Friday, April 18, 2014

Obesity and Joint Replacement Surgery

Orthopedic Surgeons do not possess the tools or the clinical skills needed to guide patients in the treatment of obesity. I am a knee specialist in Scottsdale, Arizona and I face this dilemma daily.     The Hippocratic Oath instructs physicians to “do no harm” to the people we treat.
Morbid Obesity, defined as a BMI (body mass index) of greater than 40, is a proven risk factor for adverse events before, during and after orthopedic surgery.  There is an increased likelihood of knee infections, blood clots, wound healing problems, reoperation and readmission to the hospital.  There are specific anesthesia risks such as vascular access (harder IV placement), accurate vital sign monitoring (usually need arterial line), harder breathing tube placement, difficulty getting oxygen into the lungs, and problems with safe positioning on operating room tables.  Finally, there is a greater chance for serious heart and lung problems during and in the days following surgery.  Patients with normalized body weight are more likely to have an uneventful surgery free of complications.  For the stated reasons, I embrace the Hippocratic Oath and avoid joint replacement surgery in my patients with morbid obesity.
The paradox is apparent - we, the medical community,  are not smart enough to help our patients afflicted with obesity to overcome their disease.  Sadly, modern medicine does not have a predictable treatment for obesity.
Orthopedic Surgeons do not possess the tools or clinical skills needed to guide patients in the treatment of obesity.  Race, ethnicity and gender contribute to the obesity epidemic in poorly understood ways.  Cultural differences between blacks, caucasians and latinos need to be better defined for treatment programs to be successful.
In America there is a lack of knowledge as to how to best incorporate a variety of medical and non medical specialists to combat obesity.  There is no network of treatment resources to address the multitude of obstacles obese patients require to treat malnutrition and psychological disease (anxiety/depression).  For some, socioeconomic inequalities such as lack of healthy food marketplaces and lack of public places to safely exercise propagate the problem.
Obese patients know they have a life threatening disease.  Obese patients do not want to be heavy.  America must come together to find answers to treat our sickest citizens.  The answer lies in finding ways to alter cultures, environments, economics, and education.  We have to do better.  Neglect is not a treatment plan.  Knee arthritis surgery is not the first step in the treatment plan for curing obesity because it is not safe to perform major surgical procedures on our morbidly obese patients - the health risk is too great.
I believe the orthopedic surgeon should optimize patient function with mobility assist devices such as bracing, canes, walkers, scooters and Segway's.  We will manage pain with oral and topical medications, knee injections, and low impact land and water based exercise.  As always we will provide our patients with clear rational, reasoning as the basis for our recommendations and treatments.
Orthopedic surgeons need help from our medical colleagues.   Patients will need treatment of the emotional component of their disease.  We suggest the patient explore culturally specific guidance.  Some of our patients need guidance with shopping and eating healthier.  It is the duty of health professionals to mandate exercise.
Lastly, as physicians, we offer support, encouragement and guidance.  Our American system has to do better - Our Patients Need Help.
Stefan D. Tarlow, M.D. Scottsdale Knee Specialist
Stefan D. Tarlow, M.D.
Scottsdale Knee Specialist

Monday, April 14, 2014

New Procedure Offers Treatment Option for Obese Patients With Knee Pain.

Subchondrplasty Joint Preservation Treatment Less Invasive Than Joint Replacement Surgery.
MRI of BME-Xray normal
From Zimmer Institute
Subchondroplasty® Procedure is the innovative new joint preservation procedure developed by Zimmer Knee Creations to treat the microfractures that develop just under the joint surface in painful knees.  These lesions are similar to stress fractures and develop due to overload of the bones that make up the knee joint.  

Rather than replacing the entire knee, this treatment aims to stimulate nature to heal the bone lesion which can lead to reduced knee pain and better knee function.   Subchondroplasty is an arthroscopic knee surgical procedure done as an outpatient.  This is a safer and less invasive procedure than Total or Partial knee replacement and as such may be carried out in higher risk surgical patients, such as the obese patient,  with less fear of an adverse outcome such as infection or blood clot.
BML-MRI image
From Zimmer Institute
Bone Marrow Edema (BME), or Bone Marrow Lesions (BML) are thought to cause pain in knees with early or late osteoarthritis.  These lesions can only be diagnosed with high resolution 3 T MRI scans.  In 2001 Felson identified BME/BML as the strongest predictor of the presence of pain associated with knee OA.  They also determined that arthroscopy alone will not predictably relieve knee pain associated with arthritis.  

This observation has been confirmed by other investigators.   However, the novel Subchondroplasty® Procedure is a percutaneous outpatient intervention that addresses the painful defects associated with subchondral bone marrow lesions (BME/BML). BMLs are related to stress fractures or micro-fractures, that can only be visualized using MRI scans. Left untreated, these defects have been shown to lead to cartilage degeneration, limited function, pain and greater risk for joint deterioration.  
Theoretically, mechanical enhancement and/or biologic stimulation of chronically damaged and structurally compromised SubChondral bone, juxtaposed to a region of the joint with deficient cartilage, will relieve Knee pain emanating from the SubChondral bone and slow progression both bone and cartilage deterioration.

From Zimmer Institute

In this minimally invasive, arthroscopically-assisted procedure, navigation instruments are used to inject specialized Ceramic Calcium Phosphate bone filler (Etex), without violating the joint. As the bone filler is resorbed, the pain due to BML subsides as the lesion is replaced with new, healthy bone.  The substitution of abnormal bone with healthy bone is the reason patients experience pain relief.    The Subchondroplasty Procedure is the first procedure to treat bone-based changes within a painful joint, and addresses an unmet clinical need between early interventions, such as NSAIDs and joint arthroscopy, and total joint replacement. Subchondroplasty was introduced in November 2010.  This procedure is now available in the Greater Phoenix area from Stefan D. Tarlow, M.D. of Advanced Knee Care, PC.

Friday, April 11, 2014

Managing Surgical Knee Pain in the Opioid Epidemic Era

For Surgeons the dichotomy is clear - Provide excellent pain management for our patients but do not expand the opioid epidemic.  More people are killed in the USA by prescription opioids (Percocet, Oxycontin, Vicodin, Norco, etc) than by trauma (motor vehicle accidents) and heroin.
 For the health, safety and long term well being of our patients we will strive to limit the number of opioids we prescribe to treat your surgical pain.  Typical Arthroscopy Patients take narcotics for less than a week, ACL/Patella Reconstruction Patients for less than 2 weeks and Joint Replacement Patients for less than a month.  There are exceptions, usually in difficult cases or cases with complications.  Any patient receiving opioids for longer than 60 days will be subject to laboratory drug screening and must agree to/sign the Opioid Chronic Pain Management Contract.
Pain control is defined as “Pain that does not interfere with normal daily function”.  Pain control does not mean absolutely no pain.   Patients do experience discomfort after orthopedic surgery and our job is to manage and mitigate the pain, not completely eliminate all pain.  However,  governmental and other advocates for pain as the “5th Vital Sign” have created the opioid epidemic which has been directly linked to increase patient deaths.
Hydrocodone, the narcotic in Vicodin and Norco, is the #1 prescribed opioid in our country with 131 million prescriptions written each year.  A person on hydrocodone for 90 days has a 2/3 chance of being addicted to hydrocodone 5 years later.
Most opioid abusers source their drugs from friends and families.  As a doctor I am part of the Opioid Epidemic Problem.  I contribute to opioid addiction.   Left over opioid prescriptions fuel the problem.  Now I have reassessed my prescribing habits so that I can be part of the solution.
Stefan D. Tarlow, M.D. Scottsdale Knee Specialist
Stefan D. Tarlow, M.D.
Scottsdale Knee Specialist

Friday, March 28, 2014

Peripheral Nerve Blocks Do Not Increase Fall Risk After Knee Replacement Surgery

Stefan D. Tarlow, MD, a Scottsdale Knee Surgeon, typically uses peripheral nerve blocks on patients undergoing Total Knee Replacement and Unicompartmental Knee Replacement (Makoplasty or partial knee replacement)


Chance of Falling After Knee Replacement Not Increased by Regional Anesthesia

Research suggests spinal and epidural anesthesia, peripheral nerve blocks safe to use

Released: 2/14/2014 4:00 PM EST
Source Newsroom: American Society of Anesthesiologists (ASA
Citations Anesthesiology
Newswise — Two types of regional anesthesia do not make patients more prone to falls in the first days after having knee replacement surgery as some have previously suggested, according to a study based on nearly 200,000 patient records in the March issue of Anesthesiology.
Regional forms of anesthesia – spinal or epidural (neuraxial) anesthesia and peripheral nerve blocks (PNB) – which only numb the area of the body that requires surgery, provide better pain control and faster rehabilitation and fewer complications than general anesthesia, research shows. But some surgeons avoid using them due to concerns regional anesthesia may cause motor weakness, making patients more likely to fall when they are walking in the first days after knee replacement surgery.
“We found that not only do these types of anesthesia not increase the risk of falls, but also spinal or epidural anesthesia may even decrease the risk compared to general anesthesia,” said Stavros G. Memtsoudis, M.D., Ph.D., professor of anesthesiology and public health and director of critical care services, Hospital for Special Surgery, New York, and lead author. “This work suggests that fear of in-hospital falls is not a reason to avoid regional anesthesia for orthopedic surgery.”
Researchers analyzed the types of anesthesia used in 191,570 knee replacement surgeries in the Premier Perspective database: 76.2 percent of patients had general anesthesia, 10.9 percent had spinal or epidural anesthesia, and 12.9 percent had a combination of neuraxial and general anesthesia. In addition, 12.1 percent of all patients had PNB. Researchers then analyzed the type of anesthesia used for those who suffered a fall in the hospital. Of patients who had general anesthesia, 1.62 percent fell, compared to 1.3 percent of those who had neuraxial anesthesia and 1.5 percent who had general and neuraxial anesthesia. Patients who also received a PNB had a fall rate of 1.58 percent.
When patients fall during recovery, they are more likely to have worse outcomes, including more heart and lung problems and higher rates of death within 30 days of surgery. Spinal or epidural anesthesia and PNB are used far less often than general anesthesia because of concern that regional forms of anesthesia – particularly PNB – may increase muscle weakness and make patients more prone to falls. However, there has never been a large study based on real-world practices to determine if that is true.
“In this study using data from a wide range of hospital settings we found this concern seems unfounded, especially because hospitals and physicians performing these procedures use fall-prevention programs and are able to reduce the impact of other factors shown to increase fall risk, such as higher narcotic use,” said Dr. Memtsoudis.

Friday, March 21, 2014

Knee Replacement: DVT Prevention Without Risky Medications

Vena Flow Elite - A Mobile Home Compression Device for Blood Clot Prevention After Knee Surgery -- For Total and Partial Knee Replacement Patients
VenaFlow Elite with Calf Cuff, Tubing and Compression Pump - photo from DJO website

Advanced Knee Care will be utilizing the DJO VenaFlow Elite home sequential  compression device to lessen deep venous thrombosis (DVT) risk during our patient's first 2 weeks at home.  Designed as a prophylaxis for Deep Vein Thrombosis, the VenaFlow Elite System combines two proven technologies,  rapid inflation and graduated sequential compression that work to mimic ambulation and accelerate venous velocity. 

Joint replacement patients have typically been treated with blood thinners such as Coumadin or Lovenox.  These strong medicines are also the cause of serious  complications related to excessive bleeding.  Current research suggests DVT prevention is accomplished more safely with leg compression/Aspirin. This combination avoids the bleeding risk associated with Coumadin and Lovenox.  Recent studies prove that the VenaFlow Elite home program is equally effective as Coumadin or Lovenox at lowering the risk of blood clots after Knee Replacement Surgery.   

Dr. Tarlow believes best practice mandates the use of this device.The device is shipped to your home (with return prepaid shipping label). Inside the box are  complete instructions on the use of the device, disposable cuffs for each lower leg, tubing and the electronic compression pump unit.  The prepaid fee of $200 includes up to 3 weeks of rental of the pump/tubing {fee refunded to our patient if payment received for your health insurance carrier}. These devices wrap around both lower legs and use rapid air inflation to move the blood out of the lower leg, minimizing blood clots. The VenaFlow device is used at rest (in bed or sitting on chair or couch) for 2 weeks, then returned to DJO Global. The device is NOT needed when walking normally. 

The CPT code for the rental of this unit is E0676,RR.

Advanced Knee Care - Scottsdale, AZ