Advances in Knee Replacement: Partial Knee Replacements

I recently returned from observing at a course given by a device manufacturer concerning partial knee replacements. The course is given because the FDA mandates that for the company to sell the replacement to a surgeon the surgeon has to take this course. It is a 16-hour course. It does not qualify you to put in the replacement. It does not give you any skill you did not have before. It exists because of FDA rules concerning new products and their safety.

I bring this up because I saw this on a web site of an Orthopaedic Surgeon: "Dr. X is the only surgeon FDA-certified to put in the XXXXX partial knee replacement."

This, of course, is not true. It actually could be an offense punishable by the Office of Professional Medical Conduct because the FDA does not certify surgeons to put in replacements. They can only certify the sale or distribution of the implant.

What certifies a surgeon to put in a partial knee replacement? Last year I personally implanted over 125 partial knee replacements. According to the sales department of the device company whose implants I choose, this puts me at approximately number four in the nation for this particular implant. In fact, the number of partial knee replacements I personally implanted surpassed the combined number of the four largest medical centers in NY. Maybe, maybe not.

As previously noted here in this blog, surgical quality does have a connection to surgical volume. It is not direct and it is not absolute, but there is a connection. Of all the joint replacement procedures that have gained popularity in the last 25 years, a partial knee replacement demands a high level of surgical skill and experience. When I operate at a regional medical center and teach residents (surgeons in training) I commonly inform them that "the hands can only do what the mind knows." In other words, it is what you don't know that can hurt you.

Partial knee replacements have many advantages in the right patient. The recovery is faster and the results, from a patient satisfaction point of view, are consistently better than total knee replacements. It is crtical, though that the surgeon has the experience in doing the surgery. Do not be afraid to ask the following questions:

1. When did you perform your first partial knee replacement?
2. How many have you performed in the past month?
3. Can you show me documentation that the number you said you performed is accurate?
4. How many have you performed in the last year?
5. Can you show me documentation that the number you said you performed is accurate?
6. What is the most common knee procedure that you do?
7. Can you show me documentation that the number you said you performed is accurate?

Don't be afraid to ask the obvious.

Dr. K.

Related Topics:

• Knee Pain Overview
• 4 Fixes for Knee Pain

Technorati Tags: partial knee replacements, unicompartmental knee replacements, knee resurfacing

He's a Jolly Good Fellow

On my last blog post I talked a bit about who will do your surgery. This is a very difficult decision for anyone, as even in this country there are no rules or regulations concerning specialty training in many surgical procedures. In Orthopaedic Surgery, for example, just finishing an Orthopaedic Residency allows you to legally (and morally) perform joint replacement surgery. You are trained in it. You should be able to do it. The problem is that over the past twenty years the bar of quality has been raised. It is now a standard in the community for a surgeon to do a fellowship which is an extra year of training in joint replacement.

What does fellowship training mean for you?

It means that your surgeon has spent a FULL YEAR at an established joint replacement center studying the science and surgical art of joint replacement. This is not a six week course, a weekend course, or all the other scam-like terms used by some surgeons to hide from the public their lack of fellowship. It is a level of commitment to the skill that is impressive.

Does this mean a fellowship trained surgeon is a better surgeon?

This can never be said. Evaluation of the quality of a surgeon is in many categories. What is does say is that this particular surgeon committed himself or herself to the field of joint replacement surgery at a higher level. What can definitely be said is that the surgeon who does a fellowship is a better surgeon than he or she would have been if a he or she did not do that fellowship. How much better? WAY BETTER!

How does this help me decide on a surgeon?

It is one of the many parameters you can use. In my last post I wrote of surgical volume and clearly fifty or more procedures a year is a minimum number to go by. Therefore we now have two important parameters to consider:

• Does my surgeon perform fifty or more of this procedure a year?
• Did the surgeon perform an advanced fellowship in joint replacement?

Keep in mind that these are just two important guidelines. Suffice it to say that if, for example, the surgeon you go to is a sports medicine or hand surgeon it is unlikely that this is the person you would ideally choose to do your replacement.

Ask a lot of questions of your surgeon.

Dr. K.

Related Topics:

• Joint Replacements Cut Pain for Seniors
• Beyond Arthritis: Hip and Knee Replacements for Women

Technorati Tags: joint replacement, orthopaedic surgery, arthritis, health and wellness

Who Will Do My Surgery?

Photo Credit: Gary Minnaert

On the WebMD message board on Joint Replacement there are a number of posts concerning serious problems that have occurred in each individual's surgery. One thread that ties these together is that is appears that the original surgeon that operated on the patient who posted the issue did not, would not, or could not solve the problem. What is this all about?

There are many serious problems in health care. One of the more hidden and dangerous ones is doctors performing surgeries for which they are not properly trained.

In reference to joint replacement, there is a lot of literature concerning the minimal volume of operations that separate surgeons with lower versus higher complications. I know of no US Hospital that requires surgeons to have this volume tie to their privilege to perform this surgery at that hospital.

In a report from Brigham and Women's Hospital (Harvard), for first time (primary) hip replacement, the surgeons who performed more than fifty a year had lower complications.

The same group at Harvard reported on knee replacement volume. Knee replacements done by surgeons who performed more than fifty procedures a year had lower complications an adverse outcomes. Hospitals that performed more than 200 procedures a years had lower complications as compared to hospital that did less than twenty-five procedures.

In another report, patients had higher satisfaction in hip replacement if the surgeon performed more than thirty procedures a year and the hospital performed more than one-hundred.In another report, patients has higher satisfaction in hip replacement if the surgeon performed more than thirty procedures a year and the hospital performed more than one-hundred.

In a report from the VA in Boston, surgeons who performed more than four shoulder replacements a year had lower complications than those who did less than four.

So what can we conclude here?

At the very least, the surgeon you choose should perform a minimum of thirty primary joint replacement procedures a year for you to have an optimal satisfactory result with lower complications. This means:

• Thirty total knee replacements
  
• Thirty partial knee replacements (unicompartmental)
  
• Thirty primary total hip replacements
  

I know I could have gone for the fifty number but we can at least start at the minimum of thirty.

What are you to do? Ask your surgeon. He or she should be able to tell you whether or not they do at least thirty cases. It is not important as to the actual volume. There is no proof that there is a difference in quality between a surgeon who does one hundred or three hundred. In fact, more volume per surgeon after a certain number may beg the question - who is actually performing the surgery (the surgeon, an assistant, a surgeon-in-training)?

You can follow-up the answer with a letter to your surgeon:

Dear Surgeon:

I am pleased to be having surgery with you. As per our discussion you assured me that you perform at least thirty procedures a year of the procedure I am having with you. My decision to have this procedure with you was dependent on this fact. Thank you and I look forward to this procedure.

Signed,

The Patient

What would be the purpose of this letter? It may represent an implied warranty of the accuracy of the information you were given. It will certainly scare the bejesus out of any blatant liars and scoundrels.

Should hospitals should require a minimum of a certain procedure by a surgeon on staff? Absolutely. A reasonable approach is to set the volume standards and give a surgeon a reasonable amount of time to achieve these. This allows new or growing surgeons to reach these volumes. One can say, you need to reach these volumes within three years of you performing the first procedure at this hospital.

Size may not always matter, but it appears that volume does.

Dr. K.

Related Topics:

• WebMD Video: Joint Camp - Preparing for Hip and Knee Replacement Surgery
• WebMD Video: Computer-Guided Knee Replacement

Technorati Tags: joint replacement, hip, knee, shoulder, surgery, health and wellness

Managing Arthritis Pain

When to Start and When to Stop

It is interesting that I overheard two clinicians speaking recently and this is generally what I heard:

Clinician 1: I got a call from Doctor X's patient while I was on call and he was away. The patient was 2 months after arthritis surgery and was asking for a refill of pain medications.
Clinician 2: What did you do?
Clinician 1: I don't give pain medication to drug seekers.

OK. Now I am only paraphrasing but this happened somewhat like this. It brings up an interesting point. Doctors are often blamed for being on both sides of the problem. I hear that doctors are blamed for prescribing narcotics too freely and also blamed for holding back pain medications in many situations. What is the truth?

There is no right or wrong answer here. The problem is that pain is an individualized problem and while there are numerous guidelines, many patients break out of those guidelines. Additionally, most physicians are not formally trained enough in the science (and art) of pain management. Considering one of the most common complaints any patient has when walking through a doctors doors is, "I have pain," most medical schools have little to no curriculum on pain management.

In my experience as s surgeon for over 16 years I think that most patients are undertreated for their pain. For, example, I see many junior faculty prescribing Oxycodone 5 mg for postoperative pain which is fairly low dose. In general, the current approach to pain management is referred to as "multimodal." This means a combinations of narcotics, antiinflammatories, acetaminophen, ice, exercise, and possibly alternative methods. Most hospitals, though, do not have well-developed pain management services and even fewer have modern cold treatment or ice therapy machines and continue to have nurses put on ice packs at irregular intervals.

Knowing when to start aggressive pain management after surgery is easy. Knowing when and how to stop is more difficult. In a non-surgical setting in the case of arthritis even knowing when and how to start is a challenge.

What has been your experience in the management of your pain -- good and bad?

Dr. K.

Related Topics:

• WebMD Video: Arthritis Drugs Provide the Help Patients Need
• WebMD Video: New Medications Ease Crippling Arthritis Pain

Technorati Tags: arthritis, pain management, health-and-wellness, medicine

Ten Ways to Manage Back Pain

I am a joint replacement surgeon. In the operating room, in a given year I perform over 300 procedures related to joints, arthritis, and injury. In my office, half the patients I see have hip and knee arthritis; the rest have every other joint involved. The most difficult for many physicians to manage is back pain. I know that I am not alone in this.

Back pain has many sources. In general, there are so many experts out there concerning back pain that I am now wholly convinced that no one knows what the heck they are talking about in this entire specialty. One day surgery is good, the next it's bad. The alternative medicine people will extol the virtues of acupuncture to nutrition. Sometimes it works and sometimes it does not. There are more pillows and beds and commercial crap you can buy than there is room in the entire state of Rhode Island.

How can a reasonable person try to help themselves with back pain when the medical specialties are in such disagreement?

Here are a few things that may help you:

1. Be your own best doctor. We often are more discriminating when buying a car than when seeking medical advice. After some period of time, you will know which mix of interventions help more than others. I am often amazed when a patient comes to me and says that they have back pain and have been in physical therapy for 3 years and it does not help. What exactly were they thinking after the first year?


2. Understand the source of your pain. Some people have back pain from a degenerative condition, like arthritis. The joints in the back of the spine can wear and cause pain. Other sources of pain can be from a sudden injury or muscle strain. Sometimes the pain is due to a nerve being irritated by some disc material in the spine. There are even many valid theories that stress causes back pain. If you try to get a handle on the origin of the pain then this is a good place to start.


3. See the right doctor. There are many physicians out there -- family medicine, internal medicine, rheumatologist, orthopaedic surgeon, neurosurgeon, chiropractor, and others -- that have a keen interest in back pain. There are may more from each of these specialties that don’t care as much about back pain. Choose a physician who has back pain high on their list of diseases they want to treat.


4. Do not listen to lawyers. Many patient hurt their back on the job, in a motor vehicle accident, or in a slip and fall. The lawyer you choose may send you to a group of doctors who do every test under the sun and a series of bogus treatments not designed to make you better but to build your legal case. The only time a lawyer refers a case to me is when the first doctor, who was probably in their pocket, messed up the case so much, they actually need a real doctor to bail them out. While it is possible that the doctor your lawyer sends you to is good, ask around; you will probably find otherwise.


5. Understand that there will probably not be one single treatment method that will work on its own. I have generally seen that combinations of drugs, rest, exercise, physical therapy, chiropractic, acupuncture, and more are needed in many situations. While it is important to try a number of these modalities, set a time limit on each of them. If there is no improvement within the first two months from a specific modality, the chances of it helping in the long run are low.


6. Choose your physician or other health professional carefully, then listen to their advice. I can't tell how many patients want their back pain to go away but when I recommend something the patient says that they do not want to do that. For example, I may recommend taking ibuprofen. I will then get the response, "I don't take drugs." Then I may recommend epidural steroids and I hear, "I don't want any injection." Then I send the patient to a chiropractor and I hear, "I don't believe in that." The list goes on. In the end, I am not exactly sure why the patient came to me when EVERY treatment I offered was rejected. This does not mean to accept any treatment blindly and without question. On the contrary, be open to any and all suggestions and try to stay away from biases that carry over from rumors and hearsay. Evaluate each piece of advice with an open mind and then make a decision.


7. Surgery is neither aggressive nor conservative. Surgery has a role in back pain, but not a large role. When properly indicated, surgery will always be a good choice. When not indicated, it is unnecessary and a problem for the patient. Get 2-3 opinions if surgery is recommended.


8. Don't be afraid to take it easy for some time period. You may not be able to return to 10 mile runs for 6-8 weeks. This is not the end of the world. Respect the pain and the injury. If you do not, your back will tell you.


9. Try to return to reasonable activities and work as soon as you are cleared to do this. Too many people stay out of the mainstream of work and this causes a culture of not wanting to get better. If your doctor feels it's safe to return to work in some capacity, then you should do so.


10. Make sure you do all you can to get a real diagnosis. If the doctor was with you for 3 minutes and never laid a hand on you, the diagnosis of back strain is probably wrong. A good history and physical examination is often correct 85-90% of the time. Tests like MRI's should be used to either confirm a diagnosis already known or to distinguish between one or two different diagnoses. Since many people over age 50 have significant findings on their MRI even if these patients do not have back pain, be careful with MRI's not connected to a comprehensive office visit. The finding in the office needs to correlate with any test.

Sometimes back pain goes away as fast as it came on. In some situations it stays longer than you want. Either way, I hope these tips can help you navigate through this problem.

Dr. K.

Related Topics:

• WebMD Video: Diagnosing Back Pain
• WebMD Video: Finding the Right Chiropractor

Technorati Tags: back pain, arthritis, pain management, medicine, health and wellness