Study: Surgeons Show Little Bias in Recommending Knee Replacement

Knee arthritis and knee pain are extraordinarily common. Nowadays there are a tremendous number of treatment options to help alleviate the pain that might otherwise slow you down. There are many injection options: steroid (cortisone), PRP (platelet rich plasma), and HA (hyaluronic acid viscosupplementation). There are many oral medications. And even more kinds of braces. The final stop is a knee replacement. And even this option comes in different flavors (partial, total, and other nuances).

Most patients who undergo TKA (knee replacement) experience reduced knee pain and regain function. The procedure entails a surgeon removing damaged bone and cartilage from the thigh bone, shin bone and kneecap; and implanting an artificial joint made of metal, plastic or polymers. The prosthetics are available in a range of designs for patients with differing ages, weights, activity levels and general health.

The surgery is an effective method of repairing joint damage caused by osteoarthritis or rheumatoid arthritis. Many patients are able to relieve their symptoms by taking anti-inflammatory medications, receiving physical therapy and altering their activities. However, some continue to have trouble walking, climbing stairs and getting up from chairs. They experience knee pain even while inactive. TKA (knee arthroplasty) is frequently advised for such patients.

Although arthritis does seem to demonstrate some degree of genetic predisposition, research has failed to reveal significant differences in how often orthopedic surgeons recommend total knee arthroplasty (knee replacement) for patients of varying races and genders.

More than 100 surgeons conducted a study in 2012 while attending meetings of the New York State Society of Orthopaedic Surgeons, and the American Association of Hip and Knee Surgeons. They sought to challenge previous research that seemed to insinuate that orthopedists are sometimes biased in recommending TKA (total knee arthroplasty) for men over women, and whites over blacks.

The doctors wrote that they “developed four computerized scenarios for all combinations of race (white or black) and sex (male or female) for otherwise similar patients with end-stage knee osteoarthritis.” All the patients had experienced increasing knee pain, and a gradual loss of function in the joint, for at least two years. Anti-inflammatory drugs and corticosteroid intra-articular injections had failed to relieve their symptoms.

All the surgeons reviewed the medical history of a white man, and some were also asked to look at the cases of a white woman, a black woman and a black man. The doctors then decided which patients warranted TKA.

The result was “a 15 percent difference in the likelihood of recommending surgery for white versus nonwhite patients,” the research team concluded. Thirty-nine surgeons reviewed the white male and black female cases. Thirty-three (85 percent) of them said both patients needed the surgery. Six of the orthopedists recommended TKA for just one of the people, though “no effect of patient race and sex” reportedly was involved; ie, they recommended surgery for the black female and not for the white male or vice versa.

“Of the 37 surgeons who viewed the white male plus black male scenario, there were 33 (89 percent) concordant responses and four discordant responses, with no effect of patient race,” the researchers wrote. “Of the 37 surgeons who viewed the white male plus white female scenario, there were 30 (77 percent) concordant responses and seven discordant responses, with no effect of patient sex.”

Following the trials, the surgeons declared that “patient race and sex were not associated with a different likelihood of a surgical recommendation.”

They added: “Our findings support the notion that patient race and sex may be less influential on decision making when there are strong clinical data to support a decision. Physician bias may have a greater effect on decision making in situations where the indications for surgery are less clear.”

Often times studies done that make treatment recommendations that differ based on a patient’s gender or race have results that are shrouded in doubt secondary to associated socioeconomic differences and obesity differences that are inextricably tied with body mass index (obesity) and other confounders.

If you have been told you have knee arthritis or suffer from knee pain, contact our renowned sports medicine providers at Orthopedic Surgery San Diego.

Carpal tunnel syndrome is a painful condition characterized by wrist pain, numb fingers and tingling fingers. A procedure called open carpal tunnel release usually relieves the symptoms, and restores function in the wrist and hand, if conservative measures do not provide adequate relief.

The primary signs of carpal tunnel syndrome are numbness and tingling, which is a “pins and needles” sensation, in the fingers. The pain and lack of feeling often are more intense at night, which can make it difficult to sleep; this is called “night pain”. Patients also report burning or tingling of the thumb, index finger and middle fingers. Pain can radiate into the forearm and elbow. Hand weakness is another symptom.
Women are more susceptible than men, and there is a disproportionate number of cases involving the elderly. Experts believe “medical conditions (such as) diabetes, rheumatoid arthritis and thyroid gland imbalance can play a role,” according to the American Academy of Orthopaedic Surgeons. In most cases, multiple causes are responsible.

The syndrome is a progressive condition (ie, symptoms get more severe over time) unless a patient receives treatment. In some cases, when therapy begins early, the pain and loss of function can be reduced or eliminated. Some people find that altering their activities, perhaps even changing jobs, relieves their suffering.

Patients are often advised to wear a wrist brace or splint at night and during certain activities, to limit pressure on the median nerve. Among other nonsurgical treatments are anti-inflammatory, rehabilitation (physical therapy or acupuncture), and injections of corticosteroids.

When these methods are ineffective, surgical “open release” might be warranted. The procedure entails cutting the carpal ligament to give the nerve and tendons more space, so the nerve is not irritated. This is typically an outpatient operation, in which patients receive local anesthesia.

“Significant improvements” have been reported for “the general population, regardless of age, medical (conditions) or workers’ compensation status,” according to a paper drafted by the Department of Orthopaedic Surgery at the University of Minnesota in Minneapolis and the TRIA Orthopaedic Center in Bloomington, Minn.

The paper, “Outcomes Protocol for Carpal Tunnel Release: A Comparison of Outcomes in Patients With and Without Medical Comorbidities,” was published online in the Journal of Hand Surgery in September.

The researchers analyzed the outcomes of 950 open carpal tunnel procedures involving 826 patients (between the ages of 21 and 100 years of age) at an orthopedic surgery center. They compiled symptom and function assessments reported by the patients, who filled out questionnaires two, six and 12 weeks following surgery.

“Patients demonstrated a significant improvement in symptom severity scores at two weeks and functional severity scores at six weeks,” the report concluded. “Documented patient medical (conditions) did not affect improvement after surgery. Patients with diabetes improved more slowly, but were not significantly different at six weeks. Patients with workers’ compensation insurance were significantly worse at baseline, two weeks and six weeks, but were not significantly different at three months. The risk of negative postoperative endpoints was slightly higher in patients with a medical (condition), though not statistically different.”

The syndrome, a common condition, occurs when synovium tissues around the flexor tendons in the wrist become swollen. That puts excess pressure on the median nerve, which passes through the carpal tunnel. Synovium lubricates tendons that make it possible to flex the fingers.

Researchers have determined that heredity is the primary risk factor for the syndrome. People with small carpal tunnels, due to their genetics, are more vulnerable. Those who overuse their hands by taking part in repetitive-motion activities, and pregnant women experiencing hormonal changes, also are more likely to develop the condition.

The carpal tunnel is a narrow passageway in the wrist, with carpal bones on the sides and the bottom. The transverse carpal ligament is found on the top of the tunnel. The median nerve, which connects the hand and forearm, makes it possible to have feeling on the inner side of all the hand’s digits other than the little finger. The nerve is also essential for muscle function at the base of the thumb. Flexor tendons, also found within the tunnel, allow bending of the thumb and fingers. The carpal tunnel provides a protective space for the median nerve and flexor tendons.

Some patients experience recurrences of the syndrome, requiring further surgery.

If you have wrist pain or finger number and tingling, contact our orthopedic experts for evaluation today at Orthopedic Surgery San Diego.

The best forms of exercise can help to avoid knee pain and hip discomfort by keeping you fit. The La Jolla and Carlsbad sports enthusiast is continually searching for creative ways to piggyback exercise into the tasks of their daily routine. The use of pedometers and other fitness tracking devices can be helpful in encouraging people to get more exercise, according to multiple studies.

Researchers have determined that those who take walks every day are less likely to require the services of orthopedists for knee pain, meniscus tears, and other conditions.

A review of 26 studies, recently published by the Journal of the American Medical Association, revealed that physical activity increased an average of 27% for study participants who began using pedometers. The trials involved more than 2,700 people, Christie Aschwanden reported in the Washington Post.

Researchers found that the pedometer users decreased their body-mass indexes and lowered their blood pressure. Those who set a goal, like the commonly recommended 10,000 steps per day, tended to walk more than those who did not have specific expectations.

One pedometer enthusiast told Aschwanden that the device has “changed my behavior dramatically.”

The Post blog noted that fitness tracking devices range from simple pedometers, which clip to the waistband and count steps; to “high-tech trackers” such as Fitbit, Jawbone Up, the Withings Pulse O2 and Misfit Shine. They allow users to sync their information to smartphones or computers, and keep records.

Many of the devices monitor the distance a person walks or the number of calories burned. The accuracy of the readings varies, as some devices are more reliable than others. A study published in the Medicine and Science in Sports and Exercise journal identified eight trackers that produced burned-calorie counts differing as much as 23 percent from lab results.

Public-health authorities advise that adults get 150 minutes of exercise weekly. To reach that level, taking 7,000 to 8,000 steps is necessary. Walking at a brisk pace is a form of aerobic and cardio exercise that works the arms, hips, legs, knees, ankles and feet.

Such exercise promotes fitness and healthy cardiovascular and respiratory systems, which reduces the risk of heart attacks and strokes. Walking also has been shown to help people keep their blood pressure, as well as cholesterol and triglyceride levels, under control.

Among other reported benefits are decreased vulnerability to colon, breast and other cancers; stronger bones; resistance to Type 2 diabetes; and less severe depression symptoms like anxiety and insomnia. Strenuous walking can burn nearly 400 calories per hour for a 150-pound person. People who walk at least seven hours per week reportedly are 40 percent less likely to die prematurely.

Studies indicate that those who sit for long periods are prone to many health problems and early aging. This is a widespread problem, as the average American reportedly sits for eight hours or more every day.

Among the undesirable results of sedentary behavior is knee pain due to meniscus tears and other tissue damage. Orthopedists are kept busy treating patients suffering from pain, lost mobility and osteoarthritis because of years of physical inactivity. In some cases, knee- or hip-replacement surgery becomes necessary.

As you become more active and are interesting in optimizing your ability to exercise, contact our renowned sports medicine orthopedists to evaluate you at Orthopedic Surgery San Diego.

San Diego patients who undergo hip replacement (hip arthroplasty) due to arthritis receive an amazing level of hip pain relief. Uniformly, orthopedists tend to view the hip replacement as one of the best surgeries in the field. However, it is associated with several complications: dislocation, infection, and need for revision.

An infected hip replacement can be one of the most challenging clinical scenarios in orthopedic surgery to manage. A recent study found that infections were controlled in nearly all patients who underwent the two-stage approach for total hip replacement (hip arthroplasty). Once an infection in a hip that has been replaced is identified, the first stage is to explant (remove the metal implants) and provide antibiotics. The second stage, which occurs 6-8 weeks later, is to re-implant the metal devices (redo the hip replacement).

The Bone & Joint Journal published the results of the research in its October issue. The study involved 125 patients who underwent a total hip replacement. The study participants were monitored for five years, during which 96% had no infections.

The doctors wrote that they observed “excellent control of infection in a series of complex patients and infections using a two-stage revision protocol supported by a multidisciplinary approach.

The research confirmed the prevailing view that two-stage revision, the most common approach to management of an infected hip-replacement, is more effective than the single-stage method to eradicate infection in the replaced joint.

Because two hospital admissions and an additional surgery are required to complete the two-stage technique, it can cost 70% more than the simpler single stage procedure. Patients must cope without a hip joint for two to 12 months between the two stages, which entails hip pain and disability. However, when critically evaluated, the single stage method has a higher failure rate, which warrants a second and possible third surgery nonetheless.

Factors that affect whether an orthopedist would recommend hip replacement for a patient with pain due to hip arthritis might include a person’s health, degree of hip pain, amount of arthritis, activity level, and other individual factors. Orthopedists make the determination after examining and consulting with patients, most of whom are between the ages of 50 and 80.

The primary symptom indicating the possible need for hip arthroplasty is pain in the hip or groin that restricts the ability to walk, climb stairs or perform other activities. Patients may experience stiffness that makes it difficult to move a leg, as well as hip pain that occurs without even moving the joint.

Hip-replacement surgery or arthroplasty is not recommended until conservative treatments have failed. Patients usually first try medication, physical therapy, injections and walking supports to relieve their hip pain and regain function.

A newly performed hip replacement for hip arthritis is nearly always successful. An orthopedist extracts damaged bone and cartilage, and implants prosthetic devices. THA infection offers effective infection control. The head of the femur (thigh bone) is replaced with a metal stem that is wedged into place in the thigh bone, sometimes with the use of surgical cement. A metal or ceramic ball takes the place of the femoral head at the top of the stem.

The next step is to implant a metal socket to replace damaged cartilage in the cup of the pelvis that makes up the hip joint. In some cases, a surgeon uses screws or cement to stabilize the prosthetic. A plastic, ceramic or metal device called a liner is inserted between the new ball and socket to protect the components from wear and tear.

Patients usually receive general anesthesia before the operation. Some are administered spinal, epidural or regional nerve blocks that numb their lower bodies.

After they return home from the surgery, patients must give tissues surrounding the prosthetics time to heal by avoiding activities that put stress on the joint. Excessive strain can result in hip pain and loosened prosthetic devices.

Most hip replacements, if treated gently, last for many years. Orthopedists often advise postoperative patients to install handrails on stairways and in bathrooms, and sit with straightened backs while keeping their knees lower than their hips. Recommended devices include grabbers, raised toilet seats, shower chairs, long-handled bathing sponges or hoses, and sticks for pulling on socks.

If you have been told that you are in need of a hip replacement or suffer from hip pain, contact Orthopedic Surgery San Diego to be seen by our renowned specialists today.

Concussions have been a hot button topic for quite some time in the NFL. I honestly cannot remember the last time a week has gone by without a reported concussion. Just last week NFL fans witnessed Bears safety Chris Conte, Cardinals quarterback Drew Stanton, and Chargers running back Donald Brown leave their respective games with concussions. In the week prior to that Lions running back Joique Bell and Redskins tight end Niles Paul also suffered concussions. The NFL is putting an emphasis on concussion prevention in order to alleviate this rampant and ongoing problem. The fact is, that football is a violent sport and it frequently involves player’s heads making contact with the ground or other players with a tremendous amount of force. The biggest step that the NFL has taken is the required concussion protocol. This protocol involves evaluating every potential concussion with a physical exam and a battery of questions to determine if there are any disturbances in brain function. This test often prevents players with concussions from continuing to play. It is a step in the right direction but it does very little to prevent concussions.

The brain is made completely of soft tissue and its only real form of protection is the skull, which is separated from the brain by spinal fluid. Any sudden and direct blow to the head can cause a concussion. If the force is great enough it can even cause the brain to literally move inside the head. This is where concussion prevention in the NFL has plateaued. In the past, the NFL has put a premium on helmet innovation. This has had little success in preventing concussions. In fact, despite these awesome hi-tech helmets these players wear, concussion rates in the NFL are at an all-time high. This is in part due to the sensitivity and awareness over the issue. This is also due to the fact that the athlete’s today are bigger, stronger, and faster than the old-time leather-helmet wearing athletes. Bigger, stronger, and faster athletes tend to cause more violent collisions than their smaller, weaker, and slower predecessors.

Helmets certainly can help prevent concussions from the most minor of impacts, but truthfully the helmet has zero effect on weather the brain moves inside the head. Think about it this way. Imagine someone driving a car without a seatbelt on. The car is driving at 5 mph and gets into an accident that stops the car on impact. The person may lean forward just a bit but should be just fine when all is said and done. Now if that same accident happens at 50 mph, the driver’s body would be flung around without much control and the results would likely be devastating. Similar to our car analogy, there is space between the walls of your skull and your brain and if there is an impact forceful enough to cause the brain to move it can contact the walls of the skull. Unfortunately there is no seat belt we can put around our brains. Now for argument’s sake, imagine adding a helmet around our cars. Maybe this would prevent some damage to the car itself, but would it prevent your body from being flung when the car goes from 50 mph to 0 mph on impact? I don’t think so.

Let’s play a game: The what if game. What if you had players play football without helmets, how would the game look? I’m guessing you would have a few knuckleheads here or there that play the game just like they always have, but a majority of the players would most likely play the game slower and more cautiously. There is going to be concussions in any game that involves contact like football does, but the true problem isn’t the helmets, it isn’t the kickoff rules, or the rules for tackling over the middle. The problem is the game has gotten too fast. Maybe it’s time we slow it down a little bit. Just some food for thought.

If you have sustained a sports related injury, contact our specialists at Orthopedic Surgery San Diego for an assessment.

Ankle injuries, including an ankle sprain, can plague us all. The man they call Megatron, Detroit Lions wide receiver Calvin Johnson is one of the best to ever play the game. At 6’5” and 240, he looks like a man among boys at the wide receiver position. We often see him as unbreakable because of his build, his work ethic and his toughness. Throughout his 8-year career he has only missed 6 games despite dealing with a number of sprained knees, sprained ankles, concussions, and back problems. Unfortunately, Calvin Johnson is not entirely unbreakable, he is not part robot like his nickname suggests, and he is currently battling a high ankle sprain that has limited him for two games and caused him to miss the Lions game this week.

Ankle sprains are pretty fickle injuries, they can sometimes look very minimal and in fact, they are very minimal. Other times they look minimal but are actually much worse than they are as in the case of Calvin Johnson. I watched the injury occur and it looked like there was a slight roll of the ankle outwards as the weight of Calvin Johnson’s defender landed on it during the tackle. As it turns out it was more severe than it looked and it was diagnosed as a high-ankle sprain.

High-ankle sprains involve a sprain to the ligaments that are located above the ankle. These ligaments connect the shinbone (tibia) to the fibula (outer leg bone). Injuries to these ligaments most commonly occur when there is excessive rotation of the ankle. In the case of Calvin Johnson, you can see that his right ankle rolls in an outward fashion. This is called an eversion sprain and it causes the ligaments above the ankle to over-stretch. If the ligaments stretch is excessive enough it can actually cause the ligament to tear, microscopically, partially or completely.

The symptoms of a high ankle-sprain are dependent on the severity of the injury, but pain, bruising, swelling, and an inability to walk are the most common symptoms. The ankle sprain will be especially painful when attempting to rotate the ankle one way or another. As listed in the chart above, grade I ankle sprains are relatively inconsequential. As you move down the chart, the symptoms become more severe and the effects can be relatively devastating depending on your expected level of activity.

If there is no damage to the bones or bone structure, even the more severe ankles sprains will heal completely on their own within about 8 weeks. The treatment for a high ankle sprain begins with ice. You should ice the injury for about twenty minutes for every two hours. In addition, compression and elevation should be used to reduce swelling. Once weight bearing is possible, strengthening exercises should be used to strengthen your ankle and calf muscles.

While this injury may have derailed Calvin Johnson’s season thus far, there is no reason to believe that he will not be back on the field within two or three weeks. He is an extremely hard worker and as I sit here in my computer chair, snuggled in a blanket like a caterpillar in a freshly made cocoon, Calvin Johnson is probably at the Lions team facility strengthening that sprained ankle.

If you have ankle ankle injury or pain that affects your ability to function, contact our renowned sports medicine staff at Orthopedic Surgery San Diego Clinic.

Anterior Cruciate Ligament (ACL) tears are a common knee injury to those playing physically demanding sports such as football and soccer. Basketball players also suffer from this injury due to the abrupt stopping and starting on the court.  Knee pain from ACL tears range from mild to incapacitating, and recovery time depends on the severity of the injury. Not all tears require surgery, but it is often used to give the patient full knee functions. There are three bones that meet together to form the knee. The femur (thighbone), patella (kneecap), and the tibia (shin). The kneecap actually sits in front to provide protection and it is what we can immediately feel when grasping the knee. Bones and joints are held together by ligaments: the lateral collateral, medial collateral, posterior cruciate, and the anterior cruciate. These ligaments work together to control the motion of the knee. The anterior cruciate is in the middle and runs diagonally. This ligament keeps the shin from moving ahead of the thighbone, along with giving it stability while it rotates. When the ACL tears, the shinbone is not stable, and full range of motion is lost.

 Two different Surgery

There are two different surgery options in regards to ACL reconstruction: autografts or allografts. Autografting is the process of grafting tissue from one place to another within the same body. These are the most common types of ACL reconstruction surgery, which include the options to graft the patellar, hamstring, or quadriceps tendons, the patellar being the most performed procedure.  Allografts, which is the process of grafting tissue donated from another person, have been on the rise in the last 15 years, and those have the option of using patellar or Achilles tendon tissue. Most Orthopedic surgeons believe that the type of grafting used in an ACL tear is extremely important in regards to recovery and function. However, once a tear has been grafted, a second grafting does not give the surgeon as many options as he would when performing the initial reconstruction. To determine the revision success rate of allografts versus autografts, a study was conducted on 1205 patients, with the median age of 26 years, and 58% of them being male.  First revisions were conducted on 88% of the patients, with 28% of the patients using the same surgeon who did their first reconstruction. An autograft revision was performed in 48% of the patients, an allograft was performed on 49% of the patients, and the remaining had both types performed. After two years the patients had a follow up to find out the outcome of their surgery. Only 3% of the patients had a graft rerupture which occurred from a total of 24 allografts, 12 autografts, and 1 combination surgery. Patients with autografts were 2.78 times less likely to have reruptures compared to those who had an allograft. This data was not surprising to surgeons who believe that autografts are superior to allografts, and this data will be used for furthering ACL education. If you have been told you have an ACL tear or are suspicious of one, contact our highly specialized and award winning orthopedists at Orthopedic Surgery San Diego to care for you.

Femoroacetabular impingement, a cause of hip pain, has been undergoing remarkable attention recently.  Many athletes, especially runners, cyclists, dancers, and other athletes engaged in high frequency hip flexion activities suffer from femoroacetabular impingment.

Markus Wheaton, wide receiver for the Pittsburgh Steelers, missed most of his rookie year due to broken fingers. He began this year very well as he cemented himself into a starting wide receiver role. However, last week, Markus Wheaton was limited by a groin injury. He did manage to play through the injury but was largely ineffective.

The groin is the area between the abdomen and thighs. This area consists of many different muscles including the inner thigh muscles (adductor muscles), which are the most commonly injured muscles of the groin area. There are many reasons that there may be pain in the groin and we will discuss them in this article.

Anatomy of the Groin Area

The main cause of groin pain in athletics is the groin strain. Overstretching the inner thigh muscles causes a groin strain. Groin strains are diagnosed in three different severities. Grade I strains typically cause some minor pain and discomfort but would not drastically limit the ability to run and jump. Grade II groin strains would be slightly more painful and uncomfortable and would likely limit the ability to run and jump. More severe (Grade III) groin strains are accompanied by loss of leg strength, muscle spasms, swelling, bruising, and stabbing pain. In addition, there may be inability to move the leg inward or across the body. The most severe grade III strains can include some muscle deformity although this is very uncommon. These groin strains are most likely to occur in sports such as football, soccer, and ice hockey.

Groin Strain

Groin strains will typically heal by themselves but there are methods to speed the healing process. Every three or four hours you should ice the inner thigh for about a half an hour at a time. In addition, you should use an elastic bandage to compress the thigh and take anti-inflammatories as prescribed. Once the healing process is underway, your doctor may recommend you begin doing stretching and strengthening exercises. In the most severe of groin strains, surgery may be utilized as a last resort. The time is takes to return to full activity varies but typically grade I injuries can be fully healed within one to four weeks. Grade II strains can be fully healed within four to eight weeks. Grade III strains can be fully within eight to twelve weeks.

There are many other ailments that may cause you to experience groin pain. These include an inguinal hernia, a kidney stone, a urinary tract infection, hip arthritis, and pelvic inflammation to name just a few of many. These issues are obviously accompanied by other symptoms in addition to groin pain. It is important to visit your doctor if you are experiencing unexplained groin pain. If no physical injury occurred, there is a good chance that it may be related to one of these confounding ailments.

In the case of Markus Wheaton, it seems as though his injury was likely a grade I groin strain. He was able to play through the injury on a limited basis last week and I expect we will see more strength and explosiveness from him this week against the Browns.

If you have been diagnosed with femoroacetabular impingement or are suffering from groin pain, contact our renowned sports medicine specialists at Orthopedic Surgery San Diego for treatment.