Search for tag: "total joint replacement"

Interviewer: You found out you have tendonitis. Probably wondering what treatments are available, what do you need to know about them and what to expect afterwards. We're going to talk about that next, on The Scope.

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Interviewer: Dr. David Petron is an orthopedic sports medicine specialist at University of Utah Health Care and is also the chief medical officer for the Utah Jazz basketball team. So he knows what he's doing and today we're going to talk about tendonitis.

Dr. Petron: Well first let me say what tendonitis is. There can be confusion about it. Tendon is muscle connected to bone. So at the end of the muscle, that's where the tendon is and then the tendon ultimately attaches to the bone. -Itis infers that it's an inflammation problem, when in fact most tendonitis is really what we call tendonosis because it ends up being a chronic problem. Usually in the first few weeks or maybe the first month we might call it tendonitis. After that it really is not an inflammatory problem, but it's more of a tissue break down problem and then we call it tendonosis.

Interviewer: And that's something that's not going to go away without some sort of intervention. Is that correct?

Dr. Petron: Frequently that's the case and generally the older the patient is, the longer it can take to go away. But even sometimes with prolonged rest, as soon as somebody goes back to doing their usual activity, the tendonosis problem comes back again.

Interviewer: So something's going to have to happen, what are the options? Typically are there a lot?

Dr. Petron: There a lot of options. The one thing that all these options have in common is they do something to disturb the tissue. So it gets in a chronic pattern where it won't heal itself and we need to do something to disturb that tendon to try to get the body to feel like it's an acute injury so that it can ultimately heal itself.

• Rest and ice

  Early on the treatments are conservative, later on they can become more interventional. Some of the early treatments of course are just rest and ice, and relative rest. So say it's a swimming problem and a shoulder problem, you might be able to stay in aerobic shape by running or riding a bike, working on some shoulder exercises while you ease your way back into the pool. So that can be some of the most simple treatment, just relative rest and then gradual return to activity.

• Anti-inflammatories

  Frequently people take anti-inflammatories and they're helpful for the pain, but they're not really helpful for healing. In fact there are some studies that show that they may actually slow down healing. Cortisone is something that people frequently may run into at their doctor's office. And I think that's okay when you're in the -itis phase, so the inflammatory phase. But later on we actually know that cortisone can slow down healing and cortisone in a tendon can actually weaken the tendon, so we've got to be careful about that.

Some of the more advanced treatments I'll just talk about briefly.

• Focused aspiration of scar tissue (FAST)

  There's something called FAST or focused aspiration of scar tissue. This is a newer treatment where you use a percutaneous needle that vibrates about 2000 times a second and then it has irrigation that goes in and fluid that sucks out the necrotic tissue. So it's a way of removing the scar tissue just kind of through a poke hole through the skin's surface.

• Platelet rich plasma (PRP)

  Some of you may have heard of PRP or platelet rich plasma. That's where we draw your own blood off, spin it down, remove the platelets, which have some healing properties, and then re-inject that back into the tendon. Again to disturb the tissue and try to give it a jump start to ultimately heal itself. Even some use of stem cells now using in a similar way as PRP.

• Astym

  Sometimes physical therapists will do something called Astym where they're using—I call it a butter knife—but it's basically some tools that they're rubbing, kind of like a deep tissue massage. Again to try to disturb that tendon to try to get it to turn over and heal itself.

• Extracorporeal shock wave therapy

And then one other thing that we do is called extracorporeal shock wave therapy, which is kind of like a de-tuned lithotripsy. Same kind of technology used to break up a kidney stone. But you do that on the skin surface, again to disturb the tissue, break up the degenerative tissue along the tendon to get that to heal. So there are a few of the more advanced treatments that are being used now for tendons to heal.

Interviewer: My head's spinning. There's so many of them.

Dr. Petron: There's a lot out there, and like most things when there's a lot of different ways to approach it, not one way is perfect. So the physician needs to evaluate the patient and see what might be best for their situation.

Interviewer: Yeah that really sounds like you do need an expert. I mean you can do a little reading on the internet, but it sounds like an expert really needs to decide what is going to be best for your situation.

Dr. Petron: Right, in the early phases though relative rest and gradual return to activity in a lot of patients do well. But once you've had this for three months or six months or longer, probably ought to see a physician.

Interviewer: So getting in early is always the better option.

Dr. Petron: Right, if you start to feel some breakdown say in an Achilles tendon or a rotator cuff in your shoulder, stop. Because once you get into that tendonosis phase, it can be very difficult to get better.

Interviewer: What are some common questions people have about these treatments?

Dr. Petron: One of the common things is when one of these treatments is done, is it going to instantly be better? And the answer to that is no. So some of that might be lowering the expectation. Because again, really the body still has to heal itself. So even with these treatments, it can usually be three months or so until they're healed.

Interviewer: So in three months, back to 100%? I mean is that fair?

Dr. Petron: Usually at least back to activity, their usual activity.

Interviewer: And then how do you prevent—

Dr. Petron: But there are some areas that really have a lousy blood supply, like the Achilles tendon. Once that's really inflamed, that can be even longer than that to return to play.

Interviewer: So I get the treatment, I'm back to activity. How do I prevent this from now happening again and being a vicious circle?

Dr. Petron: Well the most important thing is start out slowly. All of these problems are not traumatic injuries, they're overuse injuries. So it's doing too much too quickly. So in general, the older the athlete, the slower you ought to ease into your particular sport.

Interviewer: And then eventually your body is going to be able to handle anything you throw at it?

Dr. Petron: The body adapts to the stresses put upon it. So just like a weight lifter gradually lifting more and more weight, muscles get bigger, tendons get stronger. That can happen to every part of your body. Bones get stronger, tendons get stronger, ligaments get stronger as you put stress on it. But the key is you need to do that in a controlled manner.

Interviewer: Let's wrap this up with the final thought. What do you think the big takeaway is?

Dr. Petron: Prevention is always key, so if you start to get feeling of tendon pain then back off on that activity. Relative rest, which means you can still stay active but don't overuse that tendon. If you do overuse it and you have the symptoms for say three months or longer, probably should seek the care of a physician.

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updated: February 12, 2019
originally published: April 8, 2015

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Interviewer: In this series of podcast we're talking about knee replacement surgery and hip replacement surgery. We've already done a couple episodes talking about whether its right for you or not and the similarities and differences in the two procedures.

You've gotten to the point now that you've decided to have surgery and you've likely talked to somebody and you have an appointment. This podcast is going to help you prepare once you've decided to have surgery. We're with Dr. Chris Pelt. He's an expert in joint replacement in University of Utah Health Care at the Orthopedic Center. So what should I do before surgery to make sure it goes as well as possible? I've heard this referred to as pre-hab.

Dr. Pelt: Pre-hab is a new concept that we're really trying to optimize patients to get them ready for surgery. Pre-hab may be including physical therapy to strengthen their muscles and improve their conditioning and get them physically fit so that they're going to have a better outcome after the surgery.

But more than just pre-hab, it's optimizing patients so that they're going to have a good outcome. And that includes everything from their nutrition, their diet, their mental states so that they're ready to undergo a big surgery, to optimize their family support systems, so that they have adequate resources and people around to help them get through the surgery and the recovery process. It's about optimizing their medical condition. Again, we want to make sure people don't have a complication or a poor outcome. We want to make sure that they have a good chance of healing their wound and not getting an infection.

So if there are risk factors for outcomes that might be impacted by the things like smoking or obesity or diabetes, we want to take the time before the surgery to optimize modifiable risk factors, making sure that we have the best chance of a great outcome. So that might include visiting with your primary care doctor, working with physical therapists or diabetes specialist, weight loss specialist to try to optimize their medical condition.

We want to make sure that they're healthy. They don't have a sickness. They don't have sores or scrapes or scratches on their bodies, something that could be a source to get an infection in their blood stream. Anything that we can do to make sure that they're coming into the surgery as perfectly tuned up as possible is what we're trying to do in the pre-hab setting.

Interviewer: Because we learned in a previous podcast that infection is one of the big threats of this type of surgery. So some of these things can actually lower your chance of infection.

Dr. Pelt: That's absolutely right. Infection is rare, less than 1%. But when it does happen it can be a devastating complication. So if they are modifiable things that we can do to optimize our health and decrease our chances of an infection, we want to take all of that time and that energy and effort and do that before we go to the operating room.

Interviewer: And I understand here at the University of Utah that you actually have a class beforehand that helps people prepare for the surgery. Tell me about that.

Dr. Pelt: We have a joint academy that we ask all of our patients to attend prior to a joint replacement surgery. A lot of this helps to set some of the expectations about what is it like to have a surgery. You're going to meet with our physical therapist. You're going to hear about what type of modifications you need to make at home, what kind of things you're going to expect after the surgery from a physical therapy recovery rehabilitation process.

We find this to be a very integral portion of the preoperative period. We want patients to get that education, hear it from the people that are going to be helping take care of them, so that they know what to expect when they have their surgery. And really it does help optimize their outcomes later.

Interviewer: And I think it's important to stress it. It's okay to hear this information two or three times, because there's a lot of it. So the more you hear it the better command you have of it.

Dr. Pelt: You're going to be absolutely inundated with information from the very first visit to our office all the way through the end of this process. And hearing it multiple times really helps to reinforce it. And as hard as we try to tell it to you, to write it down, for you to listen and you're going to miss parts. And you're going to be really I think better off by having heard it multiple times.

Interviewer: And it's integral to your recovery and your quality of life after the surgery that you understand and do a lot of these things. What about family members? We talked about pre-hab in terms of changing some lifestyle stuff, but family members are important in the recovery too. Talk about that a little bit and how you should prepare them before you go in for surgery.

Dr. Pelt: We talked about the fact that it is a big surgery. So having a social support system is really valuable, actually. It helps you get through it. It also provides you resources. One of the things that we know is that patients have the best outcomes when they're able to return to their own home in their post-operative setting. There's lower risk of complications and in your own home you're going to have a more peaceful setting where you're going to recover well. And you have people around you that love you and are helping you get the best outcomes.

Please bring your family member to your preoperative visit, to your visits with your surgeon, to the visits with your therapist, to the joint academy. Get them involved. The more people that hear it and the more times you hear it, the better off you're going to be and the better you're outcomes are going to be.

Interviewer: Plus also you need to prepare for after your surgery, which we've got a podcast coming up and family is crucial to that recovery as well, just being there.

Dr. Pelt: Again, I think that the family really helps facilitate your optimal care after the surgery. And having them around, someone that can help you, light household chores, housework, maybe preparing some meals for you kind of decreasing the burden of activities of daily living for you while you spend more of your energy recovering. But the good news is, you're going to be up like I said walking, before you leave the hospital you're able to walk stairs, get in and out of cars, walk around the hallway and the nurse's stations.

You're not going to be totally dependent on your family but you're going to want somebody around to be there to support you I think.

Interviewer: Finally let's talk about how you can pre-hab your house, so to speak, to make sure that it's prepared for your return home after the replacement, because you'd have to change a few things.

Dr. Pelt: Most people will have stairs in their house. You can't get rid of stairs in your home. But you can try to optimize the placement of things on similar floors if that's an option. Perhaps you might use a guest bedroom instead of your normal bedroom because it's closer to a bathroom and the kitchen and maybe things are on the same floor. That might not be an option for everybody and it's not mandatory. But things that you can do to simply make it easier for you to co-locate certain things you're going to do throughout your activities of daily living will be helpful.

Removing obstacles throughout the house, maybe you have some bath mats or area rugs that you might want to remove because they might be a risk factor for you to trip on with your walker or your crutches. And also trying to practice using those types of things in your own home before you even have your surgery before you have to come back and try it out. Practice with your crutches, walk around your house a little bit. See how it feels and make sure that everything is looking like it's going to be a good option for you when you get back.

Interviewer: Yeah. Now, that you said that I'm like, ìThat's a great ideaî but I could see myself feeling like, ìthis is little sillyî but it probably does make a difference. You probably might see some things you might not realize before.

Dr. Pelt: I think the more you do before you have the surgery and before you get home, the better off you're going to be.

Interviewer: Coming up in the next podcast we'll talk about life after your total joint replacement whether it's in your hip. We'll talk about how will it improve your life, what to expect as far as that is concerned, what to expect with rehab and also what to expect with pain management.

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Interviewer: In this series of podcast, we're talking about hip and knee replacements and what you might need to know and what you do need to know, all the way from the beginning to the end of the process. So in this particular podcast, we're going to talk about hip and knee, the similarities and the differences, because for the most part, there are a lot of similarities. But there are some unique risks and challenges that might apply if you're getting a hip replacement or a knee replacement. Dr. Chris Pelt is a joint replacement expert at University of Utah Health Care in the Orthopedic Center. So first of all, let's look at the similarities between these two types of joint replacements.

Dr. Pelt: Hip and knee replacements are both fairly invasive surgeries. They're done in a hospital setting. Most patients will have an in-patient stay of overnight. Some patients might be eligible to go home the day of surgery and others may take a couple of extra days. In general though, they are very similar as far as the invasiveness and the risks that are associated with the surgeries. We do spend time in clinic and try to have patients understand that there are risks, and that's part of the reason that we don't invite every patient to simply jump right into joint replacement surgery. The benefits of the surgery, mean the potential for relieving pain and improving function, have to be greater than the likely risks that exist when you undergo any procedure, and in particular, with joint replacement.

Joint replacement is a unique surgery when compared to other surgeries in our bodies because we're using metal and plastic parts to resurface the end of our bones. The reason that's really important to understand is metal and plastic parts in our bodies don't have an immune system and they can't fight off infections on their own, and so they're at very high risk for infection-related complications. That being said, national averages over the last decade or so have ranged between 1 and 3% when you look at all joint replacements done throughout the country. At the University of Utah, we work really hard on our infection prevention methods and our average has been less than 1% actually over the last five years.

But it is important to understand that if an infection occurs in a joint replacement, we can't simply treat it like we might if we get an infection in a different kind of surgery of our body. We can't just give an antibiotic and hope the infection goes away. Often what that means, if we do experience an infection, that we're going to be going to the operating room and there's going to be more surgeries. Potentially, surgeries to remove the implants that we worked so hard to place and get those taken out because we have to get the bacteria and the implants out together. So that's one of the really unique issues that's related to joint replacement, as opposed, as I mentioned, to other potential surgeries people might have throughout their body.

Besides that, there are other inherent risks of joint replacement surgery. There's a slightly increased risk for blood clots. That can happen in the legs or the lungs. We work really hard to try to prevent that. Part of the prevention is just getting people up and moving which is one of the great things about joint replacement is it does help improve their function, helps them get up and move.

We encourage our patients to get up and start walking with their therapist on the day of the surgery, and in order to decrease their pain as well as to decrease their risk for blood clots. We also use some medications to help thin the blood and also to help prevent people from getting those blood clots.

And then there are other issues that anyone could have with any surgery, whether it's a joint replacement or anything else, they might have a risk for a heart attack or strokes or other bad things that could happen medically. They are exceedingly rare. In fact, the risk of those types of bad things happening with anesthesia or joint replacement is no more and perhaps even less than the risk of them getting in a car accident on the way to the joint replacement center. So we really take a lot of effort and spend a lot of time maximizing people's health and working hard to minimize their chances of having an adverse event or a risk or a complication.

Interviewer: So those are some of the similarities whether you're getting a knee or a hip. Now, let's look at some unique aspects of knee surgery.

Dr. Pelt: So with knee replacement surgery, it is a part of your body that has the effect of gravity. It's downhill from our heart. So knees tend to swell perhaps a little bit more. They tend to get fairly bruised after the surgery. And then most importantly, not just around the time of the surgery, but also for the life of the knee replacement, some patients will describe a more mechanical feel of the knee. They might notice some clicks. Most patients will have a patch of numbness on the outside of their knee after the incision is made for knee replacement. These are all very common things and they're a little bit unique to a knee replacement as opposed to a hip replacement.

Most patients will have substantial improvements in their pain, and again that is the whole purpose of doing the joint replacement, is to decrease peoples' pain. But it may not be completely pain-free. They may still have a little ache or swelling occasionally. They may notice the weather change. But often, they are performing well better than they had been before their joint replacement.

With hip replacement, many people will actually go on and even forget that they had it done. The hip does perform differently than the knee. It's a different type of joint, it's a ball and socket as opposed to a hinge type of a joint like a knee. So there's different types of soft tissues around it, it's a deeper joint, there's more muscles. In general, many patients after hip replacement after a year or more may not even remember they had it done. They become so pain-free and it becomes such a normal part of their life, so people do have those subtle differences that they notice between hip and knee replacement.

There are differences also in the risks between the two. With knee replacement, we don't much talk about the risk of dislocation or leg length, and many surgeons that will discuss hip replacement with patients may discuss these unique things. Dislocation in a ball and socket joint means the ball will pop out of the socket. That's also an exceedingly rare complication, but it is unique to the hip as opposed to the knee. What happens if a dislocation occurs, patients may have to go to the emergency room or come back to the hospital, see their surgeon to have it replaced or reduced without surgery. But again, the risk of that is very, very low. Less than 1% with the techniques that we use in today's approaches to minimize their chances of dislocation.

Leg lengths the surgeon can adjust slightly during a surgery, but our surgeons are working very hard and actually using x-rays during the surgery and measuring within millimeters, if not micrometers, to make sure that we're working hard to restore patient's leg lengths again so that patients don't feel like they're unequal. Many patients will come into surgery with one of their legs being longer or shorter actually because of the arthritis, and we're working to make those equal again with the hip replacement to restore that again.

Hip and knee replacement afford significant improvements in patient's quality of life, their improvement in their function, and decreases in their pain levels. There are unique differences between the two procedures. But in general, very similar risk profile and very similar improvements in patient's outcomes. For more information about hip and knee replacement, visit our website at UniversityofUtahOrthopedics.com.

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Interviewer: In this series of podcasts we've been talking about total joint replacements for the hip or the knee, and trying to figure out if it's right for you. If you do decide you want the procedure we're also in the series covering what to expect before, during and after. And in the first segment we talked about if a replacement may be right for you.

But another consideration is have you tried more conservative measures to alleviate your pain? And to help sort through them is Dr. Chris Pelt. He's a joint replacement expert at University of Utah Healthcare's Orthopedic Center. Tell us about some of the options patients should try before they make the next step to a complete joint replacement.

Dr. Pelt: Well the first thing that most people already do before they even come to a doctor is they that either have not addressed the fact that they have pain or they've started to modify their activities. Most people start to do that on their own, and it's one of the indicators that they're being bothered by their joint pain and arthritis. Things like they stopped running as far, or they stopped running altogether. Their hikes may become walks around the block instead of hikes in the mountains, maybe they're not skiing the double black diamonds anymore, or avoiding the moguls and they're sticking to the groomers now. Starting to change the things they do at work, starting to do the things they do at home differently. Maybe they can't even go to the grocery store as much as they used to, or they're having to use a walker or a wheelchair at times. So people start to modify their activity.

When we start to provide conservative treatments through our primary care colleagues, non-operative specialists or even ourselves, when we're trying to avoid surgery, we utilize other modalities. Things like physical therapy. Perhaps braces, or compression wraps. I mentioned wheelchairs or crutches, or walkers. Things like assistance devices. Some people start to use a cane. We can often offer medications. The mainstay in the treatment of arthritis pain is to attempt to decrease pain associated with inflammation. Arthritis is simply when we lose that smooth cartilage on the end of the bones in our joints, it creates a rough mechanical problem. That also creates inflammation so using a medication like an anti-inflammatory can decrease the inflammation and therefore also decrease the pain associated with it.

There are other things besides just anti-inflammatories, and some patients may not be able to take an anti-inflammatory. Patients with renal or kidney problems, patients with stomach issues or ulcers. They may have other reasons that they can't take an anti-inflammatory, so there are other things to take as a medication for pain as well. Things like Tylenol. Over the counter Tylenol works very well. Acetaminophen as an analgesic or a pain relieving medication. There are other types of pain relievers we often try to avoid, but they do exist for the treatment of arthritis based pain, like narcotics. Norco, or Tramadol or other similar types of medications can be tried as well. Again, we try to avoid those because there are other, better modalities often than giving people narcotics.

There are creams, topical creams. Anti-inflammatory creams. Joint relieving bio-freezes and Ben-Gay type of creams that people also can use. And we have some over the counter as well as some prescription based types of creams as well. Injections are another method that obviously we will try to use. And the idea there again is trying to decrease the inflammation and decrease the pain in the joint without performing a big surgery.

There are two types of injections that are typically tried, Cortico-steroid injections. A lot of people refer to these as the cortisone injection. It isn't actually cortisone that most surgeons or doctors are providing, but it's a type of a medication designed to decrease inflammation and therefore pain in the joint. A lot of patients will ask us about these injections. "Is this going to make my arthritis go away?" And the answer is "Probably not, but it may make you feel better that you don't care that the arthritis is there." It decreases your pain and allows you to do the activities you need to do without having to have a big surgery.

A second type of an injection might be something that is commonly known as a joint lubricant, or some people hear it referred to as a chicken comb based injection. And that's based on the material that the companies are providing in these types of injections. What this is is the building blocks of cartilage. And when injected into the joint it may provide two potential effects, one of them being to act as a joint lubricant. When we look at it in the studies it may not be that that lasts very long, sometimes even only a couple of days of this lubricating effect in the joint.

But secondly what it does is it starts to, your body starts to break down these injections it also creates an anti-inflammatory reaction or response to suppress the inflammation in the joint as well. And these injections may last even longer, with months if not years of relief for those patients that are well indicated and have a good response for that. More and more we're seeing insurance companies and others have stricter criteria for patients that might be candidates for those joint lubricant injections, but nonetheless it's one of the other things that exists as possibility for treating pain without surgery.

And the final option is a surgery of some sort. And there are two types of surgeries in general for people with hip or knee conditions. One of them, arthroscopy or minimally invasive camera type surgery, and then the other being joint replacement surgery. The lesser invasive things like arthroscopy may not be suitable for all patients with arthritis though, and that will be a discussion best had with a surgeon.

Interviewer: So it sounds like before we get to surgery, is it your goal as a surgeon to try a lot of these things before you actually do the replacement?

Dr. Pelt: It's our goal, not because we're trying to make patients jump through hoops or delaying the inevitable, but we're trying to prolong the life of their native joint. So once again, when we're putting in a joint replacement, these are parts that may not last for the rest of these patients lives, and we want to maximize the life expectancy of the implant that's going to be replaced and some point, but also to maximize their function with the current joint that they have, without perhaps undergoing a major surgery. At least not yet, if that's inevitable for them.

Interviewer: In the next episode we'll talk to Dr. Chris Pelt about the similarities and the differences between knee and hip surgery. There are a lot of things you need to know about both surgeries that are the same, and there are a few differences as well.

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