Sunlight And Your Bones

You need Vitamin D to stimulates the absorption of calcium and magnesium into your bones. Calcium alone is not responsible for bone strength–but a delicate combination of calcium and other elements like phosphorous and magnesium which are regulated by Vit D–a vitamin that is naturally produced when the sun hits your skin. In these dark and dreary northern hemisphere countries, we may need a dietary source of Vitamin D as found in fortified milk products, or via supplements.

Calcium is essential for bone health. In this chart from WebMD, you can see the daily requirements in mg for age:

 

Age

Calcium (mg)

Birth to 6 months

210

6 months to 1 year

270

1-3 years

700

4-8 years

1,000

9-18 years

1,300

19-50 years

1,000

51-70 years

1,200

Over 70 years

1,200

 

As you can see, the older we are, the more calcium we need for the exception of the 9-18 age group when our bones are growing larger faster and the body is moving through puberty to adulthood.

Dietary calcium sources may not be enough. Green veggies, dairy products and fortified foods are a source of calcium. Supplements are another source of course. Too much calcium can lead to kidney stones. And if you have ever passed one, it’s certainly not fun.

Vitamin D requirements for bone health–which pushes the calcium into your bones– are in the realm of 600 to 1000 IU’s per day. Too much Vitamin D is toxic. Not enough can lead to a disease called Rickets where the bones are brittle and deformed.

Calcium sources: Here is a slide show of some amazing and delicious nutritious sources of calcium in your diet:

http://www.webmd.com/osteoporosis/living-with-osteoporosis-7/calcium-supplements?page=5

People with low levels of dietary calcium, Vitamin D, magnesium and phosphorus–but particularly calcium deficiencies– may end up with low levels of calcium in the bones which leads to a condition called osteoporosis (a decrease in density of the bone) which can lead to fragility fractures of the wrist, hip, spine or ankles. There are medications for osteoporosis which help increase bone density, some of which have their own side effects of bone fragility and brittleness (bisphophonates).

Patients with fractures often ask me what they can do from a dietary stand point to increase bone healing. Unfortunately, the calcium in your bones at the time of the fracture relates to dietary choices you made months and years ago. Eating more calcium today will not necessarily strengthen your bones tomorrow, and will have little to no effect on rate of fracture healing. However, a well balanced diet heavy in the leafy greens, lean meats and healthy fats, and low in carbohydrates and junk foods like sugar and processed crap, will help your overall health and well-being and promote healing while reducing the risk of future fragility fractures.

For more information on osteoporosis, please visit:

http://www.iofbonehealth.org/

First Fully Digital Hospital in North America

The new Humber River Hospital…in Toronto, Canada

“It began as a dream… a desire to give our patients and our community the kind of hospital facility it deserved. On December 2, 2011 the dream began to take shape as we held our groundbreaking celebration: a wonderful day for our hospital, our patients and our community.

Redevelopment-Homepage-Banner-3

“Humber River Hospital proudly presents our new home: North America’s first fully digital hospital. A digital hospital utilizes the most current technologies possible to enhance all aspects of quality care delivery, improving efficiency, accuracy, reliability and safety. And currently no North American hospital is fully digital. There are systems interruptions in all of them that prevent full integration and full interoperability. We’re going to be the first in North America to close that gap to automate all of our processes.

Redevelopment-Homepage-Banner-12

“The centerpiece of our plans to revolutionize health care for our community, it is designed to maximize the benefits of technology, lean design and environmental planning. Our new building will enable our hospital team to further enhance the high quality, safe, efficient care they provide in our current facilities. It will allow care providers more time at the bedside, nurturing the personal interactions that form the basis of great hospital care. ”

Source: http://www.hrh.ca/redevelopment

 

New Cartilage Regeneration Procedure? Really?

It’s finally here–a cartilage regeneration/regrowth product from ZimmerimagesCA76UD4P.

We’ve been waiting for this a very long time.

Unfortunately, it costs about as much as a 1999 Ford Mustang GT or a safari in Tanzania for two, but the results are quite impressive.

A couple of weeks I was invited to a demonstration and product presentation here in Toronto hosted by Zimmer Canada. Head scientists and surgeons who have already trialed the product were on hand to answer questions and share their experience.

What is Cartilage?untitled

As a reminder, cartilage is the tissue that covers the bone surfaces within your knee joint– it absorbs shock and protects the ends of the bones from each other. It’s like the shiny ends of a chicken drumstick (which by the way is a chicken knee, in case you didn’t know).

When the knee cartilage becomes damaged, the joint begins to wear out and we develop osteoarthritis–or “wear and tear” arthritis (inflammation, pain, reduced weight-bearing tolerance and pain).

Unfortunately, once you are fully grown, cartilage has minimal regrowth potential. The individual cartilage cells are few and far between, there is little renewal of these cells and even less turnover.

So How Do We Renew Our Own Knee Cartilage?

Forget all the hype about glucosamine and shark cartilage–there is no scientific proof that lost cartilage regrows with these supplements. Over the years we have tried many different types of cartilage growth techniques–from implanting pouches of cells, to injecting cells, to transplanting cartilage from one area of the knee to another. Some of these techniques work for very small areas, but most were either too costly ($30,000 in some cases) or simply did not offer good results.

Zimmer says “Replacing lost knee cartilage with tissue grafts may help restore normal knee function and may delay or even eliminate the need for a knee replacement.”

What Are Cartilage Tissue Grafts?  -denovo-hero2

The tissue graft procedure is a relatively straightforward cartilage repair surgery. Tissue overgrowth or thickening at the repair site may necessitate a secondary arthroscopy procedure to trim the excess tissue. Some people may exhibit an allergic response to the graft. This may include short-term discomfort and swelling, and potentially an overall rejection of the graft.

Will a tissue graft to repair my lost knee cartilage limit my future options?

No. Tissue grafts will not interfere with future treatment options, such as surgery or knee replacement, should they become necessary.

DeNovo NT Natural Tissue Grafts are Zimmer’s new product now available in Canada. They are donor collections of small pieces of juvenile joint cartilage that are implanted into the affected areas of cartilage loss by a surgeon.graft

The graft contains living cartilage cells that have the potential to grow and repair areas of lost cartilage by filling defects caused by trauma or natural wear and tear.

Is using donor tissue for knee cartilage grafts safe?

According to Zummer, DeNovo NT Graft donors are screened and tested. Each lot of donated tissue is processed in a sterile environment and individually tested prior to release to reduce the risk of bacterial and fungal contamination. There is a very small risk of rejection compared to any other natural tissue such as organs.

DeNovo NT Graft has been used safely in over 1000 human clinical cases with very good results.

For more information, visit the Zimmer website here: http://www.zimmer.com/en-US/pc/article/knee-cartilage-tissue-graft.jspx

 

Orthopaedic Surgery is a Team Sport!

It Takes a Community to Care for a Patient

At the recent American Academy of Orthopedic Surgeons (AAOS) meeting in Chicago, the word “collaboration” was being kicked around like a soccer ball.

Organizational behavior consultants, marketing consultants and business professionals having been emphasizing the importance of “teamwork” and “collaboration” in the literature for years!surgery

Although surgery itself takes a team to perform, many orthopaedic surgeons in Canada work as independent practitioners within a private practice and share hospital responsibilities with a small group of other surgeons, sharing the call schedule and collaborating on difficult surgical cases.

However, although we don’t practice in a bubble, we do tend to be the lone wolf in our subs-specialty areas unless we make a point of collaborating and consulting with peers.

In a recent post in the ezine “The Pipeline” by Katie Rief of the Advisory Board Company, take-away comments were presented from the AAOS meeting which emphasized the changing role of the orthopaedic surgeon as a team player.

Says Ms. Rief, “Surgeons are interested in building efficient, dedicated care teams. This is true in the OR as well as in the clinic.”

So what does my team look like?

My core team is me and my two office partners, Dr. Rodriguez-Elizalde who specializes in trauma and joint replacement surgery, and Dr. Cayen who specializes in sport IMG_65medicine and joint replacement surgery, as well as our administrative assistants. We share an office, our staff work side by side, and we all work at the same hospital–Humber River Regional (Church Street Site).

The next team layer include our cast techs in fracture clinic, operating room nurses, anesthesia colleagues, sales representatives from our surgical instrument and implant companies, surgical unit nurses and pre/post operative nursing staff as well as other orthopaedic surgical colleagues at both the Finch and Church sites whom we work with to provide orthopaedic surgical services to our 800,000 catchment area in North York.

Beyond this is the layer that encompasses all support services–hospital services, computer and networking services, laboratory and diagnostic radiology services and the companies who provide us implants and products we need to do our jobs. This layer also includes the insurance companies, including OHIP.

Each of Us Brings a Unique Skill to the Team

On any given day, at least 6 or 8 people are working with me to get my job done, as I work them to get their job tasks accomplished. This coordinated concerted effort constitutes the “inputs” and quality patient care is the “output”.

So although we might seem to practice independently, it takes a community to care for patient–each with a unique but interrelated job.

Sources:

http://www.advisory.com/Research/Technology-Insights/The-Pipeline/2013/Three-hot-topics-at-AAOS-2013

http://hrrh/on.ca

http://orthopedicsurgery.ca

http://downsviewoac.com

Where Do I Go When I Need HealthCare?

ER, Walk In Clinic, Family Doc, or Urgent Care Centre…Where do I go when I need healthcare?

Why are we all so disgruntled with health care. It doesn’t seem to matter where you live or who you are, how much money you have or don’t have, or what your health care needs are, we all have complaints and critiques!

Waiting for care is a huge complaint. Patients are very upset to have to wait for an emergency doctor to see them, or to wait in fracture clinic to be seen by the orthopod, wait for their surgery, test results, wait for a specialist visit. They are so frustrated that many end up coming to the hospital Emergency Room (ER) because they feel they have no other options.

As Canadians, our high income tax contributions to socialized health care allow us the privilege to walk into any health care facility in the country and ask for care.

Patients with extreme pain, major trauma, who are very ill or near death will always get treated first as Emergency Room resources are prioritized to care for these more critical cases.

Triage System for Emergency Care

In Canada, the CTAS-Five Level Triage system assigns patients who present to the emergency room with a number from 1 to 5.

Level 1 patients require immediate resuscitation and include “conditions that threaten life or limb requiring immediate aggressive interventions” by the ER doc and ER nurse.

Level 2 patients are considered “emergent” and include those with “conditions that are a potential threat to life, limb or function requiring rapid intervention” within 15 minutes.

Level 3 patients, are “urgent” and include those with “conditions that could potentially progress to a serious problem requiring emergency intervention associated with significant discomfort affecting ability to function at work or activities of daily living” and should be seen within 30 minutes.

Level 4 patients have “conditions that relate to age, distress, or potential for deterioration or complications” who should be seen within 1 hour.

Level 5 “non urgent” patients have “conditions that may be acute but non-urgent, as well as conditions which may be part of a chronic problem, with or without evidence of deterioration” and should be seen within 2 hours.

The reality of the situation…

OK, how many people reading this are saying “Ya right, 2 hours? Last time I was in the ER I waited 5 hours!” The reality of the situation is that on the one hand, ER’s are busy and may not see level 5 patients for many hours because of the sheer number of Level 1, 2 and 3 patients already being treated.

In addition, there may be an overwhelming number of Level 5 patients who present to ER for treatment who could better be served at an urgent care centre, walk-in clinic or their family physician’s office.

I am amazed by the number of swollen knees and sore shoulders that come through the emergency department and are referred to fracture clinic with a history of several weeks of symptoms. Back pain patients who have had issues for years and have seen every chronic pain specialist in the city, come to the ER to be seen–why?  When I ask them why they came to the hospital instead of seeing their family physician, specialist or pain doctor, the answer is typically one of the following three:

1. I don’t have a family doctor.
2. None of the other doctors have helped me.
3. I’ve been waiting forever to see a specialist!

I find that many patients do not know their healthcare options.  So they come to the ER to have the hospital “sort it all out”. Here’s another idea: Health Care Connect!

Health Care Connect will find a doctor or nurse practitioner in your community who can assist you with your care needs.”

Remember the next time you take your long-standing complaint, strain/sprain or paper cut to the emergency department for care–you are taking up resources that are designed for people with acute, severe injuries or illnesses that need to be dealt with urgently. See the length of time you have to wait at an Emergency Room nearest you.

So let’s look at this another way…How would you feel if your mom had to wait to be seen for her hip fracture because the emergency doctor was busy seeing a patient with a bruised shin that happened 2 weeks ago? The hip fracture needs care. The bruised shin is taking up valuable ER time and could be better treated at a walk-in clinic or the family doctor’s office.

I don’t blame patients. I believe it is our job to properly educate patients on where to go for care. And our government is doing just that through the Ministry of Health website and campaigns to promote proper utilisation of services. There are urgent care centres and walk in clinics all over the GTA and other Canadian cities that are designed specifically to accept patients with minor injuries, chronic problems, or long-standing issues that are not in acute distress or danger.

 Source: http://www. health.gov.on.ca/en/public/programs/hco/

Unfortunately web-links of information will not be seen by many of the people who look for care –the elderly, lower income labor workers who might not have access to a computer, immigrants with no computer skills or access.
See where the health care services are in your neighborhood!
Source: http://www.hco-on.ca/English/Home-Page

Options for Minor Injury and Illness Care

So, here are the options for the walking wounded, tummy aches, headaches, joint pain patients, strain/sprains, small burns/cuts, and the chronic complaint patients who need help but don’t need to start at the ER:(if you have an issue that should be seen urgently, one of the health professionals at these organizations WILL direct you to the ER if needed)–

Where To Go When You Need HealthCare!

An Urgent Care Centre (UCC) can provide diagnosis and treatment for most injuries and illnesses through emergency trained doctors and other health care professionals.

Go Here If: You have an urgent, but non life- threatening illness or injury like sprains or strains, if you think you need stitches or have a minor burn that needs treatment.

Walk In Clinics or After Hours Clinics offer convenient access to advice, assessment and surgery1treatment for minor illnesses and injuries such as cuts, bruises, minor infections, sprains and skin complaints. Go Here if: You’re in a non-urgent situation; Your family doctor’s office is closed or if you don’t currently have a family doctor; You need care for minor illnesses and injuries including infection and rashes,      fractures, emergency contraception and advice, stomach upsets, cuts and      bruises, and burns and strains.

Go Telehealth!

Telehealth Ontario is a free, confidential telephone service you can call to get health advice or general health information from a Registered Nurse.

That means quick, easy access to a qualified health professional, who can assess your symptoms and help you decide your best first step. Telehealth nurses are extremely well-trained, personably, knowledgeable and multi-talented folks who can help you decide whether to care for yourself, make an appointment with your doctor, go to a clinic, contact a community service or go to a hospital emergency room. They provide a valuable service and I have always been impressed by their excellent advice, care and direction.

TELEHEALTH: 1-866-797-0000 TTY : 1-866-797-0007

Need To Know Where To Go NOW?

And if you are stll uncertain where to go, CLICK HERE! for the Government of Ontario’s “HEALTH SERVICES IN YOUR COMMUNITY” website.

Have I missed anything? So, pop quiz: you sprained your knee last weekend and it is still sore….where do you go? If your answer is “The ER”, then you need to re-read this blog!

Here is a list of Urgent Care Centres in the GTA:

Nexus Health Urgent Care
Toronto, ON M5G Map location is approximate (416) 616-0300

Midland Urgent Care
1153 Ellesmere Rd, Toronto, ON M1P 2X6 (416) 285-4406

North York Urgent Care Centre
4646 Dufferin St, Toronto, ON M3H 5S4 (416) 222-9604

Etobicoke Urgent Care Clinic
25 Woodbine Downs Blvd, Toronto, ON M9W 6N5 (416) 741-2273

Malton Urgent Care
3530 Derry Rd E, Mississauga, ON L4T 4E3 (905) 672-2273

Mississauga Urgent Care Inc
1201 Britannia Rd W, Mississauga, ON L5V 1N2 (905) 826-2273

Markham Stouffville Urgent Care Centre
110 Copper Creek Dr, Markham, ON L6B 0P9 (905) 472-8911

Pickering Urgent Care Med
1450 Kingston Rd, Pickering, ON L1V 1C1 (905) 831-8333

Finally, for more information: For other health questions please call:
ServiceOntario, INFOline at 1-866-532-3161.
Hours of operation : 8:30am – 5:00pm, Monday to Friday.
TTY 1-800-387-5559.
In Toronto, TTY 416-327-4282

Cortisone Injections for Knee Pain

There is much controversy as to how to treat knee pain nonoperatively, and if cortisone injections are dangerous in the knee. The type of cortisone used, dose, number of injections and frequency of injections, as well as side effects are all controversial topics among orthopaedic surgeons.

The knee, being one of the largest joints in the body, is susceptible to the development of conditions that cause pain and swellng, like osteoarthritis, trauma and rheumatoid arthritis. Osteoarthritis is the most common of these conditions, representing 15% of most people over the age of 60 in developed countries. Symptomatic knee osteoarthritis has been found prevalent more commonly in women tcortisone_knee_dynhan men.

Initially, we treat early osteoarthritis of the knee with physical therapy, weight reduction, anti inflammatory medications like Advil and Aleve, and eventually move to prescription anti inflammatory medications, pain killers, braces, knee injections and sometimes surgery.

Cortisone has been one of the most common injections used in the knee for decades and benefits patients by relieving both pain and inflammation for weeks to months.

celsoluspanCortisone has been demonstrated in some studies to reduce the deterioration of knees and the development of more severe osteoarthritis, but concern has been raised about the potential side effects of long-term corticosteroid injection. There is evidence to suggest that frequent doses of cortisone may degrade joint cartilage and change the properties of meniscal cartilage by altering the cartilage cells. There are also numerous scientific studies demonstrating direct toxic effects of cortisone on joint structures including ligaments.

So how often is it safe to inject cortisone into the painful knee of someone with moderate osteoarthritis who is not yet ready for joint replacement surgery?

According to a study by Zuber in 2002, cortisone can be injected into a knee every 6 weeks with no more than 2 to 3 injections per year. There is no solid evidence to suggest repeat injections of cortisone lead to joint destruction and the 3 injections/year guideline is simply that–a guideline.(Zuber TJ. Knee joint aspiration and injection. Am Fam Physician 2002; 66: 1497–501).

In 1967, Salter, Gross and Hall concluded that:

“While it is unlikely that a single intra-articular injection of hydrocortisone is harmful, multiple intra-articular injections of hydrocortisone in a given joint are probably deleterious to the articular cartilage and should be avoided in order to prevent the iatrogenic complication of hydrocortisone arthropathy.” (Salter RB, Gross A, Hall JH. Hydrocortisone arthropathy: an experimental investigation. Can Med Assoc J 1967; 97: 374–7.)

This advice is still relevant today in spite of 45 additional years of research.

Personally, I concur with the author of today’s source article in Medscape who suggests cortisone injections are effective in patients who are not yet ready for knee replacement, who are on a waiting list for knee replacement, in young patients who knee replacement is to be avoided until later life if possible, and in patients who have medical or other reasons they cannot undergo knee replacement. I administer these injections 6 weeks apart for a total of 3, if required–and wait 6 months between treatment courses before repeating if necessary. Some point along the line,doctorhdshot2 the decision would be made whether to proceed with joint resurfacing or replacement based on the patient factors such as age and medical status, as well as disease factors such as severity and functional abilities.

For more information on Cortisone, please visit:  http://en.wikipedia.org/wiki/Cortisone

Cooking for Bone Health

The two main dietary bone health-promoting nutrients are Calcium, a mineral naturally found in bone; and Vitamin D, a vitamin required to absorb calcium from your intestine.

With enough sunlight, our bodies will synthesize Vitamin D in quantities great enough for adequate calcium absorption. Calcium, on the other hand, must come from external sources or your body will start to use up the calcium stored in bone for other body functions.

Calcium is a mineral essential for many cellular functions including bone mineralization and muscle contraction. Calcium deficiency leads to osteoporosis and neuromuscular disorders including convulstions, heart rythmn disturbances, numbness and even paralysis.

BroccoliThe best source of calcium is in foods. Calcium supplements, though effective at correcting low calcium states, may cause other side effects in the body including kidney or bile stones, bone pain, nausea and vomiting, and pancreatitis among other conditions.

Foods high in calcium include: milk, cheese, broccoli, fortified cereals and almonds. Vitamin D fortified milk helps increase the absorption of calcium from the intestine into the blood stream. MP5094

According to EatingWell.com, the following recipes are calcium-rich and great for bone health: Black-eyed peas with Tofu, Chicken Cassoulet, Salmon Cakes, Manicotti, Lamb and Rice Casserole.

Check out Bone Healthy Desserts!

Low Bone Density and Fracture Risk

h9991525_001Why do we care so much about bone density? It’s true that as we age, bones lose density and become more porous, softer and susceptible to fracture. Doctors prescribe Calcium, vitamin D and even bone hardening drugs called bisphosphonates for patients with either low bone density, or who are at risk of developing fragility fractures.

What Makes Bones Hard?

Minerals in bone like calcium are responsible for the hardness. Bones are rigid organs that support all the soft tissues that make up the body. There are 206 bones in the adult body with the femur (thigh bone) being the largest and the small bones deep in the ear that regulate sound being the smallest.

Bones have several functions other than providing a skeleton for the body. They server to store minerals, acting as a reserve for calcium and phosphorous; they store growth factors; the marrow stores fat; they trap some of the heavy metals in the environment and other toxins; and the marrow in some of the bones is a repository for blood cells and stem cells.  osteoporosis_food1

Why Do Bones Get Weak?

Bones typically become weak as we age due to osteoporosis, which is a deterioration in the concentration of minerals over time. As the mineral levels diminish, the bone’s structure also weakens and fractures can result.

You can keep your bones healthy and strong by eating foods high in calcium, taking the recommended amount of Vitamin D per day (between 400 and 1200 IU depending on your age) and by maintaining a healthy level of exercise, including the use of light weights and weightbearing exercises.doac58

Most fragility fractures occur in typical places such as the wrist, the hip and the vertebrae. Some of these fractures require little treatment, others may require surgical treatment or casting.

Typically, a hip fracture, which occurs at the top of the femur bone, requires some type of surgical fixation with metal or a hip replacement type of surgery. Fractures of the wrist, if deformed, may required fixation with removable wires, or permanent hardware such as a plate and screws. Fractures of the vertebrae are rarely treated surgically unless severe and can be treated usually by a very short course of rest and then gentle physical therapy with pain management using mild medications.

Who Needs Bone Stimulating Drugs?

If bone mineral density levels are very low, as determined by a Bone Mineral Density (BMD) scan and blood tests for mineral levels, your doctor may prescribe you a once-weekly bisphosphonate drug that is designed to increase the deposit of minerals back into bone. Most of these are relatively safe, some may have mild side effects. There are a few reports of fractures of the hip even with the use of these medications.

The people at highest risk of having osteoporosis include post-menopausal women, people with calcium or vitamin D deficiencies and elderly men and women.

For more information on osteoporosis, please visit: http://www.osteoporosis.ca/ .Bonefit-Logo

Total Joint Replacement: Metal, Plastic and Ceramic Hips and Knees?

Total joint replacements are performed for severe degenerative disease of the hip, knee, ankle, shoulder and even wrist, fingers and spinal segments. The two most common procedures are total hip and knee replacements and this it where we’ll start today.

Each year, over 62,000 hip and knee joint replacement surgeries are performed across Canada. The number of these surgeries performed actually doubled over the ten year period prior to 2007 as governments and hospital systems recognized the health and wellness benefits of providing patients with the ability to keep moving into their elder years. With the “move it or lose” philosophy finally encouraged by funding bodies, programs to shorten wait times and increase access to total hip and knee replacement surgeries were launched Canada wide.knee_gsf_nexgen_glass2_200px

Hip and knee joint replacement requires removal of the degenerative joint surfaces and resurfacing with a prosthetic implant or implants. For knees, the ends of the femur (thigh) bone and the tibia (leg) bone are shaved or cut and replaced with a metal component that articulates against a space age plastic insert. The components may be cemented in place in most cases or made of a porous material that allows bone to grow into the pores to bond metal to bone over time. Although the plastic is extremely durable, it may wear away over years and require revision with a new insert. The metal components may loosen over the years and also require revision. Total knee replacements can last up to 20 or more years in many patients.

hip_mltaper_kinectiv_continuum_glass_200Hip replacements require arthroplasty of the ball and socket joint which connects the thigh (femur) bone to the pelvic cup (acetabulum). We typically remove the ball, or head of the femur bone, and replace it with a metal or ceramic ball that inserts into the marrow canal of the femur with a metal stem. The acetabulum, or socket part of the joint, is resurfaced with a metal shell typically and a plastic, ceramic or metal liner that articulates with the ball portion of the implant. Some hip replacements will last over 30 years in patients. Revision takes place for loosening, wear of the liner, instability or failure of the integrity of the prosthetic components or the bone around the components. Total hips and knees can also fail for other reasons including infection.

A patient undergoing hip or knee replacement will stay in the hospital anywhere between 2 and 5 days and start physical therapy and rehabilitation while there. Pain management and the prevention of blood clots in the legs are two of the most important post operative issues that the medical team will address. Medications are given for pain either by intravenous injections or by mouth. The use of pain patches, epidural anesthesia or spinal anesthesia has improved post operative pain management for total joint patients. Patient controlled pain pumps are also commonly used in most hospitals.surgery

The field of joint replacement is huge with billions of dollars worldwide directed at research and development of more durable, longer-lasting and better functioning prosthesis. Alternate bearing surfaces such as ceramics, and highly cross linked plastics with antioxidants to prevent degradation are currently the hottest topics in joint replacement research.

The Canadian Joint Replacement Registry (CJRR) was launched in 2000 to create a database of patients and implants used for arthroplasty procedures in order to offer insights into successes, failures, trends and complications that surgeons and patients experience. We can also see some interesting statistics about who is undergoing these procedures, in what regions, and by whom.

For example, the CJRR tells us that compared to men, Canadian females have higher age-adjusted rates per 105 for both total knee replacements and total hip replacements. Accordingly, women account for 57% of patients receiving total hips and 61% of patients receiving total knees. Using CJRR data, a strong relationship between obesity and subsequent risk of undergoing both hip and knee replacements was found.  The largest increases in both total hip and knee surgery rates occurred in the 45–65-year age groups, where the greatest increases in Canadian obesity rates have also occurred.

The CJRR also highlights some of the differences in hip and knee replacement surgeries across the globe. In Sweden, the incidence of total knee replacements in females for 2006–2007 was 136 per 105, and in Canada it was 182 per 105. Although the reasons for these differences may have many factors, it is likely that the higher rates of total knee replacement in Canada may be related to a higher levels\ of obesity among Canadians.

By adding revision surgery information to the database, we should eventually be able to develop survivorship information for specific implant types, the addition of antibiotic to cement, to surgical approach, and many others factors that are involved in procedure, implant selection and post operative care.

For more information about the CJRR please visit the website.

And for more information about total joint replacements, please visit one of zimmerthe largest manufacturers of prosthetic joint products, Zimmer.

Disclosure: the author has not received any remuneration for this blog from Zimmer. Zimmer is currently the author’s affiliate hospital’s primary hip and knee arthroplasty vendor.

Knee Injuries in the Weekend Warrior

I promised to talk a bit about some of the more common knee injuries as part of the series on weekend warriors. I’d say that half of my practice deals with treating knees. Half again of those are arthritic knees who eventually need knee replacements (arthroplasty). That leaves 25% of my practice focused on the patient with knee trauma.

The Knee is More Than a Hinge

The Knee is a rather simple joint when compared to other joints, like the elbow for example, but it is not a simple hinge joint as you might expect. It bends, but also rolls back. It pivots, and it opens laterally and medially a bit as well.

The structures that allow these movements are called ligaments, and to some extent, the cartilage cushioned called menisci (or meniscus for one–we have two in each knee). The ligaments on the sides of the knee are the collaterals (medial and lateral) and in the middle of the knee are the cruciates (anterior and posterior).

knee anatomyThe joint surfaces, on the ends of the femur and tibia bones which make up the weight bearing parts of the knee are coated with hyaline cartilage like on the end of a chicken bone. These surfaces, coated by a slippery substance called synovial fluid, create the articulation where the actions occur–similar to the contact between a ball-bearing in an engine, or a piston, coated with oil.

Internal Derangements of the Knee

Any of these structures can be damaged or injured during a twist, fall, contusion or a pull. If the bone on either side of the joint don’t break, then the ligaments, menisci and even some of the tendons from the large leg and thigh muscles which pass by the knee can tear.

Knee-anatomy-570I typically see meniscal tears and ligament injuries. Occasionally we see fractures of the top of the tibia, knee cap (patellar) or end of the femur either alone or less commonly associated with the soft tissue injuries.

Meniscal Tears

A meniscal tear usually results from a twisting injury or some type of force to the knee outside of the normal anatomic mechanical motions that happen when we walk, run, climb, kneel, crawl or jump. Forces which result in injuries may be minor–the perfect twist–or major as in a soccer collision, a motor vehicle accident or a major fall from height.

Meniscal injuries can be left alone in young people if they occur in an area of good supply–and that’s really limited to the back of the medial meniscus. Unfortunately most meniscal injuries, even in young patients, do not heal and may go on to create early-onset degenerative osteoarthritis in the knee if they act as an irritant to the hyaline cartilage surfaces, particularly in the area of the tear. They may require repair (if in an area of good blood supply) or excision, where we trim out the torn area using a minimally invasive procedure called arthroscopy.Anterior-Cruciate-Ligament-ACL-Injury

Ligament Injuries

Some ligament injuries require surgery, some are better left alone to heal. A medial collateral ligament–the ligament on the medial or inner side of the knee–will typically heal if braced to avoid stress. An anterior cruciate ligament injury–if completely ruptured and causing instability of the knee–usually needs to be reconstructed. Lateral collateral ligaments and posterior cruciate ligaments may or may not need repair/reconstruction and generally depend on the patient’s lifestyle, age, and the surgeon’s experience and clinical examination.

I probably reconstruct at least 4 to 6 anterior cruciate ligaments each month–sometimes more, sometimes less. We use the small hamstrings of the thigh or the middle third of the tendon that attaches the knee cap (patella) to the leg (tibia) in order to create a new ligament. Bracing, cryotherapy, and a significant course of physical therapy are required to recover from this injury in most patients.

The Knee of the Weekend Warrior

A typical weekend warrior injury is a twist that results in pain, swelling, stiffness and decreased weight bearing tolerance. If this does not clear up with rest, ice, gentle ,movement and elevation of the leg after 2 or 3 dthCAZTK19Uays, then you should see your doctor for a physical examination. Xrays, ultrasound and clinical findings can diagnose most major knee issues that would require immediate attention. MRI’s are typically reserved for unresolving symptoms that do not get better over a few days or a short number of weeks in spite of a good effort at nonoperative therapies.

An MRI will help to better identify hidden fractures, ligament tears and meniscal tears.

To book a visit with Dr. Smith Auguste, please ask your family doctor to send a referral to fax: 416 352 5123.