All posts by Dr. Stickney

What to Expect After a Meniscectomy

Injury knee painDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

When it comes to meniscal injuries, many patients have little knowledge about the types of treatment options available and their outcomes.  The meniscus, a significant cushion or shock absorber in your knee, is a c-shaped disc of soft cartilage that sits between the femur and the tibia.  When the knee meniscus tears, the cushioning effect diminishes and can cause knee pain and arthritis, eventually requiring treatment. One option is a meniscectomy, a surgical removal of all or part of a torn knee meniscus. A survey conducted by Brophy et al of 253 patients evaluated for meniscal pathology found 62 percent rated their knowledge of the meniscus as “little or none,” and another 28 percent had no idea that meniscectomy procedure–and not a meniscal repair–is the most common surgical treatment for surgical repair. Did you know that?

Since many meniscal tears can require surgical intervention, there’s a clear need to educate patients on options and postoperative considerations: overall outcomes, the risk of needing a subsequent surgery, the ability to return to sport (RTS), the postoperative risk of developing osteoarthritis (OA), the risk of progression to total knee arthroscopy (TKA). Meniscus tear can also affect knee stability, particularly when combined with an anterior cruciate ligament (ACL) injury. A group of doctors at the University of Colorado School of Medicine in Aurora reviewed the current literature on postoperative considerations to help orthopedic surgeons educate their patients on post-meniscectomy expectations.

The review found:

  • Successful return to sport after meniscus surgery was more likely with these circumstances: patients of a younger age, medial meniscectomy and a smaller meniscal resection. The amount of meniscus resected is a function of the size of the tear. All these factors affect the time until patients are able to return to sport.
  • Failure rates after meniscectomy are low when compared to meniscal repair and discoid saucerization procedures. Meniscus repair is done rarely for a large tear, most often in conjunction with ACL reconstruction. The majority of the meniscus has no blood supply and will not heal, so the majority of meniscus surgery involves removing the torn tissue and smoothing the remaining meniscus. Failure rates are increased in patients undergoing lateral meniscectomy.
  • Improved clinical outcomes for non-obese males can be expected in those undergoing medial meniscectomy with minimal meniscal resection. Conversely, if a preexisting angular deformity exists, varus or valgus, which results in an imbalanced load across the knee, the success rate is less predictable. Preexisting degenerative knee changes (damage to the articular cartilage attached to the bones), and anterior cruciate ligament (ACL) deficiency will negatively impact outcomes following a meniscectomy.
  • The risk of developing post-surgical osteoarthritis over the next 10-20 years should be discussed. Meniscectomy increases the risk of developing knee osteoarthritis, particularly in obese females who undergo a large meniscal resection. The development of arthritis after meniscectomy may lead to the need for knee replacement. However, leaving a mobile large meniscus tear clicking around in the knee will more likely result in early arthritis.
  • Meniscectomy is a viable and successful intervention for pain relief and functional improvement for symptomatic meniscal tears, but nonsurgical care should be used first in older patients with preexisting degenerative changes. These patients will likely end up with knee replacement, and an arthroscopic meniscectomy may be an unnecessary step along that path.

If you would like to learn more about meniscal injuries or understand post-surgical outcomes related to meniscectomy, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Diabetes and the Heightened Risk of Periprosthetic Joint Infection

Diabetes woman ready for morning run along the coastDr. Stickney, a Kirkland orthopedic surgeon, is an expert in joint replacementsports medicine, and more.

Diabetes is prevalent not just in the U.S., it affects millions of people worldwide and is one of the leading causes of disability. Its direct effects on postoperative care can impact both the patient and an already strained healthcare system. In the world of orthopedic surgery specifically, little has been documented about a diabetic patient’s incidence of infection after undergoing total knee or total hip arthroplasty.

A recent investigation by researchers at the University of Utah looked at data of type-1 and type-2 diabetes mellitus patients and the incidence of periprosthetic joint infection. By looking at historical, statewide data of more than 75,000 patients undergoing knee or hip arthroplasty between 1996 and 2013, researchers were able to identify 1,668 patients with type-1 diabetes and another 18,186 patients with type-2 diabetes, providing a strong sample size. The researchers hypothesized that arthroplasty patients with type-1 diabetes were at greater risk for infection than those with type-2 diabetes.

While age and sex were found to be insignificant factors contributing to infection rates, the study did find that the frequency of periprosthetic joint infection in non-diabetic patients was 2.6% compared with 4.3% infection rates across all diabetic patients. Looking more specifically at the differences in infection rates between the two types of diabetes, patients with type-1 diabetes were at a 1.8 times greater rate of infection than patients with type-2 diabetes (7% compared to 4%, respectively).

Diabetes-related complications indicated a greater risk of periprosthetic joint infection; these include peripheral circulatory disorders, ketoacidosis, neurological manifestations, renal manifestations, or ophthalmic manifestations, hyperosmolarity (common in type-2 diabetes, where the body tries to rid itself of excess blood sugar via urination), and coma. The odds of infection increased with each added complication, and diabetes patients with more than four of these complications put them at nine times more risk. Weight also plays a role; overweight and obese type-2 diabetes patients, as well as underweight type-1 diabetes patients were also at greater risk for periprosthetic joint infection when compared with the general population.

Findings suggest it may be important to look at the length of time patients have had diabetes, factor in a patient’s diabetes type, and understand a patient’s number of diabetes-related complications prior to any joint replacement surgery. This information can help patients to make a more informed decision and help healthcare providers better manage risk.

If you have chronic health conditions and would like to learn more about how to avoid post-surgical complications related to TKA or THA, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Chronic Prescription Opioid Use Before and After Total Joint Arthroplasty: Overall Promising News

Knee injuriesDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

An April 2019 study in the Journal of Arthroplasty explored the chronic prescription opioid use of patients under the age of 65 before and after having total knee arthroplasty or total hip arthroplasty. Looking at three years of MarketScan data between 2009 and 2012, patient opioid use was measured three months before and 12 months after their respective surgeries. With a large sample of more than 125,000 patients, a multicenter scope, and inclusion of both TKA and THA patients, the study lays out a strong and promising snapshot.

The goal of total joint arthroplasty is to reduce or eliminate the painful symptoms of a degenerative joint disease. Due to the addictive property of opioid medications, some patients may develop a pattern of chronic use after surgery. Others can develop chronic opioid use in managing their pain prior to surgery. “Chronic” was defined in the analysis as having two or more opioid prescriptions filled within a six-week period. 

Of the 24,127 patients (under 65) who were chronic opioid users before surgery, 72% were no longer chronic users 12 months post- op. Of the 100,892 patients under 65 who were nonusers before their surgeries, 4% became chronic opioid users one year post-op.  Patients under age 56 who had TKA or THA were 25% more likely to become chronic opioid users compared to those aged 56-65; and procedurally speaking, those undergoing TKA were 60% more likely to become chronic users than those undergoing THA. The length of hospital stay exceeding three days showed 32% higher odds associated with becoming a chronic opioid user. Being male or female did not significantly factor into the odds of chronic opioid use.

Patients who had TKA and hospital stays more than 3 days were significant risk factors of persisting chronic opioid use after surgery; age played a mixed use in predicting the change of opioid use.

With the authors’ definition of chronic opioid use in mind, the overall chronic opioid use decreased from 19% to 9% after total knee or total hip arthroplasty. Patients were more likely to cease chronic use after TJA (72%) than to become chronic users (4%).

My joint replacement patients seek options that reduce pain, reduce the need for narcotics and speed recovery more than ever. It’s common for patients with even the most debilitating arthritis to fear joint replacement, mostly dreading the pain of the surgery, complications around opioid use and fear or being out of commission after surgery. With the appropriate treatments, we can address your degenerative joint conditions while avoiding the pitfalls of chronic opioid use and on the path to an optimal recovery. If you have any questions about pain management before, during or after TKA or THA, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Hamstring Injuries

Young women sport has thigh muscles injury ,Health conceptDr. Stickney, a Kirkland orthopedic surgeon, is an expert in sports medicinehamstring injuriesexercise and health, and more.

Hamstring injuries are a common, and often frustratingly persistent, source of limitation for both elite athletes and weekend warriors. These injuries can involve either the muscle belly or the tendinous attachment of the muscle to bone. The hamstring is one of the longest muscle bellies in the body as it stretches from the pelvis to the tibia spanning the hip and the knee. Hamstring tears, knee muscle tears and related injuries make up nearly 30% of all lower extremity muscle tendon injuries. These injuries are commonly sustained while running particularly with running uphill. They are very common in soccer, football and all sports associated with acceleration or kicking. Hamstring injuries also are common in weightlifting, skating, or water-skiing. This can be the result of a rapid uncontrolled Hip Flexion with knee extension. If the injury is associated with a loud pop that often signifies a tendon avulsion. In that case, the tendon has pulled off of bone. On the other hand, if there is acute muscular tearing pain followed by bruising and a palpable defect in the muscle, this typically signifies an intermuscular tear. Injuries that do not adequately heal or get adequate therapy can result in scar tissue which is prone to reinjure.  Hamstring injuries have a very high rate of recurrence as a result.

    The hamstring muscles in the posterior thigh, as well as the quadriceps muscle in the anterior thigh, work in concert during running jumping, acceleration, and deceleration. A muscular balance between these 2 muscles as well as flexibility of both muscles is crucial to preventing injuries. Core muscle development and hip muscle strengthening can also help prevent hamstring injuries. Hamstring injuries more commonly occur during eccentric contraction. Eccentric contraction means the muscle is firing but at the same time it is lengthening. During running the quadriceps extends the knee as your foot reaches forward near the end of that extension the hamstring slows down the extension while the foot is still moving forward just before impact. This is an eccentric contraction of the hamstring and this is the phase of running most commonly associated with hamstring injuries. These are typically intermuscular injuries. These commonly lead to bleeding into the muscle and then the development of scar tissue in the muscle which is less flexible than muscle, and more vulnerable to tearing in the future. As a result, an athlete with a hamstring injury has a 25% rate of recurrence of hamstring injury in the following season despite rehabilitation.

     A very good study was done in professional soccer players to try and prevent initial hamstring injuries and to prevent recurrence of hamstring injuries. The results of that study is the Nordic hamstring exercise protocol. In professional athletes, this protocol led to an 80% reduction in primary hamstring injuries and a 65% reduction in recurrent injuries. The Nordic protocol is a progressive strengthening of the hamstrings through eccentric loading. This protocol is best visualized on a YouTube video.

     Once a hamstring injury occurs it is very important to establish whether or not the tendon has pulled off bone or if it is an intermuscular injury. If the tendon has pulled off bone it is important to repair it in the early period after injury. On the other hand, most intermuscular injuries require rest, elevation, icing, compression (RICE) and then range of motion with deep massage. There have been a few studies to suggest that injection of platelet rich plasma with growth factors can enhance healing.  And some other studies suggested injection of steroids may decrease the likelihood of developing scar tissue. The time to recovery is largely dependent on the location and extent of injury. Most minor hamstring injuries can be treated with physical therapy and return to sport in approximately 6-12 weeks. It is very important to regain full flexibility and equal strength before returning to competitive sports to prevent future recurrent injuries.

Should There Be Strict BMI Cutoffs for TKA and THA?

happy senior couple hiking on the mountainDr. Stickney, a Kirkland orthopedic surgeon, is an expert in total knee arthroplasty, total hip arthroplasty, exercise and health, and more.

Recently we posted a blog about candidacy for and outcomes of Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) in morbidly obese patients who underwent pre-operative weight loss. Operating on obese patients for TKA and THA continues to be a hot button topic of risk versus reward in surgical outcomes.

Two well-respected orthopedic authorities, recently faced off to have a deeper conversation about whether or not orthopedic surgeons should have strict BMI cutoffs for performing primary TKA or THA. Benjamin F. Ricciardi, MD engaged Thomas K. Fehring, MD, from OrthoCarolina and Nicholas Giori, MD and PhD, a Stanford University professor, to face off. Highlights are summarized below.

Q: To what degree does the evidence support a strict BMI cutoff to determine eligibility for primary TKA and THA?

Dr. Fehring noted many Americans (35%) are obese and the association between patients with a BMI above 40 and surgical complications/infection is irrefutable. He recommends looking at big data such as Medicare or Veterans Affairs, meta-analysis, and position statements by specialty medical societies. All findings to date underscore the need to have a strict cutoff, but Dr. Fehring noted it’s important to develop weight loss strategies for patients prior to arthroplasty. 

Dr. Giori agreed that obesity is undeniably related to complications, but BMI is a weak risk factor compared to others that are commonly accepted (such as heart and metabolic disorders).

Q: Given the expansion of strict BMI cutoffs at the administrative level, how should safety (non-maleficence) be balanced against access to care?

Dr. Giori said that while BMI cutoffs are well-intended, the ones currently used have the effect of arbitrarily rationing care without medical justification. Also, he feels it disproportionately affects minorities, women and patients in low socio-economic classes. In his opinion, the decision should be based on joint decision making between the doctor and the patient. Risk adjustments in payment models (for doctors’ compensation) would help in the future.

Dr. Fehring agreed with many of the points, but at a certain point the risk outweighs the benefit, and attempting to operate on all patients regardless of BMI becomes dangerous. Keeping his “do no harm” obligation in mind, Dr. Fehring stated a BMI cutoff of 40 as a reasonable goal for patient safety.

Q: If a patient with morbid obesity is to undergo arthroplasty, what steps should be taken before surgery to make hip or knee arthroplasty safer?

Dr. Fehring recommended the patient be in the best possible health they can be prior to elective surgery to avoid complications. An optimization program, factoring in body weight, blood glucose control, serum albumin, and smoking status are part of his clinic’s protocol; patients get tools to meet and stick to set goals before getting surgery. It’s not just about treating the knee or hip; it’s about treating the whole patient as well, he said.

Dr. Giori recognized that optimization programs can help and his clinic also offers one, but the best that can be done regarding obesity is encouragement and education, and referring the patient to a structured weight-reduction program. On the flipside, the patient should do his or her best to lose weight to get below a given BMI threshold. From there, doctor and patient can create a shared decision-making plan that may or may not involve surgery.

If you’d like to discuss weight concerns prior to your total knee or hip replacement surgery, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Can Weight Loss Before Total Knee Arthroplasty Help?

Senior man having medical exam.When obese patients undergo total knee arthroplasty (TKA), many surgeons require or request preoperative weight loss. A group of researchers sought to determine the amount of weight loss needed in this patient population, to improve TKA operative time, length of stay, discharge to a rehab facility, and functional improvement after surgery. This is the first known study to look exclusively at obese patients to understand how preoperative weight loss might improve knee surgical outcomes after TKA.

Those considered morbidly obese have a body mass index (BMI) of 40 or higher. This study looked at 203 patients with a BMI of 40 or more. They were evaluated 90 days before their TKA, and again immediately preceding TKA, to assess weight loss. Of those who lost weight preoperatively, 41% had lost five or more pounds, 29% lost 10 or more pounds, and 14% lost 20 or more pounds.

Losing 10 or less pounds before surgery made no difference in operative time, length of stay, the need for discharge to a rehab facility, or post-operative functional improvement. However, the preoperative loss of 20 pounds or more showed benefits: It lowered the odds of discharge to a rehab facility, and was associated with a shortened length of stay. There were, however, no significant differences in surgery times or functional improvements for those who lost 20-plus pounds.

A longer stay in the hospital or discharge to a rehab facility is a driver of higher costs in primary total knee arthroplasty. Preoperative weight loss may reduce overall costs. The need for Discharge to a rehab facility is also correlated with an increased rate of post-operative infection. In the future, this study could help surgeons target a specific level of weight loss prior to TKA, for their patients to improve knee surgical outcomes.

If you’d like to discuss obesity or weight concerns prior to your total knee arthroplasty, or just want to learn more about the knee replacement procedure, please contact our office. We’ll help you return to your healthy, pain-free lifestyle.

Dr. Stickney, a Kirkland orthopedic surgeon, is an expert in total and partial knee arthroplasty, exercise and health, and more.