Pushing Limits…

Written by admin on February 26, 2013 – 2:14 pm -

Younger Patients Choose Surgery; Some Sports Are OK, But Which Are Too Much?

(WSJ, April 19, 2011)

John Jeffries, a 49-year-old money manager in Dover, Mass., had hip-resurfacing surgery in 2008 and is now coaching his son’s basketball team and long-distance cycling.

Alex Douglas, a Wall Street software architect, had both knees replaced last year at 39 after years of sports injuries. He can’t wait to go kite-boarding this weekend. “I’ve been cleared to have fun,” he says.

Hard charging baby boomers and Generation X-ers are wearing out their joints at younger ages and turning to joint replacement surgery. But is it a quick fix? WSJ’s health columnist Melinda Beck discusses with Kelsey Hubbard.

Joint-replacement patients these days are younger and more active than ever before. More than half of all hip-replacement surgeries performed this year are expected to be on people under 65, with the same percentage projected for knee replacements by 2016. The fastest-growing group is patients 46 to 64, according to the American Academy of Orthopaedic Surgery.

Many active middle-agers are wearing out their joints with marathons, triathlons, basketball and tennis and suffering osteoarthritis years earlier than previous generations. They’re also determined to stay active for many more years and not let pain or disability make them sedentary.

To accommodate them, implant makers are working to build joints with longer-wearing materials, and surgeons are offering more options like partial knee replacements, hip resurfacing and minimally invasive procedures.

More younger people also need joint-replacement surgery due to obesity, and some orthopedists refer them for weight-loss surgery first to reduce complications later.

Even the most fit patients face a long period of rehabilitation after surgery and may not be able to resume high-impact activities.

“There is, to be honest, some irrational exuberance out there,” says Daniel Berry, chief of orthopedic surgery at the Mayo Clinic in Rochester, Minn., and president of the American Academy of Orthopedic Surgeons. “People may be overly optimistic about what joint replacement can do for them.”

One big unknown: How long will the replacement joints last? In the past, many doctors assumed implants would wear out in about 10 or 15 years, and they urged young patients to put off surgery as long as possible to minimize the risk of needing a costly and difficult revision surgery—or even two. (A total knee replacement typically costs $15,000 to $22,000. A revision can be $45,000 or more, with a higher risk of complications.)

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…”effect of repeat injections of hyaluronic acid unclear. May not halt progression of OA nor delay knee replacement”…

Written by admin on December 29, 2012 – 11:02 am -

“Osteoarthritis (OA) is characterized by degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth, which ultimately lead to pain and joint stiffness. Most commonly affected joints are the knees, hips, and joints in the hands and spine. OA of the weight bearing joints (e.g. knee and hip) typically have the most clinical significance. The causes of OA are presumed to be related to mechanical and molecular events in the joint (http://www.cdc.gov/arthritis/basics/osteoarthritis.htm).

OA usually begins after the age of 40. OA affects 13.9% of adults aged 25 and older and 33.6% of those aged 65 and over (http://www.cdc.gov/arthritis/basics/osteoarthritis.htm). Among those affected, approximately one quarter of them are severely disabled. [3] Osteoarthritis is the leading cause of mobility disabilities such as difficulty walking or climbing up stairs. OA of the knee is one of five leading causes of disability among non-institutionalized adults. [4]

Knee OA is the most prevalent, followed by hip OA. Both knee and hip OA result in joint pain and stiffness which can ultimately interfere with function and restrict activities of daily living [5].

There is no cure for OA. In addition, there are currently no known therapies that can prevent progression of OA. Treatment of OA typically focuses on minimizing pain and swelling, reducing disability and improving quality of life.
Treatment typically starts with non-pharmacologic therapy approaches including exercise programs, weight loss, patient education and shoe insoles. [6] Non-pharmacologic approaches are typically tried before medications are started.

Pharmacologic treatment is typically the next step and focuses on relief of pain. Pharmacologic therapy typically includes acetominophen, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase (COX-2) inhibitors and opiates. Each of these medications can be beneficial in some patients and each is associated with characteristic side effects. Given that the patient population is typically an older one, often with other comorbid conditions, the side effects associated with long term use of some of the OA medications can be particularly problematic.

Intra-articular glucocorticoid injections are another potential component of OA treatment….”

For the entire article please click below.

Hyaluronic Acid for Treatment of Osteoarthritis of the Knee…

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New Article: Fits Like a Glove

Written by admin on May 1, 2012 – 10:33 am -

To view this as a PDF, click here: Fits Like A Glove

Customization has become de rigueur in almost every facet of modern life. Very few things, today, are “one size fits all.” The same is true for knee replacement (TKA or total knee arthroplasty).

For years manufacturers and surgeons have tried in vain, to personalize the fit and match of joint replacement prosthesis to the exact physiology and mechanics of each individual patient. All too often the end result of these labors represents a triumph of marketing over science—the so-called gender-specific knee is a classic example. Recently much has been made of computer assisted surgery. We have all read about and seen television images of large computers in the operating suite directing a “robot” to make “incisions and cuts.” These purport to improve accuracy and imply better performance and longevity of the implant. Unfortunately, and not surprisingly, the results have yet to meet the expectations of such promising technology. As computer assisted surgery is dependent upon collection of independent patient data obtained in the Operating Room, the results are necessarily limited by the quality of the collection method. The accuracy of the data varies greatly by surgeon and by individual patient– “Garbage in=Garbage out.”

As the data entered into the computer is obtained via relatively inaccurate means, the results are little improved compared to earlier techniques employed by surgeons for decades. Even more, this method requires significantly increased OR time.

“Ok . . . so, computer assisted surgery offers no advantage in performance but adds cost and time. So far, doc, you are not selling me on this concept. What gives?”

It is important to understand that while the results engendered by the implementation of computer assisted surgery have been mixed, at best, the concept is excellent—Personalization of the surgical procedure to meet the exact biomechanical needs of the patient has been the Holy Grail of joint replacement surgeons. Traditionally, TKA is performed utilizing cutting blocks, “jigs,” alignment rods, plumb lines, etc.; not dissimilar from standard cabinetry techniques. These have provided good to excellent results for decades. Unfortunately these methods are limited by individual patient factors (body weight, joint alignment, range of motion) that make it difficult, time consuming, and sometimes impossible to restore the appropriate anatomic alignment for any given patient.

Many manufacturers, in response to this dilemma, now offer a solution to this problem.  In particular, I find the Biomet Signature system to provide the most intuitive and elegant approach.  This is the system that I use for all TKA that I perform. 

Signature is a software-based system that allows the  measurement and much of the technical work to be completed on computer BEFORE the patient enters the OR.  Imagine that!  Doing one’s homework, before the test– What a novel idea! 

Not surprisingly, the results are just as predictable (study before attending class, Ace the test).  The concept and execution are rather simple.  MRI images are obtained of the patient’s Hip, Knee and Ankle.  This information is used to determine the limb alignment and to create a 3-D model of the knee.  This then allows the surgeon to essentially “perform” the surgery on the computer to correct the limb alignment to normal.  Once this data is finalized, a model of the knee is created and precision cutting instruments are manufactured that are unique to each patient.  These models and instruments are then used by the surgeon to perform the procedure according to plan.  Restoration of the patient’s natural limb alignment, improved fit and range of motion are the typical result.Utilizing this technique, the procedure can be performed more quickly and with less blood loss when compared to the traditional method of knee replacement.  Patients normally report less pain, improved range of motion and sometimes a shorter duration of hospitalization and outpatient rehab. 

Today, for the first time in history, with modern surgical and computer assisted techniques you can finally have a knee replacement that “fits like a glove”


 Dr. Mark Galland is a Board Certified Orthopaedic Surgeon specializing in sports medicine, practicing in Wake Forest and North Raleigh. He serves as team physician and Orthopaedic consultant to the Carolina Mudcats, AA Affiliate of the Cincinnati Reds of Major League Baseball, as well as several area high schools and colleges. Dr. Galland can be reached at (919) 562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com.

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