Wednesday, July 13, 2011

ACL Reconstruction FAQs

This is another favorite of mine since I am doing a lot of sports medicine in my practice and treat a number of these injuries, Could be a long one here folks. A lot of information to cover. There is an excellent review article on the AAOS site which has all of the key references related to this topic should you wish to investigate that, so I won't bog everyone down with the references here in this blog, You can find the article here
1) What's an 'A-C-L' and what's all the fuss about it? The ACL or 'anterior cruciate ligament' is a ligament in the knee which connects the femur or thigh bone to the tibia or shin bone. If this ligament tears, that connection between the 2 bones is lost. This can result in the knee becoming unstable, wobbly with certain activities particularly recreational and or sports and therefore will limit one's ability to participate in those activities. This can lead to further cartilage injury, most notably meniscal cartilage tears. ACL tears receive a lot of attention these days due to their frequent occurrence in the professional sports world esp NFL.
2) I tore my ACL playing soccer. Do I need surgery? The bigger question of course is what are the indications for surgery for a torn ACL? Believe it or not this is not written in stone even today. Many factors need to be considered such as , associated meniscal and or other ligament tears, level of activity of the individual and severity of the resulting instability to name a few. For example, a 43 year old male who trips over a dog toy and tears his ACL, currently works as an accountant, activities include walking and biking and on exam has minimal degree of instability with an MRI showing only ACL tear, no other injuries, may not do any better long term with ACL reconstruction than without. ACL surgery does not protect the knee from arthritis later on (see article referenced above). In fact many studies show no difference in the development of arthritis between reconstructed and non-reconstructed knees over time. However, the presence of meniscal damage regardless of what is done with the ACL does seem to relate to osteoarthritis development over time.
Indications for reconstruction depend on the following:
 A) Participation in a level 1or 2 sport on a competitive or regular basis (Football, basketball, soccer etc) or 200 hours a year of recreational activity involving pivoting, planting turning or short stops and starts
 B) Severity of static instability. This is usually determined clinically in the office by examining the knee and assessing stability difference between injured and uninjured knees..
 C) Severity of dynamic instability. This is more subjective but in part relates to the patient's symptoms of giving way
 D) Presence of meniscal cartilage damage. Particularly if this damage consists of possibly reparable tears, the success of any meniscal repair will require operative stabilization of the knee i.e. ACL reconstruction.
 E) Presence of associated ligament injury i.e. 'combined' ligament injury.

Generally the presence of a combined ligament injury by itself is an indication for surgery. After that, activity level and degree of instability are probably the 2 most important determining factors.

3) I tore my ACL and apparently will need surgery. How long can I wait? If the ACL tear is isolated meaning no meniscal tears, then even a several week delay should not change the outcome as long as activities are modified to minimize the risk of the knee 'giving out' and causing more damage. We will often brace the knee if a lengthy period is anticipated before surgery. Generally we strongly encourage knee rehabilitation exercise BEFORE surgery to maintain muscle tone and conditioning. This greatly facilitates the post-surgical rehab. If there is a combined ligament injury, then it depends on what the 'other' ligament is that is torn. Often a collateral ligament will need to heal first before ACL surgery can be done. This amounts to possible a month or so. We generally do not recommend ACL reconstruction before 2 weeks after injury. There have been studies suggesting increased incidence of stiffness problems after surgery if it is performed sooner than that. Finally if there is the presence of a large meniscal tear that most likely can be repaired, we would probably operate soon after the 2 week minimum.

4) How is the ACL repaired?
 Unfortunately the torn ACL cannot be just sewn back together. The ligament is bathed in a bloodless environment inside the knee joint and thus there is no way for the the ends to heal even if they are reattached. Therefore in order to restore the knee stability, you have to carry out what is called a 'reconstruction', meaning you have to use something in place of the original ACL. This is usually a tendon or ligament from another part of the knee, called a 'graft'.

5) What is the best graft to use?  At the time of this posting, there are primarily 3 different types of grafts used for primary ACL reconstruction (primary meaning first time injury as opposed to a re-injury of a previously operated knee): 4 strand hamstring graft, patellar tendon graft, allograft. The first 2 are usually obtained from the injured knee. 'Allograft' is a ligament from a cadaver (dead person). The 'hamstring' refers to couple of tendons in the back of the thigh that get looped over 1 time to produce a 4-stranded graft. The 'patellar tendon' is a strip of tendon along the front of the knee right below the kneecap. Folks, there is absolutely no data that conclusively favors one of these 3 grafts over the other. Please refer to the article at the top. People tell me: 'my doc said I'm too tall I shouldn't have a hamstring graft', or 'I was told allograft is better because you don't damage other parts of the knee' or 'I was told patellar tendon is no good because it screws up your kneecap'. Forget about it! They all work well. No significant differences in outcomes based on current data, period! Now there are issues specific to each graft type which your doc will discuss more than likely, but in terms of the bottom line, no difference.

6) How much time does the operation take? Approximately 1.5 hours average

7) Is it done with laser? No. The procedure is carried out arthroscopically. However the graft harvest is carried out through an open incision, the size of which depends on the type of graft.

8) Is it an outpatient procedure? Yes.

9) Does surgery require general anaesthesia? Usually. Often a combination of general and regional anaesthesia is used where the anaesthesiologist will inject a numbing medicine into the thigh before surgery. This will provide many hours of pain relief after surgery

10) How long is recovery? There are several stages of 'recovery'. Initially the knee is placed in a long leg brace to protect the knee during walking. This is anywhere from 2-4 weeks depending on whether or not a cartilage repair is done. However we do want the knee to start moving as soon as possible outside of the brace when not walking. Physical therapy starts the very first week. Most people are walking without crutches or other assistive devices by 3 weeks.If it's the dominant leg, average time to being able to drive is around 3-4 weeks. Full knee range of motion is achieved on average by week 6. Return to sports is no sooner than 6 months.

11) Can I do my own therapy? This would be very hard to do at the beginning. Some people have transitioned to home therapy after regaining their range of motion in the first 3-4 weeks or so. That happens not infrequently. In highly motivated individuals it certainly is not impossible.

12) Will it be 'good as new', like it never happened? Only if Santa Claus is real. Not trying to be facetious here, but the only way to make it like it was is to turn the clock back. We are able to successfully stabilize the knee so people can return to their sport and perform just as they did before. That doesn't necessarily mean the knee is 'like it was before'.Now an individual can be back on the field in 6 months but usually their performance is not quite like it was before until the second season of play (total 1-2 years after surgery). Occasionally you see exceptions to this, but on average this is what usually happens. In 85-90% of the time the knee does feel like a normal knee to the individual, but the big question is what happens over a much longer period of time, for example many years. Some researchers are questioning whether the operation as is currently done alters the knee mechanics so that over a long period of time there is a chance that more cartilage damage occurs, not less. There are no conclusive studies on this to date. This research is ongoing.

13) Do I need a brace when I go back to sports? This is not required. The operation stabilizes the knee so you do not need a brace, and there is no evidence to suggest that bracing prevents re-injury. Some people feel more 'secure' with a brace on and prefer to use one, but again, not required.

14) What happens if it tears again? If it does happen again to a previously operated knee, the reconstruction can be repeated, a process called 'revision ACL surgery'. Results the second time around are not quite as good.

For more information on ACL injuries and surgery, you can find that here
Thanks for reading! Be sure to visit our website

Wednesday, June 1, 2011

Arthritis supplements (glucosamine and chondroitin). Do they work?

The short answer is: probably only occasionally. What I mean by 'do they work' is essentially do they relieve pain in an arthritic joint. That is after all the bottom line when people are judging any treatment efficacy for this condition. The pain has to be diminished first before function can improve. The data we have so far suggests that these supplements which come in a variety of brand names are not conclusively more effective long term than placebo. What I mean by that is if you decided to wear copper bracelets or drink an extra glass of water every day or put magnets on your knees you would have an equal probability of experiencing pain relief compared to taking supplements. So of course there is a chance they CAN work for you but it is up to you if the cost is worth it. Insurance plans do not cover them as far as I know. When I ask my patients who are taking it what they think, almost all of the time the response I get is "I'm not sure" and often those patients have been taking it for months.
So what are these things anyway? What are they supposed to be doing?
Glucosamine is an aminosaccharide that plays a role in the synthesis of cartilage matrix molecules. It serves as a substrate for the synthesis of chondroitin sulfate, hyaluronic acid and other cartilage matrix substances. Chondroitin sulfate is part of a huge molecule called proteoglycans that is crucial for the load bearing or 'shock-absorbing' properties, if you will,of cartilage. In osteoarthritis, these substances are depleted and the idea behind oral supplementation is that by ingesting these substances, they can be reincorporated into the cartilage matrix, thus restoring cartilage function and reducing pain. The idea is not totally unlike HA injections, as hyaluronic acid is also a cartilage matrix substance important for cartilage function.
Here is a brief comparison between HA injections (see the blog post from May on HA injections) and supplements:

                                   Supplements                                                 HA injections

Evidence based
long term efficacy           NO                                                                YES

Safe to use                    Probably, but no                                               YES
                                     long-term data

Insurance coverage         NO                                                                  YES

AAOS position              NOT RECOMMENDED                      INCONCLUSIVE
(what the American
Academy of
Orthopedic Surgeons

How long before            8 weeks or more                                              3-6 weeks average

There is an excellent review article on these supplements published in the Journal of the American Academy of Orthopedic Surgeons and I will cite a portion of the last paragraph for your review here. If you can get a copy of it I highly recommend it:
" Many unanswered questions remain surrounding their long term effects (whether beneficial or adverse) the most effective dosage and route, and product purity. A well-designed prospective study of glucosamine sulfate and chondroitin sulfate demonstrating that these agents are effective for the prevention and treatrment of osteoarthritis has yet to be conducted"
AA Brief et al J Am Aacad Orthop Surg Vol 9, No 2 March/April 2001 71-78

My advice is to try a more cost-effective treatment. More than likely you can find one. Be sure to read my last blog entry on HA injections and check out our website for more information on arthritis treatment.

Thanks for reading!
Next time a discussion on ACL surgery. Stay tuned!

Dr Doctor

Saturday, May 7, 2011

Gel shots (hyaluronic acid) they work? What are they?

Many different names for this are out there: gel shots, chicken shots, HA injections, viscosupplementation, etc. Approved for use in the US in 1997, this non-surgical treatment modality has become a popular option for many of the 21 million Americans who suffer from osteoarthritis.
First, a quick primer on osteoarthritis. For those of you who eat chicken, speaking of that, look at the end of the drumstick next time. This is part of the knee of the chicken. There is a shiny white surface on there. This is  articular or what I call 'surface' cartilage which is a key component to every joint in the body. When you're born that surface is nice and shiny, round and smooth. Over time it wears down and becomes rough and flat. This cartilage degradation is what is referred to as 'osteoarthritis'. The causes are multifactorial but affect everyone on earth and are mostly mechanical. They include: age > 50, obesity, gender (female > male), injuries, instability, malalignment (like the tires on your vehicle!), and genetics (like the different brands of tires which wear at different rates. In other words, some folks are born with a set of Pirelli tires, others have Goodyear). Now the cartilage degradation that occurs is not necessarily painful. What causes the pain is the inflammation that occurs in the joint lining, the capsule or tissue envelope surrounding the joint. It is pain that drives the treatment for the condition. Why some people have lots of pain and only intermediate degrees of the osteoarthritis and some who have advanced joint surface damage but minimal symptoms is not well understood. The bottom line is that today, the goals of treatment for osteoarthritis are to:
1) Reduce pain 2) Maintain mobility 3) Minimize disability 4) Halt progression. No non-surgical treatments at this time have conclusively demonstrated the capability to make the joint surfaces smooth again. Nothing has been shown to rebuild or regrow articular cartilage.
Current non-operative therapies for osteoarthritis include:
1) Modalities, i.e heat, ice ace bandaging 2) Weight reduction 3) Aerobic exercise 4) Strength training 5) Assistive devices (cane, walker etc) 6) Physical therapy 7) Bracing 8) Medications: tylenol, advil, alleve etc 9) Cortisone injection 10) HA injections.
I will now present this list of HA FAQs which should cover just about everything . References are provided where possible. If you have any other questions left out let me know.
1) What is HA? HA or hyaluronic acid is a major component of joint fluid. It is a protein polymer which provides the shock absorbing and other maintenance functions of the joint. Specifically it enhances viscoelasticity, joint lubrication, anti-inflammatory and anti-nociceptive (anti-pain) properties of the joint fluid. Think of it as the body's version of Pennzoil, Mobil 1 or whatever your favorite motor oil is!
2) How do HA injections work? Chondrocytes are cells that exist in the articular surface (surface cartilage) of the joint and these are the cells that produce the HA normally. When the cartilage wears down, the HA in the joint decreases. HA injections serve to replenish the joint's supply of HA, thereby restoring viscoelastic, lubricating and shock absorbing ability of the joint fluid. However, recent data suggests that HA also has many anti-inflammatory properties. It's not just a 'lube job'!
REFS: Ghosh P Arthritis Rheum August 2002; Balazs, E. J. Rheumatol 1993; Moreland Arthritis Res Ther 2003
3) Does HA rebuild or regrow cartilage? The short answer is no. See the discussion at the top.
4) Why do some HA therapies consist of 1 injection and others are as many as 5? The short answer is that this is the result of the American free market system and competition. Much like Advil vs Alleve vs Motrin, all anti-inflammatory medication with the same reported effects, there are currently 5 approved HA therapies in the US. All are weekly injections ranging from 1 to 5 weeks: Orthovisc, 3-4; Synvisc, 1 or 3; Euflexxa, 3; Hyalgan and Supartz 3-5.No data exists that conclusively demonstrates the superiority of 1 brand or 1 specific amount of injections. In my practice I first started with Synvisc, 3 injections, then went to Supartz 3 injections with no change in outcomes.
5) Where does the injectable HA come from? Orthovisc and Euflexxa are produced form bacterial cells; Synvisc, Hyalgan and Supartz are made from the cartilage in rooster combs. This is why some people refer to these injections as "chicken shots", but don't worry. No one has been seen to grow feathers or start crowing in the early morning following these injections!
6) Is HA more effective than anti-inflammatory medication or cortisone? In a 2005 study, HA was shown to be 66% more effective than placebo whereas NSAID was 30-50%. Longer term benefits were noted in comparison to cortisone. Specifically, < 4 weeks there was no difference between cortisone and HA, but from 4 weeks to 6 months HA injections were superior. REF: Bellamy  N. et al Cochrane Database Sys Rev 2005;2:CD005328
7) Do HA injections work and if so, how long do they last? As in number 6 above, most studies suggest the overall efficacy is comparable or better than NSAID, cortisone, arthroscopy and PT and results in moderate pain relief overall 60-70% of the time. In cases where it is effective, symptoms are usually improved for a minimum of about 6 months, but it can be much longer. In some cases it can last for up to 1-2 years. REFS: Waddell: Drugs Aging, 2007; Divine et al: Clin Orthop Rel Res, 2007
8) If it works for me can it be done again? Yes. There are studies documenting safe and effective repeat usage. REF: Scali JJ. Eur J Rheumatol Inflamm 1995; 15:57-62
9) What are the side effects?
Side effects are generally local at the injection site and include redness (0.4%), swelling (1%), and pain (2.5%). Severe inflammation with knee swelling is rare and usually resolves in 72hrs but can take 1-2 weeks for full resolution.
10) How do I know if HA would be a good option for me? Your doctor can help decide that, but generally HA is reasonable if you have a diagnosis of osteoarthritis, cannot take NSAID (anti-inflammatory meds such as Advil etc) or NSAID is ineffective, cortisone does not last, you're too young or not ready for total joint replacement and other conservative measures have failed. A 'good' candidate in terms of likelihood of success is someone with mild-moderate osteoarthritis, no significant knee malalignment (not too bowlegged or knock-kneed), and no evidence for inflammatory arthritis (rheumatoid etc.). Again, osteoarthritis is the sort of 'wear and tear' variety. Inflammatory arthritis is totally different. That is a condition where there is an intrinsic medical problem that causes joint damage. Rheumatoid arthritis is a disease of the immune system. Gouty arthritis is a metabolic disease. There are a hundred or so conditions such as these falling into the category of inflammatory joint disease where HA is not indicated for treatment. Practically speaking I will recommend HA injections if nothing else has worked before doing a knee replacement, unless they have already tried that or the pain and severity of the arthritis is just too great, which is a clinical judgment call.
11) Do insurances cover it? Just about all insurances cover it, however they may only cover specific brands. Some will cover only Euflexxa, others Supartz, etc. Re-injections are also covered but usually only if administered 6 months or more after the previous series.
12) What is the difference then between cortisone and HA and why would you administer one over the other ? Cortisone is a powerful anti-inflammatory medication that works well for sudden flare-ups of osteoarthritis. It is rapidly effective over days and has an excellent short term response. However it has no appreciable effect on joint function in terms of lubrication, shock absorption etc. and is not usually effective over the course of months. If an individual has moderately severe OA (osteoarthritis) affecting the whole knee and has not had injection therapy before, we will usually recommend cortisone initially as it is only a single injection and occasionally you can get long term relief. If the severity of OA is milder, perhaps only one compartment involved, then HA injections might be suggested first. There is nothing set in stone on this, however, and can vary between doctors as to what they will use when
13) Can HA be used in other joints? HA application for other joints has been studied but as of yet not FDA approved for anything but the knee.
14) Why does my doctor only use cortisone because he/she says HA injections are a waste of time? There is a wealth of data now that does support the use of HA in the ways discussed here. There are some studies mostly older that suggest HA injections are no more effective than NSAID. This is probably why the American Academy of Orthopedic Surgeons' position on HA injections is 'inconclusive' and is perhaps a reason for some skepticism in the medical community. However the Academy does not discourage it's use, i.e. it does not place HA therapy in their category of 'not recommended'.  REF Altman et al. J Rheumatol 1998.
15) Is it an office procedure?  Yes. In the majority of orthopedic practices the injections are administered in a similar manner in terms of set-up to that of cortisone injections. Some physicians may prefer to inject under xray control as an outpatient procedure because they state the placement of the material in the joint is more reproducible. This is unnecessary in my opinion. Those of us that spend a lot of time working in and around the knee joint can easily place this material inside the knee joint with 100% accuracy without the need for xray assistance.
16) What activities are allowed immediately following the injection? Generally you can resume normal activities. If you must return to sports within 1-2 days, ice application to the knee 4-6 times during the 1st 24 hours after injection is recommended for approximately 15-20 minutes at a time. I recently had a Falcons hockey player play in a game the very next day....and he scored a goal!
17) When can I expect results? For the majority of cases, you will not know for sure what the outcome will be for 6 weeks after the final injection. Some people will notice very subtle improvements after perhaps 2 injections, but rarely after 1. Do not get discouraged if , for example, after 1 month you don't notice anything. Improvement can be very sudden as well as gradual.

I think that covers most of the questions that come up on this. Let me know if you have any more and I will add them in here. Thanks for reading!
For more information on osteoarthritis and arthritis in general, you can look here
Be sure to check out our website

Wednesday, April 6, 2011

"I was told that running will destroy my hips and knees. Is this true?"

This is one of my favorites. Probably because I run and I know for a fact that my 50 year old knees have definitely taken some hits in the past! This is a frequent question. The fact is that recreational running has become more popular in recent years and many are doing it later in life and want to continue to do it. Does running lead to increased rates of cartilage deterioration in the hips and knees? If I'm still running at 50, am I looking at a joint replacement or 2 or 4 in the next 5, 10, how many years later?
First, let's go over some quick definitions. "Cartilage deterioration" is another way of saying "osteoarthritis" which is the process of wear and tear of the articular cartilage (surface cartilage) in all joints. All humans undergo this process to varying degrees over time. Sorry folks. Our joints, just like our other parts, do not last forever. For more on osteoarthritis and what it means, you can go here
For years it was assumed that "pounding the pavement" must not be good for your weight bearing joints and over time there must be increased joint damage compared to non-runners. Sounds logical but is it true?
Here is some of the data:
1) "Is Running Associated with Increased Osteoarthritis? An Eight Year Follow-up Study". From the Journal of Clinical Rheumatology 1995 by RS Panush et al. They followed eighteen non-runners and seventeen runners over eight years with serial joint examinations and xrays. "We did not find an increased prevalence of OA (osteoarthritis) among our runners now in their seventh decade. These observations support the suggestion that running need not be associated with predisposition to OA of the lower extremities"
2) From JAMA (Journal of the American Medical Association 1986;255 p1147-51 Fries et al) a study of 41 long distance runners aged 50-72. These were compared with 41 non-runners to examine associations of repetitive long-term physical impact with osteoarthritis.....They also used both repeat physical exam and xray.
"There were no differences between groups in joint space narrowing, crepitation, joint stability or symptomatic osteoarthritis"
3) This is an interesting study out of Germany from the journal 'Orthopade' 2006 by H Schmidt et al. They looked at 20 former elite marathon runners 20 years after their careers were over! Their conclusions: "Osteoarthritis of the knee joint is rare in former marathon runners. The risk of osteoarthritis of the hip joint seems to be higher than in control subjects who do not engage in much sport"
4)" Long distance running and knee osteoarthritis. A prospective study" This one is from the American Journal of Preventive Medicine, 2008 by EF Chakravarty et al.. Forty-five long distance runners and 53 controls were followed from 1984 through 2002. Conclusion: "Long-distance running among healthy older individuals was not associated with accelerated radiographic OA"
5) And finally some science out of the  American Journal of Sports Medicine 2006 by Markus A. Kessler MD et al. "Volume Changes in the Menisci and Articular Cartilage of Runners" investigated changes in knee cartilage after running. Their conclusion:"...cartilage is able to adapt well to the loads caused by running"

Bottom line is that evidence strongly suggests running does not lead to increased knee cartilage damage. There is some evidence it may affect the hip over time but this is not conclusive as the data on the hip is generally mixed. In my practice if I do see someone with xray evidence of hip osteoarthritis I generally suggest that other exercises such as cycling or swimming might be easier on the joint long term.

For more on the sports medicine of running, you can go here

Thanks for reading! Be sure to visit our website Springfield Orthopedic Surgery

Saturday, March 12, 2011

Am I too heavy for a knee replacement?

This is an excellent question. Several people who come to us with end-stage knee arthritis say they have been 'rejected' by other orthopedic groups and told they needed to lose weight before surgery could be considered. Why is that? Most of the time the reason given is that the knee implant won't last because the excessive weight will cause premature loosening. Another reason is the complication rate is higher. Adverse events like infection and blood clots for example are supposedly more likely to occur. So what's the truth? Is this REALLY the case? Let's look at a couple of definitions first. In the medical world, weight is usually quantitated by a term called the 'BMI' or 'body mass index' which is calculated by the formula: weight x 708 divided by the square of the height in inches. Optimum weight for height is somewhere between 20 and 25 . Obesity is defined as anything over 30. Morbid obesity is defined as BMI over 40. Have there been any studies looking at weight and knee replacements? The answer is yes. Let's look at some of these:
1) 'The Outcome of Total Knee Arthroplasty in Obese Patients': 2004 article in The Journal of Bone and Joint Surgery (JBJS, p.1609)) by Foran et al out of Baltimore. They looked at 78 total knees done in 68 obese patients and compared with a matched group of non-obese over 6-7 years. They concluded that any degree of obesity (BMI >30) had a negative effect on the outcome in terms of greater complication rate and higher revision rate.
2) 'Total Knee Arthroplasty in Obese patients' (JBJS Stern and Insall 1990 Vol 72 p.1400): 2-5 year study looking at outcomes for 5 weight classes including obese and severely obese. Out of 257 knees, only 4 were fair or poor. No differences were found in the overall outcome scores over the 5 groups except there did appear to be a higher incidence of patellofemoral symptoms (knee-cap related) in the moderately and severely obese groups. "No clear-cut association was found between obesity and either thrombophlebitis or complications"
3) 'Does obesity influence the clinical outcome at 5 years following total knee replacement for osteoarthritis?':
a study by A.K. Amin et al from the British JBJS in Mar 2006. 370 knee replacements followed up to 5 years, comparing obese to non-obese patients. Conclusion was no statistically significant difference in complication rates. "Obesity did not influence the clinical outcome 5 years after knee replacement. "

Actually, several more studies are out there and overall the results are somewhat mixed as shown here, but in general it would appear that good to excellent results can be expected from knee replacement in spite of excess weight. Obesity is not an absolute contraindication for knee replacement although the risks of adverse events might be somewhat increased. Certainly it would be advantageous to lose weight for general health reasons, but my own experience is that behavior especially as we get older is extremely difficult to change and even more difficult in the setting of a painful arthritic joint. If an individual is overweight or obese and has an end-stage arthritic knee with intractable pain, most likely significant weight loss will not occur. The decision to proceed with knee replacement will likely depend on the surgeon's experience with this patient group, but as we have shown here, surgery can definitely be successful.