Monday, December 6, 2010

Infected prosthetic knees cause problems


The number of people that undergo an operation to have a prosthetic knee joint is increasing. One reason is that the population is getting older, another is that people are also getting heavier, which is a factor in the development of osteoarthritis. The number of knee replacement operations has increased by 9 per cent a year in recent years.

"So if 1-2 per cent of the operations lead to bacterial infection, then the need for revision – re-operation – will also increase", says Anna Stefánsdóttir.

This often involves two operations. First, the old prosthesis is removed and temporarily replaced with bone cement, while the patient is treated with antibiotics to eradicate the infection. This takes 6𔃆 weeks and during this time the patient can usually remain at home. Then a further operation follows to insert a new prosthesis.

In some cases it is not possible to put in a new prosthesis. These patients can be treated with an arthrodesis, or removal of the prosthesis (which leaves the leg without a real knee joint, often confining the patient to a wheelchair). In exceptional cases the infection leads to amputation.

Anna Stefánsdóttir has reviewed almost 480 cases of revision knee replacement between 1986 and 2000.

"Over time more patients have received a new knee prosthesis and fewer are treated with an arthrodesis, but still there are many people who do not get rid of the infection. Other studies show that those who have to have a second operation because of an infection are less satisfied than those who have to have their knee joint changed because the prosthesis has come loose or become worn", she says.

Therefore it is important that the healthcare service does its utmost to avoid infection in the wound. This means having good ventilation in the operating theatre, ensuring the doors are tightly closed, and ensuring that preventive antibiotics are given at exactly the right time before the operation.

"It is also important to be observant of wound complications. If an infection is discovered in time, it is possible to open the wound and clean out the bacteria before they have had chance to spread. Newly operated patients should have a 'VIP lane' so that they can go straight to the hospital orthopaedics department and not have to go via primary care", says Anna Stefánsdóttir.

In Ms Stefánsdóttir's view, re-operations due to infection should be centralised to specialist units, because they require such close cooperation between orthopaedists and infectious disease specialists.

Nowadays, there are orthopaedics clinics that only carry out one such operation a year, which makes it more difficult to establish the right routines.

Friday, August 6, 2010

Lubricating the knee cartilage after ACL injury may prevent osteoarthritis


PROVIDENCE, RI – An injury to the anterior cruciate ligament (ACL) is fairly common, especially among young athletes. While it can often be corrected through surgery, the injury can lead to increased risk of developing degenerative joint diseases, including osteoarthritis (OA). The problem is that fluid in the knee joint, which lubricates the cartilage, is impacted by the trauma of the injury and begins to deteriorate. A new study from Rhode Island Hospital researchers identifies options for restoring that lubrication to potentially prevent development of OA. The study is published in the August 2010 edition of the journal Arthritis & Rheumatism and is now available online ahead of print.

The study was led by Gregory Jay, MD, PhD, an emergency medicine physician and researcher at Rhode Island Hospital. Jay says, "We know that acute ACL injury is a significant risk factor for the development of post-traumatic osteoarthritis. We also know why that occurs, due to the degeneration of the fluids in the joint and cartilage and joint instability, among other things. Our goal for this study was to determine an effective way to counter that process to prevent the development of OA."

The most movable joints in the body, known as synovial joints, contain synovial fluid (SF). This fluid acts as a lubricant to reduce friction between cartilage in the joint during movement. Following a traumatic injury to the ACL, SF concentration of the natural lubricant, lubricin, in the injured joints is significantly lower in those joints than in the healthy, uninjured joint.

The goal was to identify biologic methods to address the loss of lubricin. In their study, they used animal models with torn ACLs to test three types of fluids that could be injected into the joints and could serve as a substitute for the lost SF. The first was human synoviocyte lubricin that was created in a culture and then purified to be injected into the injured knees. The second is recombinant protein, with a change in the genetic make-up of the cell so that it makes a molecule of interest. The reasoning behind using a recombinant protein is that if it is commercialized, that is likely how it will be manufactured. The third was lubricin from human SF that would otherwise be discarded. The human SF is then purified before injection, and because it is more closely aligned with the natural lubricin, it represents a positive control in the study.

Through their study, the researchers report three key findings. Jay, who is also a professor of emergency medicine and engineering at The Warren Alpert Medical School of Brown University says, "First and foremost, we found that you can limit cartilage deterioration. This is evident by using a well-accepted OA biomarker which shows that the breakdown of cartilage collagen type 2 and recovered in the urine has been muted by treating the knee joint with lubricin." The human synoviocyte lubricin was the most effective form in this experiment, however, the recombinant form also had a good degree of success.

Second, the study results indicate that when lubricin is placed back into the traumatized joint, it encourages the joint to make its own lubricin. Jay explains, "We found that you are limiting deterioration of the joint endogenously by the greater secretion of the lubricin molecule. Basically, by placing the lubricin there, it encouraged the joint's normal activity to produce this molecule."

Jay, who is also a physician with University Emergency Medicine Foundation in Providence, stresses that this study is important for another reason. "This is a huge advance over the existing technology of viscosupplementation injections. The concept was good, but the chemistry isn't there to support it." Jay continues, "When viscosupplements were approved as devices in the 90s, it was thought then that hyaluronic acid used in this treatment was tied to joint lubrication because it was viscous. We now know that joint lubrication has little to do with viscosity. We are inventing a new type of joint lubrication strategy: Tribosupplementation, taken from the Greek, meaning to wear or to rub" "

Jay notes, "Viscosupplementation is a $500 million per year device market that just doesn't work particularly well. Past studies by us and others indicate this. We now need a paradigm shift in how we are thinking about preventing and treating arthritic diseases."

Jay and his colleagues believe the study findings represent that paradigm shift. Jay says, "We found that lubricin may prevent the fundamental process that can lead to OA following an ACL injury. It is a promising biologic candidate since it is a replacement for a normally occurring glycoprotein. This is very germane to the health care bill, which supports the creation of new therapeutic biologics." Biologics are important and their development is encouraged because they are very specific and have low toxicity profiles, meaning they are better for patients in terms of better results with fewer complications.

Jay concludes that this and related papers are key to future treatment of joint trauma. "In the peri-injury period following joint trauma, joint surfaces are vulnerable to enhanced wear. This study is pointing us in the right direction, and has shown that this can potentially be mitigated by simply reintroducing the joint's natural lubricant." He continues, "We are confident that further studies will perfect the technology and this will be the way that joints will be treated in the future to prevent OA."

Monday, July 26, 2010

Many knee and hip replacement patients experience weight decrease after surgery


Total knee and hip arthroplasties can lead to healthier living

A Mount Sinai School of Medicine study has found that patients often exhibit a significant decrease in weight and body mass index (BMI) after undergoing knee or hip replacement surgery (arthroplasty). The study is the first of its type to correct for the annual increase in BMI typically found in North Americans between the ages of 29 to 73 years. The study was recently published in Orthopedics.

A total of 196 Mount Sinai patients who had knee or hip replacement from 2005 – 2007 to treat osteoarthritis were randomly selected for the study. Mean patient age at surgery was 67.56 years, with about 65 percent female and 35 percent male. Of this group, 19.9 percent demonstrated a clinically significant decrease in weight (defined as the loss of five percent or more of body weight) and BMI following knee or hip replacement. In addition, the mean weight of the group dropped from 79.59 kg (175.47 lbs) to 78.13 kg (172.24 lbs) after surgery.

Significant BMI decrease was found to be greater in knee replacement patients (21.5 percent) than hip replacement patients (16.9 percent). Patients who were obese prior to surgery, with BMI greater than 30, were the most likely to experience significant post-surgery weight reductions.

"Total joint arthroplasties are performed with the intent of relieving a patient's pain and disability," said the study's lead author Michael Bronson, MD, Chief of Joint Replacement Surgery at Mount Sinai School of Medicine. "Both total knee patients and total hip patients experienced a statistically significant and clinically significant corrected weight loss following surgery, which indicates a healthier overall lifestyle."

The incidence of overweight and obese adults has been steadily increasing over the past five decades in the U.S. Lifestyle modification, consisting of changes in patterns of dietary intake, exercise, and other behaviors, is considered the cornerstone of overweight and obesity management. Overweight patients often argue that their osteoarthritis limits their mobility and ability to exercise. Thus, patients may feel frustrated that they are unable to lose weight, and are often hopeful that losing weight would be easier postoperatively.

These results suggest that patients have improved weight parameters when compared to North American adults. Dr. Bronson and his joint replacement team at Mount Sinai believe that additional studies of total knee and total hip arthroplasty postoperative patients, which also incorporate nutritional guidance and long-term fitness goals, may show even more encouraging results.

Friday, July 23, 2010

More Than Half of All ACL Reconstructions Could Be Avoided


Anterior cruciate ligament (ACL) injuries are common injuries to the knee, primarily affecting young people who practise sport and often treated with surgical reconstruction. A research group from Lund University has now shown that 60 per cent of these operations could be avoided, without negatively affecting treatment outcomes.

The research group's study is known as the KANON study and started in 2001. The group is publishing its results in the New England Journal of Medicine.

"In our study, patients with acute ACL injuries were randomly divided into two groups for treatment with rehabilitation plus early ACL reconstruction or rehabilitation alone with the possibility of a later operation if this was deemed necessary. After two years only 40 per cent of the latter group needed to have an ACL reconstruction.

"Despite the fact that many of the patients were active sportsmen and women, we found no difference between the treatment groups in terms of knee function, activity level or well-being two years after the injury. Neither did we find any difference in these respects when we compared those who were treated with rehabilitation alone with those who had an early operation," says Richard Frobell, researcher at Lund University, Skåne University Hospital and Helsingborg Hospital.

A total of 121 patients took part in the study, which was carried out in collaboration with Helsingborg Hospital and Skåne University Hospital in Lund. The patients were aged between 18 and 35 and had an acute ACL injury in a previously healthy knee. Professional athletes and those who did not regularly practise sport were excluded from the study. All patients underwent extensive rehabilitation, led by experienced physiotherapists.

Sixty-two patients were selected at random to also undergo surgical reconstruction of the injured ligament within four to six weeks of the injury, and 59 patients were selected at random to initially undergo treatment with rehabilitation alone. All the operations were carried out in accordance with well established methods and by experienced surgeons. The patients were examined on several occasions over two years and gave their own opinions of the status of the injured knee.

"There are almost 10 000 scientific publications addressing the ACL and 50 per cent of these are about surgical treatment. However, none of these studies have shown that surgical reconstruction produces better results than rehabilitation alone. Despite this, we perform 3 000 cruciate ligament reconstructions a year in Sweden," says Stefan Lohmander, professor and consultant at Lund University and Skåne University Hospital. "In the USA there are 200 000 operations of this type, at a cost of USD 3 billion!"

The research group's results have strengthened their conviction that there is no evidence to support the recommendation of ACL reconstruction as a first method of treatment.

Rehabilitation with experienced physiotherapists produces the same results as operation for more than half of the individuals in this patient group and only four out of ten need to be exposed to the risks involved in an operation.

The patients in the study will continue to be examined in order to find out whether the results are the same in the longer term and to see if there is any difference between treatments in terms of the risk of developing osteoarthritis in the knee.

Wednesday, July 7, 2010

Knee arthritis? Flexible options can help keep you active

Tailoring treatment programs to individual goals and activities is the key to success

Middle-aged men and women with osteoarthritis of the knee now have more options than ever before for treatments that may allow them to remain active in the sports they love, according to a review published in the July 2010 issue of of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

"The number of patients between the ages of 40 and 60 who are experiencing knee arthritis is growing, and unlike most older patients, this patient population presents a unique set of treatment challenges," noted lead author Brian Feeley, M.D., assistant professor of orthopaedic surgery, University of California, San Francisco. "Understanding available options and tailoring treatments to each patient's needs and desires is the key to successful outcomes."

The review examined both surgical and non-surgical treatments available for younger patients with knee arthritis, to determine the best course of action for patients who want to continue to participate in demanding sports. Unlike elderly patients, where pain reduction and basic mobility are the two primary goals, Dr. Feeley noted younger, more active patients require more flexible treatment programs to allow them to remain as active as they would like.

"There is an increasing trend in the United States of people who want to stay active in sports and recreational activities after the age of 40. These patients are not content with being told to stop what they love doing," added Dr. Feeley. "As a result, orthopaedic surgeons and other physicians need to come up with different treatment strategies including non-operative treatments or even cartilage restoration procedures, to address pain and functionality, and to help keep patients as active as possible."

While some patients may eventually require surgery, Dr. Feeley said in most cases, non-operative management such as bracing, viscosupplementation (injection of hyaluronic acid), activity modification or anti-inflammatory medication might be used initially, to see if the symptoms resolve or if there is enough improvement to make surgery unnecessary.

"In a vast majority of cases, the onset of arthritis is a slow, degenerative process and therefore there is rarely a need to rush to surgery," he added. "Depending on the symptoms and activity level, many patients can be managed well with non-operative treatment strategies, whereas others truly benefit from surgical procedures. For each patient, it is important to tailor treatment to their symptoms and activity level, and to look for a healthcare provider who is willing to work with them over time to keep their knee as healthy as possible."

Although alternative treatments like acupuncture, glucosamine and chondroitin may be incorporated into an overall treatment plan, Dr. Feeley noted that currently there is no strong clinical evidence supporting the efficacy of these alternative-types of treatment.

For patients suffering with arthritis of the knee, Dr. Feeley recommends the following approach to help patients remain active:

• Take control of your situation—understand the disease process and learn about different treatment options.
• Work with your physician to come up with both short-term and long-term courses of treatment to help manage your symptoms early while maintaining the health of your knee and body for as long as possible.
• Be flexible with your activities and do not put the exact same stresses on the knee everyday. In some cases, mild activity modification such as switching to more biking or swimming and less running may make a huge difference in the number and severity of symptoms. Trying new activities also can help keep morale high.
• Don't be afraid to ask questions of your physician. Look for a doctor who can help you understand the advantages and disadvantages of each treatment option, and who is willing to work with you to tailor a treatment strategy to your individual needs.

"Even when surgery is necessary, proper follow-up treatment and physical therapy tailored to the patient's needs can go along way toward keeping that patient active and satisfied in the long-term," stated Dr. Feeley.

Tuesday, July 6, 2010

Glucosamine appears to provide little benefit for chronic low-back pain

Even though it is widely used as a therapy for low back pain, a randomized controlled trial finds that patients with chronic low back pain (LBP) and degenerative lumbar osteoarthritis (OA) who took glucosamine for six months showed little difference on measures of pain-related disability, low back and leg pain and health-related quality of life, compared to patients who received placebo, according to a study in the July 7 issue of JAMA.

"Osteoarthritis is a common condition that currently affects more than 20 million individuals in the United States, and this number is expected to increase," the authors write. "Low back pain is widespread and is the second most common concern expressed by patients in primary care. It poses a diagnostic and therapeutic challenge to clinicians due to the unclear etiology [cause] and the range of interventions with limited effect." Glucosamine is widely used as a treatment for OA, despite its controversial and conflicting evidence for effect, and is also increasingly taken by LBP patients, even though the evidence of its effectiveness remains inconclusive.

Philip Wilkens, M.Chiro., of Oslo University Hospital and University of Oslo, Norway, and colleagues investigated the effect of a 6-month intake of glucosamine in reducing pain-related disability by conducting a randomized, placebo-controlled trial with 250 patients older than 25 years of age with chronic LBP (for longer than 6 months) and degenerative lumbar OA. Patients took either 1,500 mg. of oral glucosamine (n = 125) or placebo (n = 125) daily for 6 months, with effects assessed after the 6-month intervention period and at 1 year. The primary outcome was pain-related disability as measured with the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes were numerical scores from pain-rating scales of patients at rest and during activity and a quality-of-life measure. Data collection occurred at the beginning of the trial and at 6 weeks, 3 and 6 months, and at 1 year.

At the beginning of the trial, the average RMDQ score was 9.2 for the glucosamine group and was 9.7 for the placebo group. The 6-month average RMDQ score was 5.0 for both the glucosamine and placebo group, and 1-year score was 4.8 for the glucosamine group, and 5.5 for the placebo group. No statistically significant difference in change between groups was found when assessed after the 6-month intervention period and at 1 year for RMDQ, and for measures of LBP at rest, LBP during activity and quality-of-life. Mild adverse events were reported in 40 patients in the glucosamine group and 46 patients in the placebo group.

"Based on our results, it seems unwise to recommend glucosamine to all patients with chronic LBP and degenerative lumbar OA. Further research is needed to clarify whether glucosamine is advantageous in an alternative LBP population," the authors conclude.

Wednesday, June 30, 2010

Failed ACL Repairs: More Common than You May Think

Nick Van Erp, active in soccer since elementary school and lacrosse since junior high, tore the anterior cruciate ligament in his knee during a spring lacrosse game his freshman year of high school. His injury, caused by stepping into a pothole and hyper-extending his knee, required surgical repair, ending his season prematurely and the remainder of his high school sports career.

Three years and two failed surgeries later, he made his way to the University of Michigan Health System in July 2009 to get what he hopes will be his final knee surgeries.

“I haven’t played soccer since freshman year and I’ve tried to play lacrosse, but every time, [my ACL] tears,” says Van Erp, a Grand Rapids resident.

Failed ACL repairs common

This eighteen-year-old’s story is not unique—an estimated 400,000 people suffer an ACL injury each year, requiring primary reconstruction surgery to repair the injury. Unfortunately, 18,000 to 35,000 of those repairs will fail and require revisions, which are additional surgeries for reconstruction. Revisions are more complicated, less successful and require a longer rehabilitation period than the first surgery.

Orthopaedic surgeons at U-M perform 200-300 ACL primary reconstructions each year. In addition to primary reconstructions, U-M surgeons perform about 30 revisions each year to correct failed ACL primary reconstructions performed elsewhere.

“Why those ligaments fail is subject to a lot of debate but probably has something to do with the techniques used the first time, and then the fact that so many [patients] go back to the sports that originally caused the problem,” says Ed Wojtys, M.D., director of the MedSport sports medicine clinic at U-M.

Primary ACL reconstruction surgeries, performed by orthopaedic surgeons, replace the injured ligament with an autograft from the patient’s body, such as a tendon of the kneecap or hamstring.

Most reconstruction surgeries are done by making small incisions in the knee and inserting instruments to perform the repair. After surgery, typically four to six months of rehabilitation therapy is needed for the repair to fully heal. If surgery and rehabilitation is done correctly, the patient typically will have reduced pain, good knee function and stability, and return to normal levels of activity.

“The most common reason for an ACL [repair] to fail is technical error, where the actual graft is placed in a non-anatomic position and the most common wrong position is too vertical—too up and down—which doesn’t allow the graft to restore rotation,” Jon Sekiya, M.D., associate professor of orthopaedics at U-M.

Common reasons for ACL repair failure include:_• inadequate time for rehabilitation, _• physiological factors such as the alignment of the patient’s bones or muscle function, _• additional injuries at the same time as an ACL injury—such as to cartilage in the knee or another knee ligament—which may also require repair to restore stability to the knee, _• reoccurring trauma due to intense physical activity, and _• improper surgical techniques.

Finding an experienced surgeon

An American Board of Orthopedic Surgeries survey found that 85 percent of surgeons who are doing ACL [repairs] do 10 or less per year.

“I definitely don’t think that the exact number of surgeries you do is indicative of necessarily the skill level,” Sekiya says. “However, I do think there are subtleties to this surgery that if encountered during an operation, may not be recognized in a less experienced ACL surgeon and can lead to failure. We do see that.”

To reduce the chance of an ACL repair failure, Sekiya says patients should talk to surgeons and other clinical staff who may be involved in their care about their experience before deciding on where to get the surgery.__“When trying to choose a place to take care of their ACL and their injury, [patients] should make sure the surgical staff and therapists are well versed to take care of all the problems they may encounter,” says Sekiya, who is also Nick Van Erp’s orthopaedic surgeon. “Patients can simply ask their surgeon if they are comfortable doing the procedure – they will likely get an honest answer.

Long road to repair

Nick Van Erp, who was en route to a third ACL repair surgery elsewhere when he was referred to U-M for a second opinion, is now on the road to recovery.

“I think we were headed down a course that was similar to the two episodes that had previously failed,” says Jeff Van Erp, who is Nick’s father and also a practicing physician.

Upon examination, Sekiya found that Van Erp’s problem was more complicated than a failed ACL repair. He and the Van Erps opted for diagnostic arthroscopy, to fully evaluate the knee and prepare it for future surgeries. This took place in August 2009.

The procedure revealed that Van Erp’s meniscus had been removed during a previous surgery, which is a secondary stabilizer to the ACL, and that he had bowed knees, which also contributed to his two previous ACL reconstruction failures. During the procedure, Sekiya also removed previously placed hardware and filled in the tunnels left behind with bone grafts.

In October 2009, Sekiya performed a tibial osteotomy, where he had to break and re-fix Van Erp’s shin bone to realign his knee. And finally, in March 2010, Sekiya transplanted a new meniscus and performed a double-bundle ACL reconstruction to provide stronger reinforcement to the knee.

“[I have] no real pain anymore,” Nick Van Erp says. ”And I know the tibial osteotomy worked because [my knee] feels more stable.”

“We’re obviously very happy that we decided to invest the time and energy into getting an opinion from someone who specializes in essentially catastrophic joint situations like Dr. Sekiya,” says Jeff Van Erp.

Nick Van Erp hopes to play intramural lacrosse at Kalamazoo College next year.

“I’m hoping this is the last knee surgery,” he says. “Hopefully everything will work and I can go to college and not have to worry about this.”

• Nick Van Erp has been undergoing physical therapy and expects to be completed in September 2010.

Surgical repair of knee injuries does not decrease risk of osteoarthritis


Arthroscopic surgical repair of torn anterior cruciate ligaments (ACL) or meniscal cartilage injuries in the knee does not decrease the chances of developing osteoarthritis, according to a new study published in the online edition and August print issue of the journal Radiology.

A decade after the initial injuries were diagnosed using MRI, localized knee osteoarthritis was evident in patients, regardless of whether or not the injuries had been surgically repaired.

"This study proves that meniscal and cruciate ligament lesions increase the risk of developing specific types of knee osteoarthritis," said Kasper Huétink, M.D., the study's lead author and resident radiologist at Leiden University Medical Center in the Netherlands. "Surgical therapy does not decrease that risk."

According to the American Academy of Orthopaedic Surgeons, the ACL, which is one of four ligaments that connect the bones in the knee, is the most commonly injured ligament. Injury typically occurs when the ACL is overstretched or torn.

Approximately half of ACL injuries will cause damage to other areas of the knee, including the meniscus, a wedge-shaped piece of cartilage that acts as a shock absorber for the knee joints. Surgical treatment is usually advised to repair these injuries.

Knee osteoarthritis is a common public health problem affecting more than nine million Americans. It typically develops gradually over several years. Knee osteoarthritis symptoms can include pain, stiffness, swelling and reduction in knee mobility.

For the study, researchers gathered information from the database of a previous multicenter study of 855 patients. The earlier study was conducted from 1996 to 1997 to evaluate the diagnostic value of knee MRI relative to arthroscopy in patients with knee pain.

In the current study, Dr. Huétink and colleagues followed up with 326 of the original 855 patients. All 326 patients had experienced knee pain for four weeks or more prior to the initial MRI and treatment. Initial findings and differences in treatment were compared with current follow-up x-rays and MRI exams.

The results showed that patients with ACL and meniscus tears are at a greater risk for developing osteoarthritis. Meniscectomy, which is the surgical removal of all or part of a torn meniscus, did not reduce that risk.

According to Dr. Huétink, the long-term and short-term clinical benefits of partial meniscectomy vs. meniscal repair procedures need to be further investigated.

"There is a higher risk of developing knee osteoarthritis at specific sites after tearing a meniscus or cruciate ligament," Dr. Huétink said. "We showed a direct relationship between injury and long-term consequences, and showed that surgery has no impact on long-term outcomes."


Wednesday, March 17, 2010

15 Years After ACL Knee Reconstruction, 84% of Male Patients Still Highly Active


Eighty-four percent of males who had ACL knee (anterior cruciate ligament) reconstruction with a patellar tendon (the tendon that attaches the knee to the front of the tibia or shin bone) graft continue at a high level of activity 15 years later, according to a study presented today at the American Orthopaedic Society for Sports Medicine’s Specialty Day in New Orleans, Louisiana (March 13). Additionally, these patients have not developed severe osteoarthritis and their knees remain stable.

“We have done this procedure for many years and this study looks at patients as far back as 17 years,” said Leo Pinczewski, MD, corresponding author and consultant surgeon at the North Sydney Orthopaedic & Sports Medicine Centre, Wollstonecraft, Australia. “The results of this technique, which was new almost 20 years ago, were excellent at five years, outstanding at 10 years and still very, very good at 15 years. Patients went back to sport quickly, had an easy rehabilitation with no brace and were frequently walking straight away.”

The goal of ACL knee surgery is to stabilize the knee with a short rehabilitation letting patients get back to an active lifestyle. Long-term, the surgery aims to prevent additional damage to the knee and minimize osteoarthritis.

But Dr. Pinczewski’s success with the procedure almost didn’t occur, he noted. In 1989, Dr. Pinczewski had gone to a medical seminar to hear Tom Rosenberg, MD, of Salt Lake City, Utah, who had pioneered a surgery to arthroscopically reconstruct the ACL using the patellar tendon. Previously, this knee surgery had been an “open” (not minimally invasive) procedure with a long rehabilitation and a high incidence of osteoarthritis. All he was able to obtain was the procedure summary from literature left at the lecture.

“So, I worked out how to do it from the abstract,” said Dr. Pinczewski. “Little did I know that I got it wrong, according to Dr. Rosenberg’s method. But, in fact, it proved to be fortuitous. The way I performed the surgery was to drill the hole into the femoral bone before drilling into the tibia. Dr. Rosenberg’s technique drilled into the tibia first. It turned out you can get the graft into a better position and a more stable knee if you drill in that order. I didn’t know I had it ‘wrong’ until after I’d performed hundreds of successful operations.”

In the study, 90 patients (46 men and 44 women between 15-42 years) had endoscopic ACL knee surgery performed by Dr. Pinczewski. After 15 years, 82 patients (88%) were examined and documented. In evaluating knee function (limp, locking, instability, pain, swelling and trouble climbing stairs), the patients had a median score of 95 (in a range of 39-100). Rating the function of their knee on a scale of 0 – 10, with 10 being normal, excellent function and 0 being inability to perform daily activities, patients reported their knee function at an average of 9.5 after 15 years.

As for sports participation, 84 percent of males and 45 percent of females were participating in very strenuous activities such as soccer and basketball or in strenuous activities such as skiing or tennis. 24 percent of patients participated in moderate activities such as running or jogging and14 percent participated in light activities such as walking 15 years after surgery. However, 89 percent of patients had no signs of osteoarthritis at 15 years after the surgery. The study did note a concern for increased kneeling pain in patients due to the donor site for the patellar tendon graft that needed further scrutiny.

Friday, March 12, 2010

A sporting chance for active total knee replacement patients


Study finds implant durability not affected by high-impact sports participation

Total knee arthroplasty (TKA) patients may be able to participate in high-impact sports without increasing risk of early implant failure, according to a new study presented today at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). In addition, the authors observed better clinical scores in the group of patients who participated in activities discouraged by the Knee Society (KS) than those of the control group.

The Knee Society recommends TKA patients avoid activities that cause high stress loads on the implant and may increase the risk of early failure. Such activities include high-impact aerobics, football, soccer, baseball, basketball, jogging and power lifting, among others.

"Recent studies have shown that as many as one in six total knee replacement patients participate in non-recommended activities," said Sebastian Parratte, M.D., PhD, an orthopaedic surgeon from the Mayo Clinic in Rochester, MN and the Aix-Marseille University, Center for Arthritis Surgery, Hospital Sainte-Marguerite in Marseille, France. "This study offers some reassurance to those patients who choose to return to an active lifestyle after surgery."

Researchers evaluated outcomes of 218 patients between the ages of 18 and 90 who underwent primary knee arthroplasty at the Mayo Clinic and reported performing heavy manual labor or practicing a non-recommended sport following surgery. The "sport group" was matched by age, gender and BMI to a control group of 317 patients who underwent the same procedure using an identical implant and followed recommended activity guidelines.

Clinical and radiologic results were measured using Knee Society (KS) scores and implant survivorship was evaluated using multivariate analysis according to the Cox model.

At an average follow-up of seven-and-a-half years after surgery, the study found:

No significant radiological differences and no significant differences in implant durability could be demonstrated between the sport group and the control group;
The sport group showed slightly higher KS Knee and function scores compared to the control group;
The control group experienced a 20 percent higher revision rate for mechanical failure (loosening, wear or fracture) compared to the sport group;
After accounting for all variables, including co-morbidities, the sport group had a 10 percent higher risk of mechanical failure compared to the control group.
These results were quite surprising to Dr. Parratte and his team.

"We hypothesized that high-impact activities would not increase the risk of implant failure, but we did not foresee that such activities might actually improve clinical results," he said. "It is clear that more research is necessary to evaluate the short and long-term effect of high-impact activities on the durability and function of modern TKA implants."

He added that, although the industry is not ready or able at this point to revise its recommendations, that possibility may exist in the not-too-distant future. In the meantime, he noted that surgeons and patients should continue to follow all industry recommendations relating to recovery following joint replacement surgery.


Learn more.

About Joint Replacement

Joint replacement, also known as arthroplasty, is considered by many to be one of the most successful medical innovations of the 20th century. Total joint replacement is a surgical procedure in which the patient's natural joint is replaced with an artificial one, made of a combination of plastic, metal, and/or ceramic.

The most common reasons for this surgery are pain and stiffness that limits normal activities such as walking and bending and that cannot be satisfactorily treated with medications or other therapies. Therefore, joint replacement surgery often provides a significantly improved quality of life to patients who would otherwise have to live with severe pain.

In 2007, there were 550,161 total knee replacements performed in the United States, and that number is on the rise—particularly as the Baby Boomer population continues to age. Because of this trend, it is important to optimize patient outcomes.

Wednesday, March 10, 2010

Patient and doctor expectations from joint replacement surgeries not always aligned

Physicians should implement measures to align expectations

While physicians strive to set realistic expectations for patients undergoing knee and hip joint replacements, a new study reveals that doctor and patient expectations are sometimes not aligned. The study, reported by Hospital for Special Surgery researchers at the American Academy of Orthopedic Surgeons held March 9-13 in New Orleans (poster P140), suggests that steps need to be taken to bridge the expectation gap.

This study is among the first to examine discrepancies in patient and physician expectation with joint replacement surgeries, according to Hassan Ghomrawi, Ph.D., MPH, outcomes research scientist, Biostatistics and Epidemiology, at Hospital for Special Surgery (HSS) in New York, who led the study.

The two joint replacement surgeries studied are known technically as total hip replacement (THR) and total knee replacement (TKR). These procedures are common in individuals over 50 and usually result from normal wear and tear that causes osteoarthritis. At Hospital for Special Surgery alone, nearly 4,000 THRs and 4,000 TKRs are performed each year.

At HSS, patients are required to attend a 90 minute class before surgery where they receive education from a specialized nurse about what they can expect during the surgery and recovery. "A leader in offering such classes, HSS has been giving a preoperative class for many years. This practice is becoming a trend in big hospitals for this type of surgery," Dr. Ghomrawi said. The results from this study indicate that such classes could be refined and steps can be taken to use these classes to improve patient and physician dialogue.

In a study that compared expectations of 42 patients with their doctors through surveys, investigators found clinically meaningful disagreement in 68 percent of patients with 53 percent of the patients' expectations exceeding the expectations of the surgeons.

"The take home message for the surgeon is that inexpensive, educational interventions like a preoperative class can be used to better align the patient's and the surgeon's expectations prior to surgery," said Alejandro Gonzalez Della Valle, M.D., associate attending orthopaedic surgeon at HSS, who was involved with the study. "This may ultimately result in higher perceived outcome."

"If a patient has unrealistic expectations that are not properly trimmed preoperatively or achieved after surgery, the patient will most likely be dissatisfied with some aspects of the final result. Conversely, if the patient has low expectations for function after surgery, it is likely that he or she will not enthusiastically engage in the different phases of the postoperative recovery including physically therapy. That patient will probably have a lower than expected functional result.

"For the patient, the take home message is that it is paramount to discuss the expectations for pain relief and function with the surgeon and in the class before undergoing a total joint replacement to make sure that the expectations of the physician and the patient are similar," said Dr. Gonzalez Della Valle.

The study included patients who were scheduled to receive a hip or knee replacement by a dedicated hip and knee surgeon. Both patient and doctor completed either a THR or TKR recovery expectation questionnaire. The surveys involved various questions with a scale from 1 to 5, ranging from a 1 being "return to normal," to a 4 being "very little improvement," and 5 being "I don't have this expectation."

The hip joint replacement survey had 18 questions involving improvement in psychological well-being, pain relief, ability to walk, ability to stand, getting rid of a limp, getting rid of a cane, ability to go up and down stairs, ability to raise from the sitting position, and improvement in social activities that range from working at a job or doing housework to recreation including the participation in sports. Other questions evaluated the mobility of an individual's hip such as whether a person could cut their own toenails.

The knee joint replacement survey had 19 questions involving improvement in psychological well-being, pain relief, ability to walk different distances, getting rid of a cane, going up and down stairs, kneeling, squatting, using transportation, the ability to be employed, and the ability to participate in recreation, social activities, sports, and sexual activity.

The numbers from each of the questions on the survey were then plugged into a formula that calculated a score ranging from 0 to 100, with 100 being the highest expectation. The study involved 25 patients undergoing THR and 17 patients undergoing TKR. Both patients and doctors completed surveys. The average surgeon expectation score was 75 (range 43 to 93) and the average patient expectation score was 84 (range 47 to 100).

"We observed a lot of variability between what the surgeon expected and what the patient expected. In an ideal world, the expectations of the patient and the surgeon should be similar," Dr. Gonzalez Della Valle said.

Based on results from this pilot study, the National Institutes of Health has awarded Dr. Ghomrawi a five-year career development award. "The hope is to be able to study the relationship between expectation discordance and several outcomes down the road, including rehabilitation outcomes at discharge, and six month and two-year follow-up functional outcomes," Dr. Ghomrawi said. "We are trying to see which items of discordance are clinically meaningful. And then we want to use all this information to improve the doctorpatient dialogue as well as to reassess the class content, so that expectations are aligned."

"The larger study will be more complex. We will try to analyze the discrepancies that different doctors may have for the same patient and that different doctors have between themselves when assessing the same patient," Dr. Gonzalez Della Valle said. "What are the physician factors and patient factors that can predict higher or lower expectations? The goal of THR and TKR surgeries is to provide durable pain relief and improvement of function so that patients can go back to an enjoyable, productive life. We want to make patients satisfied. We know that hip and knee replacement operations are very successful. But we are trying to go a step further, looking at the psychology of the patient recovery."

Tuesday, February 16, 2010

Walking & Glucosamine Linked to Eased Osteoarthritis

"Progressive walking" combined with glucosamine sulphate supplementation has been shown to improve the symptoms of osteoarthritis. Researchers writing in BioMed Central's open-access journal Arthritis Research and Therapy found that patients who walked at least two bouts of 1500 steps each on three days of the week reported significantly less arthritis pain, and significantly improved physical function.

Dr Kristiann Heesch worked with a team of researchers from The University of Queensland, Australia, to carry out the trial in 36 osteoarthritis patients (aged 42-73 years). All patients received the dietary supplement for six weeks, after which they continued to take the supplement during a 12-week progressive walking program. The program, called Stepping Out, includes a walking guide; a pedometer; weekly log sheets and a weekly planner, all intended to help patients adopt the exercise regime.

Seventeen patients were randomly assigned to walk five days per week, while the remaining 19 were instructed to walk three days a week.

The team found that both groups achieved significant improvement in their symptoms, however being encouraged to walk five days a week was notmore effective than being encouraged to walk three days. "These findings are not surprising given that the three-day and five-day walking groups did not differ significantly in the mean number of days actually walked per week, the mean number of daily steps walked, nor their weekly minutes of physical activity," Dr Heesch said. "They provide preliminary evidence that osteoarthritis sufferers can benefit from a combination of glucosamine sulphate and walking 3000 steps per day for exercise, in bouts of at least 1500 steps each, on at least three days per week."

This amount of walking is less than current physical activity recommendations for the general population, but follows the recommendations for people with arthritis.
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Most Patients Gain Weight After Knee Replacement Surgery

You'd think folks who've had knee replacement surgery -- finally able to walk and exercise without pain -- would lose weight instead of put on pounds, but surprisingly that's not the case, according to a University of Delaware study.

Researchers Joseph Zeni and Lynn Snyder-Mackler in the Department of Physical Therapy in UD's College of Health Sciences found that patients typically drop weight in the first few weeks after total knee arthroplasty (TKA), but then the number on the scale starts creeping upward, with an average weight gain of 14 pounds in two years.

The study, which was sponsored by the National Institutes of Health, is reported in the Jan. 15 online edition of Osteoarthritis and Cartilage, the official journal of the Osteoarthritis Research Society International.

The research involved 106 individuals with end-stage osteoarthritis who had knee replacement surgery, and an age-matched, healthy control group of 31 subjects who did not have surgery. Height, weight, quadriceps strength, and self-perceived functional ability were measured during an initial visit to UD's Physical Therapy Clinic, and at a follow-up visit two years later.

"We saw a significant increase in body mass index (BMI) over two years for the surgical group, but not the control group," says Zeni, a research assistant professor at UD. "Sixty-six percent of the people in the surgical group gained weight over the two years -- the average weight gain was 14 pounds."

Those who had the knee replacement surgery started out heavier and ended heavier than the control group. The weaker the surgery patients were, as measured by the strength of the quadriceps, the more weight they gained, Zeni notes.

"These findings are making us re-think the component after total knee surgery and of patients not being in a routine of moving around," says Snyder-Mackler, Alumni Distinguished Professor of Physical Therapy at UD.

She notes that it's critical that people not wait too long to have a knee replaced because their functional level going into surgery typically dictates their functional level after surgery.

Gaining weight after one knee replacement is worrisome because it could jeopardize the patient's other knee. Between 35-50 percent will have surgery on the other side within 10 years, Snyder-Mackler says.

The researchers note that weight gain after a knee replacement needs to be treated as a separate concern and integrated into post-operative care through a combination of approaches, including nutritional counseling to help patients with portion control, and more emphasis on retraining patients with new knees to walk normally.

"For physical therapists and surgeons, the common thinking is that after a patient's knee has been replaced, that patient will be more active," says Snyder-Mackler. "But the practices and habits these patients developed to get around in the years prior to surgery are hard to break, and often they don't take advantage of the functional gain once they get a new knee," she notes.

"We need to re-train patients with new knees to walk more normally and more systematically. And we need to encourage more community participation," Snyder-Mackler adds. "If you're not getting out of the house, you won't gain the benefit. We need people with new knees to get out there -- with the help of their family, their friends, and the community at large."

Friday, January 29, 2010

Most patients gain weight after getting a new knee,

You'd think folks who've had knee replacement surgery -- finally able to walk and exercise without pain -- would lose weight instead of put on pounds, but surprisingly that's not the case, according to a University of Delaware study.

Researchers Joseph Zeni and Lynn Snyder-Mackler in the Department of Physical Therapy in UD's College of Health Sciences found that patients typically drop weight in the first few weeks after total knee arthroplasty (TKA), but then the number on the scale starts creeping upward, with an average weight gain of 14 pounds in two years.

The study, which was sponsored by the National Institutes of Health, is reported in the Jan. 15 online edition of Osteoarthritis and Cartilage, the official journal of the Osteoarthritis Research Society International.

The research involved 106 individuals with end-stage osteoarthritis who had knee replacement surgery, and an age-matched, healthy control group of 31 subjects who did not have surgery. Height, weight, quadriceps strength, and self-perceived functional ability were measured during an initial visit to UD's Physical Therapy Clinic, and at a follow-up visit two years later.

“We saw a significant increase in body mass index (BMI) over two years for the surgical group, but not the control group,” says Zeni, a research assistant professor at UD. “Sixty-six percent of the people in the surgical group gained weight over the two years -- the average weight gain was 14 pounds.”

Those who had the knee replacement surgery started out heavier and ended heavier than the control group. The weaker the surgery patients were, as measured by the strength of the quadriceps, the more weight they gained, Zeni notes.

“These findings are making us re-think the component after total knee surgery and of patients not being in a routine of moving around,” says Snyder-Mackler, Alumni Distinguished Professor of Physical Therapy at UD.

She notes that it's critical that people not wait too long to have a knee replaced because their functional level going into surgery typically dictates their functional level after surgery.

Gaining weight after one knee replacement is worrisome because it could jeopardize the patient's other knee. Between 35-50 percent will have surgery on the other side within 10 years, Snyder-Mackler says.

The researchers note that weight gain after a knee replacement needs to be treated as a separate concern and integrated into post-operative care through a combination of approaches, including nutritional counseling to help patients with portion control, and more emphasis on retraining patients with new knees to walk normally.

“For physical therapists and surgeons, the common thinking is that after a patient's knee has been replaced, that patient will be more active,” says Snyder-Mackler. “But the practices and habits these patients developed to get around in the years prior to surgery are hard to break, and often they don't take advantage of the functional gain once they get a new knee,” she notes.

“We need to re-train patients with new knees to walk more normally and more systematically. And we need to encourage more community participation,” Snyder-Mackler adds. “If you're not getting out of the house, you won't gain the benefit. We need people with new knees to get out there -- with the help of their family, their friends, and the community at large.”

Tuesday, January 12, 2010

NFL players with Achilles tendon injuries

More than a third of National Football League (NFL) players who sustained an Achilles tendon injury were never able to return to professional play according to research in the current issue of Foot & Ankle Specialist (published by SAGE). The injured players who did return to active play averaged a 50% reduction in their power ratings.

The aim of the study was to document the epidemiology of Achilles tendon ruptures in the NFL and to quantify the impact of these injuries on player performance. Previous studies have looked at the occurrence of Achilles tendon ruptures in elite athletes in general, but very little was known about how often that type of injury occurred specifically in the NFL or how it affected the athlete's future ability to play.

Researchers looked at publicly available NFL data including websites that summarized games, statistics and injuries, to identify players who sustained complete Achilles tendon rupture. Also noted were such variables as the player's position, age, and number of years in the league prior to the injury. In addition, yearly performance statistics were collected for the players for the years before and after the injuries.

The study found that Achilles tendon ruptures can be career-altering injuries. Nearly 36% of players who sustained this injury never returned to play in the NFL and the ones who were able to return were never able to return to their pre-injury levels of play.

"This article provides a novel approach to shed light on valuable epidemiologic data for Achilles tendon ruptures among NFL players and the functional outcome of the injury," write authors Selene G. Parekh, Walter H. Wray, III, Olubusola Brimmo, Brian J. Sennett and Keith L. Wapner. "Future studies with the cooperation of the NFL and their official injury database are needed to fully evaluate the impact of Achilles injuries in this at-risk population."

Injection of platelet-rich plasma doesn't help

Newer treatment for Achilles tendon disorder does not appear to be effective

An apparently increasingly used treatment method for a type of Achilles tendon disorder that includes injection of platelet-rich plasma into the tendon does not appear to result in greater improvement in pain or activity compared to placebo, according to results of a preliminary study published in the January 13 issue of JAMA.

"Overuse injury of the Achilles tendon is a frequent problem that often affects sport participants but also inactive middle-aged individuals. An estimated 30 percent to 50 percent of all sports-related injuries are tendon disorders," the authors write. Approximately 25 percent to 45 percent of patients eventually require surgery following ineffective conservative treatment. "There is a clear need for improved conservative therapy."

Chronic Achilles tendinopathy is a degenerative condition characterized by pain, swelling and decreased activity. Platelet-rich plasma (PRP) injections is a treatment method recently introduced to improve tendon regeneration. Several recent reports indicated promising results with this treatment method, although these conclusions were based on laboratory studies and on clinical studies with important limitations, according to background information in the article.

Robert J. de Vos, M.D., of Erasmus University Medical Center, Rotterdam, the Netherlands, and colleagues conducted a study to compare the effects on pain and functional outcome of a PRP injection with a placebo injection for patients with chronic Achilles tendinopathy. The trial included 54 patients ages 18 to 70 years and was conducted between Aug. 2008 and Jan. 2009, with follow-up until July 16, 2009. Patients were randomized to eccentric exercises (usual care; exercises involved stretching the Achilles tendon while contracting the calf muscle) with either a PRP injection (PRP group) or saline injection (placebo group). A questionnaire (Victorian Institute of Sports Assessment-Achilles [VISA-A]), used to gauge pain and activity level, was completed at the beginning of the study and at 6, 12, and 24 weeks.

The researchers found that the average VISA-A score improved significantly after 24 weeks within the PRP group and within the placebo group. After adjustment for different variables, including the duration of symptoms, there was no significant difference in improvement on the VISA-A scores at the different follow-up times between these two treatment groups.

There was also no significant difference in secondary outcome measures, which included subjective patient satisfaction and the number of patients returning to their desired sport.

"Among patients with chronic midportion Achilles tendinopathy treated with an eccentric exercise program, a PRP injection compared with a saline injection did not result in greater improvement in pain and activity. Therefore, we do not recommend this treatment for chronic midportion Achilles tendinopathy," the authors write.

"These findings are important and clinically relevant as PRP is thought to be growing in popularity and recent reviews supported its use for chronic tendon disorders."

Monday, January 11, 2010

Program may prevent knee injuries

A soccer-specific exercise program that includes individual instruction of athletes appears to reduce the risk of knee injuries in young female players, according to a report in the January 11 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Soccer is a dominant cause of sports-related injuries in part because of its increasing popularity, according to background information in the article. Between 2000 and 2006, the number of female soccer players around the world increased by 19 percent, to 26 million. "The most frequent and severe type of injury among soccer players is to the legs, especially the knees. The anterior cruciate ligament (ACL) injury incidence is highest among young athletes," the authors write. "Knee injuries, and especially ACL ruptures, may have long-term consequences, including a long absence from soccer, incomplete recovery and secondary osteoarthritis of the knee."

Ashkan Kiani, M.D., of Uppsala Primary Care, Uppsala County Council, Sweden, and colleagues assessed an intervention program specifically designed to reduce the risk of soccer-related knee injuries among 1,506 13- to 19-year-old Swedish female players. The program featured strengthening exercises designed to achieve an improved motion pattern, reducing strain on the knee joint. The training sessions were integrated into the regular soccer practices and required no additional equipment. In addition, players, parents and team leaders attended a seminar to raise awareness of injury risk.

During 2007, 777 girls on 48 teams participated in the program and 729 players on 49 teams served as controls. Three knee injuries, including one non-contact injury (not involving another player), occurred among players participating in the program, compared with 13 knee injuries and 10 non-contact injuries among girls in the control group. Therefore, the program was associated with a 77 percent reduction in the incidence of knee injuries and a 90 percent reduction in the incidence of non-contact knee injuries.

"The rate of injury was not only lower among teams participating in the preventive program but the injuries that did occur were also less severe," the authors write. All three injuries in the intervention group were categorized as major, but all three players regained full activity within six months. Among the control participants, most injuries were severe, and only four of the 13 regained full activity within six months.

Coaches reported their teams' adherence to the program at two time periods, after the preseason training period and after the competitive season. Of the 48 teams participating in the intervention, 45 (94 percent) reported a high adherence of at least 75 percent. "The high compliance rate in this study suggests that the program is easy to implement and incorporate into regular soccer practice," the authors conclude.

Tuesday, January 5, 2010

Strength training, self-management help knees

Researchers participating in the Multidimensional Intervention for Early Osteoarthritis of the Knee (Knee Study) determined that physically inactive, middle-aged people with symptomatic osteoarthritis benefitted equally from strength training regimens, self-management programs, or a combination of the two. Details of this study are available in the January 2010 issue of Arthritis Care & Research, a journal published by Wiley-Blackwell on behalf of the American College of Rheumatology.

Osteoarthritis (OA) is the most common form of arthritis and the second leading cause of disability in the United States. Currently OA is the most prevalent chronic condition among women, afflicting 35-45% of women by the age of 65. A number of studies have compared strength training protocols with self-management programs in older patient populations, but few have examined the potential benefit of using both approaches in conjunction. "We hypothesized that combining the 2 treatments might enhance the outcomes," said Patrick McKnight, lead author of the Knee Study.

The Knee Study, conducted at the University of Arizona Arthritis Center in Tucson, AZ, was a 24-month unblinded, randomized intervention trial to compare the effects of strength training programs, self-management programs, and a combination of both. The 273 study participants were between the ages of 35 and 65 years, reported pain and disability due to knee pain on most days in one or both knees for a period of no more than 5 years, and had Kellgren/Lawrence classification grade 2 radiographic evidence of knee OA in one or both knees.

Study participants were randomly assigned to 1 of 3 treatment groups. The strength training group engaged in a 9-month initial phase designed to improve the core areas of stretching and balance, range of motion and flexibility, and isotonic muscle strength. The second, 15-month phase of this group concentrated on developing independent, long-term exercise habits. The second study group participated in a 2-phase self-management program designed to educate participants and provide one-on-one treatment advice. The combined group participated in both the complete strength training and self-management programs. A total of 201 out of 273 participants completed the 2-year trial, with the self-management group achieving the highest compliance rates.

The study team set out to demonstrate that a combination of OA treatment programs would prove most effective, however, the study failed to uncover significant differences in results among the 3 study participant groups. All 3 groups demonstrated improvements in physical function tests and decreased self-reported pain and disability. "The logic behind the combined treatment was that the different factors addressed in physical and psychological treatments might produce an additive effect if administered together," said Dr. McKnight. "These results suggest otherwise. Instead, the comparison of the 3 treatment arms showed no difference, suggesting similar benefits for all 3 over a 2-year period."

Given the higher rate of compliance in the self-management group, the Knee Study researchers suggest that self-management may be a less intrusive and equally effective early treatment for knee OA. The CDC also recommends self-management activities to decrease pain, improve function, stay productive, and lower health care costs, including self-management education programs such as the Arthritis Foundation Self Help Program (AFSHP), or the Chronic Disease Self Management Program (CDSMP) to manage arthritis on a day-to-day basis.

Article: "A Comparison of Strength Training, Self-Management, and the Combination for Early Osteoarthritis of the Knee." Patrick E McKnight, Shelley Kasle, Scott Going, Isidro Villanueva, Michelle Cornett, Josh Farr, Jill Wright, Clara Streeter, and Alex Zautra. Arthritis Care and Research; Published Online: December 28, 2009 (DOI: 10.1002/acr20013); Print Issue Date: January 2010

Monday, January 4, 2010

Knee Replacement - I Probably Won't Die

New study finds low mortality risk following knee and hip replacement

Risks lower 26 days after surgery

Total hip and total knee replacement surgeries are highly successful and very common procedures for people experiencing pain associated with degenerative joints. With a new hip or knee, and postoperative care prescribed by their doctors, most patients are able to regain a more active lifestyle with considerably less pain.

According to a new study published in the January 2010 issue of the Journal of Bone and Joint Surgery (JBJS), the risk of early postoperative mortality – or death following surgery -- was slightly increased for the first 26 days after the elective surgery. The risk of mortality was estimated to be 0.1 percent. The size of the study and the precise statistical tools used show the increase in early postoperative mortality was highest immediately after the operation. Then, 26 days after the surgery, the increased risk of death was negligible.

"Previous studies suggesting that increased mortality exists for as long as 60 or 90 days post hip or knee replacement surgery may be wrong," said lead author of the study, Stein Atle Lie, PhD, MSc and professor in the Department of Surgical Sciences at the University of Bergen, Norway who led the study with colleagues from the Department of Orthopaedic Surgery, and the Norwegian Arthroplasty Register at the Haukeland University Hospital in Bergen, Norway. "We believe the risk is tied to a much shorter duration."

The study included data on 81,856 patients with a total knee replacement and 106,254 patients with a total hip replacement from the Australian Orthopaedic Joint Replacement Registry and the Norwegian Arthroplasty Register. Only patients between 50 and 80 years of age with osteoarthritis were included.

The study found the most important risk factors for increased early postoperative mortality were:

Male gender; and
Age, older than 70 years old.
"This very low postoperative mortality after hip and knee replacements should be reassuring for patients considering these surgeries," explains study co-author Lars B. Engesaeter, MD, PhD and Head of Norwegian Arthroplasty Register, Haukeland University Hospital in Bergen, Norway.

People considering hip or knee replacement should talk to their orthopaedic surgeon about any added risk in relation to their age and follow recovery guidelines closely. Other questions to consider prior to surgery can be found at

"We conducted this study to help people contemplating hip or knee replacement," continues Dr. Lie. "As with all surgeries, there is some increased risk of postoperative mortality. However, we were pleased to find the mortality rate is so minimal -- less than one percent -- following hip and knee replacements."


Friday, January 1, 2010

Don’t Let Arthritis Put the Kibosh on All Exercise

Achy knees and joints caused by arthritis are not reasons to stop exercising.

Regular, modest exercise improves joint stability and strengthens muscles, according to the December issue of Mayo Clinic Women’s HealthSource. Exercise also improves mood, sleep, energy levels and day-to-day functioning. Best of all, people with arthritis who exercise regularly report less pain.

When a person avoids exercise, joints become less mobile and the surrounding muscles shrink, causing increased fatigue and pain.

A physical therapist or personal trainer can tailor exercise programs to health conditions and fitness levels. The key is to choose safe, appropriate activities and to take it slowly at first. A variety of activities can be safe and helpful for people with arthritis, including:

-- Range-of-motion and flexibility exercises: Activities such as yoga and tai chi increase joint mobility. Doing range-of-motion exercises in the evening can reduce joint stiffness the next morning.
-- Low-impact aerobics: Aerobic exercise improves overall fitness and endurance as well as muscle function and joint stability. Low-impact options include water aerobics, swimming, bicycling, walking or using equipment such as treadmills and elliptical trainers.
-- Strengthening: Strength training builds the muscles around the joints to provide better support. These exercises may be done with one’s own body weight for resistance, with hand-held weights, resistance bands or weight machines.
-- Lifestyle: Many everyday activities -- gardening and housework -- provide the health benefits of moderate physical activities.

For those with joint damage, some high-impact activities can make arthritis pain worse. It’s wise to consult with a physician before starting a new exercise regimen. Exercising should be stopped when it increases pain or swelling; causes joint popping, locking or giving way; leads to abdominal, groin or chest pain; or results in moderate-to-intense shortness of breath.

Psoriasis: Effects Don’t Always Stop With the Skin

RPsoriasis, a chronic disease that causes red, raised patches of skin, is increasingly seen as a systemic disease with links to arthritis and cardiovascular disease. The December issue of Mayo Clinic Women’s HealthSource provides an overview of this sometimes embarrassing condition, what’s known about it and how it’s treated. Highlights of the overview include:

-- Symptoms: Patches of thick, red skin covered with silvery, flaky scales commonly appear on the elbows and knees, but can appear anywhere on the body. They result from skin cells on overdrive, reproducing much faster than normal. Doctors aren’t sure why this overproduction occurs, although genetic and environmental factors likely play roles. Psoriasis symptoms come and go and flare in response to triggers that can include infections, some medications, alcohol, smoking, stress, sunburn, skin irritation or injury.

-- A systemic illness: Doctors are finding that psoriasis is more than a skin disorder. About one in four people with psoriasis develop a form of arthritis called psoriatic arthritis that can cause pain, stiffness and swelling in the joints. Studies have shown that people with psoriasis face a higher risk of heart attack, stroke and other cardiovascular problems. The underlying link may be chronic inflammation, which plays a role in psoriasis and heart disease.

-- Treatment: While psoriasis can’t be cured, a variety of topical and systemic treatment options can help control the condition. For mild-to-moderate psoriasis, topical treatments often are effective. Options include corticosteroids or retinoids to reduce inflammation; vitamin D analogs to slow skin growth; and tar, to reduce scaling, itching and inflammation. Calcineurin inhibitors (tacrolimus and pimecrolimus) can help reduce inflammation and skin cell buildup.

In addition, ultraviolet light slows the rapid growth of skin cells. Ultraviolet light therapy may be used alone or in combination with other treatments. Several systemic medications are used for severe forms of psoriasis, though these options pose the risk of serious side effects.

-- Self-help measures: Home-care measures can help prevent or manage symptoms. A daily bath removes scales and calms inflamed skin. Adding bath oil, colloidal oatmeal, Epsom salts or Dead Sea salts can offer additional relief. After bathing, applying a thick moisturizing cream or ointment, such as petroleum jelly, can be helpful. During cold, dry weather, it’s beneficial to apply moisturizer several times a day. Short sessions in sunlight three or more times a week can improve psoriasis, as can avoiding known triggers.