April 2008
26/04/2008 – Chronic total hip infection, antibiotic treatment is not enough
Here is the dilemma that I am in. My wife fell down and broke a hip in June 2007 and I get more confused as we proceed to get her back to normal and the complications she has experienced.
June 13 2007 Surgery to replace the broken hip head at St Francis Hospital (probably so called hemiarthroplasty). Hemiarthroplasty failed by dislocation.
June 25 2007 Performed surgery and did a complete hip replacement
July 5 July 5 transferred to nearby Rockville hospital for test due to incision infection that was draining severely. She was prescribed oral antibiotic. Sept 10, The pain was increasing and swelling appeared on incision, and Doctor was notified and said to keep an eye on it.
Sept 17, Performed surgery to cleanup and flush infection from incision and ordered intravenous antibiotic for six weeks. Jan 2008 the pain was still persistent and swelling was starting to appear on incision. Implant left in place?
Jan15, She was examined Surgeon. He said he had to remove implant in order to cure infection.
Jan 28 Performed surgery and removed implant and inserted spacer and started six weeks of intravenous antibiotic.
April 14 scheduled for aspiration of hip, that was negative. and she is scheduled another hip on April 24. However the pain is still persistent.
April 20 AM Pain was extremety bad with some fever. and she was transferred to hospital emergency.
April 21 A second hip aspiration and X rays were performed. The pain is at this time is severe.
The surgeon plans to open the incision and do a complete hip if there is no infection present. If there is signs of infection he will clean and put another spacer and start a third round on intravenous antibiotic. He cannot give me a definite answer for the cause of the pain other that he suspect more infection. The aspiration from April 14 is negative. Is this all possible.
At this point the surgeon plans to proceed with the surgery on the April 24th.
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Hallo,
I am sorry for the development of infection in the total hip joint of your wife. Your precise description of the development of your wife’s suffering demonstrates two things:
First, Infection around a total hip joint may be only seldom cured by “flushing” and antibiotics. It is because the bacteria are very adaptable – they soon develop resistance to the antibiotics and treatment with antibiotics without removal of the infected total joint is not only without effect, it also produces antibiotics-resistant bacterial strains which are a danger to other patients.
The “flush-out procedure”, that leaves the total hip in place is appropriate in infections early after surgery and must be done immediately - the very first days after surgery. The flush-out procedure must remove not only the infected blood pool. All infected tissues around an infected total hip should be removed carefully too.
All infected total hips where the infection had time to establish itself (weeks after surgery) must be removed and temporary space with antibiotics should be placed in their place; the new total hip should be placed on only when the infection is healed with appropriate treatment.
Second, you do not report about the blood tests (SR and CRP) to establish whether the infection is healing. Until these tests demonstrate healing of the infection no new total hip device should be implanted.
These are the simple rules that should be followed in treatment of all infected total hips. Often a specialist in infection diseases should be consulted when the patient developed infection with bacteria that became resistant against many antibiotics as to the choice of appropriate antibiotics.
VS
24/04/2008 – Sounds from a total knee, not always a fracture
I had a total knee replacement done almost 5yrs ago. I found out that I fractured my patella and in pain walking. When I stand up I get a loud bang like something is falling into place . What should be done?
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Answer
You write that you ”found” that your patella is broken. I must ask how did you found it? Without x-ray picture is the diagnosis seldom secure. Sounds like a “loud bang” are no sign of fractured patella.
Rather, the sounds point to an unstable patella or to the development of a soft tissue ball inside the knee joint See the chapter: Other total knee complications.
I think that you should ask your surgeon to examine your total knee to found the cause of the sounds from your total knee and then discuss with him/her how to treat it.
VS
23/04/2008 _ Total hip - what approach should I have?
I am 10 weeks post-op on a THR. My surgeon is a master of posterior lateral approach and claims it's better than anterior approach. Says he could fit in a larger ball and he used a 36 mm ball (he knows I dance). I seem to be healing well with lots of therapy. Just a slight limp and not much pain, mainly stiffness. I had investigated the anterior approach and keep wondering about the claims of less cutting of muscles and faster healing.
My so-called good hip is beginning to show signs of wear and the old "catching" pain is ever present. So I think I will need to do that one too in a year or so. Should I switch to the anterior approach? That will mean a new surgeon.
I'm 68 years old, 5'2 small-boned, 125 lbs. and in excellent health.
Is 36 mm a "big ball"?
Thanks, Nancy
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Answer
First, The approaches to the hip joint. You just may look at the chapter Total hip operation
I think that in a good surgeon’s hands every approach is good. If it wasn’t the good surgeon would not use it.
Actually, the “pure” anterior approach either gives a bad “insight” into the hip joint or the surgeon is forced to divide (partially) some muscles. Not to speak about the risks of nerve damage with this approach. It usually is “anterolateral” approach that is used, not the pure “anterior” approach and in anterolateral approach there is the division (partial) of muscles a rule.
IN my opinion I cannot see why the patient should leave a good surgeon who carried a good work only to seek another one who uses another approach. May I ask on what recommendation would you base your decision on if you would change your surgeon? For me, I cannot distinguish how much is advertising and how much is science in these different claims about the “excellence” of individual approaches to the hip joint that are occurring on different Internet sites.
Second, the size of the hip ball component: The bigger the size of the ball, the more stable the hip joint is. That is the reason why the surgeon uses large ball components. Such total hip joints are available for certain hip models only, meaning not all manufacturers “utilize “ this opportunity. Compared with the head of the natural hip joint (the ball that our Lord provided us with) the 36 diameter is still smaller than the natural head which ranges somewhere between 48 to 60 millimeters.
Such large balls are available for surface hip replacements and some metal-on-metal total hips only, due to technical limitations. I wish only to add that “small boned” 68 years old female patient is not a good candidate for a total hip replacement – too many risk factors there.
Best wishes and much luck with both of your hips.
VS
20/04 – Piriformis muscle –further information
No I do not have any sciatic pain at all, just buttocks and pain behind the incision area. And across rear of thigh. Is it possible for the piriformis to be inflamed without sciatic pain?? Could this pain be something else?
My OS used mini incision , posterior approach and I don’t believe detached the piriformis with mini incision.
If detachment of piriformis at greater trochanter is recommended by OS is there a chance I could have sciatic nerve damage and be worse off with pain?
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Answer:
Thank you for additional info. Your questions about the operation itself would be best answered by the surgeon who carried out the surgery. On the whole, the patient should always discuss with her/his surgeon all important questions. See also the chapter: Asking surgeon.
It is unethical, improper, etc. to give diagnostic and treatment advices on Internet to individual patient.
So, in general, the piriformis syndrome is a pain syndrome occurring sometimes after minor trauma of the pelvis, sometimes without any such trauma. It is practically unknown in patients operated on with total hip replacement (I found only four cases published).
It is characterized by pain in the buttock radiating down the leg; the pain is often similar to sciatic pain.
The minority of patients have only pain in the buttock with minimal or none irradiation at all.
The piriformis muscle area is painful on touch and sometimes also swollen.
The MRI (Magnetic resonance imaging) may show changes in the muscle, or show a burse if such a present. (All this are observations on people NOT operated on with total hip replacement)
The doctor may inject Cortisone with local anesthetic in the muscle under x-ray guiding; awkward procedure because the closeness of the big sciatic nerve. Pain relief after the injection, on the other hand, verifies the diagnosis
The patient with suspected piriformis muscle engagement should ask her / his doctor among others:
What signs point to the engagement of the piriformis muscle in my case.
What other changes may cause my pain symptoms
What diagnostic measures may corroborate the diagnosis of piriformis muscle engagement (MRI?, local injection?)
What is your experience with treatment of patients with piriformis muscle syndrome (how many patients did you operate on, how were the results?)?
VS
18/04 – Pain after muscle surgery in the hip area
I had Rectus femoris surgery because the rectus femoris was to short, so they cut it and reattached it. I have had excessive swelling since the day of surgery and pain constantly. They put me on the Game Ready machine for two weeks with no relief. They took me off of weight bearing and elevated it above my heart for two weeks and was taking an anti-inflamatory on top with no relief. How long will it take to recover from surgery? And is there anything you can suggest to try, I am at my wits end the Dr. keeps telling me it will take some time but that he doesn't know how long. The surgery was done on March 18th, 2008.
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Answer:
Unfortunately, you do not tell why the rectus femoris muscle was too short and needed to be operated on, neither what was done with it. Rectus femoris is only one of four parts of the big muscle in front of the thigh. It may be “impinged” and become short after total hip surgery and it may become short after for example after thighbone fracture.
Release of the rectus femoris muscle attachment is usually “a big surgery” and the pain reaction may last longer that the usual 2 – 4 weeks, depending on the circumstances. This may still be your case.
But three alternatives need to be considered because two of them demand immediate action.
Pain may be prolonged if there formed a blood pool at the operation site which exercises pressure on soft tissues around it, causing intensive pain. The condition is called “closed compartment syndrome” and should be treated by quick evacuation of the blood pool. Your doctor should examine and consider this cause of pain.
The blood pool may become infected and developing infection usually causes intensive pain. Your doctor should exclude this possibility too, taking usual blood tests (SR and CRP) and take action accoprdingly.
And there may be forming calcifications in soft tissues damaged at operation. These calcification cause intensive pain, but usually are apparent on the x-rays first after 6 – 8 week after operation. Usuallt the pain disappears when the forming of these calcifications is finished
When one knows the real cause of your pain, one cat treat it appropriately.
You should discuss the cause and the treatment of your intensive pain with your doctor.
VS
17/04 – Pain in the hips several years after total hip replacement
Had revision hip replacement in 2000 after original THR in 1989. I was 29 years old then. Now 47. Have had increasing pain in groin and outer hip and then traveling down leg. Sitting makes it worse and it does not lessen at any time even whilst trying to sleep. Xray and Cat Scan are fine my surgeon says. Am to see him in 6 weeks for a check up but he said just slow down. Not very helpful. Have had this pain for over 3 months now. Can you suggest anything.
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Answer:
Intensive pain around the hip occurring several years after total hip surgery has usually one of the two possible causes: one is loosening of the total hip device, the other one is late infection.
The usual examination of loose total hip is by x-ray pictures and comparing them with the previous pictures. Change in the position of the total hip device on successive x-ray pictures would point to loose total hip device. A single x-ray picture usually is not enough; it does not tell the whole history.
Infection will become apparent by the change of the blood tests (Values of SR and CRP tests will be raised).
Pain radiating down the leg may also be caused by changes in the lower back, by pressure on the nerve root there. This would be disclosed by careful neurologic examination possibly combined with MRI examination of the back (lumbar) spine.
VS
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15/04 – Pain in the buttock – piriformis muscle engagement?
I had left thr 9/07 and since 12/07 have had pain behind the incision site and my buttocks. Dr says piriformis and suggests it be cut at the greater trochanter. Can you tell me about this procedure and what sort of recovery period is involved?I visited a chiropractor for ‘active release’ to try to stretch the piriformis and got a bruise and now find I have a ‘calcification’ on my buttocks as well, which is also painful-
If I move forward with the pirformis surgery will the surgeon be able to remove the pain calcification as well?
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Answer:
Very interesting question but little information. The piriformis muscle is one of the four muscles on back side of the hip joint that are divided during total hip replacement to provide posterior (back) access to the hip joint. The muscle lies across the large sciatic nerve. When the surgeon sutures the muscle back, the nerve may be impinged upon. Very rare condition to my knowledge.
The piriformis syndrome can otherwise appear in people without any hip operation, simply because this muscle presses on the sciatic nerve, or there may arise a bursa (a sack) that impinges on the nerve.
Patients with piriformis syndrome thus have signs of impingement of the sciatic nerve: pain radiating down from the buttock to the lower leg and foot. Is it your case?
The calcification in soft tissues around the hip may cause intensive pain, usually not lasting. Usually it is seen on x-ray pictures. Only when the surgeon is sure that the ossification (calcification) apparent on x-ray picture is causing the pain is the operation indicated. There is, however, no guarantee that the ossification will not return.
Searching for a small ossification on the back of the hip joint area where crosses the sciatic nerve may put this nerve at risk of damage, both during the surgery and after that by possible pressure from blood pool.
VS
March 2008
31/03/2008
Iliopsoas muscle operation –some questions
I had a revision hip surgery done in 2007. Thought everything was going fine, but started to have impingement of the iliopsoas. Did cortisone treatments, PT and tried to just ignore it. I had a localized injection in the office using ultrasound. This relieved my pain but only for 4 hours. I then had a surgery to alleviate the impingement. The iliopsoas tendon was released by the lesser trochanter. However, the iliopsoas was still tight and there was a bone spur along the anterior aspect of the acetabulum, they also released the iliopsoas there. I am in PT, as you would expect there is significant weakness. On your website you talk about tendon release and tendon dividing. Is it common to release it twice? If they release it on the top and the bottom, does this muscle attach to anything? In your experience have you ever seen this? I know the doctors were working with the Mayo Clinic, but know one seems to know much about this. Can I expect any of this muscle to regain its function? The other muscles are trying to take over, but have no signs of movement from iliopsoas muscle. The good news is I have no terrible pain..
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Answer:
The tendon of the iliopsoas muscle attaches at the lesser trochanter and is usually released there with good result. I cannot say why your surgeon released the tendon also on the second place some centimeters higher up (“anterior aspect of acetabulum”), probably was there some adhesion; best you ask your surgeon directly.
The end of the divided iliopsoas tendon usually attaches by a scar to the tissues around the hip joint. The weakening of the flexion (bending) force in the hip joint in these patients is usually not too big; most often the patients note the weakening when ascending stairs. Successively the other muscles around will take the function of the weakened iliopsoas muscle.
VS
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30/03/2008
Limp after total hip replacement
Had full hip replacement 5 weeks ago. Fantastic improvement but I still have a limp if I try to walk without a crutch. I am 57, 85kgs, in good general health. Are there exercises which will clear this limp.
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Answer:
Have a patience. Limp in the operated total hip 5 weeks after surgery is rather usual. It takes usually 8 -12 weeks until the limp disappears. Still, 12 weeks after total hip surgery, 12% of patients are limping.
Yes, there are exercises to strengthen the weak muscles; just ask your PT.
You may also look at the chapter: Rehabilitation after total hip surgery
25/03/2008
Clicking sound in the total knee
I had a total left knee replacement done in Oct. '07, the prosthesis was made by DePuy. I am experiencing a clicking and I told the surgeon and his answer was sometimes that happens and hopefully it will get better over time. It isn't getting better and I am wondering if it could be a faulty implant or perhaps a characteristic of this prosthesis. You answer will be much appreciated.
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Answer
Occasional clicking sounds from a total knee occur often. When they do not cause trouble to the patient there is no reason to examine their provenience. Surgeons often guess that it is some snapping tendon that causes them.
Regular clicking sounds, especially occurring with certain knee joint movements, are most often caused by some instability of the total knee joint.
Most often it is the kneecap (patella) that is moving out of place and back again that is causing this sound.
When these sounds are accompanied by pain in front of the knee then the cause is often a soft tissue “ball” in the joint capsule that is jerking over the rim of the total joint. You may look at the chapter Other Total knee complications / patellar clunk syndrome.
X-ray examination may discover the unstable kneecap. For discovering of the soft tissue ball it would be necessary a keyhole (arthroscopic) examination of the knee joint.
These are the two most often occurring complications producing sound from the total knee.
You may discuss further examination and treatment with your surgeon. These complications are not associated with a certain type / model of total knee joint.
VS
18/03/2008
Non-operative treatment of loose total hips - continued
Here follows the answer of professor Nelissen, who heads the Dutch investigation:
"Thank you for the interest in our research, I am the principal investigator with prof Huiznga. Jolnada de Poorter is my PhD student, now a resident in orthopaedic surgery.The trial in Leiden is the only one in the world, and is not conducted in the US"
10/03/2008
Non-operative treatment of loose total hips - continued
I have since found a journal article http://www.liebertonline.com/doi/abs/10.1089/hum.2007.111 where they have had some success.
Would you know of other physicians that would be wlling to try the procedure or other researchers performing trials.
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Answer:
Thank you for the citation of a very interesting article. As it happens it was published in a journal that orthopaedic surgeons do not come in contact with, so it was completely unknown to me. I did not find any other similar article although I searched on the usual databases. It thus seems that there are no other surgeons investigating this kind of therapy of loose total hips in old patients. So sorry because this is really a bright idea.
From this article it is not clear if the Dutch surgeons injected only the virus that dissolved the soft tissues around the loose total hip only or whether they also proceeded with injection of bone cement.
I had therefore contacted the principal author (curiously, she is named both de Poorter and Depoorter, publication year is both 2007 and 2008 and thus this article is difficult to find in the authoritative MEDLINE database)
If and when I will have the answer from Jolanta de Poorter I will contact you again.
VS
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08/03/2008
Non operative treatment of loose total hips
My mother recently fell and has been in immense pain since. After seeing many physicians, it was eventually determined that that her hip replacement has been loosened.
She is 83 and a revision surgery would be very traumatic. I have seen that they have had tremendous success by injecting bone cement into verterbrae to stablize fractures. Do you know of a similiar procedure for injecting bone cement into the femur to stabilize hip joint replacement. If so can you recommend a physician, clinic, trial, or country. She currently lives in Miami, Florida.
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Answer:
Thank for your interesting question. Injecting bone cement into broken vertebral bodies is possible because of special type of damage to the vertebral body: there is spongy bone inside the vertebral body, that was compressed by the trauma and it cannot be restored to the original volume and shape. The bone cement is injected into the space occupied previously be the now irretrievably compressed by the spongy body. The bone cement has still good “foothold” in the remaining spongy skeleton when injected almost blindly.
In the loosened total hip the mechanism of loosening; even in patients having a trauma is completely different. The skeleton around the total hip device was resorbed away and replaced be loose soft tissue. So the total hip lies loose in the sea of loose tissue. The loose soft tissue cannot offer any good foothold to bone cement when injected blindly into it. Therefore as yet one does not use blind cement injection to stabilize loose total hips.
It is an interesting idea and perhaps one will find a way in the future how to do it. As yet, however, I do not know any surgeon, clinic, or institution carrying out such procedure
You are completely right that total hip revision operations for people >80 years old are traumatic. Then also the quality of skeleton in old people may be so low that firm implantation of a new total hip may not be possible, so the patient cannot have a new total hip..
One should then consider several possibilities, two of them are: do nothing if pain is tolerable and the second one is to remove the loose total hip joint without replacing it with a new. One can live without a hip joint (the operation got the somehow poetic name Girdlestone operation, see the chapter Treatment of the hip infection )
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01/03/2008
Failures of ceramic total hips
I just received a call from a friend who'se Wright ceramic total hip replacement just shattered after only a couple of years. This occurred after he started experiencing squeaking in the hip a few months ago. He is going in for a revision next week. He is almost 50 years old, 6" 2" tall, and approximately 235 pounds.
My concern is that I received two of these, myself, approximately four years ago. I have been extremely happy with the results. In fact, last summer I played full-field soccer every Saturday morning, and in the fall played touch football, with no apparent side effects. I am almost 50 years old, 5' 8" tall, and approximately 175 pounds (down 20 pounds since the surgery). Because I have not had any complications after 4 years, are my risk factors lower or are they increasing?
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Answer:
Ceramic total hips do fail, but not more often than other total hip models. The benchmark says that >90% of all operated on total ceramic hip shall survive ten years after surgery. And they do even better. The risk of failure is usually linear, that means that the failure rates do not increase as the time goes.
Squeaking sounds from ceramic total hips occur in about 5 -15 %, the surgeons are not sure whether the sound is a sign of approaching failure,
My opinion: Enjoy life with your ceramic total hips. To minimize the risk of failure keep your weight within reasonable limits and avoid putting unnecessary stress on your hips. Contact sports may be such risk moment. But remember, you get your ceramic hips to enjoy the life not to sit immobile in fear of failure.
VS
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February 2008
29/02/2008
Pain in the leg after total hip replacement
I am 53 years of age.I also got a THR due to AVN more than an year ago. My X-RAY, Bone scan etc are normal. There is no loosening, no infection and X ray looks normal. I still have pain sensation on lower part of the thigh which faces the chair while sitting i.e when it touches the hard surface and the pain while walking starting from thigh to knee and lower part of the legs. The good leg and thigh also pains while walking and sitting but lesser than the operated one. Is there a treatment? No doctor has been able to diagnose the problem. Some doctors call it neuropathetic pain and some suggest revision surgery.
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Answer:
Pain in the leg that was operated on with total hip replacement may have several causes.
In your case the most frequent causes of pain, infection and loosening, were excluded as you say.
The pain in the shaft of the thighbone occurs in some patients operated on with cementless shaft without any obvious reason to be seen on x-rays.
In other patients one can see a wrong position of the total hip component, its femoral (lower) part, even one can see that the end of the component is coming through the thigh bone. This may need a special x-ray projection.
A long scar of subcutaneous soft tissues, hidden under the skin can be another cause of the pain that occurs when the leg comes in contact with the hard edge of the chair.
Short muscle / muscles may also cause pain in the outside of the leg during walking, raising from the chair, etc.
Eventually, there may be a nerve damage causing the trouble, either in the scar, or higher up in the spine.
So what need to be done is a comprehensive examination, inclusive of examination of nerve function by a specialist, new evaluation of x-ray pictures with assessment of the position of the femoral component. An experienced PT should evaluate the state and function of the muscles around your total hip.
Revision operation? What should be operated on anew? When there is no known cause of your pain, revision operation would probably end in a catastrophe.
VS
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28/02/2008
Bad alignment of the leg after total knee surgery
I just discovered your “Total Joints” website and I wanted to say that I am grateful to find it.
For what it is worth, I had a left total knee replacement with a DePuy mobile bearing (rotating joint) as you describe. I have generally been pleased with the results and am now 16 months post-op. my only disappointment is that the surgeon didn’t align my tibia as well as I would have liked and now my foot is very slightly too far to the outside (left). This causes soreness and some loss of feeling in my left foot, but the surgeon doesn't seem concerned.
I was also very interested in your section on materials for total hip replacement prosthesis, as that will likely be my next surgery. My surgeon talked about types that were “metal-to-metal and mentioned cobalt-chromium. He also talked about Alumina-Zircon ceramics, but he said that contrary to what the salesmen say, he had seen them chip.
I have a younger friend who had the surface hip replacement at just over age 50 by Dr. Mott in Baltimore. He has been extremely pleased with it and is back to playing tennis. I do believe his physique helps, as he is short, very slender and has always been physically active.
I don’t know if you can make recommendations for hip replacements, but would appreciate any general or specific comments you might care to make. I am just turned 64, but fairly active, though overweight. I wish to be more active, but have had a lot of pain the last couple of years that has reduced my activity level.
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Answer:
Congratulations to the results of your Total Knee operation. You say that the alignment of your lower leg is not perfect “which causes soreness and some loss of feeling in the foot”. Generally, however, soreness and loss of feeling in the foot, especially on the outside is rather caused by a pressure on the nerve that passes on the outside of the knee (fibularis nerve). If the soreness will increase in the future one should look at the function of this nerve.
As to the total hip materials. The basic rule is to choose an experienced surgeon, an experienced surgeon has his proven total hip model made from materials that worked well in his hands.
Surface replacement is suitable for certain patients. The deciding factor is the quality of the skeleton of the hip joint to be replaced. For patients with good quality skeleton, there is no reason why they should be denied surface replacement surgery. Patients with “moderate” overweight have equally good results as normal weight patients; but their rehabilitation is slower.
VS
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27/02/2008
Numbness after arthroscopy of the knee
I had an arthroscopy on my left knee due to a torn meniscus. During surgery they also had to "clean up the cartilage". I now have a numb area on the left side of my knee and down my shin approximately 8 inches x 4 inches wide. A rather large area. My doctor is dumbfounded. Can you explain this numbness?
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Answer:
Thank you for your question. A numb area after arthroscopic examination of the knee joint occurs with varying frequency.
It is caused by the damage to one of the many thin skin nerves that pass over the knee area. When the surgeon sticks through the skin with the pointed knife to make entry for the arthroscopic instrument, he / she may be unfortunate and cut through one of these thin nerves. This results in that the skin area innervated by the nerve becomes numb.
It then depends on luck if the nerve “grows together” or if a scar tissue prevents healing of the damaged nerve. In the first case the sensibility returns, in the other it will not.
Usually surgeons can find the entry hole in the skin where the skin nerve was damaged and explain to the patient what happened.
In very rare cases, in patients where a bloodless field was used during arthroscopy, the nerve damage may occur through pressure of the inflatable cuff. In these patients the numbness is usually transitory.
Patients are recommended to ask their surgeons for close examination and then discuss possible treatment. (Usually none is necessary)
VS
26/02/2008
Failed femoro-patellar replacement, what to do?
I’m 29 and had a right patello- femoral replacement 3 years ago operations wasn’t successful. I know I need my patella removed and was wondering how long the recovery time is if you can help that would be helpful searched the web and can’t find a thing about this procedure. Any info would help or any website addresses would be great. L
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Answer:
Thank for interesting question. Isolated replacement of kneecap in young patients is not done so often nowadays, so there are only sparse reports on the results of these operations.
It seems that young patients (<40 years of age), patients with previous operations on their knee, patients with pain but no x-ray changes, and patients operated on with certain types of replacement devices ( Lubinus model) run a substantial risk of failure.
Treatment of failed patello-femoral replacement by a new operation is a very responsible dead and should be done after careful evaluation of possible causes of failure. The surgeon who would treat such patient should have good practice in treating these patients.
Depending on the evaluating of the reasons for the failure, one chooses the appropriate treatment. If the cause of failure is further progress of wear of the knee joint cartilage then one often chooses to do a total knee replacement.
Total recovery time after total knee replacement is usually 3 or more months, whereas the hospital stay is usually only some (4 -5) says long.
You are right; it is difficult to find good reports about this issue.
Recently there appeared a report in the renowned The Journal of Bone and Joint Surgery-Am, 2006, 88-A Supplement 4: 122 – 137 about this procedure, written by Doctor Leadbetter and his colleagues. You may ask your librarian to procure a copy of this article for you (there are many pictures there and an e-mail address to doctor Leadbetter). You may perhaps also contact Doctor Leadbetter about his opinion.
VS
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21/02/2008
Infected total hip – should it be removed before antibiotic treatment?
Should a major infection of total hip be treated with antibiotic whereas the device is left in place or should the implant be removed before the antibiotic treatment starts?
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Answer:
Thank you for your very short question. What are you really interested of? Your question is too short, without facts that would help to answer the question.
The treatment of infection around total joint depends on many factors. Very important is the time factor.
If the infection appeared early after surgery the bacteria had not the opportunity to colonize the surface of the total joint. It is then sufficient to remove only the infected blood pool around the total joint and let the total joint stay in place. The antibiotic treatment thus proceeds with total joint in place.
If the infection developed more slowly and bacteria had time to colonize the surface of the total joint, antibiotic treatment only will be ineffective. Bacteria adherent to the surface of the total joint are inaccessible for the effect of antibiotics.
In that case the whole total joint together with surrounding soft tissues that contain adherent bacteria must be removed completely; together with this removal an intensive antibiotic treatment should start. This is called a two stage replacement of infected total joint.
Please read more in the chapter Total hip infection
VS
20/02/2008
PATH operation technique for TH – are there any drawbacks?
I had a total hip replacement on the left side Dec. 6, 2007. It was done in the traditional style. I was not cemented, but was full weight bearing the day after surgery. I returned to work after 8 weeks. I'm very pleased with the results- so far. It was a very hard recovery-painful and slow- and yet I did better than my two friends who also had THR the previous year. I was referred to a Dr. in Cleveland who does the PATH technique. It almost seems too good to be true. I am 58. I need to have my right hip replaced also. What are the drawbacks to the PATH technique versus the traditional method? I am 200 lbs. -but the Wright Medical video I watched says weight doesn't have an impact on the successful placement of the implants. Is that true? Also- since I had my first hip done - ceramic on ceramic- or maybe ceramic on plastic- would there be a problem having metal on metal?
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Answer:
The PATH technique is another of the minimally invasive operation approaches to the hip joint. It was developed by doctor Pennenberg who is collaborating with Wright Company. As you yourself noticed, this technique seems to provide what it promises – quick return of the function in the replaced hip joint.
There are as yet no more comprehensive reports about the results and potential drawbacks of this modification of the minimally invasive approach to the hip joint. From the presentation of doctor Pennenberg it seems that this technique has no obvious drawbacks, except for the learning curve of the surgeon.
If the surgeon is confident with the PATH method, there seems to be no obvious drawbacks.
As to the use of PATH technique in overweight patients: There are no published reports as yet that will give definitive answer on this question. Generally, the overweight patients have equally good results of total hip operation as their leaner colleagues but it seems from some published reports that recovery after operation may be slower in overweight patients and some minor wound complications may occur more often in overweight patients.
The PATH technique is designed to be used with total hip models fabricated by Wright Company specifically. Wright Company has also surgeons who are paid for use of company’s total hip models together with PATH technique.
It thus seems that it would be best to discuss with your surgeon which total hip model he would use in replacement of your second hip joint.
VS
14/02/2008
Osteoarthritis of the hips and changes in the spine
I've had osteoarthritis in my hips for nearly forty years (old Perthes disease) and now find after x-ray of my dorsal spine that I have widespread moderate disc and joint degenerative features. I asked the GP if anything could be done to ensure that it doesn't get worse and he said not to bend or twist too much. Should I be referred to a consultant? There would be no point unless something could be done to help me. I have always tried to watch my posture and as far as I know I haven't lost any height yet. Can you suggest anything that I can do to help myself.
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Answer:
Thank you for an interesting question. I assume that you do not have any special pain from your dorsal spine and that the quality of bone tissue (as shown on x-ray pictures) is good, no signs of osteoporosis (lacking of bone tissue).
In that case one should consider the widespread disc and joint degeneration in your dorsal spine as “accentuated” signs of aging. There is hardly any known method how one could slow down this process.
A PT can instruct you about the right exercises and life style to preserve the resting motion in your spine as long as possible.
An orthopaedic specialist may assess how osteoarthritis in your hips influences changes in your spine. He / she should also assess if any physical therapy would be useful to mitigate the stiffness in your hips which is usually present in patients with hip osteoarthritis.
VS
January 2008
21/01/07
Overstretched nerve after total hip operation?
Sorry to have not given you enough information. The leg that is longer is the right leg which has had the 2 revisions on. The shorter leg is in my opinion a lot shorter as I have to have the all my shoes built up not a lift. The x-rays do show the right leg 3/4 inch longer. My surgeon says the position of the new cup is great. What kind of test would show the function of nerves? Is it common to pull on the nerves to make them stretch over a new hip part? Will the nerves adjust on their own?
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Answer:
To ally your fears, I must say that it is exceedingly uncommon to overstretch the nerves that pass over hip joint during a total hip replacement operation.
If it happens, it is only under special circumstances, such as when there was a previous operation on that hip joint that produced much scar tissue. Such scar tissue may fix the nerve so that it then cannot move away during surgery.
Such overstretched nerve is a serious complication. It causes severe pain and produces grave signs of disturbed nerve function that are not difficult to discover even for a surgeon. I think such complication could not your surgeon miss and you would not stand the pain for so long time.
Less damage of the nerve that may cause pain can be, however, difficult to discover by “untrained” people and would need assessment of a trained specialist in neurology,
Most pain in the total hip area, where the x-ray pictures “look normal” is caused, however, by overstretched muscles. Although it is impossible to make any diagnostic conclusion on Internet, one can say that lasting pain in the total hip of a patient who has too long leg is often caused by overstretched soft muscles and tendons.
So my previous recommendation is, I think, still valid: Seek examination by an neurologist to exclude the nerve damage and discuss with your surgeon and your PT the possible overstretching of your muscles and tendons and how to treat such condition.
VS
13/01/ 2008
My X-ray pictures look fine, says the doctor- but I have still pain
Once again thank you for all your help, and again I have another question for you. When I had my last revision done, the surgeon had to make my leg longer so that I had no more impingement. This was done in July. I went through months of Physical Therapy. But, I am still having pain. I do wear a shoe with a lift of 3/4 of an inch at all times. The sciatic nerve is very sore. In your opinion, how long does it take for the muscles and nerves to stretch to finally absorb the trauma of stretching of surgery? I do Physical Therapy and swim everyday. What else can I do to make this better? The doctor is at his wits end as the x-rays look fine. He believes that it has to do with the stretching of the nerve. Any Advice?
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Answer:
I read this phrase “My x-ray pictures look fine, says the doctor” so often from patients with continuing pain in their total hips. Something must be wrong there.
Because there are always two possibilities:
One, that in reality the x-ray pictures do not look so fine, notwithstanding what the doctor says.
The other one: that the pain is caused by damage to soft tissues around the total hip. These damages are not visible on x-ray pictures and thus do not exist for some surgeons.
(I do not reflect here about the third possibility that the pain has its origin somewhere else then in the total hip area). Se also the chapter: Pain in the total hip.
You write that your surgeon made your leg longer at last revision, but you also say that you still wear shoe lift (1,5 centimeters high); this makes little sense. You do not say which leg is shorter, the operated one or the opposite? This is important to know closer examination of the leg leg difference may decide why you have still pain.
What did show x-ray pictures of both of your hips: has one of your legs been really shorter after the second surgery and which one?
Is the position of the new total hip, of both components, really right?
With wrong placement of total hip components you leg may be in faulty rotation, shorter, and the stretching of soft tissues may produce severe pain.
After deciding these questions one should do careful muscle examination to decide which muscles are shorter (contracted). These muscles would need special PT treatment.
One should also carefully examine the function of the sciatic nerve to see if the nerve shows signs of overstretching or signs of other damage. If there are signs of nerve damage, one should find where is this damage located and what treatment it needs.
With all these carefully done examinations (and it will certainly need an experienced neurologist and radiologist too) one can then make straightforward treatment plan.
This is on you and on your surgeon. If your surgeon cannot continue with your treatment you should find an experienced surgeon who can.
VS
10/01 /2008
Cementless total hips – are they full of holes like Swiss cheese?
Are there any total hip instruments that bone grows into , thus being non-cemented? Am 49 Yr. Old looking at reversal of total hip fusion (10 degree mobility only for 49 years) which will be UNDONE and revised with a total hip replacement. I’m told 20-30 year life of prosthetic, but which is better? metal on ceramic? ceramic on ceramic? metal on metal? I Am told that bone can grow into shaft as if shaft resembled Swiss-cheese holes. This would solidify bond and prolong life. Is there such a thing? Surgery in two months.
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Answer:
Yes, the modern total hip devices in young patients are fixed to the skeleton without the use of bone cement. The surgeon makes a precise bed in the skeleton and the device is then pushed into it. The surgeon call it “Fit and fill” fixation.
The surface of the device is covered with a spongy layer of metal. Thus, not a Swiss cheese but rather a microscopic sponge. The openings and holes in this layer are only 20 to 50 thousands of a millimeter large, that is the size that the bone tissue needs to grow into it. This ingrowth of bone tissue would create a lasting and stable fixation of the device that surpasses the fixation with bone cement. See also the chapter “Cemented and cementless total hips”.
When it comes to the question which combination of bearing surfaces is best, metal on polyethylene, ceramic, metal on metal my answer is: Let the surgeon decide together with you.
An experienced surgeon uses proven total hip models that produced good results for him/ her – otherwise he/ she would not stay in the trade. When the surgeon finds a total hip model with which he / she is comfortable with and which gives excellent results he/ she uses this model only. It is economical too.
It can be that the surgeon uses models with different bearing surfaces for different categories of patients (old vs young, for example).
If the patient finds the surgeon’s arguments good then there is no reason why not to accept the total hip model recommended by the surgeon.
VS
06/01/2007
Stiff and painful total knee 9 months after surgery – what to do?
. IM 49 YEARS OLD. HAD A FULL KNEE REPLACED IN 5 MARCH 2007. AFTER OPERATION VERY BAD PAIN. AND SWELLING. RANGE OF MOVEMENT WAS 95 BUT WENT RAPPID DOWN TO 67 PERCENT BEND. BACK INTO HOSPITAL ON 9 AUGUST 2007. HAD SCAR TISSUE REMOVED. BEND WAS 90 PERCENT. IN NOVEMBER THE 12. 2007 HAD MORE SCARE TISSUE REMOVED. WICH MADE THINGS WORSE. BACK DOWN TO 90 PERCENT BEND. THE WHOLE TIME I HAVE HAD BAD PAIN. AND SWELLING FROM DAY ONE. MY SURGEON HAS NOT TAKEN EX-RAY OR A MRI SCAN. I AM STILL ON 400MG OF TRAMADOLL. AND DIXCOLFLEX. BUT STILL IN PAIN. MY SURGEON DOESN’T KNOW WHAT TO DO NEXT. DO YOU KNOW. IM MORE DISABLED NOW THAN BEFORE.
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Answer:
I understand that your have severely limited flexion (bending) and pain in your total knee, not improved since surgery. There is no information what treatment, especially rehabilitation you had, except that there was an unsuccessful arthroscopy and manipulation in narcosis.
Actually, there is a well known pathway how the surgeon should examine a stiff, swollen, painful total knee and how to treat it.
First the surgeon should assess the size and the placement of the total knee prosthesis on good conventional x-ray pictures. Wrong placement and / or too big size of the total knee prosthesis are often the cause (or one of the many causes) of total knee stiffness.
If this cause of stiffness may be excluded, the surgeon should evaluate whether there are signs of ongoing infection. Blood tests and bacteriological testing of joint fluid should be done to exclude this possibility.
When / if this possibility was excluded, the surgeon should evaluate what soft tissues may cause the stiffness, especially what caused the lack of the flexion (bending) of the knee.
Most often the cause is too short / contracted quadriceps muscle. The treatment of this condition is by comprehensive and intensive rehabilitation. One uses often special elastic braces and electric muscle stimulation.
When a course of such intensive rehabilitation is not successful, one may conduct arthroscopic examination that must be followed by a new course of intensive rehabilitation.
Pain may be also caused by compression (impingement) of the nerve on the outside of the knee (peroneal nerve). There are specific signs how to discover this complication. If there is such nerve compression the operative decompression (making the nerve free) is usually successful.
Stiffness may be also caused by too much joint fluid. It such increased quantity of joint fluid is present it should be tapped out by joint puncture.
Now I think this is a clear pathway how a stiff painful knee should be examined and treated.
You may discuss this treatment plan with your surgeon or find a surgeon who is experienced to treat such total knee problems for a second opinion.
VS
02/01/2008
Night snoring – is it an obstacle to total hip and knee replacement?
Needing both knees and both hips. I have a-fib and have just been told I have severe low oxygen levels due to sleep apnea. I am on oxygen at night and when needed tell I get c-pap machine. When can I have my surgery or surgeries I am in so much groin pain.
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Answer:
A very interesting question. However, it can be answered only by an anesthesiologist -the doctor that would give you anesthesia during operation.This doctor will also tell you the risks associated with your condition when undergoing total hip and / or total knee operations. I recommend that you ask him/her directly.
VS
December 2007
29/12
Scan showed small activity areas around my total hip – what is this?
Because I was having pain in my new hip I was sent for a scan in the nuclear medicine dept. When I saw my consultant for the result, he said there was no loosening of the joint and does not want to see me for four years. He said the same in the letter to GP. I phoned up to ask for a copy of the scan report and it says that there are two areas in acetabulum with very minor degree of uptake (of nuclear injection presumably) and medial aspect of greater trochanter. It concludes that the appearance is inconclusive for loosening. Does it sound OK to you?
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Answer
Thank you for your question. It does say that you have had a scan, but not what kind of scan. I presume that it was the commonly used Strontium scan to asses the bone turnover activity around your total hip.
The finding of “two small uptake areas” of injected radioactive material in the skeleton around your total hip is assuring. It means that no great destruction of skeleton with great bone turnover is ongoing around your total hip. (But this examination is not regularly done for a painful hip joint).
But of course this examination says nothing about the cause of the pain in your total hip joint.
Please return when something is unclear.
28/12
The perpetual question: which total hip model is best?
I will be having hip replacement soon. I have two doctors that I am comfortable with. One uses a Zimmer hip and the other uses a Biomet hip. The Biomet magnum hip looks to be a good choice for someone my age. (I am 48 and in good health) Do you have an opinion on either of these? Do either of these have a history of success or failure?
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Answer:
As to the question which total hip model is best: The ground rule is: Choose an experienced surgeon and then accept the total hip model that your surgeon is acquainted with and has been using for his patients.
An experienced surgeon would never use a bad total hip model. In that case the failures would force him / her out of the trade.
23/12
The perpetual question: which bearing surface? Is ceramic the best?
I am on the eve of hip replacement surgery and I am struggling with my choice of surfaces. I am a very athletic 48 year old male cyclist, approx. 68 kilograms. Six years ago I had a complete replacement on my right side..
I am leaning towards the ceramic on ceramic surface because the wear rate is so minimal as compared to metal on metal, and metal on poly. I understand the ceramic on ceramic surface has been used in Europe for over 30 years but only recently adopted in Canada. My big question is: "is the risk of failure very small as compared to the benefit of no particulate and subsequent revisions?
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Answer:
As to the question which total hip model is best: The ground rule is: Choose an experienced surgeon and then accept the total hip model that your surgeon is acquainted with and has been using for his patients.
An experienced surgeon would never use a bad total hip model. In that case the failures would force him / her out of the trade.
For young patients it is said that ceramic bearing surfaces are best because they produce the smallest quantity of wear particles. The reasoning then goes that the lover the quantity of wear particles the lower the risk of late failure of the total hip joint.
So long is all well. However, the experience with the ceramic total hip is still short, the modern ceramic total hips have still the follow up observation time maximally around 10 years (You may look at the chapter Ceramic total hips).
So it all boils down to recommendation to discuss the option of the total hip with the surgeon whom you confide enough to carry out the surgery on your hip joint
VS
19/12
Stiff total knee – a sorry story
I had total knee replacement on Feb. 6, 2007. It has not gone well. I had a manipulation done May 18. The surgeon finally told me on June 18 that my leg was misaligned and I needed a redo. He sent me for a second opinion to a surgeon who agreed that it needed to be done over. After, they conferred, they said it was mainly a scar tissue issue but the only way it could be done was to be cut open again. If they noticed it needed to be redone, they would do it at that time. I went to doctors of my own choosing for a second opinion, they said the knee was misaligned, rotated wrong and that the surgeon had hyper-extended my leg. One suggested I might now need a hip replacement before the knee would be redone due to the misalignment issues. Two doctors said it was not a scar tissue issue but a botched surgery issue. Another suggested trying arthroscopic knee surgery to remove scar tissue first before going through a redo. I really am confused to know how to proceed. Should I try arthroscopic scar tissue surgery to remove scar tissue as one surgeon has said or would this be a waste of time if the device is in wrong? Is there research that shows that arthroscopic knee surgery works to remove scar tissue?
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Answer:
I really can understand that you may be confused by so many different answers from so many surgeons.
What is this “misaligned total knee joint” ? Every healthy knee joint has a mechanical axis (see picture of it in the chapter Total knee operation). This axis is changed by the knee joint disease. The surgeon must restore the mechanical axis at the total knee replacement operation. (It is not easy and small deviations from perfect restoration do not matter).
Now, x-ray pictures of the whole leg standing should demonstrate how much the mechanical axis of your total knee deviates from normality.
This should your surgeon show you and you should discuss with him how much is the mechanical axis misaligned (he should to show you on x-rays) and discus what to do about it.
Is stiffness of the knee joint your main problem? Is the misalignment really the cause of your knee joint stiffness?
You do not tell what your total knee problems really are and what treatment you have had. For example; What was the mobility of your total knee before the manipulation that your surgeon did on May 18 and how much it improved after this manipulation?
Did you have a comprehensive rehabilitation program for your total knee, really directed at “soft tissue problems”?
With the scarcity of information on your your total knee problems I am sorry that I cannot come longer.
15/12
Cancer related to metal / metal total hips – need to worry??
I have corresponded with a few times in the past but it has been awhile, I was just was wondering have you heard from any colleagues about cancer that is related to m/m hips or any other metal ion issues. I have had my m/m hip for 5 years and it is doing fine.
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Answer
Total hip and cancer is a well rehearsed question. Presently, there is no clear evidence that metallic ions released from total hips increase the risk of cancer. The modern metal / metal total hip have too short observation period to come to clear conclusion, the “old” m/m total hips (yes, the first total hips used only metallic parts) on the other side have no good observation data.
One (Finish) surgeon, doctor Visouri, published in the 1980’s a statistics that demonstrated that the “old” total hips were associated with greater risk of blood cancer. Later on, he, however, retracted his previously published report on a conference on the modern surface replacements.
You may also look at the data in the chapter Total hip and cancer.
I think that patients with m/m total hips should not be concerned unnecessarily by the possible risk of cancer, because if this risk exists at all, it is very small, several times lower than for example the cancer risk associated with smoking.
10/12
Impinged and short muscles around a total hip – find people who can treat these problems
I am a 50 year old male entering my 3rd post-op year posterior MIS LTHR. Pre-op I had 40 years of severe bone deformity subsequent to fractured hip and tibia at age 8. A few months after my surgery I experienced, and continue to experience more pain post-op then I ever did pre-op. My operative leg is slightly anatomically longer post-op then it was pre-op, but only by 1.4mm (as revealed on CT Scanogram). There are reports indicating a leg length discrepancy also due to pelvic obliquity representing a functional leg length discrepancy. My muscles are extremely tight with predominant pain in Psoas, Iliacus (Iliopsoas), Rectus Femoris, Piriformis, Gluteus muscles, IT Band - Tensor Fascia Lata, and suspected Trochanteric and Iliopsoas Bursitis. The pain is in my groin area and down the front and side of my thigh. I have received long term PT over the past three years – (land, manual and aqua therapy, ultra sound, etc.), multiple trigger point injections through Pain Management Center at Cedars Sinai, prescribed anti-inflammatory medications i,e, Mobic, as well as a variety of medicated Ketoprofen creams – all with no improvement. I have consulted with a few surgeons and underwent extensive work-ups over the last three years with every test/study known to mankind but all came back negativeGetting in and out of the car is painful. Any false movement (on average 1-2 times a day – I’m not clumsy) triggers the Iliopsoas pain. It is painful to sit, walk, or stand for lengthy periods of time. Sleeping on affected side is also painful around trochanter area. When I attempt to chase after my kids (mission impossible) to prevent them from crossing the street I am absolutely helpless due to weakness and pain. Walking up flights of stairs is difficult and painful. I am unable to strengthen operative leg due to increased pain. Trochanter is sensitive to the touch. It appears that all conservative measures have been exhausted. I suspect that 40+ years of severe bone deformity resulted in extremely shortened muscles, and that, compounded with functional discrepancy maybe the possible culprit. Post-op I have learned that MIS is not recommended for patients with severe bone deformity and that lengthening of overly shortened muscles is sometimes recommended at time of THR, however this was not performed.
I have reviewed some of the published articles that discuss surgical procedures involving removal of Bursas as well as articles pertaining to surgically lengthening and/or releasing the Iliopsoas,
One surgeon is contemplating surgical removal of suspected iliopsoas and trochanteric bursitis, and if that doesn’t work to perhaps release I believe the illiopsoas, however, a radiologist at Cedars advised today that there is no evidence of bursa “fluid build-up” per 64 Slice CT. The surgeon has prescribed a CT or ultrasound guided injection of the Psoas and Trochanter (is this same as a “Sonography”?) to confirm diagnoses of bursitis and I assume Iliopsoas Impingement. However, the radiology department at Cedars believes that ”…..this test would be doing something for the sake of doing something, and that it is not deemed medically necessary”. Another surgeon advised that he “…only treats bones and joints and has nothing to offer” and is against doing any type of injection due to risk of infection with THR implant. He believes that CT guided injection “would only serve my curiosity”. However, I did consult another surgeon 18 months ago in Las Vegas – Dr. Tod Swanson – who recommended “12 weeks of rigorous physical therapy to include stretching of adductors, abductors, IT Band, and rectus femoris” and if this was not successful he believed that “it was possible to surgically release several of these structures in order to provide some relief”.
Dr. Surin perhaps you can attempt to answer the following question; Since the radiology department advised no evidence of ”fluid build-up” is it possible to have “Iliopsoas Impingment” without Iliopsoas bursitis? If so, then I am still left with question of touch sensitive trochanter.
I am becoming increasingly frustrated. In the interim do you have any relations with surgeons in my area (as that is my preference) that have experience treating these specific symptoms? I look forward to your comments and suggestions.
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Answer:
Thank you for your e-mail that reveals your insight in the orthopaedic surgeons’ ways of thinking. Really, many of surgeons see only the bones and artificial joints; because the soft tissues are not depicted on plain x-ray and other (CT) pictures, these structures do not exist for the majority of orthopaedic surgeons.
It is impossible to arrive at a diagnosis from an Internet letter, but it is possible that your total hip problems really are caused by short / impinged muscles around your total hip.
Now, there are really 19 such muscles, not only the iliopsoas, but also rectus femoris that may cause pain anteriorly, there is a muscle called tensor fasciae latae that may cause pain on the side that is indistinguishable from the trochanteric bursitis, and there are also other muscles that may be short, irritated and cause problems.
Personally, I think that doctor Tod Swanson’s advice and assessment of your total hip problems are very valuable. Perhaps he has also a good PT that can guide you through the course of rehabilitation and assess which muscles are short and possibly would need lengthening.
You asked after someone who treats these soft tissue problems that occur in patients with total hip joints. Living in Sweden my knowledge of these people in the USA is rather limited.
You may in every case read an article from Anil Bhave and colleagues: “Functional problems and treatment solutions after total hip and total knee joint arthroplasty”, which was published in The Journal of Bone and Joint Surgery 2005; 87-A Supplement 2: 9 – 21.
His address is:
Anil Bhave, PT, (collaborates with doktor Mikael Mont) and works at: Rubin Institute of Advanced Orthopedics, Sinai Hospital, 2401 West Belvedere Avenue, Baltimore, MD 21215. E-mail address: abhave@lifebridgehealth.org or anilbhave@yahoo.com .
10/12
Stiff and painfull total knee – cannot find people who will take care of it
Had total Knee replacement on right knee,3 years ago and it still is so tight and when walking the pain. I been to at least 4 doctors. They said the x-rays look fine, one did a bone scan couldn't see anything wrong. And a year and half ago a doctor did arthroscopey and could'nt find anything. I don't know where to turn, I know its tight and hurt, in a degree 8. I don,t know what to do, I know its not in my head. Thank you. if you can advise me in any way. thank you again
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Answer:
There are a lot of causes that make the total knee joint stiff. S