Dr. Gold's Orthopedic Surgery Blog

Transforaminal lumbar interbody fusion, or TLIF, is a surgical procedure to fuse vertebrae together. Since the procedure creates a solid, inflexible bone “bridge,” the patient will be unable to bend his back at the spot where the fusion is performed. TLIF back surgery is frequently used to treat herniated discs that recur repeatedly, degenerative disc disease, spondylolysis or other conditions in which the patient’s pain level might be reduced by the stabilization.

TLIF is open surgery requiring a hospital stay of three to five days. The patient will normally begin physical therapy within 24 hours of the surgery, but initial activity will be limited. Many patients must wear a brace for all or part of their recovery

. After discharge, patients will receive pain medications to take at home and will be restricted to light activities. Office workers can normally return to work in one to two months. Those whose jobs are more physically demanding typically have a longer recovery time before they can resume their normal occupations.

TLIF fuses both the posterior and anterior of the spinal column. The surgeon uses hardware and bone, if needed, to lock the posterior into place. The bone graft and spacer stabilize the anterior region.

To perform a TLIF back surgery, the surgeon will make an incision in the back to expose the spine. The disc between the two operative vertebrae is removed. The surgeon will harvest a bone graft from the patient’s hip and insert it in a cage or spacer that is inserted in the gap left by the disc he removed. He will also add bone to the sides of the disc space and the vertebrae. Plates or rods are screwed into place and the incision is closed.

Patients who have disabling leg and back pain and have failed all nonsurgical options may obtain significant pain relief from a TLIF. Studies report that 60 to 70 percent of patients undergoing the procedure indicated they experienced an improvement in their level of pain.

While TLIF normally results in reduced pain levels and solid fusion of the bone, rare complications can occur. As is true with any surgery, patients are at risk for complications from the anesthesia, excessive bleeding, damage to the nerves and infection. Patients may also develop blood clots, pneumonia, experience a stroke, or suffer a heart attack. Risks specific to the TLIF procedure include the possibility that fusion fails to occur, requiring another operation. The procedure may not alleviate the patient’s pain, and in a few rare cases, patients report their pain levels actually increased.

I hope that helps you learn more about TLIF back surgery!

Until next time,

Stuart

A common question I receive from patients suffering knee pain is, “Would I benefit from knee arthritis surgery?” Before I answer that question, I perform the necessary tests to understand the patient’s diagnosis

. I also make sure that my patients understand the anatomy of the knee and the surgical expectations. Here is some information that I hope helps you as well.

Arthritis of the knee causes the joint to become painful and stiff. It may take the form of osteoarthritis, which results from wear, or rheumatoid arthritis, which is an autoimmune disease. Other factors, such as infections or lupus and other diseases, notably complex fractures of the knee, can also lead to arthritis.

The knee is an important weight-bearing joint. The tibia, or shinbone, and the femur, or thighbone, meet at the knee, which operates like a hinge. The kneecap, or patella, glides over the femur tip when the knee is bent. In a healthy knee, articular cartilage covers the patella and the ends of the tibia and femur. The cartilage reduces friction when the joint moves.

With osteoarthritis, the cartilage cushioning the bones becomes eroded. This allows the ends of the bones to grind against each other. The cartilage may be thinned, due to disease, or it may be completely missing. Bits of cartilage may be left to float inside the joint, causing additional pain.

Rheumatoid arthritis leads to inflammation of the surrounding synovial membrane. Eventually, it will destroy the cartilage. Adjacent bone may also become soft and damaged.

In the early stages of knee arthritis, anti inflammatories i.e. Motrin, naprosyn, etc, are effective. Injections used appropriately like cortisone and viscosupplementation are helpful in some patients.

If the patient’s condition involves severe pain and marked lack of mobility, a surgeon may recommend knee replacement surgery. Each patient must make an informed decision, after consulting with his physician, regarding knee replacement surgery. The operation has a success rate of approximately 96 percent, and has become one of the more routine procedures that orthopedic surgeons perform.

To replace the knee, the surgeon makes an incision and exposes the joint. The ends of the femur and tibia are removed. Only a minimal layer of bone is removed, which is replaced with two layers of metal and a plastic spacer. If needed, a layer of plastic is applied to the back of the patella. These replacement components are cemented into place in most cases.

The knee has both and outer and an inner compartment. It is possible for only one of these compartments to be severely damaged. A unicompartmental or partial knee replacement addresses only the damaged compartment. Recovery time may be shorter and the patient may obtain an improved range of motion.

Rarely, a patient may opt to have the femur and tibia fused. This procedure is referred to as a knee fusion. The procedure leaves the patient with total and permanent stiffness of the joint. Few patients willingly choose to deal with the inconvenience such stiffness causes. However, if a successful fusion is achieved pain relief is excellent.

Arthritis can cause the legs to bow, which can accelerate the degeneration. An osteotomy changes the leg’s alignment. The surgeon makes an incision and then cuts either the femur or the tibia so he can realign the leg and unload the more diseased compartment. The procedure is usually recommended only for younger individuals whose arthritis is not yet advanced and who still have a good range of motion. While the procedure can alleviate pain, most patients eventually will have the joint replaced.

Until next time,
Stuart

The other day a patient asked me, “Are there different types of elbow surgery?” To help her (and perhaps you), I put together the information below.

The elbow is an important joint and is subject to extensive use during daily activities. Because it often has to bear a great deal of overuse, there are many things that can go wrong with the elbow. Doctors have developed numerous procedures to deal with the problems that can arise in and around the joint.

The biggest type of elbow surgery that orthopedic surgeons typically perform on the elbow is a total elbow replacement (TER). When medical treatment has been exhausted for advanced elbow arthritis or in the elderly with very complex fractures, a TER should be considered after the patient has been given anesthesia, a tourniquet is applied on the upper arm to reduce the blood flow. An incision, normally about six inches in length, is made to expose the bones. The elbow joint is removed and the bones prepared for the prosthetic. Metal stems are inserted into the center of the bones, into which cement has been injected. After the cement hardens, the two stems are connected with a pin.

If the patient is not a candidate for a joint replacement, or if movement causes the pain in the elbow, the surgeon may perform an interposition arthroplasty

. This procedure involves placing either a portion of the patient’s soft tissue or an artificial tissue between the ends of the bones that comprise the elbow joint. This usually eliminates the abrasive action of bone on bone and can provide pain relief.

A synovectomy is often recommended for those with rheumatoid arthritis or other forms of inflammatory arthritis when nonoperative treatments have failed. This procedure can be performed arthroscopically or open in order to remove the synovial tissue surrounding the elbow that has become swollen and inflamed. The inflamed synovial tissue is a frequent cause of elbow pain among rheumatoid arthritis patients, and the procedure may alleviate the pain.

A debridement is an arthroscopic procedure to remove bone chips, damaged cartilage, or bone spurs, all of which can occur in patients with osteoarthritis. An osteocapsular arthroplasty is a combination of debridement and synovectomy. This procedure is also used frequently for arthritic elbows, and may involve re-contouring the ends of bones that have degenerated or become deformed.

Surgery for tennis elbow is seldom recommended unless the patient is experiencing pain that is incapacitating and that does not improve after six to twelve months of treatment. The procedure is normally performed on an outpatient basis using a local anesthesia. The surgeon normally makes a small incision through which he can remove the damaged portion of the tendon and reattach the healthy tissue to the bone.

Elbow surgery is also performed if a nerve is being compressed, limiting function and causing pain. Surgery for an ulnar nerve entrapment is normally performed in the area around the elbow. Techniques vary, but the most common involves moving the nerve from the back to the front of the joint. This technique is known as an anterior transposition. The nerve can be repositioned beneath muscle tissue in a submuscular transposition, inside the muscle in an intermuscular transposition, or on top of the muscle but beneath the skin in a subcutaneous transposition. The procedure is normally performed as outpatient surgery, but in some instances, it may involve one-day hospitalization.

Another common procedure, particularly among athletes, is to repair a biceps tendon tear. This surgery is normally performed no later than two weeks after the injury, since a longer delay can leave the tendon scarred and impossible to return to its normal position. Various techniques are used, including implanting devices to which the surgeon can tie the tendon or drilling into the bone to anchor sutures. Recovering from surgery to repair a ruptured tendon can be lengthy. Physical therapy is often required, but patients are typically advised to avoid pulling, lifting, or overtaxing the arm for many months.

Until next time,

Stuart

I often get questions about the anterior approach to hip replacement. To help you learn more about this unique form of orthopedic surgery, here is some helpful information I’ve learned during my 24 years as an orthopedic surgeon in Torrance, California and other parts of the country.

As you may know, hip replacement surgery has become an increasing common procedure to alleviate the pain caused by arthritis. Although the anterior, or front, approach was developed many decades ago, potential difficulties made it an unpopular choice among orthopedic surgeons. However, as less invasive surgeries proved their benefits, and improved imaging and surgical tools were developed, the technique began to see more widespread use.

In traditional hip replacement surgery, the surgeon accessed the hip from the back or directly from the side. This typically involves the surgical release of the connecting muscles, which must then be reattached. With an anterior approach, the surgeon only releases a minimal amount of muscle, which reduces the damage.

When the technique was first used, surgeons found that, although the anterior approach offered a better view of the joint, there were sometimes problems inserting the metal stem into the femur. If there were difficulties, problems with modifying the incision could result. Since they lacked “instant” X-ray techniques, there was a risk of improperly placing the prosthetic, which could mean unnecessary wear and the potential for dislocation. It should be noted, however, that anterior approach replacement surgeries have historically had fewer incidences of dislocation. This was particularly true when the prosthetics used a smaller head, but as prosthetic designs changed, the rates of dislocation became more evenly distributed.

During surgery, the patient is placed on a special operating table. Spars give the surgeon the ability to manipulate the leg into optimal position. The table may also have a robotic arm attached that can be used to hold the femur during surgery

.

After making an incision, the surgeon removes the diseased joint. The acetabulum is reamed to prepare the bone to accept the prosthetic. The part of the prosthetic that fits into the acetabular cavity is slightly larger than the cavity. Real-time imaging devices can be used to ensure accurate placement of the prosthetic. The surgeon may use screws to hold the prosthesis in place during initial healing. As the patient recovers, new bone growth will provide the necessary stability.

The surgeon will then prepare the femur and place the prosthetic. He may use real-time imaging devices to compare the patient’s other hip to the one undergoing surgery. If needed, he can make adjustments to the length of the leg through the femoral implant.

Whether or not the surgeon cements the prosthetic in place depends on the type of prosthetic and the surgeon’s preference and is based upon the patient’s bone quality. Most often, cement is not used on the acetabulum or on the femur.

The anterior approach offers some advantages to the posterior approach. The surgeon can control any needed adjustments to leg length with greater accuracy. The incision is smaller with an anterior approach, potentially reducing scarring and pain. The advantage of the posterior approach is a better view of the femur and smaller risk of under sizing the femoral component. The choice of prosthetic is not a factor in determining which surgical approach should be used. All modern prostheses can be used with anterior, posterior, or lateral approaches.

Until next time,

Stuart

The other day I was asked, “Stuart, What is orthopedic surgery?” It was a great, simple question. And since I’ve been practicing orthopedic surgery for 23 years (now in Torrance, California), I think I had a pretty good answer that you might find interesting.

The musculoskeletal system is comprised of the bones, muscles, joints, tendons and ligaments the body needs for movement. An orthopedic surgeon diagnoses and treats injuries and illnesses that affect some part of the musculoskeletal system. Treatment may involve traditional surgery, but an orthopedic surgeon may use non-surgical treatments in many cases as well.

The term “orthopedics” was coined in 1741 with the publication of a work on correcting deformities in children. Less than forty years later, the first European orthopedic institute was established. The hospital focused on treating skeletal defects or deformities in children.

Many advances in the field over the next two hundred years were the result of war. Saving lives and limbs on the battlefield required physicians to invent better methods of treating injured soldiers. As the twentieth century progressed, additional advances came from treating sports injuries, resulting in more athletes returning to their sport from what had once been career-ending injuries.

During the 1950s, orthopedic surgeons began developing arthroscopic surgical procedures for cartilage and ligament repair. Arthroscopic surgery is a minimally invasive technique that reduces scarring and speeds recovery over traditional open surgery (e.g

. shoulder surgery). Today, a great many orthopedic procedures can be performed using arthroscopic techniques.

Among the most common operations orthopedic surgeons perform are arthroscopic surgery of the knee or shoulder surgery, carpal tunnel release, replacement of the knee or hip replacement surgery, and repair of fractures. Reconstruction of the anterior cruciate ligament, or ACL, surgery to repair rotator cuff tendons, debridement of a joint surface, and disc surgery are also common procedures.

An orthopedic surgeon may also be called on to treat congenital defects such as hip dysplasia or clubfoot. He may work with patients who have spinal scoliosis, cerebral palsy, or Marfans syndrome. Some surgeons focus on rheumatoid arthritis and the joint replacements many of these patients need. In short, an orthopedic surgeon may be called on to treat virtually any part of the musculoskeletal system that can become diseased or injured.

In addition to diagnosing a patient’s problem, an orthopedic surgeon must also be knowledgeable about the physical or occupational therapy a patient may need for post-surgical rehabilitation. He can also advise on injury prevention. Lifestyle changes, diet, and exercise are among the recommendations he may make as part of a treatment plan.

In the United States, most orthopedic surgeons complete a four to five year residency in surgery after graduating from medical school. Three-fourths of the residency is typically spent in orthopedic surgery, with the balance in general surgery. Six months of the orthopedic surgical training is normally devoted to pediatric orthopedics.

After completing a residency, an orthopedic surgeon may choose to complete a one or two year fellowship in a sub-specialty. Orthopedic surgeons in the U.S. may elect to specialize in one part of the body, such as the hand or spine, or a procedure, such as joint replacement and reconstruction. He may also elect to focus on pediatrics, sports injuries, or trauma.

If he desires, an orthopedic surgeon may apply for certification by the American Board of Orthopedic Surgeons once he completes his residency. To become board-certified, the surgeon must successfully pass both a written and an oral exam. He can also sit for an additional examination to earn a Certificate of Added Qualifications if he has sports medicine or hand surgery as a sub-specialty. Finally, to insure the orthopedist is keeping up on continuing his education, as treatment evolves, a board recertification exam needs to be completed every ten years.

I hope that helped you answer the question, “What is orthopedic surgery?”

Until next time,

Stuart

One of the key elements of a successful shoulder replacement surgery is a proper and well guided recovery.

A shoulder replacement can often allow a patient to resume many of his or her pre-operative activities. The procedure predictably provides pain relief, but functional improvement is variable and patient dependent. Additionally, an important part of this recovery requires the patient to commit to the surgeon’s recovery and post surgical rehab plan

. This may involve restricting certain activities, performing the prescribed exercises, and, if needed, attending occupational or physical therapy sessions on a regular basis. Each plan takes the patient’s age and health into account, so it is highly unlikely that one patient’s plan will be identical to another’s.

After the surgery is completed, the patient will spend one or two hours in the recovery room. He or she will not be moved to a hospital room until awake. If a nerve block (done to control post op pain) is placed before the procedure, upon awakening, the patient may notice that the arm on which surgery was performed is numb and that the wrist and fingers may not move normally for up to 24 hours.

While still in the recovery room, many surgeons order an icing machine for placement on the shoulder. These devices help reduce swelling and pain. Typically, the patient is instructed to continue using the device or ice packs after discharge. Other key elements of a shoulder replacement recovery include:

• As soon as the patient regains movement in the hand, it is helpful to begin exercising. This is normally just making a fist with the hand on the arm on which surgery was performed. The patient will likely be instructed to hold the fist for five seconds before releasing and to repeat the action frequently. This exercise can help keep the blood in that arm circulating and can reduce bruising.

• Most patients wear a sling for four to six weeks following surgery. It should definitely be worn in crowds or when the patient is mobile, such as climbing stairs. It may be possible to relax the sling while performing sedentary activities, such as watching television.

• During the first six weeks, most patients are told to refrain from driving. It normally takes this long to regain adequate range of movement in the shoulder to perform many activities of daily living. Few patients are able to return to work within the first 3-4 weeks, and those with more strenuous occupations may require eight months. As a rule, patients may use the arm for routine activities, such as writing or eating, but should not lift with the arm or make sudden movements with it for six weeks.

As for your hospital stay, most patients are in the hospital for two days following the surgery, and during this time, they usually see a physical therapist once or twice a day. The physician may order a patient to begin exercises as soon as the day following surgery. Exercises are designed to strengthen the arm as well as keep it flexible. The precise exercises will depend on the patient’s age, physical ability, and health, but as a rule, they are not load-bearing movements.

The surgeon will probably want to see the patient 7-14 days after shoulder replacement surgery. At this visit, the sutures are normally removed. Until that appointment, the patient should keep the incision clean and dry as possible. Once the wound is sealed and dry without any drainage, getting it wet, but avoiding scrubbing, is permitted.

Shoulder replacement surgery has an excellent success rate for resolving pain and improving functionality. Often, the patient can resume many activities, including low impact sports. Patients who pick the right surgeon and follow their therapy plans typically reap the greatest benefits.

I hope that helps you learn more about the recovery from shoulder replacement.

Until next time,

Stuart

Tennis elbow is a painful inflammation of the tendons connecting the outer forearm muscles to the elbow. Although it can be caused by a traumatic injury, it most often results from overuse. Repetitive actions that require twisting the arm can cause stress and small tears in the tendon, causing pain and soreness. As the name implies, those who play racquet sports may develop the condition, but it can also be caused by activities such as painting, working with a screwdriver, or gardening.

Approximately 95 percent of the people who develop tennis elbow can find relief through temporarily eliminating the activity, applying ice packs periodically during the first three days followed by heat, and taking non-prescription pain relievers. A brace (elbow band) may also be used to redistribute pressure away from the tendon. Physical therapy and stretching exercises may also be beneficial. One or two selective injections of cortisone frequently accelerate the recovery if other measures have failed.

Should other treatments fail, a patient may consider a surgical solution. Whether a patient undergoes a traditional tennis elbow operation or has arthroscopic surgery depends on his or her physician’s assessment. The surgeon must determine the best point of entry into the elbow and the nature of the repair or reconstruction that must be done. The specifics of the case will determine the technique used.

A tennis elbow operation, whether performed through open surgery or arthroscopically, involves certain common steps. The tendon is cut, or released, so that the surgeon can remove the damaged tissue. If it is possible to do so without tightening the tendon excessively, the tendon is then reattached. Whether the procedure is performed under local or general anesthesia is determined by the patient’s case history and the surgeon’s knowledge and experience.

Both open and arthroscopic elbow surgery can produce successful results, eliminating the most of the pain the patient was enduring

. However, regardless of the method used, patients will likely need to commit to an exercise program to strengthen and stretch the muscles and tendons in the elbow. The most successful operations are those involving patients who follow a post-operative program of rehabilitation.

Recovery time varies by patient and the type of tennis elbow operation performed. Those with relatively minor damage who have arthroscopic surgery can usually resume normal activities, including sports, in six to twelve weeks. If the damage was more severe, it can be as long as six to eight months before the patient is cleared to resume heavy lifting or racquet sports.

I hope that helps you understand more about operations for tennis elbows.

Until next time,

Stuart