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.