It is a fact of life that, as we grow older, our bones become thinner and weaker. In theory, therefore, we are all at risk of developing osteoporosis. Certain factors may accelerate this process, however, and it is important that we become aware of them.

Menopause
Women are at greater risk of developing osteoporosis than men. Of course, this does not mean that every woman will get osteoporosis, simply that osteoporosis occurs with greater frequency in women.

After the menopause, the ovaries stop producing the female hormone, estrogen. Estrogen is important for maintaining bone strength. Without estrogen, bone loses calcium - one of its most important components. If you have had a particularly early menopause (before the age of 45, for example), your bones will have lost the important benefits of estrogen much earlier than usual, and it is likely that you are at an increased risk of developing osteoporosis.

The amount of estrogen in your body may also decrease due to reasons other than the menopause. If, for example, you have had a hysterectomy, and if your ovaries were removed, you are likely to have a very low estrogen level, and your risk of osteoporosis may be higher than normal.

Women whose periods have stopped for a long time, for any reason other than pregnancy, may have weaker bones as a result of having a deficiency of estrogen during that time. If you are still having regular periods, your ovaries probably are producing enough estrogen.

Smoking/Alcohol
We all know about the health risks associated with smoking and a high alcohol intake. In addition to all the other problems that they can cause, smoking and a regular high alcohol intake can also interfere with the body's ability to maintain normal, healthy bones.

Smoking speeds up the rate at which you lose bone, which makes you much more likely to suffer from osteoporosis.

Lack of Exercise
The strength of our bones is determined partly by the physical demands placed on the skeleton. Similar to the way in which our muscles weaken if they are not used, bones need a certain amount of exercise to stay strong and healthy. People who are confined to bed or a wheelchair, or who lead a particularly inactive lifestyle, have a higher risk of developing osteoporosis.

Diet
We are what we eat! To a certain extent this is true, particularly with regard to the maintenance of healthy bones. An inadequate intake of calcium in the diet deprives the body of the raw materials it needs to maintain bone mass and strength. Anyone who is nutritionally deficient or who has a low dietary intake of calcium-rich foods, such as dairy products and fresh vegetables, may be at increased risk of developing osteoporosis. In addition, as we grow older, the amount of calcium that our body needs changes. For example, a higher calcium intake is recommended for children, adolescents, women who are breast-feeding, and postmenopausal women.

As we grow older, we should be more conscious about what we eat. This is because, as we age, the ability of our digestive system to absorb the important vitamins and minerals contained in the food that we eat is reduced. Therefore, it is often easy for older persons to become malnourished, even if they think that they are eating properly.

Family History
If your mother or grandmother suffered from osteoporosis, then you are more likely to be at an increased risk of developing the disease. How do you find out if you have osteoporosis in your family? First, your relative may have been diagnosed with osteoporosis by a physician. Because osteoporosis may be present for many years without any obvious signs or symptoms, you may have relatives who have the disease but who are unaware of it. Alternatively, you may have a relative who has characteristic signs of osteoporosis, such as broken bones following minor trauma, a hunched back, or height loss.

Medical History
Some medical problems, for example, an overactive thyroid gland, liver disease, or anorexia nervosa, can cause osteoporosis. In addition, certain medications, such as steroids, when used for a long time can have a detrimental effect on bones. Steroids often are used in the long-term treatment of asthma and conditions like rheumatoid arthritis. If you have been taking steroids, you should discuss this with your physician.

Previous Fracture
A previous broken bone, particularly of the hip, wrist, or spine, that has resulted from minor trauma may be an indication that your bones are already weak. If this is the case, the likelihood of breaking additional bones, or possibly the same bone, could be increased. Your physician will advise you on how to try to lower your chances of having more fractures.

Low Body Weight
Women who are unusually slender may be at increased risk of osteoporosis. This is because their skeleton is small to begin with. Once the bones start to thin and weaken after the menopause, they will reach a stage at which they fracture more easily than the bones in women who have a normal build.

If you suspect that you are at risk of developing osteoporosis, you should discuss your concern with your physician.

We cannot slow the passing of time or change the effects that aging has on our bodies. There are steps that you can take, however, to reduce your risk of developing osteoporosis. Remember, even if you are well past the menopause, or your physician has told you that you already have osteoporosis, it is never too late to act. Your physician will advise you.

Changing Your Lifestyle
A great deal of information is available to us on how to improve our general health, and much of the information is relevant to our bones.

Give up smoking
If you have not already given up smoking for the sake of your lungs, heart, and circulation, osteoporosis is another reason to stop! There are many ways to help you give up smoking, and your physician will be able to advise you on the best way for you to stop.

Reduce your alcohol intake
A small amount of alcohol may not harm you, but if you drink regularly, you may increase your risk of developing osteoporosis. Your physician will be able to advise you as to whether you need to cut down on your alcohol intake and how to do this.

Exercise
Regular exercise helps to prevent bone loss and is good for your heart, as well. You do not have to exercise vigorously to obtain benefit. More important is that you exercise regularly. A walk with the dog every day is much better than an active game of tennis once a week. The key is not to push yourself too hard to begin with, especially if you have not exercised for a while. Even if you are housebound or, indeed, if you already have osteoporosis, there are some simple exercises that you can do. You should consult your physician before you begin any exercise program.

Dietary calcium
One of the most important ways to reduce your risk for developing osteoporosis is to have a strong skeleton in the first place! By making sure that children have plenty of calcium in their diet, we ensure that their bones are strong. After 20 to 30 years of age, our bones stop growing, but good evidence suggests that maintaining an adequate calcium intake is important, whatever your age.

The following foods are rich in calcium:
Milk 770 mg/500 ml (whole or skimmed)
Cheese 760 mg/100 g
Yogurt 150 mg/100 g
Bread 7.5 to 45 mg/slice
Sardines 440 mg/100 g
Broccoli 100 mg/100 g
Eggs 27 mg/egg

Other dietary sources that are rich in calcium include:
* salmon
* all milk products such as ice cream
* spinach
* soy beans
* peanuts

A daily intake of 1000 mg of calcium is recommended for most adults, although if you are postmenopausal, you may need to increase your daily intake to 1500 mg.

If you are not getting adequate calcium in your diet, your physician will be able to advise you of the appropriate steps to take.

Osteogenesis imperfecta (OI) is a genetic disorder characterized by bones that break easily, often from little or no apparent cause. There are at least four recognized forms of the disorder, representing extreme variation in severity from one individual to another. For example, a person may have just a few or as many as several hundred fractures in a lifetime.

While the number of people affected with OI in the United States is unknown, the best estimate suggests a minimum of 20,000 and possibly as many as 50,000.

OI is caused by a genetic defect that affects the body’s production of collagen. Collagen is the major protein of the body’s connective tissue and can be likened to the framework around which a building is constructed. In OI, a person has either less collagen than normal, or a poorer quality of collagen than normal—leading to weak bones that fracture easily.

It is often, though not always, possible to diagnose OI based solely on clinical features. Clinical geneticists can also perform biochemical (collagen) or molecular (DNA) tests that can help confirm a diagnosis of OI in some situations. These tests generally require several weeks before results are known, and approximately 10 to 15 percent of individuals with mild OI who have collagen testing, and approximately 5 percent of those who have genetic testing, test for OI despite having the disorder.

The characteristic features of OI vary greatly from person to person—even among people with the same type of OI, and even within the same family—and not all characteristics are evident in each case. The general features of the four recognized types of OI, which vary in characteristics and severity, are as follows:

Type I
Most common and mildest type of OI:

	Bones predisposed to fracture.  Most fractures occur before puberty.
	Normal or near-normal stature.
	Loose joints and low muscle tone.
	Sclera (whites of the eyes) usually have a blue, purple, or gray tint.
	Triangular face.
	Tendency toward spinal curvature.
	Bone deformity absent or minimal.
	Brittle teeth possible.
	Hearing loss possible, often beginning in early 20s or 30s.
	Collagen structure is normal, but the amount is less than normal.

Type II
Most severe form

	Frequently lethal at or shortly after birth, often due to respiratory problems. In recent years, some people with Type II have lived into young adulthood.
	Numerous fractures and severe bone deformity.
	Small stature with underdeveloped lungs.
	Collagen is improperly formed.

Type III

	Bones fracture easily. Fractures are often present at birth, and x-rays may reveal healed fractures that occurred before birth.
	Short stature.
	Sclera have a blue, purple, or gray tint.
	Loose joints and poor muscle development in arms and legs.
	Barrel-shaped rib cage.
	Triangular face.
	Spinal curvature.
	Respiratory problems possible.
	Bone deformity, often severe.
	Brittle teeth possible.
	Hearing loss possible.
	Collagen is improperly formed.

Type IV

	Bones fracture easily, most before puberty.
	Shorter than average stature.
	Sclera are white or near-white (i.e., normal in color).
	Mild to moderate bone deformity.
	Tendency toward spinal curvature.
	Barrel-shaped rib cage.
	Triangular face.
	Brittle teeth possible.
	Hearing loss possible.
	Collagen is improperly formed.

Most cases of OI are caused by a dominant genetic defect. Some children with OI inherit the disorder from a parent. Other children are born with OI even though there is no family history of the disorder. In these children, the genetic defect occurred as a spontaneous mutation.

Because the defect—whether inherited or due to a spontaneous mutation—is usually dominant, a person with OI has a 50 percent chance of passing on the disorder to each of his or her children. Genetic counselors can help people with OI and their family members further understand OI genetics and the possibility of recurrence, and assist in prenatal diagnosis for those who wish to exercise that option.

There is not yet a cure for OI. Treatment is directed toward preventing or controlling the symptoms, maximizing independent mobility, and developing optimal bone mass and muscle strength. Care of fractures, extensive surgical and dental procedures, and physical therapy are often recommended for people with OI. Use of wheelchairs, braces, and other mobility aids is common, particularly (although not exclusively) among people with more severe types of OI.

A surgical procedure called "rodding" is frequently considered for individuals with OI. This treatment involves inserting metal rods through the length of the long bones to strengthen them and prevent and/or correct deformities.

Several medications and other treatments are being explored for their potential use to treat OI. The OI Foundation can provide current information on research studies and experimental treatments for OI, as well as information to help individuals decide whether to participate in clinical trials.

People with OI are encouraged to exercise as much as possible to promote muscle and bone strength, which can help prevent fractures. Swimming and water therapy are common exercise choices for people with OI, as water allows independent movement with little risk of fracture. For those who are able, walking (with or without mobility aids) is excellent exercise. Individuals with OI should consult their physician and/or physical therapist to discuss appropriate and safe exercise.

Children and adults with OI will also benefit from maintaining a healthy weight, eating a nutritious diet, and avoiding activities such as smoking, excessive alcohol and caffeine consumption, and taking steroid medications—all of which may deplete bone and exacerbate bone fragility.

The prognosis for an individual with OI varies greatly depending on the number and severity of symptoms. Despite numerous fractures, restricted activity, and short stature, most adults and children with OI lead productive and successful lives.

Paget's disease is a chronic disorder that typically results in enlarged and deformed bones. The excessive breakdown and formation of bone tissue that occurs with Paget's disease can cause bone to weaken, resulting in bone pain, arthritis, deformities, and fractures. Paget's disease may be caused by a "slow virus" infection, present for many years before symptoms appear. There is also a hereditary factor since the disease may appear in more than one family member.

Who is Affected?
Paget's disease is rarely diagnosed in people under 40 years of age. Men and women are affected equally. Prevalence of Paget's disease ranges from 1.5 to 8 percent depending on age and country of residence. Prevalence of familial Paget's disease (where more than one family member has the disease) ranges from 10 to 40 percent in different parts of the world. Because early diagnosis and treatment is important, after age 40, siblings and children of someone with Paget's disease may wish to have an alkaline phosphatase blood test every 2 or 3 years. If the alkaline phosphatase level is above normal, other tests such as a bone-specific alkaline phosphatase test, bone scan, or x-ray can be performed.

Symptoms
Many patients do not know they have Paget's disease because they have a mild case of the disease with no symptoms. Sometimes, symptoms may be confused with those of arthritis or other disorders. In other cases, the diagnosis is made only after complications have developed. Symptoms can include:

	Bone pain -- the most common symptom. Bone pain can occur in any bone affected by Paget's disease. It often localizes to areas adjacent to the joints.
	Headaches and hearing loss -- may occur when Paget's disease affects the skull.
	Pressure on nerves -- may occur when Paget's disease affects the skull or spine.
	Increased head size, bowing of limb, or curvature of spine -- may occur in advanced cases.
	Hip pain -- may occur when Paget's disease affects the pelvis or thighbone.
	Damage to cartilage of joints -- may lead to arthritis.

Diagnosis
Paget's disease may be diagnosed using one or more of the following tests:

X-rays -- Pagetic bone has a characteristic appearance on x-rays.

Alkaline phosphatase blood test -- An elevated level of alkaline phosphatase in the blood can be suggestive of Paget's disease.

Bone scans -- Useful in determining the extent and activity of the condition. If a bone scan suggests Paget's disease, the affected bone(s) should be x-rayed to confirm the diagnosis.

Prognosis
The outlook is generally good, particularly if treatment is given before major changes in the affected bones have occurred. Any bone or bones can be affected, but Paget's disease occurs most frequently in the spine, skull, pelvis, thighs, and lower legs. In general, symptoms progress slowly, and the disease does not spread to normal bones. Treatment can control Paget's disease and lessen symptoms but is not a cure. Osteogenic sarcoma, a form of bone cancer, is an extremely rare complication that occurs in less than one percent of all patients.

Other Medical Conditions
Paget's disease may lead to other medical conditions, including:

	Arthritis -- Long bones in the leg may bow, distorting alignment and increasing pressure on nearby joints. In addition, Pagetic bone may enlarge, causing joint surfaces to undergo excessive wear and tear. In these cases, pain may be due to a combination of Paget's disease and osteoarthritis.
	Hearing -- Loss of hearing in one or both ears may occur when Paget's disease affects the skull and the bone that surrounds the inner ear. Treating the Paget's disease may slow or stop hearing loss. Hearing aids may also help.
	Heart disease -- In severe Paget's disease, the heart works harder to pump blood to affected bones. This usually does not result in heart failure except in some people who also have hardening of the arteries.
	Kidney stones -- Kidney stones are somewhat more common in patients with Paget's disease.
	Nervous system -- Pagetic bone can cause pressure on the brain, spinal cord, or nerves, and reduced blood flow to the brain and spinal cord.
	Sarcoma -- Rarely, Paget's disease is associated with the development of a malignant tumor of bone. When there is a sudden onset or worsening of pain, sarcoma should be considered.
	Teeth -- When Paget's disease affects the facial bones, the teeth may become loose. Disturbance in chewing may occur.
	Vision--Rarely, when the skull is involved, the nerves to the eye may be affected, causing some loss of vision.

Paget's disease is not associated with the following disorder:

Osteoporosis -- Although Paget's disease and osteoporosis can occur in the same patient, they are completely different disorders. Despite their marked differences, many treatments for Paget's disease can also be used to treat osteoporosis.

Treatment
Types of physicians
The following types of medical specialists are generally knowledgeable about treating Paget's disease.

	Endocrinologists -- Internists who specialize in hormonal and metabolic disorders.
	Rheumatologists -- Internists who specialize in joint and muscle disorders.
	Specialists -- Orthopedic surgeons, neurologists, and otolaryngologists (physicians who specialize in ear, nose, and throat disorders) may be called upon to evaluate specialized symptoms.
	Drug therapy The goal of treatment is to control Paget's disease activity for as long a period of time as possible. The U.S. Food and Drug Administration (FDA) has approved the following treatments for Paget's disease.
	Bisphosphonates. Five bisphosphonates are currently available. As a rule, bisphosphonate tablets should be taken with 6-8 oz of tap water on an empty stomach. None of these drugs should be used by people with severe kidney disease.
	Didronel® (etidronate disodium) -- Tablet; approved regimen is 200-400 mg once daily for 6 months; the higher dose (400 mg) is more commonly used; no food, beverages, or medications for 2 hours before and after taking; course should not exceed 6 months, but repeat courses can be given after rest periods, preferably of 3-6 months duration.
	Aredia® (pamidronate disodium) -- Intravenous; approved regimen 30 mg infusion over 4 hours on 3 consecutive days; more commonly used regimen 60 mg over 2-4 hours for 2 or more consecutive or non-consecutive days.
	Fosamax® (alendronate sodium) -- Tablet; 40 mg once daily for 6 months; patients should wait at least 30 minutes after taking before eating any food, drinking anything other than tap water, taking any medication, or lying down (patient may sit).
	Skelid® (tiludronate disodium) -- Tablet; 400 mg (two 200 mg tablets) once daily for 3 months; may be taken any time of day, as long as there is a period of 2 hours before and after resuming food, beverages, and medications.
	Actonel® (risedronate sodium) -- Tablet; 30 mg once daily for 2 months; patients should wait at least 30 minutes after taking before eating any food, drinking anything other than tap water, taking any medication, or lying down (patient may sit).
	Calcitonin
	Miacalcin® is administered by injection; 50 to 100 units daily or 3 times per week for 6-18 months.

Surgery
Medical therapy prior to surgery helps to decrease bleeding and other complications. Patients who are having surgery should discuss pre-treatment with their physician. There are generally three major complications of Paget's disease for which surgery may be recommended.

	Fractures -- Surgery may allow fractures to heal in better position.
	Severe degenerative arthritis -- If disability is severe and medication and physical therapy are no longer helpful, joint replacement of the hips and knees may be considered.
	Bone deformity -- Cutting and realignment of Pagetic bone (osteotomy) may help painful weight-bearing joints, especially the knees.
	Complications resulting from enlargement of the skull or spine may injure the nervous system. However, most neurologic symptoms, even those that are moderately severe, can be treated with medication and do not require neurosurgery.

Diet and Exercise
In general, patients with Paget's disease should receive 1000-1500 mg of calcium, adequate sunshine, and at least 400 units of vitamin D daily. This is especially important in patients being treated with bisphosphonates. Patients with a history of kidney stones should discuss calcium and vitamin D intake with their physician.

Exercise is very important in maintaining skeletal health, avoiding weight gain, and maintaining joint mobility. Since undue stress on affected bones should be avoided, patients should discuss any exercise program with their physician before beginning.

Introduction
Hand function is inseparably linked to the condition of the thumb carpometacarpal joint. Although fractures, ligament injuries, and rheumatologic processes may damage this important articulation, basal joint arthroplasty is most often performed to relieve pain and increase motion in joints damaged by osteoarthritis1.

Considerations
Thumb joint replacement may be considered for:

	Impairment of the thumb basal joint with localized CMC bony changes.
	Localized pain and palpable crepitation during circumduction movement with axial compression of the of involved thumb ("grind test").
	Decreased motion, decreased pinch, and decreased grip strength.
	X-ray evidence of arthritic changes isolated to the trapeziometacarpal joint.

Procedure
The patient is placed supine on the operating table with the arm abducted 90 degrees over an arm table. A tourniquet is applied, and the patient's arm is prepared and draped out in the usual sterile manner. Either block, axillary block, or general anesthesia is preferred.

Post Operative Care
A thumb spica splint is worn continuously for 2 weeks. A removable thumb spica splint is worn for 4 weeks and removed for skin care and bathing. At 6 weeks post op, more aggressive use of the hand is encouraged. Unrestricted activity is allowed 8-12 weeks post-op. Hand therapy may be required to regain motion and strength.

1Calandruccio, JH and Jobe, MT, "Arthroplasty of the Thumb Carpometacarpal Joint", Seminars in Arthroplasty, vol. 8, no. 2, 1997, pp. 135-47.

Rheumatoid arthritis damages the joints, ligaments and tendons in the hand. This causes distortion of the fingers and loss of movement in the joint.

Replacement of knuckle joints (MCPJ) with artificial silicone joints and straightening the fingers by realignment and/or transfer of the tendons.

Post-operative care
You will be initially placed in a bulky dressing, consisting of gauze, wool and crepe bandage to rest the hand. A small tube (drain) may be left in the wound to allow any blood to escape.

The operation is usually performed under general anaesthetic. Local anaesthetic is often injected into the arm at the end of the operation. The fingers will remain numb for up to ten hours after surgery. As this effect wears off, it may be worth taking some pain killers. You will stay in hospital for one night after your operation.

Hand elevation is important to prevent swelling and stiffness of the fingers. Please remember not to walk with your hand dangling, or to sit with your hand held in your lap.

The dressing and drain will be removed after 24-72 hours and replaced by a light dressing to allow mobilization of the fingers. At this time, you will see the Occupational Therapist who will fit you with splints: dynamic for day-time, which allows movement of the fingers while protecting the tendon surgery with elastic supports; static for sleep, which rests the hand.

You will be seen by a physiotherapist who will instruct you on your exercise program.

You will be discharged after 3-5 days when the hand is moving well.

	After two weeks, you will be shown some passive exercises (using the other hand to help with movements).
	After four weeks, you will start using the hand without the protection of a splint during the day-time but keeping the static splint for the night.
	After eight weeks, you should be returning to normal activities and driving.

There will be some swelling and bruising. Look out for any redness or tenderness in the area around the wound which might indicate an infection. Do not apply antiseptic.  At this stage, it is safe to get the hand wet in a bath or shower. The wound and the surrounding skin often become very dry and will be more comfortable if a moisturizer is applied. Your stitches will be removed between 2-3 weeks after the operation. Following this, the scar will be somewhat firm to touch and tender. This can be helped by massaging the area firmly with the moisturizing cream.

After the operation, movement in the joints averages 45º which is less than half that of a healthy joint. In general, complications are rare (overall 5%) and outcomes are satisfactory. Inevitably, the implants will not last forever and sometimes they need to be replaced. There can be a tendency for the fingers to become deviated again over the years.

  Complications

	Wound Parts of the wound can break down and be slow to heal (3%)
	Infection Deep infections may not respond to antibiotics and may require removal of the implant (1%).
	Fracture Breakage of the implant becomes more likely with time but does not necessarily cause problems (5%)
	Bone wear Absorption of bone around the implant related to loosening (3%)
	Dislocation The implant can slip out of position or become unstable. Again, this does not necessarily cause problems (1%)
	Silicone Spread of silicone particles into the lymph glands causing enlargement (0.1%)
	Synovitis Inflammation of the joint lining due to fragmentation of the implant (0.05%)
	Removal The implant is removed if significant problems are encountered (see above). They can be replaced if needed later (3%).

Today there are few people in the United States who have never heard of carpal tunnel syndrome. Most have a friend or family member who has had carpal tunnel syndrome and many have had a carpal tunnel release operation themselves. As with any common entity there are all sorts of tales told about carpal tunnel syndrome, various ways to treat it, and even some real horror stories about bad outcomes.

Carpal tunnel syndrome (CTS) has long been regarded in the medical community as a “simple problem” and unfortunately there have been very few comprehensive publications in either the medical or the lay literature to clear up some of the misinformation that surrounds carpal tunnel syndrome.

History
Carpal tunnel syndrome was a term first used in the 1930’s to describe an entrapment neuropathy of the median nerve at the wrist. There is nothing new whatsoever about carpal tunnel syndrome. Human beings have had carpal tunnel syndrome for as long as there have been carpal tunnels. The first open carpal tunnel release was described in 1947 and nothing changed very much for 50 years until the advent of the endoscopic procedure in 1990. Along about the same time, the media publicized the fact that some individuals involved in repetitive-type work activities, such as those who work on computers all day, have an increased incidence of carpal tunnel syndrome. In point of fact, most people who come in the hand surgeon’s office with carpal tunnel syndrome are perplexed as to why they have this disease because they do not engage in classical repetitive-type work activities.

Anatomy
Carpal tunnel syndrome is easily understood if one begins with the anatomy. The carpal tunnel is formed by a semi-circle of carpal bones on three sides. The fourth side that forms the carpal tunnel is the transverse carpal ligament. The ligament cannot stretch. Thus the carpal tunnel is a defined space that cannot enlarge. There is only so much room in that opening. Through that opening passes the median nerve, nine tendons, and spongy tissue around the tendons called tenosynovium. We start our lives with that extra space. When we run out of extra space due to the swollen tenosynovium, then pressure is placed on the nerve. When this happens, one begins to develop carpal tunnel symptoms.

Symptoms
Classic textbook carpal tunnel syndrome symptoms are tingling and numbness in the thumb, index and middle finger (median nerve distribution), aching in the forearm which can radiate to the shoulder, and clumsiness or weak grip. Only about one or two patients out of ten presents with a classic textbook carpal tunnel picture. Some present with tingling in all fingers while others present with tingling only in the thumb or the middle finger. Some present with aching and pain in the hand while others have radiating pain just medial to the back.

Diagnosis and Treatment
A nerve test is done to confirm the diagnosis. Once the patient has been diagnosed with carpal tunnel syndrome, a decision versus treatment must be made. One must keep in mind what is going on with the nerve. The nerve is being squeezed. If one has a wedding band on the ring finger and the hand is crushed between two objects, then the entire hand begins to swell and the ring acts as a tourniquet cutting off the flow of blood to the finger. It is easy to understand that the ring has to be cut off the finger or else the finger will die. Likewise the nerve is being pinched. The nerve fibers are being pinched and they will be deprived of blood flow and undergo irreversible changes and ultimately die unless the pressure is released before those irreversible changes take place.

Thus the goal of treating carpal tunnel syndrome is not simply to reduce the pressure on the nerve so that the symptoms are tolerable and the patient can live with it, but rather to alleviate the pressure entirely. Waiting “until it gets too bad” is not advised and one may actually end up with permanent nerve damage.

Treatment Myths
Make no mistake; carpal tunnel is big business.  Countless millions of dollars have been wasted on gimmicks and gadgets trying to prevent carpal tunnel, treat carpal tunnel, and avoid surgery. Almost all of them do not work. Rarely do ergonomic devices work. “Therapy” and “exercises” do not work. Think about it, repetitive motion contributed to the carpal tunnel to begin with in many cases. It’s not a problem that can be exercised away. Magic lasers waved over the hand have not been proven effective by scientific evaluation. There is no evidence to suggest that they actually decrease the flexor tenosynovium. Splints worn during the day decrease the muscle pumping action of the hand, cause more swelling in the hand, and increase carpal tunnel symptoms. Splints can be helpful at night for positioning the hand to avoid sleeping in marked flexion which puts increased pressure on the nerve. Vitamin B-6 is almost always ineffective. Topical creams by “renowned doctors” don’t work. Magnets don’t work for carpal tunnel syndrome. Dietary supplements don’t work.

Steroid injections are only temporary and can cause permanent injury to the nerve if the needle is accidentally placed in the nerve, which usually happens on the third or fourth injection.

An open carpal tunnel release works, but it can cause weeks or months of pain and inability to work.

What’s the answer?
So why do carpal tunnel sufferers, employers, and insurance carriers fall for all of these worthless remedies? Simple. In the United States, one can sell just about anything if it’s packaged right, even if it is worthless. Carpal tunnel is big business.

Unfortunately, that means a lot of hard-earned money is being wasted and people are going untreated. Not only are they suffering, but also they risk permanent damage to the nerve the longer the condition persists.

There is an excellent treatment however. It’s not magic. It is a quantum leap forward in the treatment of carpal tunnel.  It is the first major breakthrough in 50 years. It will almost certainly be the standard by which all other treatments are measured in years to come. Tens of thousands of people have been effectively treated in this manner, which requires about eight days of inconvenience; afterwards one can do whatever they choose to do. This is the treatment that informed people choose.

What is Carpal Tunnel Syndrome?
Carpal tunnel syndrome (CTS) begins with numbness and tingling in the hand and may involve aching in the hand, forearm or shoulder.  It is a very common condition that is caused by a pinched nerve in the palm of the hand.  The symptoms may occur intermittently during the daytime and sometimes occur at night and awaken one from sleep.  It is not uncommon for the sufferer to think that the hands have "poor circulation" and shake the hands in an attempt to "restore circulation".

What causes CTS?
Repetitive motions typically cause carpal tunnel syndrome.  Any activity that involves grasping, squeezing or clipping motions such as using a computer, using tools, knitting or playing the piano.

Certain diseases and other situations can significantly contribute to the development of carpal tunnel syndrome.  These include:

	Diabetes mellitus
	Hypothyroidism
	Inflammatory Synovitis (such as rheumatoid arthritis)
	Smoking
	Pregnancy

Can I wait until it gets worse?
Maybe it will just go away.
Doing nothing can possibly lead to irreversible damage.  If you have CTS, the nerve that provides sensation to the hand and function to the thumb is being "pinched." After remaining in the pinched stage for a period of time, permanent injury to the nerve will result.  There is no treatment that can fully restore hand function and sensation once permanent damage is sustained.

Is surgery always necessary?
No.  The hand surgeon will first examine your hands and review your symptoms.  If you have something other than carpal tunnel syndrome, the doctor will suggest the appropriate treatment.  If CTS is suspected, he will first prescribe non-operative treatment with splinting and anti-inflammatory drugs.  A test conducted on the nerve will positively determine whether or not it is pinched and if you have carpal tunnel syndrome.

What then?
If all your symptoms go away with splinting and medication, then surgery will not be necessary.  If not, then the "carpal tunnel release" surgery is recommended.  The procedure is performed on an outpatient basis.  No hospital stay is required.  With the new endoscopic technique the recovery period is about 10 days compared with several weeks or months with the old technique of cutting through the palm to reach the tight ligament.

What about cost?
The cost of the new endoscopic surgery is comparable to the traditional open carpal tunnel release surgery.  Actually, when considering the additional cost of therapy often necessary after the traditional surgery and the loss of work due to a lengthy recovery time, the new endoscopic surgery may in fact be less costly.

Why us?
Dr. Neff is extensively trained in hand and upper extremity surgery.  Most orthopaedic surgeons are not trained in the newest techniques of true endoscopic carpal tunnel release.  Special training, cadaver surgery, and special certification is necessary before the surgeon should state to the public that he or she is trained and capable of expertly and safely performing the newest endoscopic carpal tunnel release techniques.

What do I have to do now?
Call for appointment today 515-222-3151 or Toll Free  877-348-9341.

Do I have a choice of surgeries?
Yes. You can either have the traditional carpal tunnel release surgery in which a longitudinal incision is performed in the palm of the hand or have it done through the new endoscopic technique.  Both are effective, but with the traditional technique, the wound in the palm remains tender for several weeks or months and prevents a quick return to work or recreational activities.  With the traditional technique, normal tissues are divided in the palm, whereas, with the endoscopic technique these structures are not injured.

The hip is a 'ball and socket' joint. The ends of the ball (femoral head) and the socket (acetabulum) are normally covered with a layer of smooth cartilage. If the cartilage wears out, bone will rub on bone, resulting in a stiff and painful arthritic hip.  An x-ray of the hip joint usually shows a space between the ball and the socket because the cartilage does not show up on x-rays. In the normal hip this joint space is approximately 1/4 inch wide and fairly even in outline.

(x-ray and illustration of a normal hip)

Most hip arthritis is genetic, with a family predisposition. It is probably not activity related, and, in fact, activity may be helpful in reducing the risk of arthritis.

The symptoms include pain when walking, difficulty tying your shoes ( or putting on socks), difficulty with stairs, and difficulty getting in and out of cars. The pain is usually felt in the groin area. Symptoms also include decreased range of motion of the hip, with pain on extremes of motion.

Conservative (nonoperative) treatment includes weight control, continuing activity, anti-inflammatorymedication, and the use of a cane or walker.

Surgical treatment includes total hip replacement (total hip arthroplasty).

Total hip replacement is a surgical procedure for replacing the hip joint. This joint is composed of two parts - the hip socket (acetabulum, a cup-shaped bone in the pelvis) and the "ball" or head of the thigh bone (femur).

During the surgical procedure, these two parts of the hip joint are removed and replaced with smooth artificial surfaces. The artificial socket is made of high-density plastic, while the artificial ball with its stem is made of a strong stainless metal.

These artificial pieces are implanted into healthy portions of the pelvis and thigh bones and affixed with a bone cement (methyl methacrylate).

Cementless total hip replacement
An alternative hip prosthesis has been developed that does not require cement. This hip has the potential to allow bone to grow into it, and therefore may last longer than the cemented hip. This is an important consideration for the younger patient. In some cases, only one of the two components (socket or stem) may be fixed with cement and the other is cementless. This would be called a "Hybrid" hip prosthesis.

When do we consider total hip replacements?
Total hip replacements are usually performed for severe arthritic conditions. The operation is sometimes performed for other problems such as hip fractures or aseptic necrosis (a condition in which the bone of the hip ball dies). Most patients who have artificial hips are over 55 years of age, but the operation is occasionally performed on younger persons. Circumstances vary, but generally patients are considered for total hip replacements if:

	pain is severe enough to restrict not only work and recreation, but also the ordinary activities of daily living
	pain is not relieved by arthritis (anti-inflammatory) medicine, the use of a cane, and restricting activities
	significant stiffness of the hip
	x-rays show advanced arthritis, or other problems

What can be expected of a total hip replacement?
A total hip replacement will provide pain relief in 90 to 95 percent of patients. It will allow patients to carry out many normal activities of daily living. The artificial hip may allow you to return to active sports or heavy labor under your physician's instructions. Most patients with stiff hips before surgery will regain near-normal motion, and nearly all have improved motion.

What are the risks of total hip replacement?
Total hip replacement is a major operation. The effect of most complications is simply that the patient stays in the hospital longer. The most common complications are not directly related to the hip and do not usually affect the result of the operation. These include:

	blood clots in the leg
	urinary infections or difficulty urinating
	blood clots in the lung

Complications that affect the hip are less common, but in these cases, the operation may not be as successful:

	difference in leg length
	stiffness
	dislocation of hip (ball pops out of socket)
	infection in hip

A few of the complications, such as infection or dislocation, may require re-operation. Infected artificial hips sometimes have to be removed, leaving a short (by one to three inches), somewhat weak leg, but one that is usually reasonably comfortable and one on which you can walk with the aid of a cane or crutches.

How do artificial hips stand up over time?
As we noted earlier, 90 to 95 percent of hip replacements are successful up to 10 years. The major long-term problem is loosening of the prosthesis. This occurs either because the cement crumbles (as old mortar in brick building) or because the bone melts away (resorbs) from the cement. By 10 years, 25 percent of all artificial hips will look loose on x-ray. Somewhat less than half of these (about 5% to 10% of all artificial hips) will be painful and require revision.

Loosening is in part related to how heavy and how active you are. It is for this reason we do not operate on very obese patients or young, active patients. Loose, painful artificial hips can usually, but not always, be replaced. The results of a second operation are not as good as the first, and the risks of complications are higher.

Preparing for Surgery

Maintain Good Physical Health
Preparing for a total hip replacement begins several weeks ahead of the actual surgery date. Maintaining good physical health before your operation is important. Activities which will increase upper body strength will improve your ability to use a walker or crutches after the operation.

Your teeth need to be in good condition. An infected tooth or gum may also be a possible source of infection for the new hip.

If at any time you become ill, such as with a cold or flu, you need to call your physician.  It is important that you are healthy for surgery.

Donate Blood
A blood transfusion is often necessary after hip surgery. You may wish to donate several pints of blood prior to your surgery. Then, if you require a transfusion, you will receive your own blood. This is called autologous blood donation. The first donation must be given within 42 days of the surgery and the last, no less than seven days before your surgery.

You must be healthy when donating blood.  Eat a nourishing meal two to four hours prior to donation, and avoid strenuous exercise for twelve hours following the procedure.

The blood donor center will check the blood count before drawing additional units. A prescription for iron will be given. Iron may be constipating for some people, so sometimes a stool softener is prescribed. Stool softeners can also be purchased over the counter.

You may be a candidate for autotransfusion after your surgery. Blood collected from the wound drain is filtered and transfused back to the patient early in the post-operative period. The physician will assist you in deciding whether this procedure will be done.

Pre-op Testing
The physician may order blood tests and urinalysis two weeks before surgery to make sure that a urinary tract infection is not present.  Chest x-rays and an EKG are obtained if you have not had one taken for six months or if otherwise indicated.

Planning for Recovery After Surgery
When making preparations for surgery, you should begin thinking about the recovery period following surgery. A patient with a new total hip replacement may need help at home for the first several weeks. Assistance with dressing, getting meals, etc. may be necessary.

Most often discharge from the hospital is anticipated in about one week. Your energy level will not have returned. If assistance from someone at home is not possible, it may be necessary to think about making arrangements to stay a few weeks in an extended care facility.

Night before Surgery

Nothing to eat or drink after midnight

Day of Surgery
The actual surgical procedure may take two to four hours. However, preoperative preparation as well as wake-up time may make your operating room and recovery room stay longer.

After Surgery
After surgery you will be taken to the Recovery Room for a period of close observation, usually one to three hours. Your blood pressure, pulse, respiration and temperature will be checked frequently. Close attention will be paid to the circulation and sensation in your legs and feet. It is important to tell your nurse if you experience numbness, tingling, or pain in your legs or feet. When you awaken and your condition is stabilized, you will be transferred to your room.

Although circumstances vary from patient to patient, you will likely have some or all of the following after surgery:

1. You will find that a large dressing has been applied to the surgical area to maintain cleanliness and absorb any fluid. This dressing is usually changed 2 to 4 days after surgery by the surgeon.
   
2. A hemovac suction container with tubes leading directly into the surgical area enables the nursing staff to measure and record the amount of drainage being lost from the wound following surgery. The hemovac is usually removed by your doctor two to three days after surgery.
   
3. An IV, started prior to surgery, will continue until you are taking adequate amounts of fluid by mouth. When you are taking fluids well, the IV may be changed to a Heparin lock, a small sterile tube, that will keep a vein accessible for antibiotics and allow for easier movement. Antibiotics are frequently administered every eight hours, for two to three days, to reduce the risk of infection.
   
4. Elimination: One side effect of anesthesia is often a difficulty in urinating after surgery. For this reason, a sterile tube called a catheter may be inserted into your bladder to insure a passageway for urine. This may remain in place for one to two days.
   
5. Besides the elastic hose (TEDS), you may also have on compression stocking sleeves. This is a plastic sleeve that is connected to a machine which circulates air in the plastic and around your legs. This is another method of promoting blood flow and decreasing the chances of blood clots. You will also be given medications and exercise instructions (moving your ankles up and down), which also helps to prevent clots.
   
6. Post-operatively you may have temporary nausea and vomiting due to anesthesia or medications. Anti-nausea medication may be given to minimize the nausea and vomiting.
   
7. Diet: You will be allowed to progress your diet as your condition pemits; starting with ice chips and clear liquids to diet as tolerated.
   
8. Coughing and Deep Breathing: To help prevent complications, such as congestion or pneumonia, deep breathing and coughing exercises are important. Inhale deeply through your nose; then slowly exhale through your mouth. Repeat this three times and then cough two times. You will be encouraged to use your incentive spirometer.

Pain Control After Surgery
When the PCA is discontinued, your doctor will prescribe pain medication to be taken by mouth.

Activity
Some patients experience back discomfort after surgery. This is caused by the general soreness of the hip area and partly by the prolonged lack of movement required before, during, and after surgery. Periodic change of position helps to relieve discomfort and prevents skin breakdown.

The head of your hospital bed should not be elevated more than 70 degrees during the first few days after surgery. Sitting up may allow the artificial ball to dislocate from the hip socket.

There will be some precautions, mostly to prevent dislocation, which is more likely to occur the first six to eight weeks after surgery. These precautions include:

1. using 2-3 pillows between your legs and not crossing your legs
2. not bending forward 90 degrees
3. using a high-rise toilet seat

Initial rehabilitation
The first day after surgery you will be assisted to a reclining chair, and physical therapy may begin. You will gradually begin to take steps, walk, and learn to climb stairs with the aid of a walker or crutches.

This initial rehabilitation generally takes 5-7 days. During this time, discomfort may be experienced while walking and exercising. Pain medication will be ordered by the doctor as needed. Most patients are relieved of their painful pre-surgical hip condition.

Therapy and rehabilitation program
Following surgery, you will work with a physical therapist to become independent in walking, going up and down stairs, getting in and out of bed, and doing exercises to improve the range of motion and strength of your hip. You will be instructed by your physical therapist in a specific home exercise program to meet your needs.

If an exercise is causing pain that is lasting, reduce your intensity. If it continues to cause pain, contact your physical therapist or physician.

Range of motion exercises

Active hip and knee flexion:
Lying on your back with legs straight, toes pointed toward the ceiling; arms by your side. Keeping the heel in contact with the bed, bend your hip and knee. Return to starting position. Progress to 20 repetitions, 2 times a day.

Active Abduction:
Place a smooth surface (card table, plywood sheet, etc.) under your legs. Begin with your legs together, then move the operated leg out to the side as far as you can. Keep your toes pointed toward the ceiling. Return to the starting position. Progress to 20 repetitions, 2 times a day.

Strengthening Exercises Quadriceps Setting:
Tighten the muscles on the top of your thigh, pushing the back of your knee downward into the bed. The result should be straightening of your leg. Hold for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 2 times a day.

Gluteal Setting:
Lie either on your back with your legs straight and in contact with the bed. Tighten your buttocks in a pinching manner and hold the isometric contraction for 5 seconds, relax 5 seconds. Progress to 20 repetitions, 2 times a day.

Isometric Hip Abduction:
Keeping your legs straight, together, and in contact with the bed. Place a loop or belt around your thighs just above your knees. Slowly spread your legs against the belt. Hold for 5 seconds, relax for 5 seconds. Progress to 20 repetitions, 2 times a day.

Activities of Daily Living

Do's and don'ts
Your new hip is designed to eliminate pain and increase function. There are certain movements that place undue stress on your new hip. For your safety, these should be avoided. This is especially true during the first few months after your surgery.

DO NOT move your operated hip toward your chest (flexion) any more than a right angle. This is 90 degrees.

DO NOT sit on chairs without arms.

DO grasp chair arms to help you rise safely to standing position. Place extra pillow(s) or cushion(s) in your chair so that you do not bend your hip more than 90 degrees.

DO NOT get up like this. Keep your involved leg in front while getting up.

DO use a chair with arrns. Place your operated leg in front and your uninvolved leg well under.

DO NOT sit low on toilet or chair.

DO get up from toilet as directed by your therapist. Use the elevated toilet seat if we have given you one.

DO NOT pull blankets up like this.

DO use a long-handled reacher to pull up sheets or blankets or do as directed by therapist.

DO NOT bend way over.

DO NOT turn your knee cap inward when sitting, standing, or lying down.

DO NOT try to put on your own shoes or stockings in the usual way. By doing this improperly you could bend or cross your operated leg too far.

DO these activities as directed by your therapist.

DO NOT cross your operated leg across the midline of your body (in toward your other leg).

DO NOT lie without pillow between legs.

DO keep a pillow between your legs when you roll onto your "good" side. This is to keep your operated leg from crossing the midline.

Guidelines at Home

What happens after I go home?
Upon discharge from the hospital, you will have achieved some degree of independence in walking with crutches or a walker climbing a few stairs, and getting into and out of bed and chairs.

Someone at home is needed to assist you for the next six weeks, or until your energy level has improved.

Medication

	You will continue to take medications as prescribed by your doctor.
	You may be sent home on prescribed medications to prevent blood clots.
	You will be sent home on prescribed medications to control pain. Plan to take your pain medication 30 minutes before exercises.

Activity

	Continue to walk with crutches or a walker as directed by the doctor or physical therapist.
	Your physician will determine how much weight you can place on your operated leg.
	Walking is one of the better forms of physical therapy and for muscle strengthening.
	If excess muscle aching occurs, you should cut back on your exercises.

Sitting
Avoid sitting more than 60 minutes at a time. DO NOT cross your legs. In fact, keep your knees 12 to 18 inches apart. Always sit in a chair with arms. The arms provide leverage to push yourself up to the standing position. A high kitchen or bar-type stool works well for kitchen activities. Avoid low chairs and overstuffed furniture because they require too much bending (flexion) in your hip in order to get up. Do not bend forward while sitting in a chair, causing more than a 90 degree bend in your hip. Use the toilet seat riser for the next eight weeks to avoid excessive bending of the hips.

Bending
For the first eight weeks, you should not bend over to pick up things from the floor. You may want to acquire a pair of slip-on shoes and a long-handled shoe horn to avoid excessive bending.

Other Considerations
It is recommended that you do not drive until six weeks following surgery. When getting into a car, back up to the seat of the car, sit and slide across the seat toward the middle of the car with your knees about 12 inches apart. A plastic bag on the seat will help you safely slide in/out of the car.

For the next 4-6 weeks avoid sexual intercourse. Sexual activity can usually be resumed after your two-month follow-up appointment.

You can usually return to work within three to six months, or as instructed by your doctor.

Continue to wear elastic stockings (TEDS) until your return appointment.

No shower until after staples are removed. Showers may be taken two days after your staples are removed. Do not sit in a bathtub until your physician okays that activity.

If you have to stay alone for the first six weeks, there are some special devices that are available from the occupational therapist.

Your incision
Keep the incision clean and dry. Also, upon returning home, be alert for certain warning signs. If any swelling, increased pain, drainage from the incision site, redness around the incision, or fever is noticed, report this immediately to the doctor. Generally, the staples are removed in three weeks.

Prevention of infection
If at any time (even years after the surgery) an infection develops such as strep throat or pneumonia, notify your physician. Antibiotics should be administered promptly to prevent the occasional complication of distant infection localizing in the hip area. This also applies if any teeth are pulled or dental work is performed. Inform the general physician or dentist that you have had a joint replacement. You will be given a medical alert card. This should be carried in your billfold or wallet. It will give information on antibiotics that are needed during dental or oral surgery, or if a bacterial infection develops.

When Do I Return to the Clinic?
Your first return appointment is 6 weeks after discharge, unless you return here to have your staples removed. (You may wish to have your staples removed by your local doctor.) At your 6-week return you will be examined and have x-rays. Subsequent appointments are then at 6 months, one year, and two years after surgery. You should return every three years after this.

Once you return home, if you have any questions or concerns regarding your total hip replacement, please do not hesitate to call us at 515-222-3151.

Should I have a total hip replacement?
The total hip replacement is an elective operation; it is not a matter of life or death. There are always nonoperative alternatives. The decision to have the operation is not made by the doctor. It is made by you, for it is you who must accept the risks and complications. The doctor may recommend the operation; however, your decision must be based upon weighing the benefits of the operation against the risks. You may wish to discuss the surgery with your own doctor or even get another opinion. All your questions should be answered before you decide to have the operation. Please feel free to ask any questions you have in order to make your decision easier.

Remember: Your physician, physical therapist, and nurses are striving to make a painless, functional hip possible for you. The real success of your hip replacement, however, depends partly on you - especially how conscientiously you exercise and how diligently you apply the principles of home care and self-limitation.

Summary

	When you are ready to schedule your surgery, you may want to donate 1 to 2 units of blood or be typed for donated blood.
	The hospital will contact you the day prior to surgery to tell you when you should arrive at the hospital.
	You will be admitted to the hospital on the same day of your surgery.
	Anesthetic is typically general or spinal, and that is usually decided by you and the anesthesiologist on the day of your surgery.
	Surgical time is approximately one hour.
	The incision is approximately 10 to 12 inches.
	When you awake from surgery, you will find a pillow between your legs. This is called an abduction pillow, and you will be in it approximately 8 to 10 days.
	The average hospital stay for total hip replacement is 3 to 5 days, depending on your health and home situation.
	You may walk the day after surgery with a walker or crutches.
	The staples will be removed 8 to 10 days following surgery.
	The average healing time is 2 to 3 months.

Ligament Injuries of the Knee

Anatomy
A ligament injury to the knee involves partial or complete damage to one of the major supporting ligaments. It can be as simple or minor as a stretching of the ligament resulting in some inflammation or as severe as a complete rupture causing instability of the knee. The ligaments are essential to proper knee function. There are four primary ligaments of the knee, two on the side: the lateral collateral ligament and the medial collateral ligament, and two in the center: the anterior cruciate ligament and the posterior cruciate ligament. They attach the femur or thigh bone to the tibia or leg bone. They are the primary stabilizers of the knee preventing abnormal motion of the femur relative to the tibia.

How the injury occurs
When the knee sustains a twisting-type injury, the force is sometimes greater than the ligaments can tolerate and a partial or complete tear results. Depending on which ligament is damaged, there are various consequences of such an injury. If the ligament becomes attenuated or lengthened, it will no longer hold the tibia in correct relationship to the femur. There may be an associated injury to the meniscus or shock absorber of the knee or damage to the cartilage covering the bones. Ligaments have small blood vessels in them and when torn these may bleed, causing swelling. This may be within the knee joint itself or outside the joint into the tissues.

Symptoms
Many patients feel the ligament tear or pop at the time of the injury. If it is one of the inside ligaments (the cruciate ligaments), there is usually an accumulation of blood within the knee joint causing swelling. There is approximately a 60 to 70 percent chance of an associated meniscal injury with this type of ligament rupture. After the swelling starts to diminish and the knee becomes less painful, the patient usually notices a giving way sensation or an abnormal looseness. This may be particularly true when trying to pivot or turn but depends on which ligament was injured.

Physical Examination
Within the first few days to weeks after an injury, it may be difficult to demonstrate the ligamentous instability by physical exam due to swelling of the knee and the patient's inability to relax because of pain. Eventually, when compared to the opposite knee, there will be a demonstrable difference in the physical exam. Depending on which ligament is involved, the instability may slowly increase over time as a result of stretching of the other ligaments and tissues known as the secondary restraints. This is one argument for not allowing certain ligament injuries to become chronic.

Treatment
Treatment depends on which ligament is torn and the severity of the injury. The medial collateral ligament, even when completely torn, will often heal relatively well with nonoperative treatment in a brace. Unfortunately, the other ligaments do not fair so well. Most patients who are active in pivoting-type sports and activities will find it difficult to function well with a major ligament injury. The giving way of the knee which they experience can lead to further injury, particularly to the meniscus. With time, if the other restraining ligaments and tissues become stretched, the instability may increase.

Some patients, however, do tolerate ligament insufficiency. Those whose activities do not require strenuous knee use or those who give up this type of activity can sometimes function adequately without one of their ligaments. Muscle strengthening and occasionally, bracing can assist in tolerating a ligament injury. The bottom line is that one must avoid meniscal damage as this is important for the longevity of the knee. If this cannot be done with an unstable knee, then consideration should be made for stabilization.

Once a diagnosis has been made and the severity of the ligament injury has been established, the treatment options can be considered. A partially injured ligament, and usually even a completely injured medial collateral ligament, can be treated conservatively with bracing and rehabilitation while it heals. The patient is then progressed back to full activity gradually. Those with complete ligament injuries--the anterior cruciate ligament rupture being the most common--can try a course of conservative treatment and see how they do. This, of course, is assuming that they do not have an accompanying meniscal injury. They may decide to give up certain activities and try muscle strengthening and perhaps bracing, although bracing has been recently shown to offer little, if any, benefit to the athlete with an anterior cruciate deficient knee.

If the patient is young, very active -- especially in pivoting-type sports, or has an associated meniscal tear, consideration should be made for stabilization. There are various ways to stabilize or reconstruct a ruptured ligament. A healthy tissue graft is usually used to replace the injured ligament. The source of this graft depends on which ligament is being reconstructed and, given various options, the patient's choice.

Surgery
The ligament reconstruction procedure is performed with the assistance of an arthroscope. All meniscal surgery and other indicated surgery is performed at the same time. Usually the procedure can be done as an outpatient, not requiring hospitalization. Small incisions are made about the knee to assist in placing the graft. The graft is secured using screws or staples.

Risks
The risks of ligament reconstruction are the same as those for general arthroscopy with a few additions. If the graft is harvested from around the patient's own knee, risks of harvest site morbidity exist (e.g. weakness to donor tissue, longer rehabilitation, etc.). If a donor graft (allograft) is used, the potential for disease transmission (e.g. AIDS) is present. These grafts are very carefully selected from donors who are not at risk and who test negative for the AIDS virus. However, at present there is no test that can insure absolutely that the graft is disease-free. When the patient decides to use his or her own tissue for the graft, the risk of weakening the donor site and the possibility of donor site pain must be considered. If a donor graft is obtained from a bone bank (allograft), the risk of disease transmission must be considered. In addition, the risk of the graft breaking or stretching is present, as is the fact that not all reconstructed ligaments function as well as the original equipment.

After Surgery
A brace is worn after surgery to protect the graft fixation as it becomes secure. An important part of the process is the postoperative rehabilitation and physical therapy. The muscles must be strengthened and motion regained without disrupting the graft. This process varies depending on which ligament is reconstructed and what other surgery is necessary (such as meniscal repair or excision).

The long-term outlook for patients with reconstructed ligaments is generally good. The majority return to pre-injury activities, although some have to modify them somewhat. Many say that they can tell the difference between their reconstructed knee and their normal knee but that it does not keep them from participating in most of their activities. Much of the prognosis depends on the accompanying knee injuries such as meniscal or cartilage injuries that occurred at the same time or as a result of the ligament injury.

Synvisc

Synvisc® is a milestone viscosupplementation treatment used to relieve knee pain caused by osteoarthritis. This elastoviscous joint fluid supplement acts as a shock absorber and lubricant for the knee, and is used in patients who do not obtain adequate relief from simple painkillers or from exercise and physical therapy.

Synvisc is a milestone viscosupplementation treatment used to relieve pain due to osteoarthritis of the knee. This elastoviscous supplement, injected directly into the knee joint, acts as a shock absorber and lubricant, and is used for patients who do not obtain adequate relief from simple painkillers or from exercise and physical therapy. Synvisc is a device, not a drug, and is designed to replace the diseased synovial fluid found in osteoarthritic knees.

What is Synvisc made from?

Synvisc is an elastic and viscous fluid that is made up of hylan A and hylan B biological polymers. The two hylans are manufactured from hyaluronan that comes from chicken combs. Hyaluronan is a natural chemical found in the body and is present in all tissues, but there is a particularly high amount in joint tissues and in the fluid that fills the knee joint. The body's own hyaluronan acts like a shock absorber and lubricant in the joint, and is needed for the joint to operate properly. In painful osteoarthritic knees, there is deterioration of the quality (low elasticity and viscosity) of the hyaluronan in joint fluid and tissues, or there may not be enough hyaluronan.

How does Synvisc differ from other hyaluronan preparations?

Synvisc is the only viscosupplementation product that has physical properties comparable to those of the healthy synovial fluid found in 18- to 27-year-old humans. Due to its high molecular weight, Synvisc has superior shock-absorbing and lubricating   properties and remains in the joint longer than hyaluronan.

Is Synvisc a drug or a device?

Synvisc is classified as a device because it exerts its effect by a physical action (elastoviscosity), not by a chemical action. Because it is a non-drug, Synvisc should not interfere with any medicine that the patient may take.

What is viscosupplementation?

Viscosupplementation is the therapeutic procedure by which the physical properties (elastoviscosity) of diseased synovial fluid are restored and augmented with an elastoviscous fluid like Synvisc. This will result in a decrease of joint pain, thereby helping the joint to become more mobile.

How is Synvisc eliminated from the body?

Once injected into the joint space, Synvisc passes through the lymph system into the blood and is completely metabolized in the liver, where it is broken down into water and carbon dioxide.

TREATMENT ISSUES

How is Synvisc administered?

Synvisc is injected directly into the knee joint three times (Days 1, 8 and 15) over a 15-day period by a qualified physician.

Why are three injections required?

Clinical investigations with Synvisc have demonstrated that three injections one week apart provide optimal pain relief and restoration of joint mobility. Completion of the full three-injection treatment course is recommended to achieve the greatest therapeutic benefit.

How do I know if Synvisc is right for me?

A physician is the best person to advise you on any course of treatment, including Synvisc. So to find out if you are a good candidate for Synvisc treatment, the first step is to make an appointment with your physician.

Am I too old for Synvisc?

There are no specific precautions or contraindications regarding the use of Synvisc in elderly patients. During clinical trials, the safety profile of Synvisc was well established in elderly patients. This may be attributed to the local, nonpharmacologic action of Synvisc, as well as to its lack of interactions with medications of other concurrent diseases. The mean age of men and women who participated in Synvisc premarketing clinical trials was 61 years (range of 18 to 93), with the majority of patients over 40 years.

At what point in the treatment of osteoarthritis should Synvisc be considered?

Synvisc is indicated for the treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics, e.g. acetaminophen. And of course, a physician is the best person to advise you on any course of treatment, including Synvisc.

Can I receive Synvisc in both of my knees?

Yes, if both knees have pain. Synvisc treatment may be given in both knees simultaneously or separately, according to your physician's recommendations.

Can I take other medications while receiving Synvisc treatment?

Yes. Since Synvisc is an elastoviscous fluid device injected directly into the knee joint, it does not interfere with any medicine that your physician recommends, including pain relievers and anti-inflammatory drugs. You should discuss with your physician any medicine taken.

Should I modify my level of physical activity after receiving Synvisc treatment?

You should consult your physician about what level of activity is right for you, but in general, patients are able to maintain their normal daily activities after receiving treatment. However, patients should avoid strenuous activities such as jogging, tennis and heavy lifting for at least 48 hours after receiving an injection.

Is Synvisc treatment effective in knees with advanced osteoarthritis and loss of cartilage?

Synvisc has been shown to be effective in all stages of this disease, although it is most effective in the early stages of joint pathology. However, some patients with advanced osteoarthritis have also responded to Synvisc with variable results. All patients receiving Synvisc should be mobile and have no health conditions that prevent normal use of the knee.

Can Synvisc be used in joints other than the knee?

The U.S. Food and Drug Administration approved patient information which states: "The safety and effectiveness of Synvisc in locations other than the knee and for conditions other than osteoarthritis have not been established."

Is Synvisc a cure for osteoarthritis of the knee?

There is no cure for osteoarthritis. Synvisc is a treatment for the pain of osteoarthritis. In some patients, successful treatment may reduce pain within the first week after treatment begins. In most patients, the most pain relief and the greatest amount of treatment success occurred 8 to 12 weeks after Synvisc treatment began.

BENEFITS

What are the benefits of receiving Synvisc treatment?

Successful treatment with Synvisc should reduce pain in an osteoarthritic knee, resulting in increased mobility. In addition, because it is a non-drug, local treatment, Synvisc should not interfere with any medicine that the patient may take.

How soon after Synvisc treatment should I experience relief?

Each patient's response to Synvisc regarding relief of pain and restoration of joint mobility will vary, depending upon the stage of joint pathology and pre-existing medical conditions. In general, however, some patients experienced significant pain relief within the first week after Synvisc treatment began. In most patients, the most pain relief and the greatest amount of treatment success occurred 8 to 12 weeks after treatment began.

How long can I expect the benefits of Synvisc to last?

Each patient reacts differently to Synvisc treatment. The benefits of Synvisc can last for months, but in most patients, the most pain relief and the greatest amount of treatment success occurred 8 to 12 weeks after treatment began. There are several clinical studies which address the effectiveness of Synvisc treatment.

SAFETY

How safe is Synvisc?

Extensive safety and toxicity tests were performed on Synvisc before the first clinical trials. Preclinical studies showed that Synvisc is nonantigenic, nontoxic, noninflammatory, and does not elicit foreign body reactions. Hyaluronan, from which hylan is derived, has been safely used in ophthalmic and orthopedic applications in millions of patients. In clinical trials, transient local pain, swelling, and/or effusion occurred in 2.2% of intra-articular injections of Synvisc.

What are the side effects of Synvisc?

There have been no general (systemic) side effects attributed to Synvisc. However, because Synvisc is injected directly into the joint, some patients may feel localized discomfort after treatment. Some pain, swelling and effusion may occur in and around the knee. Both usually go away within a short period and do not interfere with the success of the treatment. If you continue to feel discomfort or notice other problems, you should consult your physician.

Are there any allergies that may affect Synvisc treatment?

No cases of anaphylaxis or anaphylactoid reactions have been reported in connection with Synvisc treatment. You should consult your physician if you have a history of hypersensitivities to hyaluronan preparations or are allergic to avian proteins, feathers and egg products.

Do I need a prescription for Synvisc?

Yes, Synvisc is a prescription device. In most cases, it can be prescribed and dispensed simultaneously in a physician's office. In other instances, the physician can write a prescription for the patient to pick up Synvisc at his or her pharmacy and return it to the physician for injection.

Will Synvisc be reimbursed by medical insurance plans?

Most insurance plans will pay for Synvisc.  You should call your insurance company to make certain.

How can I find out more about Synvisc?

Talk to your physician for more information about Synvisc.

OSTEOARTHRITIS

What is osteoarthritis of the knee?

Arthritis is a medical condition which can affect joints. The most common form of arthritis is osteoarthritis, affecting nearly 16 million Americans. This degenerative joint disease typically affects people over the age of 50, but can affect anyone above the age of 18. Risk factors include age, obesity, female gender, genetic predisposition and previous trauma to the knee joint. The first and most important symptom of osteoarthritis is pain, which can be accompanied with swelling of the joint and accumulation of fluid in the joint.

The space between the cartilage-covered bones in the knee joint contains synovial fluid which acts as a cushion for the tissues of the joint. But with the onset of osteoarthritis, the synovial fluid becomes thinner and loses its elasticity. The thin synovial fluid simply cannot act as an effective shock absorber. This lack of protection aggravates the condition because the cartilage protecting the bones in the osteoarthritic knee is increasingly exposed to impact and friction. The pain felt when weight is put on the knee is caused by the increased sensitivity of the nerve endings in the soft tissues of the joint. This increased sensitivity to pain is the result of the decrease of the protective capacity of the synovial fluid (low elastoviscosity).

The unprotected cartilage begins to wear away and lose its smoothness. The cartilage continues to break down as the disease progresses; the bones which are normally protected by the cartilage and synovial fluid develop bony spurs. As a result, even simple movements of the knee can become extremely painful. Pain in the knee can seriously limit mobility, making the sufferer feel weak and unstable when performing even the most common activities, like walking or climbing stairs.

What causes osteoarthritis of the knee?

The exact cause of osteoarthritis is not known. However, the most important and debilitating symptom of OA is pain.

How do I know if I have osteoarthritis of the knee?

Only your physician can make such a diagnosis. The cardinal symptom of OA is pain which may be amplified with swelling of the joint. Pain can be experienced at rest or during movement.

What treatments are available for osteoarthritis of the knee?

Traditional treatments for osteoarthritis of the knee vary according to the severity of the disease. In the early stages, weight control, regular exercise, physiotherapy, assistive devices (canes, braces) as well as the use of simple analgesics (acetaminophen) may provide relief. However, not all patients respond adequately to conservative nonpharmacologic therapy and simple analgesics. After conservative therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) are used. Some people experience unpleasant side effects (to the NSAIDs) such as heartburn, dyspepsia, vomiting and ulcers. The longer one takes NSAIDs, the more likely he or she is to suffer from irritation of the gastrointestinal tract. Local cortisone injections or surgery were the last defenses against OA. Now there's another treatment option – viscosupplementation with Synvisc.

Where does Synvisc fit into the sequence of treatments for osteoarthritis of the knee?

Synvisc is indicated for the treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics, e.g. acetaminophen, which occurs before NSAID therapy. Synvisc has been shown to be effective in all stages of OA, although it is most effective in the early stages of this disease.

Arthroscopic Knee Surgery

What is an arthroscopy?
Arthroscopy has become one of the most frequently used procedures for diagnosis and treatment of knee injuries. It is a minor surgical procedure that is done as an outpatient. The physician inserts the arthroscope into your knee through several small incisions. This allows the physician to see the entire knee joint and permits the repair of some injuries.

Arthroscopy has revolutionized the treatment of joint injuries. In the past, treatment of orthopedic injuries involved extensive surgery, including large incisions, a hospital stay, and a prolonged recovery period. But today, with the help of an arthroscope, today's orthopedic surgeon can easily examine, diagnose, and treat problems in the joint that previously may have been difficult to identify.

The arthroscope is a small fiber-optic viewing instrument made up of a tiny lens, light source and video camera. The surgical instruments used in arthroscopic surgery are very small (only 3 or 4 mm in diameter), but appear much larger when viewed through an arthroscope.

Shown below -- both as it appears on the operating table and when viewed arthroscopically -- is a probe, used for examination of internal structures (in this case the underside of a patella, or kneecap).

The surgeon inserts the arthroscope into the joint through a tiny incision (about 1/4 of an inch) called a portal. Two or three incisions may be made for portals. Other portals are used for the insertion of surgical instruments, such as the probe shown above.

Typical incision sites and sizes for knee arthroscopy are shown. These incisions result in very small scars which in many cases are unnoticeable.

Preparing for Surgery
Before Surgery
It is very important that you observe the following instructions:

	Do not eat or drink anything after midnight unless otherwise instructed by your physician or the anesthesiologist. Your surgery may be canceled if you eat or drink after midnight or as instructed.
	Take routine medications only as directed by your anesthesiologist or physician.
	Remove all nail polish and do not wear make-up the day of surgery.
	Leave all jewelry, money, watches and valuables with family. The facility can not be responsible for your valuables.
	Wear comfortable casual clothing that is easy to get on and off (drawstring-style sweat pants, boxer-style shorts, or loose clothing).
	If you have crutches, a knee immobilizer, or a brace, please bring them with you on the day of surgery. You may need these after surgery.
	You may wish to bring reading material or crossword puzzles to occupy your time.
	Arrange to have an adult (someone over 18) available to drive you home after discharge, and have someone stay with you at least 24 hours once you are home.

Day of Surgery
You will be asked to change into a hospital gown and remove jewelry and contacts. (We suggest you leave your contacts out the day of surgery.) The nurses will check your (pulse, blood pressure and temperature), and ask you a few questions. You will then be directed to a waiting area until the operating room notifies the nurses. Then you will be taken to the operating room on a cart. The anesthesiologist will talk with you briefly, an IV (needle inserted to give you fluids) is inserted, and final preparations are carried out.

Waiting room
Your family will be directed to waiting rooms. Medical staff will notify them when your procedure is completed, and how you are doing. They will be directed to the appropriate area once you have completed your recovery room stay.

After Surgery
When surgery is completed, you will be taken to the recovery room. The usual length of stay in the recovery room is 1 hour, but may be longer according to the surgical procedure and the type of anesthesia.

While you are in the recovery room, the nurses will be checking your blood pressure, pulse, respirations, and temperature frequently. They will also be checking the sensation and circulation in your surgical leg.

You may have a large bandage, a brace or an ice cuff on your knee.

After your stay in the recovery room you will be transferred to an inpatient floor. The nursing staff will continue to monitor your recovery, provide medication for pain and/or nausea, and give you ice chips and liquids. During this final recovery stage, your nurses review discharge instructions and obtain prescriptions. You may be seen by a physical therapist.

Discharge is based upon your recovery from the effects of anesthesia and your degree of pain. Your physician determines if you are ready for discharge. If additional observation is required, you may be admitted to the hospital.

What happens at home?
It is normal to feel drowsy for 24-48 hours after surgery and to require pain medication at regular intervals. These symptoms will gradually subside and each day you will feel less sleepy and painful.

Activity:

	Crutches are used for a short time. Put only as much weight on your surgical leg as advised by your physician.
	Always wear your brace when walking, or as instructed by your physician.
	Daily knee exercises are important for the return of function.

Wound care:

	Keep your wound and bandage clean and dry. Change and remove bandage as instructed.
	Your wound should not come in contact with water. Change any bandage immediately if it becomes wet or bloody.
	You may shower with a plastic bag securely taped beyond the upper edge of your brace. It is recommended that you sit on a chair in the shower, keeping your bandaged leg out of the direct water spray.

Pain control:

	Applying ice for the first 24-48 hours after surgery will reduce pain and swelling.
	Elevating your leg above heart level as much as possible will also reduce pain and swelling.
	Elevate your leg after exercises and always at night, with your knee above heart level.
	Take pain medication as prescribed. Do not drink alcohol when you are taking this medication. Take medication 30 minutes before exercises.
	Eventually pain subsides and Tylenol should control your pain.

Rehabilitation program:
A physical therapist will instruct you on crutch ambulation, range of motion and strengthening exercises. Continuing these exercises after your surgery is important to maintain knee range of motion, reduce scar tissue and strengthen weakened muscles. Your physician will specify when you should begin an exercise program to gain motion and/or to strengthen muscles above your knee. Two commonly-used exercises are quadriceps setting and straight leg raises.

Quadriceps setting:
Lie on your back with your knees straight, legs flat and arms by your side. Tighten the muscles on the top of the thigh (quadriceps), and at the same time push the back of the knee down into the table and raise only the heel. Hold for 5 seconds, relax 5 seconds. Repeat this exercise 6 times on a firm surface at least 4 times a day.

Straight leg raising:
Lie on your back with your operative knee flat and straight. Keep the other leg bent with foot flat on the floor. Slowly raise your operative leg about 6 inches off the floor, keeping the leg as straight as you can. Hold for a count of 5 seconds, then lower the leg. Repeat this exercise 6 times on a firm surface at least 4 times a day.

Return appointments:
Follow-up visits are necessary for your doctor to chart progress, change bandages, check for any complications and evaluate your rehabilitation progress.

Reminders:
Call us immediately if any of the following occur:

	Swelling, tingling, pain or numbness in your toes which is not relieved by elevating your knee above heart level for 1 hour.
	Drainage that is foul smelling, green or yellow, or drainage where there was none before.
	Chills or temperature above 38.5° C (101.3° F). or if greater than 38° C (100.4° F) for 24 hours.

Carticel
A step forward in the treatment of knee cartilage damage.

A severe knee cartilage injury can radically change an active adult's lifestyle. Symptoms such as locking, catching, localized pain and swelling often affect your ability to work, play, even perform normal activities. Injuries resulting in lesions may require surgical intervention in order to return to an active life. But long-term results of many treatments have been disappointing, and some patients require further surgeries within a few years.

With Carticel®(autologous cultured chondrocytes), you and your orthopedic surgeon now have an option that may regenerate the cartilage and allow you to get back in the game.

About Carticel and the treatment of femoral focal chondral lesions:
The goal of Carticel treatment is to restore the articular surface and regenerate hyaline cartilage without compromising the integrity of healthy tissue or the subchondral bone. This may be achieved through autologous cultured chondrocyte implantation.

Carticel has demonstrated important benefits in some patients with a type of femoral defect called a Focal Chondral Lesion (FCL). If your orthopedic surgeon has determined that you have this type of lesion, then Carticel may be an appropriate treatment option.

The procedure takes place in several stages described here.

Implantation of Carticel (autologous cultured chondrocytes)

Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

 Dr. Neff has had special training in this procedure and has done several of these surgeries.  hey are primarily indicated in the patient with one specific type of lesion and who are less than 50 years of age.

Knee Surgery

Knee Anatomy
The knee joint is formed by the lower leg bone (shin bone), called the tibia, and the thigh bone, called the femur. The ends of the bones are covered with a smooth layer of cartilage. The joint is enclosed by a fibrous tissue envelope or capsule with a smooth tissue lining called the synovium. The synovium produces fluid that reduces friction and wear in the joint. Normal joints allow nearly frictionless and pain-free movement. When the cartilage is damaged or diseased by arthritis, joints become stiff and painful.

Osteoarthritis
Osteoarthritis is the result of wear and tear on the joint. The normal cartilage lining is gradually worn away and the underlying bone exposed. It may be many years before the damage to the joint becomes noticeable. Pain and stiffness are the usual problems associated with osteoarthritis. The medial (inside) part of the knee is most commonly affected by osteoarthritis. Previous injury to the knee ligaments or cartilages (menisci) may predispose to this kind of arthritis. Being overweight may also increase the likelihood of arthritis, or make it worse.

Inflammation 
Inflammation of the joints can be caused by a variety of conditions, the commonest of which is rheumatoid arthritis. Inflammation causes damage to the cartilage lining of the joints. This causes arthritis which is often more widespread than osteoarthritis, and typically affects several joints. This kind of arthritis can affect people when they are relatively young and may cause severe disability.

Treatment of arthritis
If the arthritis is inflammatory in nature, then a specific diagnosis should be sought. Blood tests and other tests can help to determine the type of arthritis involved. Anti-inflammatory and other drugs may be helpful.

For patients with osteoarthritis, it is important to remain flexible and to maintain as much movement as possible. Analgesics (pain killers) can help patients to maintain activity. Many modern pain killers also have an anti-inflammatory effect, which may be beneficial in arthritis.
If arthritis is severe and significantly affects activity, then surgery may be appropriate.

Knee Replacement Surgery
In knee replacement surgery, the damaged bone and cartilage are replaced with metal and plastic surfaces that are shaped to restore knee movement and function. The new artificial knee is called a prosthesis. The prosthesis is generally composed of two metal pieces fitted onto the ends of the tibia (shin bone) and the femur (thigh bone) and a plastic piece inserted between them to act as a bearing. Stainless steel, cobalt or chrome alloys or titanium may be used for these components. Durable, wear resistant polyethylene (plastic) is used for the bearing. A plastic bone cement may be used to anchor the prosthesis into the bone. Some joint replacements also can be implanted without cement when the prosthesis is designed to fit and lock onto the bone directly.  See Total Knee Replacement Surgery RealPlayer Video.

Unicompartmental knee replacement surgery
When only one part of the knee joint is arthritic, it may be possible to replace just this part of the joint. The procedure is similar to a total knee replacement, but only one side of the joint is resurfaced. A metal component is fit onto the femur (thigh bone) and a plastic bearing is inserted either directly onto the tibia (shin bone) or onto a metal tray which has been fit onto the tibia. Recovery time is generally slightly shorter following this kind of surgery.  See Shockwave Animation.

High Tibial Osteotomy
Sometimes, if predominantly one side of the knee is arthritic, an operation may be performed to realign the knee joint in order to take pressure off the affected side and redistribute weight bearing more onto the other side of the knee. This operation, called a high tibial osteotomy, involves making a cut in the tibia (shin bone) and removing a wedge of bone to change the angle of the knee joint. A staple or plate and screws are used to hold the bone in place until it heals. Although this procedure is not suitable for all patients, it may produce significant relief and delay the need for knee replacement surgery.

Anesthesia for knee replacement surgery 
Knee replacement surgery can be performed under general, spinal or epidural anesthesia. A combination of techniques is often used.

General anesthetic
The patient is asleep throughout the procedure. A breathing machine (ventilator) may be used to assist the patient's breathing during anesthesia. Many patients feel drowsy or groggy after a general anesthetic. The use of newer anesthetic drugs has significantly decreased the occurrence of post-operative nausea and vomiting.

Spinal block or epidural block
These techniques use local anesthetic to block the passage of nerve impulses, including pain, in the spinal cord. The block can be positioned at various spinal levels, but the patient generally has no feeling from the waist down. The patient is usually sedated during the procedure, but a ventilator is usually not required for this kind of anesthetic. It thereby can lower some of the risks of general anesthetic. Depending on the medications used for the block, the period of pain relief after surgery can be prolonged for several hours, reducing the need for pain medication after surgery. Because these blocks provide temporary loss of sensation below the waist, a urinary catheter (tube into the bladder to drain urine) is often inserted.

Possible Complications of total knee replacement surgery
Any surgical procedure carries various risks and potential complications. Although uncommon in joint replacement surgery, the following complications sometimes occur:

Blood Loss Requiring a Blood Transfusion
In any joint replacement surgery, some blood loss will occur. Occasionally a blood transfusion may be required. Precautions will be taken during the operation to minimize blood loss. Some patients may be given the option to donate their own blood pre-operatively.

Infection
Any surgery performed via an incision in the skin carries the risk of infection. Many precautions are taken during surgery to minimize the risk of infection. Intravenous antibiotics are usually given during surgery to help prevent infection. The operating room is also equipped with special air flow devices that minimize bacteria in the air.

Blood Clotting in the Legs (Deep Venous Thrombosis [DVT])
The circulation to the legs may be decreased during knee replacement surgery due to immobilization of the legs. Decreased movement of blood through the veins (venous stasis) can cause the blood to clot. Blood thinning medication is used to help minimize this risk, but a small percentage of patients still develop blood clots in the leg.

Blood Clot Moving to the Lungs (Pulmonary Embolism [P.E.])
Occasionally, blood clots that form in the legs may become detached and travel to the circulation in the lungs. This complication, although extremely rare, can be life threatening. Symptoms include chest pain and shortness of breath.

Nerve Injury
Any incision can result in damage to the sensory nerves in the area of the incision. Significant nerve damage, which may cause loss of muscle function, can occur after knee replacement.

Activity after a Knee Replacement
Very few restrictions to activity are required following knee replacement surgery. It is extremely important to move and exercise the knee early in the postoperative period in order to regain the best range of movement possible. Physiotherapy will usually be commenced on the first postoperative day, or on the day of the operation. If the joint is not moved early on, it will become stiff and have a decreased range of movement, which will limit the utility of the new knee.

Recovery time after a Knee Replacement
By the time patients are discharged, they should be able to get in and out of bed and walk to the bathroom. Most patients are around 80% recovered by six weeks after surgery. They will continue to improve more gradually over the next three to six months. Recovery varies from person to person depending on their level of pain and activity before their surgery.

The New Era in Knee Replacement Surgery Increases Mobility and Reduces Costs, Thanks to Use of Unicompartmental Knee Arthroplasty Through a Small Incision

A new approach to knee replacement surgery using a specially-designed prosthesis and instrumentation that enables access to the knee through a small incision, dramatically reduces time in the hospital, pain and expenses, while increasing the immediate and long-term mobility of patients who receive the procedure compared with traditional knee replacement surgery.

The surgical instrumentation that permits minimally invasive unicompartmental knee replacement, introduced to the United States in April by orthopedic surgeon Dr. Mitchell Sheinkop at Rush-Presbyterian-St. Luke's Medical Center, Chicago, reduces the size of the incision required to place the knee prosthesis from about 18 inches in conventional knee replacement surgery to about three inches.

"The smaller incision speeds the patients' time to reach maximum medical improvement, and more importantly it offers patients greater function than a total knee replacement. It also cuts down time in the length of stay in the hospital, time in the operating room, the need for physical therapy and reduces the chances of complications," Sheinkop noted.

The use of precision instrumentation assures the reproducibility of the cut of the bone and the orientation of the prosthesis implant through the small incision. As a result, long-term outcome and survivorship of the prostheses are greatly improved, according to Sheinkop.

"This is important as the baby boomer population is growing older, living longer and wanting to keep vigorously active as they move through their 50s, 60s and 70s," said Sheinkop. "Patients who receive the 'uni' knee replacement through the small incision can play doubles tennis, ride a bicycle, bowl, dance and in most cases ski."

Knee replacement surgery is often recommended for individuals generally over 55 years of age with arthritis that is too advanced to benefit from other treatment options including medications, cellular and cartilage transfers, arthroscopy or less complex procedures involving surgery to realign the knee. They suffer from pain that limits routine as well as athletic function and performance.

"Patients are able to leave the hospital within 24 hours compared with a hospital stay of four days that is the average for a partial knee replacement through traditional approach, and compared with 5 days for a full knee replacement," said Sheinkop.

Of those individuals who require knee replacement surgery, about 30 to 40 percent have arthritis that affects only one part of the knee and can benefit from a unicompartmental knee replacement. Many of these individuals have degenerative (osteoarthritis) or post traumatic arthritis as a result of a previous fracture or injury. The unicompartmental knee replacement is not for individuals with rheumatoid arthritis.

Extensive research and clinical work on unicompartmental knee surgery had been done at Rush since the early 1980s when the procedure was learned from European orthopedic surgeons.

As a result of their experience in refining and developing implant materials used over years, Rush orthopedic surgeons have enjoyed a high success rate in reducing pain and restoring function to the knee following conventional unicompartmental knee replacement and a long survivorship of the prosthesis.

Sheinkop developed the minimally invasive instrumentation approach to unicompartmental knee surgery because of his interest in retaining a higher level of athletic activity than what is common for people in their 50s and 60s. He borrowed from the techniques developed by orthopedic sports medicine colleagues using arthroscopy to do knee repair through small puncture wounds, and worked with the Zimmer, Inc., of Warsaw, Ind., to manufacture the prosthesis and precision instrumentation that enables success working through the small incision.

The new instrumentation includes nine pieces of equipment including a cutting guide device that is inserted into the knee through a small holes to guide the angles of the cuts of the bone so that there is a perfect alignment for the placement of the prosthesis with the existing bone. The knee prosthesis includes a polyethylene surface that replaces the cartilage, which is attached to metal that replaces the bone. The metal bone replacement glides along the polyethylene surface in the same manner that the bone had moved along the surface of the cartilage.

Instructions for
Total Knee Replacement Surgery

We will make the arrangements and call you~

	We will call your insurance carrier and make the arrangements for surgery.
	We will call you to let you know when and where your surgery will be performed.
	Please keep a pencil and paper by the phone to write down the information when we call you.
	The exact time of your surgery will not be known until the evening before your surgery.

Before surgery~

	A blood transfusion is usually required. Before surgery, you will need to donate 2 units of blood that is either your own, a family member's, or a close friend's.
	You need a history and physical by your family physician within 7 days prior to the day of surgery. If necessary, Doctor Neff or Doctor Boulden will perform a history and physical.
	If you are taking medications, you should call your family doctor to find out if it is okay to continue taking that medication.
	Do not eat or drink after midnight the night before surgery. This includes sips of water, coffee, or anything else.
	Make sure you have someone to drive you home the day of surgery.
	If you are 18 or under and are not married, you must be accompanied by a parent or guardian.
	Do not wear jewelry or take other valuable items with you.
	Do not wear make-up or nail polish.

Day of surgery~

	The average stay in the hospital is 3 to 7 days, depending on your general overall health and the help you will have at home.
	Total knee replacement surgery is done either under a general anesthetic (puts you to sleep), or a spinal anesthetic (numb from the waist down).
	The surgery usually takes 1 to 2 hours.
	Risks include blood clot, anesthesia complications, and infection.
	The scar on your knee will be approximately 10 inches long.
	You will be given a prescription for pain medication to take home with you.

After surgery~

	Following surgery, you will need to use a walker for 3 to 4 weeks and then use a cane for another 3 to 4 weeks.
	Your staples will either be removed while you are still in the hospital or at your follow-up visit with your doctor. If your staples were not removed in the hospital, you will need to see us 8 to 10 days following surgery. Otherwise, you should schedule your follow-up visit one month following surgery.
	If you notice any changes such as fever, bleeding, drainage, or unusual symptoms at all, you should contact our office immediately.
	After surgery, you will be at risk of infection from total joint surgery. We will issue you a medic alert card as a reminder that if you should ever have any sort of infection, such as a urinary tract infection, or if you should have dental work or surgery, you will need an antibiotic medication. You will be given a pamphlet which will further discuss this.
	After surgery, you can walk and do normal activities that you can tolerate. Many patients complain of swelling in the knee and ankle following surgery, and it may take 3 months for the swelling to completely diminish.
	You may be wearing Ted hose following surgery. These are a support hose that are worn either below the knee or full length of the leg. We will discuss this with you again in further detail on the day of surgery.

Please call our office at 515-222-3151 if you have any questions. Please do not call the hospital. If you have questions or concerns, we want to hear from you.

Implant Improves Success Rate of Total Knee Replacements

The use of a specific implant is helping orthopaedic surgeons improve the success rate of total knee replacement procedures in patients less than 55 years old.

The orthopaedic surgeons use a posterior stabilized, posterior cruciate substituting design prosthesis. Patients receiving this prosthesis have had excellent results.

Patients' activity levels are improved following surgery. Many of the patients continued their sports schedules or began participating in recreational activities that originally we advised not to do.

Concerns about loosening, polyethylene wear, osteolysis, and the need for multiple revisions has prevented the widespread application of total knee replacement in young patients.  Studies have confirmed that total knee replacement surgery for younger patients in non-rheumatoid populations should not necessarily be discouraged.

It should, however, be emphasized that findings are for a conforming prosthesis of a specific design and may not apply to all types of total knee replacements.

Ninety-four percent of the patients in one study had a survivor rate of 15 years with the prosthesis.  Of particular interest was how the younger patients were doing with the prosthesis, and the study revealed no significant evidence of adverse problems in patients involved in high-level activities.  These findings suggest a cautious re-evaluation of activity restrictions in younger patients.

The results were obtained from 84 patients who had a total of 108 total knee replacements. The average age of the patients at the time of surgery was 51 years old.

Tests developed by the Hospital for Special Surgery and the Knee Society were administered before and after surgery to help determine patients' pain, function, range of motion, and stability. Patients also were assigned a Tegner activity score to help determine their sports activity level before and after surgery.

The average Hospital for Special Surgery score was 55 prior to surgery and 92 after surgery. Following surgery, the average Knee Society score was 94.

The patients' Tegner activity score improved from 1.3 before surgery to 3.5 after surgery. Twenty-four percent of the patients received a Tegner activity score greater or equal to five. These patients were able to participate in tennis, skiing, biking, or heavy farm or construction work.

New LPS-FLEX Knee Prosthesis

The Insall Scott Kelly Institute for Orthopaedics and Sports Medicine at Beth Israel Medical Center consists of a team of world-renowned orthopedic surgeons including John N. Insall, M.D., Director of the Institute and designer of the Total Condylar Knee Prosthesis which became the first widely used knee implant over 25 years ago. Since then, Dr. Insall and his colleagues have designed many successful variations of the implant. There are over 250, 000 total knee replacements performed annually in the United States and this number doubles when you consider worldwide procedures. Dr. Insall’s designs have been instrumental in the global success of total knee replacement. 

Recently, Dr. Insall and his associate, Giles R. Scuderi, MD, in association with Zimmer engineers, developed an innovative version called the LPS-Flex Knee Prosthesis, which allows the patient’s knee to obtain a normal range of motion. Current knee implants allow no more than 125 degrees of flexion, while the new LPS-Flex Knee provides as much as 160 degrees of flexion. 

Dr. Insall comments, "Current implants are not suitable for patients requiring full motion or whose lifestyle requires full flexion. With an increasing number of active baby boomers considering total knee replacement, this may be the appropriate implant. It is our belief that only this type of prosthesis can successfully replicate normal knee motion. Redesigning the femoral and tibial components along with an improved cam mechanism accomplished the greater range of motion with the LPS-Flex Knee Prosthesis: the unique cam mechanism helps drive the knee into deeper flexion" 

Dr. Scuderi, Associate Chief of Adult Knee Reconstruction at Beth Israel Medical Center says, "While this prosthesis is designed for normal knee motion, it is important to realize that the pre-operative knee flexion will influence the final outcome. Therefore, this implant may not be useful in all patients. But, in developing this knee prosthesis we have also modified our surgical technique to create a flexion-friendly environment for our flexion-friendly prosthesis. This new surgical technique has beneficial implications for all our patients."

The procedure takes about an hour and a half and is performed under an epidural anesthetic. Following the operation, the patients participate in a supervised rehabilitation program, which is specially designed to regain greater flexion. A team of physicians, nurses and therapists guide the patient through their recovery. Most patients are discharged from the hospital in five days and are then followed in the office as an outpatient.

Exercises for Your Sore Shoulder

These stretching and strengthening exercises for your shoulder should be done only if they don't cause pain. Try to do these exercises twice a day. If you don't have hand weights, you can use a 15 or 16 ounce can of soup instead. If you have weights, start out with a low weight and increase the weight after you become comfortable. Don't use more than five pounds of weight. For exercises with an exercise band, the further you stand from the door, the more resistance the band gives. Start close to the door and move back until you find a comfortable resistance. For all of these exercises, start by doing three sets of 10 repetitions and work your way up to three sets of 20.

Warm-up with Pendulums
While standing, lean over so that you're directly facing the floor. Let your sore arm dangle straight down. Draw circles in the air with your dangling arm. Start with small circles and then draw bigger ones for about one minute.

Across the Chest
While standing or sitting, use the arm that isn't sore to hold the bent elbow of the arm on the side that's sore. Pull the arm that is sore gently across your chest until you feel a good stretch of the muscles in your shoulder. If pain occurs, don't pull your arm so far across your chest. Hold the stretch position for 10 seconds and release the arm. Repeat this stretching exercise three times.

Climb the Wall
Stand with your side next to a wall and have your fingertips touching the wall. Now slowly "walk" your fingers up the wall until you feel a good stretch of your shoulder muscles, but not pain. Once your armpit is as close to the wall as is comfortable, hold the position for 10 seconds. Repeat this stretching exercise three times.

Towel Pulls
While standing, hold a towel in the hand of your sore arm and then toss the towel over your sore shoulder (don't let go of the towel). Reach behind your back with your other hand and grab the other end of the towel. With each hand holding each end of the towel, pull the towel up as far as you can comfortably. Hold your arms in this position for 10 seconds. Then pull the towel down as far as you can and hold your arms in this position for 10 seconds. Repeat this stretching exercise three times. Then put the towel over the other shoulder, switch the position of your hands and do the same stretches.

Strengthening Exercises with Weights
Lie on your back with your right arm next to your side. With a weight in your right hand, bend your arm so that your elbow forms a 90° angle. Lower your forearm to the side, keeping your elbow close to your side.

Lie on your right side with your left arm at your side. With a weight in your left hand and your forearm across your abdomen, raise your forearm. Be sure to keep your elbow near your side.

Sit upright and hold both arms out beside your body. Hold your arms a little lower than shoulder level. With weights in both hands, raise your arms until your hands are at shoulder level. Keep your thumbs pointed down.

Strengthening Exercises with an Exercise Band
Stand next to a closed door with a doorknob. Loop the exercise band around the doorknob. With your hand that is on the side of your body farthest from the door, grab the loop of the exercise band and pull the band across your abdomen and out to the far side. Keep your elbow bent at 90° throughout the entire motion.

Stand next to a closed door with a doorknob. Loop the exercise band around the doorknob. With your hand that is closest to the door, bend your arm at a 90° angle and grab the loop of the band. Pull the band across your abdomen.

Stand with your feet slightly apart and the exercise band under your foot. With your arm straight and your thumb pointed down, grab the loop and pull upward to shoulder level. Keep your thumb pointed down during the entire exercise.

This information provides a general overview on exercises for the painful shoulder and may not apply to everyone. Talk to your doctor to find out if this information applies to you and to get more information on this subject.

Shoulder Surgery

Bursa - is a small sac filled with fluid that cushions the tendon from the bone.
Labrum - is a rim of cartilage that helps to stabilize the joint.
Capsule - is an envelope filled with fluid that assists in joint stability.

The shoulder is classified as a ball and socket joint. It is the most mobile joint in your body.

There are four common problems a person may have with his/her shoulder:

1. Impingement caused by inflammation of the rotator cuff and bursa. Pain occurs when raising the patient's arm above his/her head.
2. Recurrent Dislocation caused by a tear in the labrum or excess laxity in the joint's capsule may result in a disability.
3. Painful Instability occurs when a shoulder is forced beyond the joint's normal range of motion causing the ball to move abnormally in the socket.
4. Arthritis may be caused by long-term wear and tear, infections, injuries or a variety of other diseases. It is characterized by roughened joint surfaces with worn cartilage. Fragmentation of bone and cartilage is also known as loose bodies.
   

1. Arthroscopy: allows the surgeon to look inside the shoulder joint using small incisions and identify the problems. The surgeon may often be able to correct the problem using this procedure by removing loose unwanted tissue from the joint, with less disturbance to the joint. Recovery time is usually short.
2. Bankart procedure: an operation that tightens ligaments and repairs torn capsular detachments, restoring shoulder stability. It is often performed for athletes involved in throwing sports who suffer from recurrent dislocations and subluxations. It allows the patient to return to contact sports such as baseball, football, wrestling, and ice hockey because the muscles and tendons are returned to their anatomic locations.
3. Rotator cuff repair: a procedure that is performed to repair the tear, therefore, relieving the patient's pain and improving function of muscles and tendons that move the joint. The surgery is commonly performed on older patients who complain of pain and weakness in the deltoid region that occurs with normal daily activities as well as work and sports. The pain is often worse at night.
4. Prosthetic shoulder replacement: a procedure involving replacement of the head of the humerus or "ball" (hemiarthroplasty) or in some cases the resurfacing of the "socket" or glenoid as well (total shoulder replacement). This surgery is sometimes performed for patients with arthritis in the shoulder joint because it provides pain relief, which is the major indication for the procedure. Improvement of function may result but is less predictable.

Cast Care

To care for your synthetic cast, follow all instructions for plaster casts. If your cast should accidently become damp, it should be dried thoroughly with a blow dryer set on a cool setting. Failure to dry the cast completely may result in sores under your cast.

Plaster Casts
To maintain your comfort and to assist in minimizing cast breakage due to misuse, please follow these guidelines.

	Do not put weight on your newly casted leg for 48 hours, which is the appropriate time needed for the plaster to dry. Use your crutches.
	Elevate your casted extremity (preferably above heart level) for 12 hours after the cast is applied.
	Place your wet cast on a pillow or soft pad. (Hard surfaces may dent wet plaster.)
	Do not use anything to scratch under the cast, as this may cause a sore. Do not allow any small objects to fall down inside the cast, as this will irritate your skin.
	Do not attempt to shorten or loosen your cast in any way, as this can cause serious problems.
	If you are given a boot for your cast, wear it whenever you are walking. Failure to do so, even for short periods of time, can cause your cast to crack and soften.

KEEP YOUR CAST DRY
Whenever you shower, wrap your casted arm or leg with a plastic sack and fasten it securely beyond the upper edge of the cast.

If a tub bath is taken, your cast should not come in contact with the water. Do not attempt to clean your cast with any wet substance.

If you need to walk in the rain or snow, protect the cast with a plastic or waterproof covering or a cast shoe and use your crutches to keep your cast dry.

Please call our office immediately (515-222-3151) if you have any problems with your cast such as those listed below:

	Your cast feels too tight or too loose, becomes broken or cracked, or if you feel painful pressure areas or rubbing beneath the cast.
	There is marked swelling, tingling, pain, or numbness in the fingers or toes which is not relieved by elevation.
	There is excessive odor present from your cast. (Perspiration odor from the cast is normal.)
	You notice any extremely reddened skin or any bleeding or draining sore around the edges of your cast.
	Your oral temperature rises to above 38.5 ° C (101.3 ° F).

Auto-Transfusion

1. Before surgery: You may schedule appointments and donate your own blood. This is known as autologous blood. It will be stored and reinfused as needed during or after your surgery. Your body will replace your blood cells between donations.
2. During surgery: Blood lost from your surgical site may be saved, washed, and replaced while in surgery. This is known as cell saving. While many orthopaedic surgical sites shed little blood during surgery, a significant amount may be lost following surgery.
3. After surgery: In many orthopaedic patients, a wound drain is placed in the surgical site to reduce bruising, swelling, and the risk of infection. Drains are important to aid in healing. The blood collected from the wound drain can be reinfused into the patient in the recovery room or on the nursing unit within six hours.
   

This system helps to return your lost blood to your circulation quickly and efficiently. Your own blood is easily accepted by the body. It is a perfect match. While there are always some risks with reinfusion, each transfusion is carefully monitored. The reinfusion system is a safe way to help you in your recovery. You supply the best blood to aid in your healing - your own.

Discuss the possibilities of auto-transfusion with your physician. In most cases, auto-transfusion is possible.

Patient Controlled Analgesia

PCA stands for patient controlled analgesia. Analgesia simply means relief of pain. After your operation or injury, your doctor may prescribe PCA for pain control.

How does the PCA machine work?
The machine contains a syringe of pain medication as prescribed by your doctor. The syringe is attached to tubing and connected directly to your intravenous (IV) line. Often the machine is set to deliver a small, constant flow of pain medication. When you fell pain or discomfort, you should firmly press the button on your machine and it will give you additional medication. You should hear a soft "beep" when the button is pressed properly. You will generally feel the effect of the medication within five minutes. Your machine has several safety features and an alarm system. The machine is set up as prescribed by your doctor and will give only small, measured amounts. The total amount you can give yourself each hour is within a safe limit.

How often should I press the button?
Press the button when you are having pain! A small amount of pain medication will be released into your bloodstream. Don't press the button if you are feeling too sleepy. The more alert you feel, the better you are able to participate in your therapy program, which will aid and may quicken your recovery.

How is PCA different from "hypos?"
The nurse must prepare a "hypo," which is a shot given into a muscle. It usually takes about half an hour to feel the pain relieving effects of the medication because it is absorbed more slowly into the bloodstream. Often you will become quite sleepy, but after a few hours awaken with pain. Remember, with PCA you usually receive a small continuous flow of medication, and also may give medication yourself to provide a more constant level of comfort. This is the reason your doctor often prescribes PCA for the first few days following your surgery or injury, when you feel the most discomfort.

Can I become addicted?
No! Studies have shown that patients using PCA often use less medication during their hospital stay. Usually you use the machine for only a few days, and them oral medication is enough to relieve your pain.

Are there any side effects?
As there is with any medication, you may feel some side effects. A small number of people feel nauseated, have some itchiness, or have difficulty passing urine. If any of these symptoms occur, you should notify your nurse.

We think you will like using patient controlled analgesia. It lets YOU control your pain. After all, you know best how you feel, and PCA allows you to give your own medicine and get relief in a faster, less painful way.