

end, the order in which they are done will make little difference.

Young patients and previous surgery: There are patients who are predisposed to a longer

recovery –younger patients (less than 60 years of age), and those who have had previous surgery.

These patients have a much longer recovery and a more painful recovery – It is unclear why this is so,

but it relates to the sensitivity of younger pain receptors.

COST OF PROCEDURE

While we try to focus on the medical issues related to joint disease, cost increasingly is an issue

in medicine today. While insurance plans differ significantly, the total costs with and without

insurance can be provided to you by a member of my team.

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PRE-ADMISSION INFORMATION

If you have not seen a dentist in the past year, this examination is recommended prior to

surgery. Patients contemplating this surgery are encouraged to see their private physician (internist or

family practitioner) to be checked medically before surgery. If you have recently seen your private

physician, please obtain a copy of all recent visits, exams and studies (bring this copy to your next visit

at our clinic).

If you see and Medical Specialist such as a:

- Cardiologist

- Pulmonologist

- Oncologist

- Urologist

Or have a history of heart, lung or urinary problems, such as difficult urination in men with

prostate problems. We will want you to be fully evaluated by one of these specialists before surgery.

To prevent excessive bleeding during surgery, stop taking arthritis and anti-inflammatory

medications at least one week before surgery. However, if you are taking low dose aspirin (81mg baby

aspirin), one tablet a day, you should continue to take this. You should consider taking the coated

version (Ecotrin) of this medication.

For those that smoke: You should strongly consider stopping smoking for one week prior to surgery

and two weeks after surgery (until your staples are out). Smoking hurts wound healing and increases

your risk for infection (a significant increase).

Blood Transfusion

Patients often require a blood transfusion after total joint replacement. Blood borne diseases

(AIDS, hepatitis, etc.) and allergic reactions are rare, but significant major complications of a

transfusion. The screening procedures at our blood bank are as thorough as possible and the risk

associated with blood transfusion is exceedingly small.

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An option is autologous (self) blood transfusions. Patients 75 years of age or younger may

donate one or two pints of blood in the four week period prior to surgery. For patients over 75 years

old, the risks of giving this much blood, do not outweigh the benefits. You must take iron supplement

pills (Ferrous Gluconate 325mg po BID – available over the counter. The Iron may be constipating for

some patients.

PRE-OPERATIVE EVALUATION

You will come to our office one to two weeks prior to surgery. A full set of X-rays of your joint will be

made if we do not have a complete film series taken within the past six months.

You will be seen by members of my team during this visit. A consent form for surgery will need to be

signed.

You will complete your preoperative visit at Durham Regional Hospital. Once you enter the Hospital,

take the elevators down to the second floor. You will then register at the Patient Registration desk.

At this appointment, you will obtain blood labs, EKG, Chest X-ray, and meet with a member of the

anesthesia team. Spinal anesthesia is preferred because there are fewer complications, such as less

bleeding and fewer blood clots.

You will also meet with the hospitalist who is part of a group of board certified Internal Medicine

Physicians who provide in-house coverage of the hospital 24 hours a day. Should you develop a

serious medical problem during your hospital course, this group of highly qualified physicians will be

familiar with your case and ready to assist in your care.

Preparing your house for your return

Several suggestions can make your home easier to navigate during your recovery. Consider:

Secure handrails along your stairways.

A stable chair for your early recovery with a firm seat cushion (height 18-20 inches), a firm

back, two arms, and footstool for intermittent leg elevation.

A toilet seat riser with arms, if you have a low toilet.

A stable shower bench or chair for bathing.

Removing all loose carpets and cords.

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A temporary living space on the same floor, because walking up or down stairs will be more

difficult during your early recovery

HOSPITAL OVERVIEW:

ADMISSION, HOSPITAL COURSE, DISCHARGE

MENTAL PREPARATION

Admission to a hospital for any reason is stressful. This will be the case for your surgery.

I have worked in hospitals from New York to the Mayo Clinic and have yet to see a hospital where the

process is not dehumanizing at times. In these times of declining reimbursement and nursing

shortages, this reality is not improving.

Each hospitalization involves hundreds of people behind the scenes. While my goal is to have your

hospitalization be uneventful, I cannot guarantee that every encounter during your hospitalization will

be beyond criticism. That does not mean we don’t want to hear criticism, we need this feedback to

improve.

Durham Regional Hospital has invested resources into bringing our team into their system. I have

gone to great lengths to ensure that all risks impacting the success and the longevity of your surgery

have been minimized. Another words, I am confident that you will be happy with the end result.

While everything matters, nothing matters more than the end result.

PREPARING YOUR HOUSE FOR YOUR RETURN

Several suggestions can make your home easier to navigate during your recovery. Consider:

Secure handrails along your stairways.

A stable chair for your early recovery with a firm seat cushion (height 18-20 inches), a firm back, two

arms, and footstool for intermittent leg elevation.

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A toilet seat riser with arms, if you have a low toilet.

A stable shower bench or chair for bathing.

Removing all loose carpets and cords.

A temporary living space on the same floor, because walking up or down stairs will be more difficult

during your early recovery

Packing and preparation for your surgery day

You should not eat or drink after midnight the night before surgery. It is most practical to bring

pajamas, short gowns and robes, shorts, or sweat pants to the hospital. Long gowns and robes interfere

with walking. Bring a pair of shoes (or sneakers) that you are accustomed to wearing; bedroom

slippers usually don’t give the foot enough support. This is not a good time to “break in” new shoes.

Also, bring a bottle of each of your current medications with you to the hospital. You will not be able

to use your own medications, unless they are not available on our formulary. We suggest you seal

them in a plastic bag, so they are available if needed.

Please continue to take your cardiac medications the day of surgery. This is especially important if you

are taking a beta-blocker. Do not take your diabetic medicines and diuretic (fluid pills) the day of

surgery. Check with our team if you have questions.

DAY OF SURGERY

You will be informed when to arrive at the hospital the day prior to surgery by phone. If you need this

information prior to their call or if you have not heard by 4pm the day prior to surgery, you are free to

call the numbers shown.

Call the numbers in the following order until you get the information you need:

919-470-8426,

919-470-4000

If they don’t know at either of these numbers… then ask them to page the operating room charge nurse

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Upon arriving, check into the ambulatory care unit (ACU) on the main level (which is the third floor of

the hospital), for admission. You will be directed to a staging room, where you will change clothes and

be prepped for surgery.

At some point, an intravenous line will be placed in your arm. At the appropriate time you will be

transported (on a stretcher) to the operating room (O.R.).

The personnel in the room during your surgery will usually consist of the anesthesiologist, a nurse

anesthetist, a circulating nurse, a surgical technician (who will pass the instruments), a surgical

assistant and my pa. This team will prepare you for surgery prior to my entering the room.

The operating room is considered a clean air environment and may be a bit cool. We use UV lights,

body exhaust systems and IV antibiotics to reduce your chance for infection.

In the operating room, a urinary catheter will be inserted, usually after the anesthetic has been given.

This will be left in place for one to three days.

The surgery usually takes two to three hours. Either someone on our team or in most cases I will talk

to your family and friends if they are available. Usually they will be instructed to wait in a waiting

area near the front lobby. Please have them ask for a pager at the reception desk if they need to leave

the area for food or errands. Family and friends will not be able to see you until you arrive at your

hospital room about three hours later.

After surgery is performed, you are then transferred to the PACU (recovery room), for two to three

hours.

The nurses there will take your blood pressure and pulse frequently.

You will have an IV line (for intravenous fluids) in your arm, a catheter in your bladder, and

(sometimes) a drain in your joint. The drainage tube prevents blood from collecting in the joint. It is

painless and will be removed in 24-48 hours.

There will be a dressing over the joint incision

An x-ray will usually be taken in the recovery room.

OVERVIEW OF HOSPITAL STAY

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Day of surgery

After going to your hospital room (most likely on the 6th floor), the nurse will continue to check your

blood pressure, pulse, and have you cough and breathe deeply.

The first opportunity you will have to see your family will be after you are transferred to your hospital

bed and room. In many cases, they will be waiting for you there.

We have ordered various medications to help with fever, nausea, pain, sleep and gastritis in case you

need them. For patients with allergies we may have to alter our regimen. Since these are standing

orders, it is always a good idea to specifically ask what you are being given.

Pain management (this will be described in more detail later in this chapter) - As a general overview, a

PCA pump should be set up for your use, to allow you to control your own pain medication. There

will be oral pain medications available as well. Some patients may have an epidural catheter for pain.

In regard to pain, for the first 24 hours - some patients are on the fence between overmedication and

pain control. Overmedication with these drugs is a serious issue and may impact our ability to control

your pain. In most cases, your pain will be adequately controlled.

Postoperative day 1

Exercises will be performed in bed. A blood transfusion may be given. Physical therapy and

occupational therapy will begin. You may only complete one session.

The simple concept for the day is, “don’t be a hero”. Get your pain under control. If you don’t do well

with therapy the first day, you will have ample time to catch up.

Postoperative day 2

The simple concept for day 2 is, “lighten your load and get rid of your tubes.”

The intravenous line, the drain in your joint (if placed), and the bladder catheter will be removed (if

they were not removed on the first day). In some cases, we may have already changed your dressing,

but for most patients this will occur on day 2. Physical therapy will be provided twice a day.

Occupational therapy will be provided as well.

Postoperative day 3

The simple concept for day 3 is, “finalize plans for your leaving the hospital. Half of our patients are

discharged from the hospital before the end of day 3 (either to home, rehabilitation hospital, other).

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You will discuss your living situation with the social worked, physical therapist and occupational

therapist to guide them in your preparation for discharge from the hospital. It always helps to learn

their names and get to know them.

Hopefully, plans have been initiated, but often not finalized until this day. Your bowels may begin

functioning, usually starting with gas. Laxatives or stool softeners are ordered should you need them.

Your legs will be checked for blood clots with an ultrasound scan.

Postoperative day 4

By the fourth day after surgery, you should be ready to leave the hospital. Depending on your level of

function you will either go home (with assistance), go to a rehabilitation hospital, or in rare cases go to

an intermediate care facility (i.e. nursing home).

Going home and recovery

Physical therapy will be provided twice a day. For patients that both qualify and desire to go to a

rehabilitation hospital, arrangements will be made by the social worker. Unfortunately, these

arrangements cannot be made until your progress after surgery has been assessed.

ISSUES APPLICABLE TO THE ENTIRE HOSPITALIZATION

General issues

The nurses will be close by to care for you and answer any questions you have, but a good deal of your

progress is up to you.

Preventing clots (or deep vein thrombosis):

Our protocol to reduce leg clots includes the use of compression stockings and pneumatic sleeves on

your legs. For patients undergoing knee replacement, the compression stocking will not be placed on

the involved leg until the dressing is changed.

An important aspect of this protocol involves a duplex scan of your legs prior to discharge on the third

or fourth day after surgery. This scan is similar to the ultrasound done on pregnant women. The

scanner rests on your skin such that there is no discomfort with this study - it is non-invasive. If you do

not have any sign of a clot forming, it is unlikely to form now that you are mobile.

Hip replacement patients will be placed on Heparin-based blood thinner, a medication injected under

the skin. You will stay on this for a short period of time after you leave the hospital. Please inform us if

you have had any bad reactions to this medication in the past.

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Blood Transfusions:

A blood transfusion may be given, depending on the situation. This is more likely if you donated your

own blood. We will obtain daily blood counts to help us make the decision. Other contributing factors

will be your blood pressure, urine output, strength and symptoms of dizziness.

Food and water:

While you are in bed, you may eat normally and should drink large amount of fluids (as tolerated) to

keep your kidneys functioning properly. You may take sips of water as soon as you are awake if you

are not nauseated.

Your food intake will be advanced as your fluids increase, and are tolerated. You will most likely be

asked about your diet, but if your diet is not being advanced to solid foods, let your nurse or our team

know.

Activity while in your hospital room: sitting, CPM and, lung (pulmonary) exercises, and leg

Sitting:

Sometime in the first few days after surgery, you will begin to sit in a chair and eventually use an

elevated toilet seat. However, we recommend that you limit sitting during the first six weeks after

surgery. Sitting impedes blood flow and increases swelling and risk for clots. Instead of sitting, we

want you to be exercising by walking or lying down.

Pulmonary:

You will need to take deep breaths at frequent intervals and cough out the mucus that accumulates in

your lungs during and after surgery. It is very important that you do this to keep your lungs fully

expanded and free from infection. This deep breathing also helps prevent blood clots.

You will be given an incentive spirometer to help guide your breathing exercises. You should use this

device 10 times each hour that you are awake.

CPM:

For knee replacement patients you will spend a portion of your day using a CPM machine to slowly

move your knee. The amount of time and the degree of motion is variable among patients. You will

Leg Exercises

You cannot get out of bed by yourself or turn over. Although you can’t roll onto your side, you can roll

yourself to the side 10-20 degrees. You will probably need help in positioning the necessary pillows.

You will not have to lie flat all the time; you may raise the head of your bed periodically and can use

the overhead bar to strengthen your arms to reposition yourself.

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You will begin to do your exercises in bed shortly after arriving to your room. These exercises will

help prevent blood clots and improve the motion in the joint. At first, it will not seem like you are

doing much, but it is persistence that counts.

Roll your knees in and out.

Tighten the buttocks together.

Tighten the muscle above your knee (quadriceps) by pushing your knee down toward the bed.

Bend your feet up and down at the ankles. You can feel your calf muscles tighten. This

motion helps your circulation by pumping blood from your legs back to your heart.

While you can try and do leg lifts, you will probably be unsuccessful for the first few days,

but just the act of trying will help.

It is important that these exercises be done five times every hour and that you exercise both legs. The

exercises above must be done slowly. Tighten for the count of five and then relax for the count of five.

You will make your muscles sore if you do the exercises too fast. These exercises improve circulation

and strengthen the muscles that help stabilize your joint so that when the day comes for you to get up,

you’ll be ready.

You will have a catheter in your bladder for one to two days. After it is removed, you will have to use

the bedpan (and eventually bedside commode). Ask questions about this early in your hospital stay, so

that you are prepared to help yourself should your needs be urgent.

Impediments to feeling good:

There is nothing enjoyable about being sick. Nothing helps a patient’s morale more than feeling

healthy. Unfortunately, after surgery, there are impediments to feeling good. Joint replacement is

major surgery and will place a stress on the rest of your body. In addition to pain, there are other

bodily functions and sensations that will be altered including: fever, weakness, fatigue, gastrointestinal

dysfunction, sleep disturbance, confusion and depression:

Pain –

We will make every effort to control the inevitable pain after the surgery. Usually this pain is located

in your operative joint.

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Based on your preferences and the recommendations of the anesthesia team, the management of this

pain may vary. Patients who have spinal anesthesia will have a small amount of a pain medication

placed around the spinal nerves. Some patients may have a small spinal catheter left in place next to

the spinal nerves to assist in pain relief for 24-48 hours (called an epidural catheter). Some patients

require only oral medication for pain following surgery, while others require that the medication be

given by injection. Others are able to administer their own intravenous pain medication through the

use of a PCA machine. Make sure that you administer this and not your family.

The postoperative pain that you will experience is expected and perfectly normal. The nurse will ask

you to note the severity of your pain before and after giving you pain medication. The discomfort after

surgery is usually different from the pain you have before surgery. Be assured it will soon lessen in

severity as your hospitalization progresses. Also, remember that the post-surgical pain is good, healing

pain. Not the bad pain that says something is going wrong. It is good, healing pain.

Temperature Regulation

Low grade fevers and even chills are very common during the first 48-72 hours. There are many

benign reasons for this including the stress of surgery and pulmonary congestion from lack of activity.

If your temperature exceeds 38.5 Celsius, (101.3 Fahrenheit) we will obtain blood cultures as a

precaution.

Weakness and fatigue

Weakness and fatigue is understandable immediately after the surgery. Often this can be improved by

blood transfusion.

One of the most bothersome, but benign medical issues many patient’s experience, is reduced

endurance or fatigue, for about 2-4 months after the surgery. With time strength returns -

understanding is half the battle.

GI system:

Nausea and vomiting are among the most unpleasant conditions to endure. Appetite and bowel

function often are both altered. Laxatives (stool softeners) are ordered for you if you should need

them. Usually gastro-intestinal system returns to normal by the fourth day after surgery, if not sooner.

Sleep:

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One of the most common complaints during the 2 to 6 weeks after surgery is difficulty sleeping. Some

patients have pre-existing problems, like sleep apnea, that may be exacerbated. For those without

previous problems, there are three potential problems that may occur after surgery:

1) Sleep disturbance, stress to your system can always affect your sleep. Many patients need a sleep

medication (such as ambien) for the first 1-2 months after surgery.

2) Pain - pain can be an obvious source of sleeping problems. We may need to increase your pain

medications at night for a short period.

3) Restless leg syndrome - lastly, some patients develop a restless leg syndrome, similar to that seen

with too much caffeine. This can be treated with medications such as klonipin.

If you are not sleeping well, please discuss this with us so that we can try to help you through this

period.

Confusion:

It is not uncommon to experience some confusion during the first 1-3 days after surgery. Rarely does

this confusion require significant medical evaluation or treatment. Occasionally, the confusion is a

sign of medical issues, such as alcohol withdrawal.

Usually this confusion is similar to what people experience when traveling and waking up in

unfamiliar surroundings (such as a hotel room) – but the confusion in the hospital after surgery,

magnifies this experience.

Why is the confusion prolonged and so much worse? In addition to the new surroundings, other things

that magnify confusion include older age, stress of surgery, lack of nutrition, loss of appetite and

narcotic pain medication. This confusion can be quite distressing to familiar members, especially

when the confusion results in agitation and combativeness. The best treatment is to surround the

patient with familiar possessions and people. Conversations recalling past events can be quite helpful.

Often the confusion is worse in the evenings.

Depression:

Mild depression is extremely common and often brought on by the problems just discussed. While

sometimes medical treatment is required for these symptoms, usually with time they will pass.

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Usually the symptoms improve over a period of days. Occasionally, the confusion does not fully

resolve until the patient returns home to familiar surroundings.

PHYSICAL AND OCCUPATIONAL THERAPY

Ambulation

Nothing will overcome the problems just discussed like activity. You need to move to get better.

On the first day after surgery, you will begin getting up to walk with the physical therapist (pt). You

will begin exercises and review precautions to protect your new joint. Physical therapy will continue

twice a day until you go home. If it is getting late in the day, don’t be shy about asking when your next

session will be.

Your operative leg may seem longer at first. This sensation corrects itself in a few days. Infrequently,

there is a true leg length discrepancy.

You should be given your own crutches (in some cases a walker, but crutches are recommended). Our

preference for crutches is because they help you to walk normally rather than the halting gait seen with

a walker.

Initially you will be partial weight bearing, but will walk with equal steps, heel down (instead of on

your toes), with your head up, bottom in, while your crutches stay even with your operative leg.

Bilateral joint replacement patients will need to learn what is called a 4-point gait.

As you progress, the weight you bear will be determined by our surgical team, based on your progress.

Do not advance weight bearing until instructed to do so.

The distance you walk will be determined by you and your therapist. Discomfort at this point is usually

muscular and is normal. You usually do not walk far the first time you are up (you may only sit up at

the side of the bed), but the distance improves each time. As you progress, you can walk as far as you

can tolerate.

Stairs

Stair climbing is an excellent strengthening and endurance activity. At first, you will need a handrail

for support and will be able to go only one step at a time.

Always lead up the stairs with your good leg and down the stairs with your operative leg. Remember,

“Up with the good” and “down with the bad.”

Do not try to climb steps higher than the standard height (7 inches) and always use a hand rail for

balance. As you become stronger and more mobile, you can begin to climb stairs foot over foot.

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After you leave the hospital, you may want to have someone help you until you have regained most of

your strength and mobility.

Occupational therapy

After your surgery, you should see an occupational therapist as well. They will help you practice tasks

that will make it easier for you to take care of yourself at home, such as going into the bathroom and

getting yourself dressed (and also provide assistive devices).

Planning for therapy at home:

By the fourth day (1/2 of patients will leave on the 2nd or 3rd day) after surgery, you should be ready to

leave the hospital. Depending on your level of function you will either go home (with assistance), go

to a rehabilitation hospital, or in rare cases go to an intermediate care facility (i.e. nursing home).

Many patients want arrangements for the rehabilitation hospital to be made in advance. Unfortunately,

the insurance companies (and Medicare) will not approve this until certain criteria during your

postoperative course are met. For those of you intent on going to rehabilitation, we will make every

effort to “guide” the process.

For those who go home, most will need further therapy after you leave the hospital. The social

workers will make arrangements for someone to visit you at home. You may want to have someone

help you until you have regained most of your strength and mobility.

GOING HOME AND RECOVERY (FIRST 6 WEEKS)

DISCHARGE AND APPOINTMENTS

You will usually be able to go home about four days after surgery. You will be given an appointment

for your return visit to our clinic, usually about 14-21 days after surgery after surgery.

INCISION:

If your incision still has a scab on it, wash it with rubbing alcohol (70%) twice a day until all scabs are

gone.

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The staples or sutures will be removed about two to three weeks after surgery. You may shower while

you still have the staples. You must wipe the incision site with 70% alcohol prior to and after having

the shower. This 70% alcohol will help keep the incision site clean and dry. The occupational

therapist or physical therapist will instruct you on how to get in and out of your shower safely.

The incision will allow you to monitor the inflammation deep within your new joint. Redness along

the incision represents inflammation and as long as your incision remains reddish, there will be

inflammation throughout your joint all the way down to the prosthesis. This lasts for 6 to 12 months

after the surgery. While this redness and inflammation persists, your joint will have an array of

symptoms including burning, numbness, tingling, sharp/shooting pain, swelling, fullness, tightness, a

band like feeling around the joint, a heavy sensation and/or a dead sensation. You will not experience

all of these, but you may experience many of them. It is normal for these symptoms to change from

one to another. You should not be concerned, as long as none of these symptoms persist and progress.

Once this inflammation resides and the color returns to “near” normal skin color, these symptoms

should almost completely resolve. As the swelling goes down, it is normal to feel a slight clicking

sensation in your joint, between the two prosthetic components.

A small percentage of patients will develop a thick scar called a keloid. Many topical ointments have

been used to reduce the severity. To date, we have found Neosporin Scar Solution to be most effective.

Others include Elicina Cream, Silicone Scar Therapy, Imiquimod 5% Cream, Neosporin® Scar

Solution™, and Vitamin E Creams.

SITTING

As previously discussed, we recommend that sitting be limited to 3 hours a day (for the first 4-6

weeks) and the remainder either walking or laying flat (on bed, couch or floor). You should only sit for

meals and short visits, but never more than 30 minutes at a time without getting up and stretching or

taking a short walk. Sitting kinks veins, slowing return of the blood to the heart and increase risk of

swelling and potentially clot formation.

When sitting, use a chair with arms and a firm seat. .

Avoid lawn chairs, recliners, lounge chairs, or sofas.

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For knees, your most significant issue is to gain full extension of your knee, a problem made worse

with prolonged sitting. When lying down, try to keep your leg straight, resting with a pillow behind

your ankle. This is an uncomfortable position to place your knee and you will be tempted to place the

pillow behind the knee, rather than your ankle. Your goal is to prevent a flexion contracture (which

means the inability to fully straighten out your knee).

TRAVEL: driving, flying (or both)

Drive car: we suggest that you do not drive a car until six weeks after the operation because your

reflexes are slow (your car insurance company may not cover you in the event of an accident, since

you have not had any special tests to license you for driving in a handicap situation). When riding in a

car to go home, you should stop and stretch about every thirty minutes.

Long distance travel: generally, travel is discouraged in the first 4-8 weeks. For the out-of-state

patients, this may not be possible. When traveling during this time period (and for up to six months

after the surgery), it is recommended that the patient walk for 5-10 minutes each hour of travel. When

being driven in a car (as a passenger), this will require frequent stops. When flying, walking can be

done in the aisle of the plane. Simply standing and stretching may be an acceptable alternative, if

crowding of the aisles is an issue.

Airport security: a frequent question regarding flying pertains to airport security. Yes, the metal in the

prosthetic implants can set off the airport metal detectors. Knees more so than hips. Obviously, the

likelihood will increase the more joints you have had replaced. We can provide you with a card or a

letter, confirming that you have had this surgery. Since neither a card nor a letter constitutes a legal

document, the airport screeners may request you show them your scar.

ACTIVITIES (first few weeks)

There are a few things that you will not be able to do for yourself for two or three weeks. You will

need some help in the morning and evening with dressing and bathing. Be as active as possible when

you return home. The more active you are, within the limitations mentioned, the better you will do.

You should slowly increase what you have been doing in the hospital.

Wear your elastic stockings for the first six weeks after surgery to decrease the swelling of your legs.

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To shave, put on makeup, or wash dishes, you may stand without crutches. Stand with equal weight on

both feet.

Most of these instructions (and restrictions) apply only until your six week check-up. When you get

home, if you find there is something new or different that you have a question about, please contact our

surgical team (919-471-9622). Nurse, physical therapist, or surgeon. It is a good idea to make a list of

any questions you have and ask your surgeon a few days before you go home.

ACTIVITIES (AFTER RECOVERY)

AMBULATION

At some point (usually about 6 weeks after the operation), you may be progressed to walking with a

cane. Do not make this transition until you have been told to do so. You should not quit the use of

your cane until you can walk comfortably without a limp, and that could be another month or so.

Weight bearing may be delayed for patients with previous surgery.

Over the following months, you will continue to gain strength and endurance and your joint will get

stronger. Remember to walk correctly, as discussed in the previous ambulation section. Walk as much

as possible but do not overtire yourself. It is better to take short, frequent walks, rather than one long

walk.

A short walk should be 100 to 400 feet, gradually progressing to 600 to 1200 feet. If the weather

doesn’t allow you to walk outdoors, go to a shopping center or grocery store with long aisles. You

should lie down and rest after your walk, which means you do not want to go too far from home.

INCISION

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Once the incision is fully healed, there are some issues to keep in mind. First, some numbness will

always remain along one or both sides of the incision. This reduced sensation makes kneeling more of

a risk. While I have never seen a problem, there is a theoretical risk with reduced sensation, that

prolonged kneeling could result in pressure sores. The prosthesis is so close to the surface of the skin,

that kneeling is risky anyway, especially when kneeling outdoors where there is a higher risk of a sharp

object to cut or puncture the skin. If a splinter or nail were to penetrate the skin and make contact with

the prosthesis, there would be an obvious risk of infection. We recommend wearing kneepads when

gardening or working on your knees.

LIGHT WORK:

Most people are able to return to light work for limited periods of time at about two to three months

following the operation. Consider starting with a half day of work.

Avoid returning to a full day’s work at a desk job for 8-16 weeks. This will vary by how much

swelling in your legs you are having and by your ability to take frequent ‘walking’ breaks.

Returning to light labor (lifting less than 50 pounds) should be delayed four to six months.

RECREATION:

Sports in general should be non-competitive (play for enjoyment not to win). You may swim

(including limited water aerobics) two to six months after the operation. Golf may not be comfortable

until six months or so after surgery. However you may begin limited use of the driving range after

you are walking without a limp (and do not require a cane). You may ride a bicycle, dance, or

participate in doubles tennis six months to a year following the operation. Competitive singles tennis

is discouraged.

Resumption of sexual activity is a common question. Minimal levels of intimacy can be resumed as

soon as the patient is comfortable. Use common sense and do not play an active role in the first 6

weeks.

Running and other strenuous sports should not be performed at any time. If you are an accomplished

skier, skiing could be considered on beginner slopes. The purpose should be to enjoy the outdoors, not

be to compete and push the technical limits of any sports but to enjoy the outdoors. The closer any

activity approximates simple walking activities, the better for the longevity of your joint replacement.

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This information is intended to help you understand your surgery and your care; it does not replace

talking with our team. Every patient is unique, so your care may differ somewhat from that of other

patients. Differences are expected.

RESULTS AND COMPLICATIONS RESULTS OF SURGERY

Based on our experiences to date, after you have fully recovered, you have a 95% chance of having

what we call a good result. This means you will be able to walk with minimal or no limp, minimal or

no pains, without cane or crutches, as far as you want to walk.

Motion will be sufficient to permit you to sit and stand normally and very likely to put on your socks

and shoes. In other words, you should be able to do most of what you need or want to do. You will not

have a normal joint. The purpose of the operation is not to give you a perfect joint, but one that

functions significantly better and with less pain than your arthritic joint. With common sense, you

should be able to live a reasonably normal life. You should return to see your surgeon at 2-3 weeks, six

weeks, three months, six months and one year after the operation, then every 1-2 years. These annual

visits are important to check for wear of your prosthesis, something we will pick up with x-ray before

you are aware of a problem.

COMPLICATIONS

Complications rarely occur in my practice, but there is always a chance a complication could

occur. I have not seen most of the complications that I am going to go through. The list I will review

includes all complications ever reported in the literature – whether I have personally seen them or not.

Your chances of getting these are exceedingly low.

There are two categories of complications: those that usually occur early in post-operative

period (first 6 months) and complications that usually occur many years after surgery. Early

complications will be discussed first.

EARLY RISKS

The most serious complication from this surgery, as with any major surgical procedure, is death. The

risk is low with joint replacement surgery. While this complication would be more appropriate for the

general medical section that follows, its significance merits discussion FIRST.

Infection:

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Likewise, there is a risk of infection with any surgical procedure. Again, the risk of infection in my

hands is low (<1%). We take many precautions to make infection an unlikely event, including air

circulation, uv lights, body exhaust systems, and antibiotics.

Dislocation:

This complication is rare for both the hip and knee. In regard to the knee, only a few true dislocations

of the prosthetic joint have been reported. Rather than a true dislocation (of the femur and tibia), more

likely, the patellar component (resurfaced knee cap) may slip out of position (dislocate).

Dislocation of the hip (ball coming out of the socket) is more likely to occur, but is also rare (less than

one in a hundred). In almost all cases, I perform an anterior surgical approach to the hip joint.

Although this approach is less commonly used, it is associated with lower dislocation rates.

If this complication should occur, it will immediately be obvious there is a problem – it will

rarely spontaneously reduce. In almost all cases, you will need to go to the (local) emergency room –

usually by ambulance. Usually this problem will not be persistent and the soft tissue will heal and

stabilize the hip with bracing for 4-6 weeks. The need for further surgery is rare.

Leg Length Inequality and Malalignment:

It is not possible to reproduce perfect anatomic leg length and alignment 100% of the time.

Leg length inequality is more often seen with hips and malalignment, with knees. As with

dislocation, leg length inequality (legs different lengths) is rare with an anterior approach.

With modern instrumention, we can achieve 98% accuracy with alignment and leg length. In

extremely rare cases do patients have any noticeable problem.

Scar and Stiffness:

Occasionally formation of bone or scar tissue about the joint, may limit motion. When bone is the

culprit, it is called Heterotopic Ossification.

Rarely do patients with knee stiffness require further treatment. About 5-10% of patient’s knees

require a manipulation under general anesthesia to free up the adhesions. If you do not have 90

degrees of flexion (or bend) by 6-8 weeks, we will consider this outpatient procedure.

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Infrequently thick scar can form that actually ‘catches’ with joint movement. While rare, it most

commonly occurs with scar right above the kneecap and can easily be excised with arthroscopy, if it

does not resolve on its own.

Muscle Weakness:

Performing your surgery often requires cutting through muscle planes. Rarely this is a problem in the

knee, accept in revision (re-do) surgery.

In some hip surgery cases, this may occur, but rarely does this becomes a long term problem. Usually,

with aggressive muscle strengthening programs, all muscle weakness can be restored to an acceptable

level.

Joint Pain Flare-ups:

There are a few causes of painful flare-ups after joint replacement that deserves discussion, such as

sprains, strains, and soft tissue irritation. These conditions are similar to problems seen in the pre-

surgical joint. It is not difficult to twist and injure a normal joint. It is even easier to injure a joint after

replacement surgery (especially in the first two years).

Nerve damage:

Fortunately, this complication is not only rare, but it often resolves over a 6-12 month period.

Prosthetic and Peri-Prosthetic Fractures (Fractures ‘of’ or ‘near’ the joint)

There are a few things that could be considered unbreakable, but this is not the case for bone

and prosthetic joints.

Ingrowth Complications

A problem specific to uncemented or ingrowth total joint replacement is the failure to obtain

ingrowth of the bone into the prosthesis. The failure of this ingrowth can lead to thigh pain, but thigh

pain can also occur with ingrowth of the prosthesis because the difference of stiffness of the prosthesis

compared to the bone in which it is fixed.

LATE (OR LONG TERM) RISKS

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Over time, other things that can go wrong with your replaced joint include loosening of the

components, excessive wear of the plastic liner in the socket. These are usually late complications that

occur in only a small percentage of cases, although additional surgery may be required for their

correction. Loosening of the prosthetic implants from the bone is the major long-term problem of joint

replacement.

With modern prostheses and proper technique, the rate of loosening should be less than 5% at ten years

(see results discussed previously). As with component loosening, wear of plastic may be a serious

problem requiring re-operation at ten or more years.

General Medical Complications

Total joint arthroplasty is major surgery, which can affect almost any organ in the body including the

lungs, heart, vascular system, neurological system, gastrointestinal, and genitourinary systems. While

these complications can result in severe illness or death, these outcomes are rare.

Exacerbation of known medical complications is not unusual. To name a few, conditions such as

diabetes, heart conditions (ischemia), pulmonary conditions (emphysema), skin conditions (psoriasis),

gastrointestinal disorders (inflammatory bowel disease), gout, sickle-cell anemia, vascular disease

(including risk for stroke) and glaucoma, can all be aggravated by the stress of the surgery.

One of the more common complications is venous thrombosis, or clots forming in the veins of the

lower limbs. This complication becomes more severe if these clots dislodge and go to the lung causing

a pulmonary embolism. We have studied and contributed to the literature regarding this problem. In

addition to avoiding long periods of sitting, we have strong data to support our use of compression

boots, regional anesthesia and Duplex scanning prior to discharge.

Other pulmonary problems include Fat Embolism, pneumonia and atelectasis (areas of lung collapse).

You must understand that even with all the precautions taken by me and my team to avoid these

complications, the risks of these complications, although very small, cannot be avoided.

With positive thinking, the better your joint will move, the stronger you will be, and the more

comfortable it will be. You have reason for positive thinking because the chances that anything will go

wrong are extremely low. The chances are very high that you will get a very good result.

CALL US If there is any suspicion that you are experiencing one of the complications discussed after

your discharge from the hospital, please call our office (919-479-7952) rather than waiting for your

next appointment. After hours, you can contact us through our answering service at the hospital (919-

470-4442).

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INFECTION PREVENTION (American Dental Association)

At this time, we recommend that joint-arthroplasty patients receive an antibiotic before any dental

procedure (i.e. filled, capped or removed) during the first 2 years after surgery (when you are most at

risk for an infection in your prosthetic joint). It is no longer recommended by our national

organizations that you take antibiotics for routine cleaning.

The prescription for the medication should be written by your dentist. We recommend 2 grams of

Amoxicillin one hour prior to dental work. If you are allergic to penicillin, then take clindamycin (600

mg one hour prior to dental work) instead.

Please see your primary care physician if you develop symptoms of

infection in other body organs (i.e. bladder, gastrointestinal, pulmonary) for immediate treatment of

the infections. If you are contemplating other (non-orthopaedic) surgery, particularly abdominal and

urologic, then an antibiotic before the procedure is also suggested. Alert your surgeon regarding your

prosthetic joint. If sores, insect bites or ulcerations develop on your lower legs or feet, contact your

medical doctor immediately. Infection can spread by the bloodstream and then to your replaced joint

(resulting in additional surgeries).

Recommended antibiotics for prevention of an infection of a prosthetic joint are the same as those for a

prosthetic heart valve. Most doctors are more familiar with preventive antibiotics for heart valves, so

if there is any question always ask.

CLOT PREVENTION

One of the more common complications is venous thrombosis, or clots forming in the veins of the

lower limbs. This complication becomes more severe if these clots dislodge and go to the lung causing

a pulmonary embolism. We have studied and contributed to the literature regarding this problem. We

have strong data to support our use of compression boots, regional anesthesia and Duplex scanning

prior to discharge.

Spinal &/or Epidural Anesthesia:

This type of anesthesia lowers your risk of clots significantly. We avoid blood thinners, because they

make it risky to use this type of anesthesia.

Compression boots (pneumatic boots) –

These keep the blood flowing through your veins and reduce clots.

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TED Hose Compression stockings:

These keep blood from pooling in your lower legs and veins. It is important to try to wear these for 4-

6 weeks after the surgery, full time (except for bathing). Some patients are not able to find a size that

comfortably fits their leg and refuse to wear the TED hose. Except in rare instances, discontinuing the

TED hose is not a good decision.

Avoiding prolonged sitting:

Sitting kinks veins, slowing return of the blood to the heart and increase risk of swelling and

potentially clot formation. It is recommended that sitting be limited to 3 hours a day and the remainder

either walking or laying flat (on bed, couch or floor). Lazyboy type recliners are considered sitting and

not a substitute for lying down.

Low dose coated aspirin (baby ecotrin, 81mg):

This medication reduces the stickiness of your blood and subsequently reduces clot formation.

Duplex Scan:

This check to see if you are starting to develop a clot. We make sure you don’t have any clots before

you leave the hospital

Blood thinners:

About 7% of our patients show changes consistent with early clot formation. We reserve treatment

with blood thinners for this small group of patients. Blood thinners have many side effects, especially

the first 3-4 days after surgery. We try to avoid them, unless your Doppler studies are abnormal.

REOPERATION (REVISION SURGERY)

This section is mostly written for those of you that have sought out or been referred to me for revision

surgery of a previously replaced joint. As mentioned earlier, it is sometimes necessary to replace the

artificial parts if they fail to function properly. The procedure is generally similar to the original

operation, but there are a few differences.

The operation involves taking the joint apart and removing the artificial parts. At this point, your

surgeon has to decide whether or not it is feasible to insert new parts. This depends in large part on

how much bone has been destroyed in the loosening process. It is usually possible to insert new parts.

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Often in Revision Hip surgery, we need to improve our surgical exposure by making longer incisions

and performing a trochanteric osteotomy.

A trochanteric osteotomy involves cutting through the bone of the greater trochanter, keeping the

abductor muscle attachment. This allows us to enlarge our exposure without damaging muscle. When

we are finished, the trochanter is wired back down into place with 2 to 4 wires. These wires are strong

enough to hold the trochanter down while it heals back into place. By the time the wires break, they

have done their job. Usually they stay in place without irritating the surrounding tissues, but in about

5% of the cases, may be removed with a simple outpatient procedure.

Another option in special circumstances is the use of bone grafts. Grafts provide immediate bony

support and encourage further development of bone in situations where a large amount of bone had

been destroyed. This may be your own bone or bone obtained from a bone bank. We will discuss this

with you in greater detail if we think it might apply in your case.

If adequate bone remains or can be provided, a new joint is inserted. This is a much more extensive

operation than the original procedure. You will be in the hospital about four days after the operation

and the remainder of the postoperative course is very similar to the original operation.

In many cases, you will be placed in a brace postoperatively for approximately 4-6 weeks. For the hip,

this brace will go around your waist and another around your leg – the two attached together with a

hinge.

All of the complications mentioned for the original operation apply to a re-operation. The results of a

re-operation are similar to the original operation; however, because the operation is much more

extensive and because a certain amount of bone may have been lost, the risks are somewhat higher and

the results somewhat worse than if the operation was being done for the first time.

MEDICAL MANAGEMENT

The role of your private physician

(Family physician or internal medicine physician):

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Please inform your private physician’s office of your plans for surgery (including dates). Should a

serious condition arise (such as severe chest pain, joint pain, fever, chills, symptoms of infection,

difficulty breathing, dizziness, confusion, vision or hearing disturbance, anything that seems unusual to

you) it will be in your best interest to immediately go to your nearest emergency room and have both

your medical physician and our office alerted on your arrival. Do not take chances and delay going to

the emergency room in order to talk to our office first.

Pain medications:

Your Orthopaedic Team will manage your post-operative pain medications for the first 2-3 months. It

is unlikely that you will require pain medications beyond that point.

Other medications:

In situations where your hospitalization for joint surgery results in your being placed on blood thinners,

(toxic) antibiotics, or new medications that you have not been on before, it is good medical practice for

only one physician to be adjusting medications and doses. Medical physicians are more qualified than

Orthopaedic Surgeons, to oversee medical management.

Problems with your operative leg (wound problems and swelling):

Swelling of either leg, after your surgery, is a concern. It is normal to have increased swelling

beginning the first few days after surgery. It is not normal to have new swelling. If either of your legs

develops new swelling after your discharge, you will need to obtain a repeat Duplex scan. This should

be performed at the nearest facility available (notify your primary care physician and our team).

Problems localized to the surgical wound

(such as separation of the wound edges, drainage, increased redness, swelling or pain), should be seen

by our team (ideally within 24 hours). Please call our office to arrange for your surgical wound to be

seen.

Summary of medical management after discharge:

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While your Orthopaedic Team wants to be kept informed about all changes in your condition,

especially during the first 2-3 months after the surgery, it will often be in your best interest to contact

your local medical physician for non-orthopaedic issues (i.e. head, chest, abdominal, and appetite

issues) and in some cases to proceed directly to the nearest emergency room to evaluate obvious

serious problems.

EXERCISES

There are thousands of potential exercises that could be recommended – however since there are

limited hours in a day and limited attention spans – we recommend that patients focus on those

exercise which will help the most. Better, overemphasize a good to excellent exercise than to try to

teach multiple fair to good exercises.

The above argument is made with the assumption that the exercises will be performed correctly. Doing

exercises incorrectly can be worse than no exercise. The more exercises a patient is asked to do, the

higher the chance an exercise will be performed incorrectly. It is far easier to learn 1-2 exercises –

learn them correctly.

For the reasons above, when patients feel they are progressing poorly, it is better to simplify the

exercise routine and focus on the exercises that will help the most. From our standpoint, there are

three categories of exercises: Gait, Hip and Knee. We will demonstrate Normal Gait and gait with a

walker, crutches and cane. For the hip, we will demonstrate abductor strengthening and jumping jacks.

For the knee, we will demonstrate range of motion and strengthening exercises.

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