Dr. Gold's Orthopedic Surgery Blog

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

If you are having issues with your wrist tendons, I’m hopeful this discussion about tendonitis wrist surgery well help you.

Tendons are the thick cords that connect muscles to bones. If they become strained due to overuse or improper stress, they come become inflamed, a condition referred to as tendonitis. The result can be pain, tingling, or numbness. Pain may occur only when the affected area is moved, or it may occur at any time, including when the joint is at rest.

Wrist tendonitis should not be confused with carpal tunnel syndrome. Although the two conditions are quite similar and share many symptoms, they affect different parts of the wrist. Both conditions are normally caused by repetitive strain. However, a patient may have only carpal tunnel syndrome, only wrist tendonitis, or both conditions at the same time.

Tendons run down the forearm on both the back and the front and attach the arm to the wrist. These tendons work in harmony to raise and lower the hand or to move it in a sideways or circular motion. The tendons can develop tiny (micro) tears or rips or just become irritated from rubbing against the sheaths that enclose them.

Patients with wrist tendonitis may experience pain in the forearm as well as the wrist. The pain may be very sharp or it may manifest as a constant, tight ache. There may be a loss of flexibility in the wrist. The affected hand may lose strength or become numb.

Few orthopedic surgeons will consider operating for wrist tendonitis until all other options have been exhausted. Overall success rates show the surgery can be an effective way of dealing with the condition. However, the tendonitis can quickly reappear if the patient does not make the changes necessary to prevent its return.

Surgery for wrist tendonitis is often performed in an outpatient setting. If hospitalization is required, the stay rarely exceeds one day. The procedure can be done under local, regional, or general anesthesia.

The surgeon makes an incision over the affected tendons. Damaged or scarred tissue is surgically removed, allowing more room for the tendon to move without constriction. If necessary, torn or damaged ends may need to be sutured. Occasionally, the damage is so severe that a graft is necessary. If so, a small strip is removed from another tendon in the patient’s body, typically his toe or foot, to patch the wrist tendon.

Recovery can take up to six weeks after surgery. The wrist on which the surgery was performed may require immobilization in a cast or splint. Physical therapy is often required to restore full function and to decrease the possibility of scar tissue forming. Should scar tissue form, the tendons can be prevented from moving properly, resulting in reduced function of the wrist

.

Typically, patients must make some accommodations to prevent a return of tendonitis. This may involve wearing a wrist brace during stressful activities or giving up a hobby. Certain ergonomic tools, such as a well-designed computer mouse, may help some individuals whose jobs subject them to repetitive stress.

Until next time,

Stuart

For those of you needing ankle fracture surgery, I hope this helps you evaluate your broken ankle and your surgical options.

The ankle joint is comprised of the tibia, or shinbone, the fibula, which is a small bone located on the ankle’s outer side, and a bone in the foot called the talus. The parts of the tibia that are part of the ankle are the medial malleolus, or inside of the tibia, and the posterior malleolus, or the back of the tibia. The point where the fibula connects in the ankle is called the lateral malleolus.

Ankle Surgery Screws

The lateral malleolus can be fractured at various points. The precise location of the fracture and the stability of the ankle are major determinants in deciding whether surgery is necessary. The surgeon may use a plate and screws attached to the side of the fibula to stabilize the joint. If the bone has fragmented, the surgeon may place a rod inside the fibula to realign the fragments of bone and hold them in place while healing occurs.

Surgery for a fractured medial malleolus is normally indicated if the bones are so misaligned that they cannot be treated successfully with a cast or if there is instability in the joint. If the joint has an indentation or impaction, a bone graft may be used to repair it, which may reduce the patient’s risk of arthritis. The nature and scope of the fracture will determine which of the various techniques the surgeon will choose, but screws, plates, or wires may be used to reduce and hold he fracture in place until as it heals.

A fracture of the posterior malleolus is seldom the only injury the patient receives. The lateral malleolus often breaks as well, since it shares many of the same ligaments. Occasionally, the medial malleolus is fractured as well. Most doctors recommend surgery if the broken part comprises more than one-fourth of the joint size. As a rule, the larger the fractured piece, the greater the chances that the ankle will be unstable. In addition, if more than two millimeters or so misplaces the bones, the cartilage covering the posterior malleolus may not heal properly. This can cause uneven, increased pressure and lead to arthritis in the ankle. The surgeon may screw plates onto the tibia or insert screws parallel to the foot to reduce and hold the bones together.

A fracture can involve one, two, or all three of the ankle’s malleoli, and can occur at any point along the malleolus. The more fractures the ankle suffers, the more unstable the joint becomes. In the event of multiple fractures, each type is generally treated with the same techniques available for an isolated fracture.

Most patients can expect a lengthy recovery period. It can take as long as three months to resume normal activities, excluding sports. Full recovery from more complex ankle fracture surgery can take up to one year. Each patient, however, must be individually evaluated. Patients should not place weight on the ankle until told to do so by the surgeon, since it can lead to failure of the surgery if the fragments move. It is equally important to perform any exercises prescribed by the physician or to attend any physical therapy sessions he recommends. Otherwise, the ankle may become stiff or weak

.

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

Discs are like pillows or donuts between the vertebrae that act as shock absorbers and also provide for movement as they are positioned between the vertebrae (bone blocks of the neck and back). These discs consist of a tough outer layer (annulus) surrounding a filling of softer spongy/jelly material (nucleous pulposis). A disc can be bulging minimally (1-3mm) or in some cases very significantly (6-10mm). A herniated disc exists when the tough outer layer of the disc ruptures and the soft spongy jelly material has been pushed out or extruded.

A bulging disc, which can affect any part of the spinal column, is one that protrudes beyond the vertebrae. The bulge is normally part of the outer layer. Many physicians consider a bulging disc as a normal part of aging. Most of the time, the patient experiences little or no pain from the bulge. However, others may find the condition painful if the bulge is in a position to exert pressure on a nerve. In many situations the soft spongy jelly material is pushed out(herniation) and places more significant pressure on the nerve root. This pressure may also cause numbness and weakness in an arm or a leg. If the pain is severe and the numbness and weakness persists and there has been no response to conservative treatments, surgery may be necessary.

One common procedure used for a large bulging or herniated disc is a minimally invasive technique called a microdiscectomy. In this procedure, the surgeon makes a small incision, normally two inches or less, and inserts a tiny microscope through which he can see the nerves and discs. He then removes a small part of the disc that is placing pressure on the nerve or spinal cord. Scarring is usually minimal, and recovery can be less than a few months in many cases. In fact, many patients are able to walk within hours of the procedure. Patients may need to start an exercise program about one month after the procedure to strengthen the back and maintain flexibility. In some case this procedure is carried out in an outpatient facility and no hospital stay is needed.

Should a microdiscectomy fail to relieve the pain or a larger procedure be necessary, there are two surgical procedures that can be used for a herniated disc, a laminectomy or a laminotmy. These procedures are performed under general anesthesia. The surgeon makes an incision near the disc problem and moves any tissue or muscles that obstruct his view. He then removes the lamina, the back part of the vertebra, and, if needed, part of the disc or damaged tissue. This gives the disc more space so that it does not press against a nerve. The second surgery is called a laminotomy. It is identical to a laminectomy except that only a portion of the lamina will be removed.

Complications from surgery for a herniated disc can happen. Potential risks include damage during surgery to nerves and dura, infection, and, if the surgery is performed on the lower back region, nerve damage that causes incontinence

. Nerve damage can be temporary or permanent, depending on which nerve suffers the injury.

I hope this helped you learn more about back surgery for bulging or herniated discs.

Until next time,

Stuart

A complete knee replacement surgery is often performed on patients whose own joints have been damaged by rheumatoid arthritis or osteoarthritis. It may also be an option for patients who have suffered a traumatic injury and developed post traumatic arthritis. The goal of the surgery is to alleviate the pain and restore functionality to the joint.

Knee replacement surgery began during the 1950s. Since that time, numerous improvements have been made to the prosthetic, the materials used, and surgical techniques. The most common technique to expose the joint is to divide the quadriceps muscle along the side where it attaches to the kneecap, or patella. The patella is then moved aside so that the surgeon can shape the ends of the femur and tibia. Cartilage is removed, and the anterior cruciate ligament is sacrificed and depending on the type of knee replacement, the posterior cruciate may be removed as well. The prosthesis is normally cemented in place, but other methods, including a process to integrate the prosthetic with the bone (porous ingroeth), are occasionally used.

On the end of the femur, the surgeon implants the femoral component, which is contoured to imitate the normal end of the bone. The component for the tibia is normally flat, with a stem that is inserted down into the bone to add greater stability. A polyethylene “cushion” is inserted into the tibial plate to replace the cartilage and provide a spacer between the two components. The patella or the kneecap may then be resurfaced with a polyethylene button. This decision is made by the surgeon and currently is more commonly done than not.

Total knee replacement surgery has continued to evolve

. The equipment and components have improved where smaller incisions and in some cases customized components can be used. The key point to remember regarding incision size is that it may smaller and less invasive, but should be as large as it needs to be to do the job properly. Computer navigation is also continuing to be developed and may lead to better results.

Depending on the patient’s health, the average hospital stay is 3-4 days. A walker or crutches will be necessary until sufficient time has passed for the extensor (quadriceps) mechanism to function well. Physical therapy is required for several months if the patient is to recover strength and motion in the knee. It is often possible to achieve the functional range of motion by the end of the second or third week. By the first week, most patients can place full weight on their leg. Full function, with proper physical therapy, normally takes about three months, but some patients may experience a more gradual recovery that lasts longer.

Due to the demands that post-operative therapy can require, some surgeons have their patients prepare for the surgery over a three to four week period. The patient may be asked to perform daily exercises to strengthen the ankle, knee and hip and to maximize the range of motion in the leg. Some patients may need to take iron supplements for about the same length of time. If the surgeon allows the patient to store his own blood (referred to as autologous predonation) in case it is needed after surgery, arrangements must be made to accomplish the task. In addition to a full medical clearence, numerous tests must be completed before admission, such as blood tests, X-rays of the knee and chest, and an electrocardiogram.

I hope that helped you learn more about complete knee replacement surgery.

Until next time,

Stuart