Dr. Gold's Orthopedic Surgery Blog

Earlier today a patient asked me to describe what happens during a herniated disk neck surgery. That said, I had a few minutes to jot down parts of our discussion for you to learn from. Here are the highlights of our discussion.

In between the vertebrae are discs filled with a jelly like fluid contained by a more rigid structure, similar to a jelly donut. The discs help provide an articulation (joint) which facilitates movement, but more importantly they serve as shock absorber

. Age or injury can cause the discs to leak, and the jelly or disc material can exert pressure on nearby nerves. When this occurs in the neck (cervical region), nerves leading to the arms or legs can be affected. Pain, numbness or weakness in the arms and legs can occur, and may be quite severe. While many patients heal with time and rest, herniated disk neck surgery may be required to provide relief and to prevent further damage to the nerves.

Herniated disk neck surgery is reserved for only the most serious cases. The patient will typically be treated with non-surgical methods for several months first, and neck surgery is then considered if the patient does not improve. If there are neurological problems that are being caused by the compression, such as limited functionality, loss of balance, pain, tingling or numbness, or severe headaches, the surgeon may also recommend an operation to resolve the problem.

There are two primary types of herniated disk neck surgery. The surgeon may choose to make a small incision and insert a tiny camera to view the damaged disc and then remove and or repair it. A larger incision allows the surgeon to view the damage firsthand, as well as locate any other problems in the area.

• The first method carries a lower risk of infection and a faster recovery time
• The second method allows the surgeon to view a more complete picture of the affected area.

Both methods involve the surgical removal of the damaged tissue, or herniated disc. Depending on the approach used and the amount of damage that must be corrected, incisions are seldom more than two inches in length and require only minimal cutting of muscle tissue.

After the damaged disc is removed, the vertebrae are often surgically fused, typically with a bone graft, to close the gap. In most cases now, a plate is added to provide greater stability. In some cases an enlargement of the opening (foramen), the canal where the nerve exits is performed. A fusion is not used in all of these cases.

Many times, surgery to correct a herniated disc can be done on an outpatient basis or with only one night in the hospital. Depending on the procedure used, post-operative pain can be minimal. Patients may be required to wear a neck brace after the operation to stabilize the area and prevent re-injury for a short period of time. The specifications for the brace and the duration of its use will vary by patient. Patients may need to limit certain activities for a time after surgery, but again the specifics are determined on a case-by-case basis. Typically, however, the recovery time is measured in weeks, although complete fusion takes several months.

I hope that helps you learn more about what happens during a neck surgery for herniated disk.

Until next time,

Stuart

Arthritis in the ankle may be caused by normal cartilage wear from activity or after a specific injury such as an ankle fracture resulting in post-traumatic arthritis. Ankle arthritis may also be caused by inflammatory conditions such as Lupus or Rheumatoid arthritis. In early stages, patients may experience little or no pain, and discomfort is usually attributable to activities that are high-impact or weight bearing. As the condition progresses, however, some patients may find that the pain does not abate even at night or is present even without weight placed on the joint. Ankle surgery for arthritis is far less common than surgery for other arthritic joints, such as knees or hips. However, there are three basic surgeries that can be an option for patients that do not respond to other treatments, such as splints and special shoes, steroid injections, weight loss or changes in activity levels.

The most commonly performed ankle surgery for arthritis is a debridement. This procedure is typically performed as day surgery on patients in the early stages of arthritis. It is normally an arthroscopic procedure, requiring a minimal incision. Most patients have a short recovery period and can begin placing weight on the ankle within an hour or two of surgery. The procedure has a success rate of 75 to 80 percent for improvement, with about a five percent chance that the debridement may actually worsen symptoms.

Arthroscopic ankle surgery for arthritis normally requires two incisions, each less than one centimeter in length. To perform the debridement, the surgeon uses a telescope and small instruments inserted through the incisions to remove any damaged cartilage or bone spurs. He then cleans and smoothes the surfaces of the bones.

Patients with arthritis of the ankle may also undergo fusion surgery. This involves removing the covering of the joint (cartilage) and placing it in position so that the bones will join together. The ankle must be kept in position while the bones fuse, and this is usually accomplished by screwing the two sides of the joint together. In some cases, a metal rod is inserted in the heel to compress the sub-talar and ankle joints. It generally takes about three to four months for the bones to fuse, but some patients may require a longer time for fusion to occur

.

The third ankle surgery arthritis is joint replacement. This procedure is relatively new, so fewer of these operations have been performed than on other joints. Patients normally recover their range of motion, but the operation is unsuitable for those who are active in sports or who perform heavy-duty manual labor. In an ankle replacement, the surgeon removes the worn surfaces on the ends of the two primary bones. The articulation (joint) between the tibia and the talus gets replaced with contoured metal components. A spacer, typically made of polyethylene (a special type of plastic), is added between the two surfaces.

I hope this helps you better understand ankle surgery for arthritis.

Stuart

Earlier today, I saw a patient needing hand surgery due to arthritis. We had a great conversation about arthritis, her hands, her wrists and the surgical process. That said, I thought you might like to read what I explained to her about what happens during hand arthritis surgery.

The hand joints receive a great deal of stress from normal use, although not as much as the knees or hips. However, stress in the joints of the hand is concentrated into a smaller area. The low ratio of area to stress can lead to worn cartilage over time, which is what occurs with osteoarthritis. When the cartilage is damaged, the two ends of the bone rub against each other, causing swelling, pain, and limited mobility. In patients with rheumatoid arthritis, the patient may also develop nodules around the finger joints and marked deformities. Hand arthritis surgery may alleviate some or all of the symptoms.

The best surgical procedure for arthritis depends on several factors. Which type of arthritis the patient has developed is one factor. The patient’s age, activity level, occupation, and the degree of pain suffered are also considerations. The specific joints involved can also dictate the best hand arthritis surgery for the patient. There are three basic surgical procedures available for arthritis sufferers

. The affected joints can be replaced, the joint can be fused, or the surgeon can remove any bone spurs and damaged cartilage, sometimes referred to as a salvage procedure.

Salvage procedures are typically performed on those with rheumatoid arthritis if the patient has a great deal of inflamed tissue in the hand. It is also a common procedure for those with osteoarthritis in the early stages who have bone spurs that are painful. If the joint closest to the fingernail, called the distal interphalangeal or DIP joint, is involved, removing any bone spurs may be especially beneficial.

Fusing a joint requires the removal of the joint and a surgical fusion of the two ends of the bone, which effectively turns them into one bone. This procedure can eliminate the pain at the joint, but it also eliminates motion. Joint fusion is typically reserved for those whose arthritis is quite advanced. However, it is often preferable to joint replacement for younger, active patients. Higher levels of activity can place enough stress on the artificial joint that it wears out quickly.

Joint replacement surgery can be an effective type of arthritis wrist surgery for older patients with low activity levels or for rheumatoid arthritis sufferers. The surgery can alleviate pain while increasing motion and functionality. Unlike replacement joints for the knee or hip replacement surgery, which are typically made from ceramic or metal, artificial hand joints are also made from silicone or tissue from the patient’s body.

Replacement of the DIP joint is normally not recommended. The bones involved are too small to effectively hold the implant in place. Many orthopedic surgeons recommend fusion for this joint, since it eliminates the pain but has a minimal impact on overall hand functionality. The finger’s second joint is a better candidate for replacement, particularly on the two smallest fingers. The index finger is subjected to lateral pressure during many routine motions, such as turning a key in a lock, so it is not considered as good a candidate for replacement surgery. The third joint is seldom affected by osteoarthritis, so most replacement surgery on this joint is performed on rheumatoid arthritis sufferers.

Deciding on a type of hand arthritis surgery can be a complex issue. The patient may need to consult his primary care physician, his rheumatologist, and an orthopedic surgeon to arrive at the best option for his situation.

I hope this helped you learn more about what happens during a hand surgery for arthritis.

Until next time,
Stuart

Every so often, I see a patient suffering from scoliosis. Like many other conditions, I usually answer the question, “Is Back Surgery For Scoliosis Common?” Well, here are my thoughts on that question:

Scoliosis is a condition that occurs when the spine develops a curvature to the side. Normally, the spine is straight between the neck and tailbone, with a slight curvature in the lower section and a slight outward curve in the upper back. With scoliosis, the spine forms either a C or S-shaped curve. The cause of most scoliosis is not known, although it sometimes is seen in families, suggesting a genetic predisposition to the condition. It can also be caused by conditions such as cerebral palsy and muscular dystrophy, as well as birth defects, asymmetrical leg length, and arthritis of the spine.

Scoliosis normally occurs in childhood, just before puberty when the body is growing quickly. Since patients typically experience no pain or discomfort, the condition is usually found by a physician during a routine check-up. Most patients will not require back surgery for scoliosis or even a brace, and the condition will have little impact on their lives. Children should be monitored every few months so that corrective actions can be taken should the curvature worsen.

Severe cases may require back surgery for scoliosis, since the spinal curvature can take up the space that the lungs need to expand properly. A twisted spine can also apply pressure to the heart, which can sometimes damage the heart. The patient may also be more prone to pneumonia, and, over time, arthritis of the spine and back pain may develop.

Back surgery for scoliosis can reduce the spinal curvature and prevent further curving. Typically, two or more vertebrae are surgically fused together. If necessary, the surgeon may use metal rods, screws, or wires to align the spine and keep it straight while healing occurs.

The physician will make treatment recommendations based on certain factors. The severity of the curve, its shape and location, and the gender and age of the patient are all considered. More pronounced curvatures are more likely to worsen, as are S-shaped curves or those in the middle of the back. Females with scoliosis are more likely to see the curvature worsen than males

. After growth is complete, there is little likelihood that the curvature will worsen. All of these factors are evaluated by the physician when deciding whether to use braces, perform back surgery scoliosis, or just monitor the condition.

Spinal manipulation, such as is performed by chiropractors, has been shown to be ineffective for scoliosis. In fact, many chiropractors will not treat patients with scoliosis. Physical therapy is likewise ineffective for straightening the curvature, but may provide some relief from pain. General exercise to promote overall good health, however, is usually recommended for patients with scoliosis.

I hope this helped you learn more about the frequency and commonality of back surgery for scoliosis.

Until next time,
Stuart

I often get questions about reverse total shoulder replacement surgery. To help patients understand this surgical approach, I thought you might like to read my thoughts on this form of treatment.

In a healthy shoulder, the rounded end of the humerus, or upper arm bone, fits into a socket on the scapula, or shoulder blade. This creates a ball-and-socket joint that allows the arm to be lifted, bent, and rotatated. It also permits the arm to be moved laterally as well as forward and back. The tendons and muscles of the rotator cuff provide stability for the joint, counteracting the deltoid muscle, which tends to pull the humerus upward.

Patients who have a severe rotator cuff tear as well as arthritis in the shoulder may be candidates for reverse total shoulder replacement surgery. Those who have undergone a traditional shoulder replacement that failed may also be helped by the procedure. Candidates are normally experiencing severe pain, decreased mobility, and instability in the shoulder joint.

A reverse total shoulder replacement is the surgical removal of the diseased joint and the insertion of a prosthetic joint. It is called a reverse procedure because it reverses the body’s anatomy

. Instead of locating the ball on the end of the humerus, it is on the scapula, while the replacement socket is attached to the humerus. This arrangement allows the deltoid muscle to assume much of the work required to lift and stabilize the shoulder.

The operation normally is about two hours long and usually takes place in the hospital under general anesthesia. A nerve block can also be used if the surgeon and patient deem it preferable. Most patients will remain as inpatients for two days after surgery. Extensive physical therapy is normally required, but patients may have their activities limited for the first few weeks. Driving is not recommended for the first five or six weeks, lifting should be avoided, and the arm may be placed in a sling around the clock for a time. Reverse total shoulder replacement surgery will not allow the patient to play contact sports or work at jobs that require heavy lifting. It is seldom performed on patients whose rotator cuffs are intact.

Once surgery is complete, the patient will be transferred to the recovery room, normally for one or two hours. Occasionally a tube is placed to drain fluid from the area of the incision. The drainage tube is typically left in place until the day after surgery. Once pain is controlled, the patient can be discharged home. However, he pr she may need to arrange in-home care and physical therapy to assist with routine activities for a week or two. The surgeon will establish an exercise routine that the patient should follow faithfully after discharge.

After surgery, the patient may be given pain medications orally or intravenously. Each patient requires a different level of pain medication, and some patients experience little need for analgesics. Pain medication is usually not required after the first two weeks except for therapy in cases where the shoulder tightens up or scars.

I hope this helps further explain a total reverse shoulder replacement surgery!

Until next time,
Stuart

When patients are preparing for hip replacement surgery, I typically answer the following three questions about their recovery from hip replacement — “What Will Happen During My Recovery From Hip Replacement?” and “How Long Is The Recovery?” and “Will I experience Pain During Hip Replacement Recovery?”

Here are my thoughts given those questions:

• Everybody recovers from surgery in his or her own way. Recovery from hip replacement surgery is no different. In most cases full weight on the operative limb is permitted immediately after surgery. The use of ambulatory aids such as a walker or crutches are used until balance and strength is regained. Depending on your healing potential you may be without the ambulatory aids as early as 10 days. In slower healers this may be extended for up to 6 weeks. Full recovery again is patient dependent. The range is 6 weeks to 6 months; with the average time to full recovery is 3 months.

• Hip replacements require a 2-4 day stay in the hospital in the majority of cases. The first few days can be painful, primarily as a result of the incision

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  . Pain is controlled with medication by mouth or intravenously. In many cases an epidural catheter is placed for 12-36 hours. Pain medicine is introduced through the catheter and dulls or eliminates the surgical pain while still allowing you to move. Following the first few days the pain resolves quickly.

• The best point regarding hip replacements is how successfully the preoperative arthritic pain is resolved. This procedure will predictably restore a patient’s lifestyle in almost every case. This accurate prediction as always depends on establishing the correct preoperative diagnosis and assuring that there is no overlapping neurogenic reason for hip pain.  As always please check with and question your own surgeon regarding his estimate of your recovery.

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

Best regards,
Stuart

A common question I receive from patients needing shoulder surgery, knee surgery, ankle fusion surgery, wrist surgery, neck surgery, hip surgery and other orthopedic procedures is, “Can you fix me?”

Without a doubt, there is great value in orthopedic surgery and with the ever-expanding array of techniques and new technology available to surgeons like myself, there is a lot we can do to ease people’s pain and give them back their lives. That being said, I have also found that, unfortunately, while it can correct many problems, there are some things that orthopedic surgery cannot fix. Some things just aren’t fixable.

So you know, that was a hard lesson to learn and one that in all my years of training was never clearly addressed. We are surgeons. We fix things. That means we make things better, improve situations and conditions using knee replacements, hip resurfacing, and elbow surgery via synovectomy.

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