All posts by Dr. Stickney

Return to driving after lower extremity orthopedic procedures

There are a number of components going into the decision as to when it safe to return to driving.  First of all, whether your procedure involves your driving leg, and whether or not you have an automatic or a manual transmission.  In addition to the functional ability to break in time there is also the concern of medication effect on reaction time.  We would never recommend returning to driving while taking narcotics.  Beyond the narcotics question the other issues are how quickly you can move your foot from the gas to the brake and then how forcefully you can press the brake.  Studies have shown that the force of depressing the brake pedal is probably the most important factor in returning to safe driving.  In general, my advice is to sit in the driveway and pretend a child just ran out into the street in front of you If you can quickly get from the gas to the brake and slam it on hard you are probably ready to drive that said there have been a number of studies looking at this question.  On average it is safe to return to driving 4 weeks after a right knee replacement and 2 weeks after a left knee replacement.  In general patients can return to driving after a right hip replacement a week or 2 earlier than a right knee replacement.  Operative repair of an ankle fracture or Achilles tendon repair often results in 6 to 9 weeks postoperatively with inability to drive.  Typically, you want to wait at least 2 weeks after coming out of a cast before driving.  ACL reconstruction is similar to a knee replacement; it oftentimes takes 4 to 6 weeks after surgery for a right knee ACL reconstruction.

There are many other factors that play a role in safe returning to driving after an orthopedic surgery.  For example, medication side effects and preoperative function.  If he were slow to push the brake preoperatively, it will take that much longer to recover postoperatively. Please sit in the driveway and slam the break a few times to assess how competently you can break before you try driving.

Radio Frequency Ablation vs. Hyaluronic Acid

Radio frequency ablation compared with a single injection of hyaluronic acid for chronic knee pain. Reported in the Journal of Bone and Joint Surgery September 2020

There are many potential approaches to alleviating the pain associated with osteoarthritis. The most common approach is suppressing the inflammatory response to cartilage breakdown. This would include icing, oral anti-inflammatory medication, Injectable anti-inflammatory medication like steroids.

Activity modification, weight loss, and physical therapy can also mitigate some of the symptoms of arthritis.

Injection of platelet rich plasma which provides growth factors for cartilage regeneration has been shown to be effective in early arthritis theoretically improving or repairing the cartilage through the delivery of growth factors.

There are also injectable medications that rehydrate the remaining cartilage in an arthritic joint, and lubricate the joint, by incorporating into the articular cartilage. Examples of this would be Synvisc or Euflexxa. (  hyaluronic acid ).

Another approach is simply to try to suppress the pain and stay active despite the arthritis. Examples of this would be Tylenol, Narcotics, or nerve ablation. Nerve ablation is an attempt at decreasing the nerve stimulation Signal coming from the arthritic joint to the brain. Prior studies of radio frequency ablation have demonstrated 6 to 12 months of relieving knee arthritis pain.

The final option is joint replacement which is removing the worn out cartilage and bone spurs, thus eliminating the source of ongoing inflammation and pain in the knee or hip. Joint replacement is a resurfacing of the joint with metal and plastic creating a new weight bearing surface. This new metal cap over the end of the bones ( Joint replacement ) shields the underlying nerves in the bone from stimulation and therefore relieves the pain associated with arthritic wear. This is a permanent solution but a very difficult surgical recovery, Associated with it.

In this randomized perspective trial of 260 subjects. The patients were either given intra-articular injection with hyaluronic acid or underwent nerve ablation. They were comparable and randomly assigned to the treatment option. They were followed at one months three months and six months after the procedure. Consistently the group with radio frequency ablation did better in terms of pain and function. At six months follow up the group with radio frequency ablation still had 48% improvement while the hyaluronic acid group had 22% improvement. The results also demonstrated a much more significant improvement in pain and function in patients with early-stage arthritis versus in stage bone on bone arthritis.

In conclusion radio frequency ablation of the sensory nerves around the knee is a viable alternative with better functional outcome compared to hyaluronic acid injection.

 

What to Expect After a Meniscectomy

Injury knee painDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

When it comes to meniscal injuries, many patients have little knowledge about the types of treatment options available and their outcomes.  The meniscus, a significant cushion or shock absorber in your knee, is a c-shaped disc of soft cartilage that sits between the femur and the tibia.  When the knee meniscus tears, the cushioning effect diminishes and can cause knee pain and arthritis, eventually requiring treatment. One option is a meniscectomy, a surgical removal of all or part of a torn knee meniscus. A survey conducted by Brophy et al of 253 patients evaluated for meniscal pathology found 62 percent rated their knowledge of the meniscus as “little or none,” and another 28 percent had no idea that meniscectomy procedure–and not a meniscal repair–is the most common surgical treatment for surgical repair. Did you know that?

Since many meniscal tears can require surgical intervention, there’s a clear need to educate patients on options and postoperative considerations: overall outcomes, the risk of needing a subsequent surgery, the ability to return to sport (RTS), the postoperative risk of developing osteoarthritis (OA), the risk of progression to total knee arthroscopy (TKA). Meniscus tear can also affect knee stability, particularly when combined with an anterior cruciate ligament (ACL) injury. A group of doctors at the University of Colorado School of Medicine in Aurora reviewed the current literature on postoperative considerations to help orthopedic surgeons educate their patients on post-meniscectomy expectations.

The review found:

  • Successful return to sport after meniscus surgery was more likely with these circumstances: patients of a younger age, medial meniscectomy and a smaller meniscal resection. The amount of meniscus resected is a function of the size of the tear. All these factors affect the time until patients are able to return to sport.
  • Failure rates after meniscectomy are low when compared to meniscal repair and discoid saucerization procedures. Meniscus repair is done rarely for a large tear, most often in conjunction with ACL reconstruction. The majority of the meniscus has no blood supply and will not heal, so the majority of meniscus surgery involves removing the torn tissue and smoothing the remaining meniscus. Failure rates are increased in patients undergoing lateral meniscectomy.
  • Improved clinical outcomes for non-obese males can be expected in those undergoing medial meniscectomy with minimal meniscal resection. Conversely, if a preexisting angular deformity exists, varus or valgus, which results in an imbalanced load across the knee, the success rate is less predictable. Preexisting degenerative knee changes (damage to the articular cartilage attached to the bones), and anterior cruciate ligament (ACL) deficiency will negatively impact outcomes following a meniscectomy.
  • The risk of developing post-surgical osteoarthritis over the next 10-20 years should be discussed. Meniscectomy increases the risk of developing knee osteoarthritis, particularly in obese females who undergo a large meniscal resection. The development of arthritis after meniscectomy may lead to the need for knee replacement. However, leaving a mobile large meniscus tear clicking around in the knee will more likely result in early arthritis.
  • Meniscectomy is a viable and successful intervention for pain relief and functional improvement for symptomatic meniscal tears, but nonsurgical care should be used first in older patients with preexisting degenerative changes. These patients will likely end up with knee replacement, and an arthroscopic meniscectomy may be an unnecessary step along that path.

If you would like to learn more about meniscal injuries or understand post-surgical outcomes related to meniscectomy, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Diabetes and the Heightened Risk of Periprosthetic Joint Infection

Diabetes woman ready for morning run along the coastDr. Stickney, a Kirkland orthopedic surgeon, is an expert in joint replacementsports medicine, and more.

Diabetes is prevalent not just in the U.S., it affects millions of people worldwide and is one of the leading causes of disability. Its direct effects on postoperative care can impact both the patient and an already strained healthcare system. In the world of orthopedic surgery specifically, little has been documented about a diabetic patient’s incidence of infection after undergoing total knee or total hip arthroplasty.

A recent investigation by researchers at the University of Utah looked at data of type-1 and type-2 diabetes mellitus patients and the incidence of periprosthetic joint infection. By looking at historical, statewide data of more than 75,000 patients undergoing knee or hip arthroplasty between 1996 and 2013, researchers were able to identify 1,668 patients with type-1 diabetes and another 18,186 patients with type-2 diabetes, providing a strong sample size. The researchers hypothesized that arthroplasty patients with type-1 diabetes were at greater risk for infection than those with type-2 diabetes.

While age and sex were found to be insignificant factors contributing to infection rates, the study did find that the frequency of periprosthetic joint infection in non-diabetic patients was 2.6% compared with 4.3% infection rates across all diabetic patients. Looking more specifically at the differences in infection rates between the two types of diabetes, patients with type-1 diabetes were at a 1.8 times greater rate of infection than patients with type-2 diabetes (7% compared to 4%, respectively).

Diabetes-related complications indicated a greater risk of periprosthetic joint infection; these include peripheral circulatory disorders, ketoacidosis, neurological manifestations, renal manifestations, or ophthalmic manifestations, hyperosmolarity (common in type-2 diabetes, where the body tries to rid itself of excess blood sugar via urination), and coma. The odds of infection increased with each added complication, and diabetes patients with more than four of these complications put them at nine times more risk. Weight also plays a role; overweight and obese type-2 diabetes patients, as well as underweight type-1 diabetes patients were also at greater risk for periprosthetic joint infection when compared with the general population.

Findings suggest it may be important to look at the length of time patients have had diabetes, factor in a patient’s diabetes type, and understand a patient’s number of diabetes-related complications prior to any joint replacement surgery. This information can help patients to make a more informed decision and help healthcare providers better manage risk.

If you have chronic health conditions and would like to learn more about how to avoid post-surgical complications related to TKA or THA, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Chronic Prescription Opioid Use Before and After Total Joint Arthroplasty: Overall Promising News

Knee injuriesDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

An April 2019 study in the Journal of Arthroplasty explored the chronic prescription opioid use of patients under the age of 65 before and after having total knee arthroplasty or total hip arthroplasty. Looking at three years of MarketScan data between 2009 and 2012, patient opioid use was measured three months before and 12 months after their respective surgeries. With a large sample of more than 125,000 patients, a multicenter scope, and inclusion of both TKA and THA patients, the study lays out a strong and promising snapshot.

The goal of total joint arthroplasty is to reduce or eliminate the painful symptoms of a degenerative joint disease. Due to the addictive property of opioid medications, some patients may develop a pattern of chronic use after surgery. Others can develop chronic opioid use in managing their pain prior to surgery. “Chronic” was defined in the analysis as having two or more opioid prescriptions filled within a six-week period. 

Of the 24,127 patients (under 65) who were chronic opioid users before surgery, 72% were no longer chronic users 12 months post- op. Of the 100,892 patients under 65 who were nonusers before their surgeries, 4% became chronic opioid users one year post-op.  Patients under age 56 who had TKA or THA were 25% more likely to become chronic opioid users compared to those aged 56-65; and procedurally speaking, those undergoing TKA were 60% more likely to become chronic users than those undergoing THA. The length of hospital stay exceeding three days showed 32% higher odds associated with becoming a chronic opioid user. Being male or female did not significantly factor into the odds of chronic opioid use.

Patients who had TKA and hospital stays more than 3 days were significant risk factors of persisting chronic opioid use after surgery; age played a mixed use in predicting the change of opioid use.

With the authors’ definition of chronic opioid use in mind, the overall chronic opioid use decreased from 19% to 9% after total knee or total hip arthroplasty. Patients were more likely to cease chronic use after TJA (72%) than to become chronic users (4%).

My joint replacement patients seek options that reduce pain, reduce the need for narcotics and speed recovery more than ever. It’s common for patients with even the most debilitating arthritis to fear joint replacement, mostly dreading the pain of the surgery, complications around opioid use and fear or being out of commission after surgery. With the appropriate treatments, we can address your degenerative joint conditions while avoiding the pitfalls of chronic opioid use and on the path to an optimal recovery. If you have any questions about pain management before, during or after TKA or THA, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Hamstring Injuries

Young women sport has thigh muscles injury ,Health conceptDr. Stickney, a Kirkland orthopedic surgeon, is an expert in sports medicinehamstring injuriesexercise and health, and more.

Hamstring injuries are a common, and often frustratingly persistent, source of limitation for both elite athletes and weekend warriors. These injuries can involve either the muscle belly or the tendinous attachment of the muscle to bone. The hamstring is one of the longest muscle bellies in the body as it stretches from the pelvis to the tibia spanning the hip and the knee. Hamstring tears, knee muscle tears and related injuries make up nearly 30% of all lower extremity muscle tendon injuries. These injuries are commonly sustained while running particularly with running uphill. They are very common in soccer, football and all sports associated with acceleration or kicking. Hamstring injuries also are common in weightlifting, skating, or water-skiing. This can be the result of a rapid uncontrolled Hip Flexion with knee extension. If the injury is associated with a loud pop that often signifies a tendon avulsion. In that case, the tendon has pulled off of bone. On the other hand, if there is acute muscular tearing pain followed by bruising and a palpable defect in the muscle, this typically signifies an intermuscular tear. Injuries that do not adequately heal or get adequate therapy can result in scar tissue which is prone to reinjure.  Hamstring injuries have a very high rate of recurrence as a result.

    The hamstring muscles in the posterior thigh, as well as the quadriceps muscle in the anterior thigh, work in concert during running jumping, acceleration, and deceleration. A muscular balance between these 2 muscles as well as flexibility of both muscles is crucial to preventing injuries. Core muscle development and hip muscle strengthening can also help prevent hamstring injuries. Hamstring injuries more commonly occur during eccentric contraction. Eccentric contraction means the muscle is firing but at the same time it is lengthening. During running the quadriceps extends the knee as your foot reaches forward near the end of that extension the hamstring slows down the extension while the foot is still moving forward just before impact. This is an eccentric contraction of the hamstring and this is the phase of running most commonly associated with hamstring injuries. These are typically intermuscular injuries. These commonly lead to bleeding into the muscle and then the development of scar tissue in the muscle which is less flexible than muscle, and more vulnerable to tearing in the future. As a result, an athlete with a hamstring injury has a 25% rate of recurrence of hamstring injury in the following season despite rehabilitation.

     A very good study was done in professional soccer players to try and prevent initial hamstring injuries and to prevent recurrence of hamstring injuries. The results of that study is the Nordic hamstring exercise protocol. In professional athletes, this protocol led to an 80% reduction in primary hamstring injuries and a 65% reduction in recurrent injuries. The Nordic protocol is a progressive strengthening of the hamstrings through eccentric loading. This protocol is best visualized on a YouTube video.

     Once a hamstring injury occurs it is very important to establish whether or not the tendon has pulled off bone or if it is an intermuscular injury. If the tendon has pulled off bone it is important to repair it in the early period after injury. On the other hand, most intermuscular injuries require rest, elevation, icing, compression (RICE) and then range of motion with deep massage. There have been a few studies to suggest that injection of platelet rich plasma with growth factors can enhance healing.  And some other studies suggested injection of steroids may decrease the likelihood of developing scar tissue. The time to recovery is largely dependent on the location and extent of injury. Most minor hamstring injuries can be treated with physical therapy and return to sport in approximately 6-12 weeks. It is very important to regain full flexibility and equal strength before returning to competitive sports to prevent future recurrent injuries.