Category Archives: Knee

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.

Should There Be Strict BMI Cutoffs for TKA and THA?

happy senior couple hiking on the mountainDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

Recently we posted a blog about candidacy for and outcomes of Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) in morbidly obese patients who underwent pre-operative weight loss. Operating on obese patients for TKA and THA continues to be a hot button topic of risk versus reward in surgical outcomes.

Two well-respected orthopedic authorities, recently faced off to have a deeper conversation about whether or not orthopedic surgeons should have strict BMI cutoffs for performing primary TKA or THA. Benjamin F. Ricciardi, MD engaged Thomas K. Fehring, MD, from OrthoCarolina and Nicholas Giori, MD and PhD, a Stanford University professor, to face off. Highlights are summarized below.

Q: To what degree does the evidence support a strict BMI cutoff to determine eligibility for primary TKA and THA?

Dr. Fehring noted many Americans (35%) are obese and the association between patients with a BMI above 40 and surgical complications/infection is irrefutable. He recommends looking at big data such as Medicare or Veterans Affairs, meta-analysis, and position statements by specialty medical societies. All findings to date underscore the need to have a strict cutoff, but Dr. Fehring noted it’s important to develop weight loss strategies for patients prior to arthroplasty. 

Dr. Giori agreed that obesity is undeniably related to complications, but BMI is a weak risk factor compared to others that are commonly accepted (such as heart and metabolic disorders).

Q: Given the expansion of strict BMI cutoffs at the administrative level, how should safety (non-maleficence) be balanced against access to care?

Dr. Giori said that while BMI cutoffs are well-intended, the ones currently used have the effect of arbitrarily rationing care without medical justification. Also, he feels it disproportionately affects minorities, women and patients in low socio-economic classes. In his opinion, the decision should be based on joint decision making between the doctor and the patient. Risk adjustments in payment models (for doctors’ compensation) would help in the future.

Dr. Fehring agreed with many of the points, but at a certain point the risk outweighs the benefit, and attempting to operate on all patients regardless of BMI becomes dangerous. Keeping his “do no harm” obligation in mind, Dr. Fehring stated a BMI cutoff of 40 as a reasonable goal for patient safety.

Q: If a patient with morbid obesity is to undergo arthroplasty, what steps should be taken before surgery to make hip or knee arthroplasty safer?

Dr. Fehring recommended the patient be in the best possible health they can be prior to elective surgery to avoid complications. An optimization program, factoring in body weight, blood glucose control, serum albumin, and smoking status are part of his clinic’s protocol; patients get tools to meet and stick to set goals before getting surgery. It’s not just about treating the knee or hip; it’s about treating the whole patient as well, he said.

Dr. Giori recognized that optimization programs can help and his clinic also offers one, but the best that can be done regarding obesity is encouragement and education, and referring the patient to a structured weight-reduction program. On the flipside, the patient should do his or her best to lose weight to get below a given BMI threshold. From there, doctor and patient can create a shared decision-making plan that may or may not involve surgery.

If you’d like to discuss weight concerns prior to your total knee or hip replacement surgery, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Can Weight Loss Before Total Knee Arthroplasty Help?

Senior man having medical exam.When obese patients undergo total knee arthroplasty (TKA), many surgeons require or request preoperative weight loss. A group of researchers sought to determine the amount of weight loss needed in this patient population, to improve TKA operative time, length of stay, discharge to a rehab facility, and functional improvement after surgery. This is the first known study to look exclusively at obese patients to understand how preoperative weight loss might improve knee surgical outcomes after TKA.

Those considered morbidly obese have a body mass index (BMI) of 40 or higher. This study looked at 203 patients with a BMI of 40 or more. They were evaluated 90 days before their TKA, and again immediately preceding TKA, to assess weight loss. Of those who lost weight preoperatively, 41% had lost five or more pounds, 29% lost 10 or more pounds, and 14% lost 20 or more pounds.

Losing 10 or less pounds before surgery made no difference in operative time, length of stay, the need for discharge to a rehab facility, or post-operative functional improvement. However, the preoperative loss of 20 pounds or more showed benefits: It lowered the odds of discharge to a rehab facility, and was associated with a shortened length of stay. There were, however, no significant differences in surgery times or functional improvements for those who lost 20-plus pounds.

A longer stay in the hospital or discharge to a rehab facility is a driver of higher costs in primary total knee arthroplasty. Preoperative weight loss may reduce overall costs. The need for Discharge to a rehab facility is also correlated with an increased rate of post-operative infection. In the future, this study could help surgeons target a specific level of weight loss prior to TKA, for their patients to improve knee surgical outcomes.

If you’d like to discuss obesity or weight concerns prior to your total knee arthroplasty, or just want to learn more about the knee replacement procedure, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in total and partial knee arthroplasty, exercise and health, and more.

After One Joint Wears Out, Will More Go?

Hip, back and spinal problems in young ages.Here’s a question I’m often asked by patients: “If one of my joints has worn out, how likely are the others to go?” A recent publication from the Osteoarthritis Initiative (OAI) lends some insights into this question. The study, found in the Aug. 12, 2019 issue of Clinical Orthopaedics and Related Research, is the first of its kind. The likelihood of undergoing a 2nd Arthroplasty (Joint replacement) after hip or knee replacement had not previously been evaluated.

The authors prospectively asked two questions: “What is the likelihood of second Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA) after primary TKA or THA?” and “What risk factors are associated with undergoing addition joint replacement. The study identified 332 patients who underwent primary TKA and another 132 who underwent THA across five OAI-participating centers in the U.S., who hadn’t previously had a THA or TKA. The patients were followed for 8 years after their primary joint replacement.

  • The incidence of contralateral (opposite Knee) TKA after primary TKA was 40%
  • The incidence of THA after any TKA was 13%
  • The incidence of contralateral (opposite) THA after primary THA was 8%
  • The incidence of any TKA after primary THA was 32%

As for the second question in the study: Risk factors for undergoing contralateral TKA were younger age and a loss of medial joint space with a varus angulation, or bow leg deformity.

The conclusion is clear: Patients who underwent TKA or THA for osteoarthritis had a relatively high rate of subsequent joint arthroplasty. There’s no question that osteoarthritis is common and debilitating, and often it affects more than one large, weight-bearing joint.

If you need a joint replacement or want to learn more about the procedure, hip or knee replacement surgical outcomes, recovery and quality-of-life prognosis, please contact our office. We’ll help you return to your healthy, pain-free lifestyle. Dr. Stickney, a Kirkland orthopedic surgeon, is a knee and hip expert specializing in joint replacement surgery.