Orthopedic Surgery

Understanding Rotationplasty – Alternative to Limb Sparing Surgery

Rotationplasty Child Limb Sparing Surgery AlternativeRotationplasty is a surgical option for young children who have been diagnosed with a variety of malignant or benign conditions. Rotationplasty is most commonly used as a treatment option for osteosarcoma or Ewing’s sarcoma in the distal femur or proximal tibia. This procedure can also be used in the proximal femur for rotationplasty in the hip, but this is much less common than the knee.

In rotationplasty, the bone cancer and surrounding tissues are removed and the remaining lower section of the leg is rotated before reattaching to the healthy upper section.  Rotationplasty is typically recommended when a portion of the limb is injured or diseased.

During the leg rotationplasty procedure, the ankle becomes the knee joint.  A prosthesis is built that allows the foot and ankle to function as the patient’s knee.  This prosthesis is different than a typical prosthetic device since it requires consideration of an anatomical ankle to act as the knee.  The ankle (new knee) requires structural support so that the patient does not overextend the ankle.  Prosthetic fit and function are very critical and should only be performed by a skilled prosthetist.

Patients who undergo rotationplasty as a surgical option for treatment require intensive physical therapy to gain motion and strength in the reconstructed limb. A physical therapist and prosthetist who are skilled in this specific design/procedure should work very closely with the patient’s orthopedic surgeon to guide the exercise program and prosthetic fitting.

Other surgical options for young patients with sarcomas such as osteosarcoma or Ewing’s sarcoma are:

When making the decision whether to receive rotationplasty versus the other treatment options, parents should take into consideration the age of the child, the location and size of the cancer, medical diagnosis and prognosis as well as the “functional outcomes” that the parents/child/physician agree on.

Rotationplasty is a good option for young patients who have not finished growing and have a malignant bone tumor around the knee joint.  Because their legs have not grown completely, the leg length difference will not be as great.  Also, the young patient will be able to run and jump and keep up with their friends and classmates.  The patient can participate in most sports even those with jumping and high impact.  Because the ankle joint is a natural joint functioning as the “new knee,” the patient has greater control of the “knee” with sensation of how it is moving as well as the position of the knee as the patient walks and runs.

At Emory Orthopaedics & Spine, we work closely with the resources at Children’s Healthcare of Atlanta’s Aflac Cancer and Blood Disorders Center, one of the largest childhood cancer programs in the country. Our continuum of care features pediatric experts in orthopedic surgery, radiation oncology, social work, case management, physical therapy and prosthetics.

Related Resources:

About the Experts

Dr. David MonsonAbout Dr. Monson
David K. Monson, MD, assistant professor of Orthopaedic Surgery and Chief of Orthopaedic Surgery at Emory University Hospital Midtown, started practicing at Emory in 1988. Dr. Monson is an expert in the treatment of rare tumors (sarcomas of the bone and soft tissue). Dr. Monson’s specialties are Orthopaedic Surgery (Board certified since 1990) and Orthopaedic Oncology. His areas of clinical interest are orthopaedic tumors, sarcoma, and limb reconstruction.

 

Dr. Shervin OskoueiAbout Dr. Oskouei
Shervin V. Oskouei, MD, assistant professor of Orthopaedic Surgery at Emory University, is an expert in the treatment of musculoskeletal (extremity) tumors, total hip and total knee replacements and revisions. Dr. Oskouei started practicing at Emory in 2004. Dr. Oskouei is board-certified and fellowship trained in orthopaedic surgery. Combining his experience and interests with the state-of-the-art facilities of Emory University and the Winship Cancer Institute of Emory University allows Dr. Oskouei to treat patients with the latest modalities using a multi-disciplinary approach.

About Emory Orthopaedic Oncology
Dr. Monson and Dr. Oskouei lead the Emory Musculoskeletal Oncology and Limb Reconstruction program at Emory.  The world – class program treats a variety of conditions, including benign and malignant tumors of the extremities and spine, as well as metastatic disease. Together, they offer a combined 34 years of clinical practice experience. They care for both pediatric and adult aged patients.

Both of these physicians belong to the Musculoskeletal Tumor Society which requires fellowship training in orthopaedic oncology.  Physicians belonging to this group must also have a primary clinical focus in orthopaedic oncology.  This is important for patients because it means the specialist you are seeing has had extra training in this area and is viewed by peers as an expert in the care of orthopaedic oncology. Patients should take the time to research physicians in their area to determine if they are seeing an orthopaedic oncology specialist that belongs to this organization.

What is an Osteosarcoma and What is the Best Way to Treat it?

Bone and soft tissue sarcomas are rare conditions that affect approximately 13,000 people each year. In the US, 10,000 are diagnosed with soft tissue sarcomas and approximately 3,000 are diagnosed with bone sarcomas, of which 1,000 are osteosarcomas.

The most common type of sarcoma that develops in the bone is called an osteosarcoma while sarcomas that develop in the connective tissue are called soft tissue sarcomas. Soft tissue sarcomas can develop in soft tissues like fat, muscle, nerves, fibrous tissues, blood vessels, or deep skin tissues. The rarity of sarcomas means most doctors seldom see one, which explains why patients are often referred to specialty hospitals where experienced surgeons utilize limb-sparing (no amputation) surgery whenever possible.

Understanding Osteosarcomas

Osteosarcomas are aggressive malignant bone tumors and are the most common type of bone cancer in young people. They usually occur between the ages of 10 and 25, but can occur at any age and are more common in males than females. They encompass about 20% of all primary bone cancers and it is estimated that the incidence rate in U.S. patients under 20 years of age is 5 per million. Osteosarcomas most commonly start in the ends of long bones of the arms or legs where new bone tissue rapidly forms.

Symptoms of Osteosarcoma

  • Pain near the affected bone is the most common osteosarcoma symptom
  • Swelling of the bones and joints. Noticeable swelling or protrusion near the location of the tumor
  • Brittleness/weakness of the bone which can lead to fractures
  • Difficulty moving during physical activity
  • Noticeable limp when the osteosarcoma is in the leg

Treatment for Osteosarcoma

Typically chemotherapy is given to shrink the tumor before surgery. Most often, chemotherapy results in a necrosis (or death) of the tumor and allows the physician to treat possible cells in the blood stream. In most cases, surgery is required to remove the section of cancerous bone. Limb sparing surgery (LSS) is a special operative procedure performed by oncology orthopedic surgeons and has become the accepted standard of care for patients with sarcomas of the extremities. Limb sparing surgery can be accomplished in approximately 90% of the cases. During limb sparing surgery, the cancer in the bone is removed surgically and the portion of the bone that was removed is either replaced with special metal prostheses or a bone allograft. An allograft is a bone transplant obtained sterilely from a person that has died and agreed to be an organ donor. Emory Orthopaedic surgeons have mastered the limb-sparing surgery in order to save as much bone as possible without compromising the ability to cure the patient.

Emory offers a unique multi – disciplinary treatment approach to bone sarcoma care. Emory Orthopaedic oncology surgeons collaborate with medical oncologists, radiation oncologists, pathologist, radiologists, thoracic surgeons, plastic surgeons and vascular surgeons to develop a treatment plan catered to each individual patient.


Dr. David MonsonAbout Dr. Monson
David K. Monson, MD, assistant professor of Orthopaedic Surgery and Chief of Orthopaedic Surgery at Emory University Hospital Midtown, started practicing at Emory in 1988. Dr. Monson is an expert in the treatment of rare tumors (sarcomas of the bone and soft tissue). Dr. Monson’s specialties are Orthopaedic Surgery (Board certified since 1990) and Orthopaedic Oncology. His areas of clinical interest are orthopaedic tumors, sarcoma, and limb reconstruction.

 

Dr. Shervin OskoueiAbout Dr. Oskouei
Shervin V. Oskouei, MD, assistant professor of Orthopaedic Surgery at Emory University, is an expert in the treatment of musculoskeletal (extremity) tumors, total hip and total knee replacements and revisions. Dr. Oskouei started practicing at Emory in 2004. Dr. Oskouei is board-certified and fellowship trained in orthopaedic surgery. Combining his experience and interests with the state-of-the-art facilities of Emory University and the Winship Cancer Institute of Emory University allows Dr. Oskouei to treat patients with the latest modalities using a multi-disciplinary approach.

About Emory Orthopaedic Oncology
Dr. Monson and Dr. Oskouei lead the Emory Musculoskeletal Oncology and Limb Reconstruction program at Emory. The world – class program treats a variety of conditions, including benign and malignant tumors of the extremities and spine, as well as metastatic disease. Together, they offer a combined 34 years of clinical practice experience. They care for both pediatric and adult aged patients.

Both of these physicians belong to the Musculoskeletal Tumor Society which requires fellowship training in orthopaedic oncology. Physicians belonging to this group must also have a primary clinical focus in orthopaedic oncology. This is important for patients because it means the specialist you are seeing has had extra training in this area and is viewed by peers as an expert in the care of orthopaedic oncology. Patients should take the time to research physicians in their area to determine if they are seeing an orthopaedic oncology specialist that belongs to this organization.

Related Resources:

Osteoarthritis Pain Treatment – Using your own Stem Cells?

hip resurfacing procedureIt is reality now! Physicians at Emory Orthopaedics & Spine are among a select group of physicians around the country to offer a unique procedure using stem cell injections to relieve osteoarthritis (OA) pain. During the procedure, the physician extracts stem cell blood from the bone marrow in a patient’s hip and then injects the stem cells directly into the patient’s damaged joint. The stem cells are from the patient’s own body so the risk of rejection is very low.

Hear first hand from Dr. Mautner and one of our patients how this new treatment option is helping relieve pain from Osteoarthritis:

About Ken Mautner, MD

Ken Mautner, MD is an assistant professor in the Department of Physical Medicine and Rehabilitation and the Department of Orthopedic Surgery. Dr. Mautner started practicing at Emory in 2004 after completing a fellowship in Primary Care Sports Medicine at the American Sports Medicine Institute in Birmingham, Alabama. He is board certified in PM&R with a subspecialty certification in Sports Medicine. Dr. Mautner currently serves as head team physician for Agnes Scott College and St. Pius High School and a team physician for Emory University Athletics. He is also a consulting physician for Georgia Tech Athletics, Neuro Tour, and several local high schools. He has focused his clinical interest on sports concussions, where he is regarded as a local and regional expert in the field. In 2005, he became one of the first doctors in Georgia to use office based neuropsychological testing to help determine return to play recommendations for athletes. He also is an expert in diagnostic and interventional musculoskeletal ultrasound and teaches both regional and national courses on how to perform office based ultrasound. He regularly performs Platelet Rich Plasma (PRP) injections for patients with chronic tendinopathy. Dr. Mautner also specializes in the care of athletes with spine problems as well as hip and groin injuries.

Related Resources

Tennis Elbow & PRP (Platelet Rich Plasma) Therapy – Is it Right for Me?

Tennis Elbow PDFEmory Sports Medicine Center orthopedist, Dr. R. Amadeus Mason, recently spoke with the team from CNN about a study involving people with tennis elbow and the effectiveness of the treatment options. Check out this story to see what Dr. Mason recommends for treating tennis elbow.

Another treatment option available for chronic tendinitis like tennis elbow is Plasma Rich Platelet therapy, also know as PRP. The Emory sports medicine physicians use PRP to treat patients with chronic tendinitis or arthritis symptoms. Typically the patient will have tried other treatment options such as physical therapy, medications, and refraining from activity before being considered for PRP.

Dr. Mason explains, “PRP treatment is innovative because it takes a patient’s own blood and targets a specific area and harnesses its healing ability and allows us to treat specific types of injuries that otherwise would not be able to treat effectively.”

Typically during a PRP injection, a patient’s blood is drawn from his arm and transferred to a centrifuge machine where it spins the blood for about 15 minutes. The spinning separates the platelets from the other components of the blood. Using an ultrasound machine, the platelets are injected back into the patient into the damaged, painful area of the body.

Dr. Ken Mautner adds, “For the first time we can do a non-invasive, non-surgical procedure where we are just drawing blood from your arm and injecting right to the area of damage and actually get the body to heal itself without the need for a scalpel or any significant bed-rest or downtime.”

Watch this short video of Beth, an Emory Sports Medicine patient with tennis elbow. Beth tried several treatment options but in the end, PRP therapy allowed her to again be pain free and get back to the active lifestyle she wants to live.

Related Resources:

About R. Amadeus Mason, MD
Dr. Amadeus MasonDr. Mason is an assistant professor in the Orthopaedics and Family Medicine departments at Emory University. He is board certified in Sports Medicine with a special interest in track and field, running injuries and exercise testing. He has been trained in diagnostic musculoskeletal ultrasound, and Platelet Rich Plasma (PRP) injection. Dr. Mason is Team Physician for USA Track and Field and the National Scholastic Sports Foundation Track and Field and Cross Country meets, Tucker High School, and Georgia Tech Track and Field.Dr. Mason is a member of the American College of Sports Medicine, the American Medical Society for Sports Medicine, the America Road Racing Medical Society, and the USA Track and Field Sports Medicine and Science Committee. He has been invited to be a resident physician at the US Olympic Training Center, a Sports Medicine consultant in his homeland of Jamaica and the Chief Medical Officer at multiple USA Track and Field international competitions. He has also been a frequently featured guest CNN’s fit nation commenting on a wide variety of topics related to athletics and running injuries. Dr. Mason attended Princeton University and was Captain of the track team.

Dr. Mason is an active member of the Atlanta running community. He attended Princeton University and was Captain of the track team. His other sports interests include soccer, college basketball and football, and the National Hot Rod Association (NHRA). A Decatur resident, he is married with three children.

About Ken Mautner, MD
Ken Mautner, MDKen Mautner, MD is an assistant professor in the Department of Physical Medicine and Rehabilitation and the Department of Orthopedic Surgery. Dr. Mautner started practicing at Emory in 2004 after completing a fellowship in Primary Care Sports Medicine at the American Sports Medicine Institute in Birmingham, Alabama. He is board certified in PM&R with a subspecialty certification in Sports Medicine. Dr. Mautner currently serves as head team physician for Agnes Scott College and St. Pius High School and a team physician for Emory University Athletics. He is also a consulting physician for Georgia Tech Athletics, Neuro Tour, and several local high schools. He has focused his clinical interest on sports concussions, where he is regarded as a local and regional expert in the field. In 2005, he became one of the first doctors in Georgia to use office based neuropsychological testing to help determine return to play recommendations for athletes. He also is an expert in diagnostic and interventional musculoskeletal ultrasound and teaches both regional and national courses on how to perform office based ultrasound. He regularly performs Platelet Rich Plasma (PRP) injections for patients with chronic tendinopathy. Dr. Mautner also specializes in the care of athletes with spine problems as well as hip and groin injuries.

Get the Facts about the Orthopaedic Considerations for Children with Cerebral Palsy

Cerebral palsy (CP) is the most common motor disability during childhood. It is a life-long condition that affects the communication between the brain and the muscles and the condition can cause a variety of motor disabilities and issues. Disability resulting from cerebral palsy can be very mild, with the child appearing to be a little clumsy, to more severe, where the child may be unable to walk. Despite the difficulty with motor control/movement, many children with cerebral palsy have normal intelligence.

Common Symptoms of Cerebral Palsy include:

The signs and symptoms of cerebral palsy vary depending on the type of cerebral palsy, degree of disability, and how each child experiences these symptoms.

• Muscle weakness
• Difficulty controlling the arms or legs
• Shaking of the arms or legs (called spasticity)
• Muscle stiffness in the legs
• Clenched fists

Causes of Cerebral Palsy 
The cause of cerebral palsy is often unknown, but there are some links to premature birth, severe jaundice after birth, and an injury to the brain. If you have any concerns about your child’s development, talk to your pediatrician at your routine visit.

Unfortunately there is no cure for cerebral palsy right now. The best course of action is to manage the symptoms with a team of specialists including an orthopedic surgeon. At Emory Orthopaedics and Spine Center, when it comes to pediatric patients coping with cerebral palsy, we focus on preventing or minimizing deformities.

Orthopaedic Considerations & Risks From Cerebral Palsy:

Limb Shortening 
As a child develops, some children will develop a shortening of the leg and arm on only one side of the body. The difference between the legs can be up to two inches. If the parent notices a shortening, please contact a pediatric orthopedic surgeon who will be able to help determine the degree of difference between the legs and recommend appropriate treatment options. The surgeon may recommend a heel lift that is to be worn in the child’s shoes. A heel lift may also help prevent problems in the hip and spine. A leg length difference left untreated could eventually lead to a curvature of the spine called scoliosis.

Scoliosis
Scoliosis is a curvature of the spine and is very common in children with cerebral palsy. One in five children with CP will have scoliosis so it is very important to see a pediatric orthopaedic surgeon to help monitor it. Scoliosis is usually mild and will not need anything more than regular observation by your doctor. Occasionally scoliosis can worsen and require more extensive treatments.

At the Emory Orthopaedics and Spine Center, we typically use non-operative treatments such as modification of a wheelchair, bracing or casting to minimize the worsening of scoliosis before we consider surgical treatments. Surgery is typically reserved for more severe cases of scoliosis. Emory pediatric orthopaedists Dr. Robert Bruce, Jr. and Dr. Nicholas Fletcher have extensive experience with growing rod and Vertical Expandable Prosthetic Titanium Rib (VEPTR) for the management of severe scoliosis in young patients. These techniques allow for continued growth of the spine in younger children to allow normal development and function. Some older children may need true spinal fusion surgery in order to stop the spine from curving.

Joint Problems
In children with cerebral palsy, it is often difficult to prevent “contracture,” an extreme stiffening of the joints caused by the unequal pull of one muscle over the other. The child will usually work with his or her care team to learn how to stretch the muscles to try to help prevent the joints from stiffening. The orthopaedic surgeon may also recommend braces, casting, or medication to improve mobility in the child’s muscles and joints. Occasionally contractures may begin to cause significant problems in the joints such as an inability to straighten out the leg and stand or a hip which may slide out of the socket. These are problems best managed by a surgeon with lengthening of tendons or perhaps a joint realignment surgery.

Foot Problems
Children with cerebral palsy will often also have difficulties with their feet due to the unequal pull of one muscle over another. These can result in problems with things as basic as getting a shoe on to walking or running. Most patients can be managed with physical therapy or possibly a special brace to hold the foot in a better position. Problems that are more severe may require surgery to rebalance the muscles in the foot or realign the foot so that it functions better.

If you have additional questions about Cerebral Palsy and its implications for pediatric patients, please leave them for us in the comments below.

About the Authors

About Robert Bruce, Jr., MD
Dr. Bruce has been a fixture in the Atlanta community for 17 years having started practicing at Emory in 1995. He is the director of the Children’s Healthcare of Atlanta (CHOA) cerebral palsy program and has a tremendous experience caring for all types of orthopaedic conditions in children with cerebral palsy from the spine to the hips to the feet. Dr. Bruce is also specialty trained in Ilizarov and the treatment of leg length differences and angular deformities. Outside of his clinical duties, Dr. Bruce serves on the CHOA medical board, is the past medical director of Egleston campus, and is currently the head of the orthopaedic team at Egleston hospital.

About Nick Fletcher, MD
Dr. Fletcher has been practicing at Emory since 2010 and cares for all forms of pediatric spinal problems including adolescent scoliosis, neuromuscular scoliosis, congenital scoliosis, early onset scoliosis, kyphosis, and spondylolisthesis. 
He also has spoken locally, nationally, and internationally on his research in scoliosis. His work on adolescent scoliosis has been presented as far away as Japan and he has published multiple studies on early onset and adolescent scoliosis. He also received the 2010 T. Boone Pickens Award for Spinal research for his research in Adolescent Idiopathic Scoliosis. Dr. Fletcher is a current member of the Pediatric Orthopaedic Society of North America’s (POSNA) evidenced based medicine committee and the Children’s Healthcare of Atlanta spinal infection prevention taskforce. His current research on post operative care following spinal surgery will be presented at this year’s POSNA annual meeting in Toronto, Canada.

Dr. Fletcher also specializes in pediatric and young adult hip conditions including hip dysplasia, femoroacetabular impingement (FAI), perthes disease, avascular necrosis, and slipped capital femoral epiphysis. He is one of only a handful of surgeons in the southeast with expertise in the Ganz or periacetabular osteotomy (PAO) for hip dysplasia and the modified Dunn osteotomy for slipped capital femoral epiphysis. He takes care of children of all ages with hip conditions in addition to young adults with hip dysplasia and impingement. He also has extensive experience in hip reconstruction for children with cerebral palsy and hip conditions such as dysplasia, subluxation, or dislocation.

Advancing the Possibilities in Orthopedic, Sports Medicine & Spine Care

Emory University Orthopaedics & Spine Hospital AtlantaEmory Healthcare is known for its strong focus on patients and families, as well as its sharp attention to detail in Orthopaedics, Sports Medicine and Spine Care. At Emory, we have the most highly trained orthopaedic and spine specialists in the country working together to diagnose and treat a wide variety of orthopaedic, spine and sports medicine conditions. Our physicians use innovative approaches to care – many of them pioneered via research right here at Emory – to ease your pain and get you back to the life you love. We bring all aspects of musculoskeletal diagnosis, treatment and rehabilitation together in one location – from state-of-the-art CT and MRI to a world-class outpatient surgery center and physical therapy suite– at the Emory University Orthopaedics and Spine Hospital (EUOSH).

Many of our musculoskeletal inpatient procedures occur at EUOSH, which is unlike any other facility in Georgia. When planning for this hospital, doctors, nurses and patients presented their wish lists, and we worked tirelessly to bring our patients the care that set the standards and raises the bar higher than ever. The hospital has been completely renovated to provide our orthopaedic, spine and sports medicine patients with access to exceptional service and the most advanced, sophisticated technology tailored specifically to their unique needs. The combination of our unique facility amenities at EUOSH and our team’s dedication to truly patient- and family-centered care allow us to provide an unparalleled level of musculoskeletal care to the Atlanta and Georgia communities. Find out more in the video below:

We pride ourselves on being uniquely focused on patient satisfaction and comfort. In fact, we call upon 75 various patient committees and have adopted listening practices to ensure that we fully understand the needs of the patient. Further, we make it a point to avoid being married to any sort of protocol; for example, there’s no limit on patient visiting hours, and family members are welcome to sit with patients right up until the time of surgery.

Our efforts have not gone unnoticed—we’re proud to say that we have over a 90% satisfaction rate among our patients. Every room is equipped with everything a patient could possibly need for a comfortable recovery, including an interactive television that offers hospital information, a “my education” feature, access to the patient’s chart, health notes, and of course, regular TV channels and movie options.

Emory truly strives to exceed patient expectations every day. Learn more about our Orthopaedic, Spine and Sports Medicine care by watching this short video.

Orthop(a)edics 101

Orthopedics 101Is it “orthopaedic” or “orthopedic”? What does “musculoskeletal” really mean? What’s the difference between a ligament and a tendon? Today we’re going to answer some of the more pressing questions people have about this fascinating area of medicine.

First off, let’s discuss the use of orthopaedic v. orthopedic. Orthopaedic is derived from the Greek orthos, for correct or straight, and paideion, for child. Today, orthop(a)edics refers to the correction of spinal and bony deformities in both children and adults. In the U.S., we like to keep things simple, so “orthopedics” has become the standard spelling. In Great Britain and its other former (non-U.S.) colonies, orthopaedics is preferred. The academic world, like the Brits, enjoys fancying things up, so in most universities and other academic settings, orthpaedics stands. Microsoft Word prefers it without the “a.” Take your pick.

Simply put, orthopaedic (or orthopedic) surgery is the branch of surgery concerned with conditions of the musculoskeletal system. What’s the musculoskeletal system? Clearly, it’s a system that involves the muscles and the skeleton. Also called the “locomotor system,” the musculoskeletal system includes the parts of your body that help you move. And help you stay in one place. The bones provide stability, while the muscles help the bones stay in place and move. Joints allow motion, and cartilage keeps the bone ends from rubbing against one another. It’s all about how bones are connected to other bones and joints and muscles by connective tissues called tendons and ligaments.

What’s the difference between a tendon and a ligament, you ask? A tendon (or sinew) is a tough band of tissue that connects the muscle to the bone. A ligament connects bones to other bones. But wait—let’s not forget the fascia. The fascia is a layer of fibrous tissue that surrounds muscles and groups of muscles, as well as blood vessels and nerves, and binds all of these together. The layers of fascia include a superficial fascia (connected to the dermis, or skin), a deep fascia (surrounding the bones and muscles), and a subserous, or visceral, fascia (supporting the organs).

The surgeons and physiatrists at the Emory Orthpaedics & Spine Center are intimately familiar with every aspect of the musculoskeletal system and can diagnose and treat myriad ailments, both surgically and nonsurgically. So if you’re hurting, whether from a broken bone or a stretched or torn ligament or tendon, come see us. With or without the “a,” we know our orthop(a)edics.

New Biomaterials Mean Fewer Hip and Knee Replacement Reoperations

James Roberson, MDIn Emory Orthopaedics, we perform hundreds of hip and knee replacement operations every year. Most of these operations are highly successful, but occasionally, a reoperation is necessary. In these cases, it’s usually because the materials originally used in the knee or hip have worn down over time.

At Emory, we’ve been testing new and improved biomaterials for use in hip and knee replacements for more than a decade, and we’ve found that a new generation of biomaterials is making a significant difference in the longevity of these replacements. This means fewer patients will need reoperations down the road.

The failure rate in a knee replacement operation is directly related to how fast the knee wears, which is affected by how well the knee was put in, the patient’s activity level, the patient’s weight, and the wear resistant properties of the materials used. Think of the tires on a car. The stronger the tire material, the longer it lasts. What if, instead of getting 30,000 miles on a set of tires, you could get 100,000 miles? In essence, that order of magnitude difference is similar to the improved wear resistance of new biomaterials used in hip and knee replacement.

I’ve been using alternative bearing surface materials in hip replacements for about 12 years, starting with metal on metal, then ceramic on ceramic, and now highly cross-linked polyethylene. All three materials have dramatically improved wear resistance and have worked very well for several thousand patients, with no measurable wear on any patient visible through x-rays. But while metal on metal and ceramic on ceramic are useful in hip replacements, they aren’t an option in knee replacements. Until recently, this was also true of cross-linked polyethylene. However, the more recent second generation techniques for cross-linking now make this a viable option for knee replacement also.

Polyethylene, simply put, is a plastic formed from long molecular chains made of carbon and hydrogen atoms linked together. Prior to cross-linking manufacturing techniques, these molecular chains consisted of carbon atoms linked to other carbon atoms in single long chains with the remainder of the molecular bonding sites filled with hydrogen atoms. On a molecular level, cross-linking simply means that the single chains now are cross bonded together to, in essence, create a woven structure. This results in a material that looks identical but is actually a more wear-resistant form of plastic.

Over the past three to five years, we’ve performed approximately 1,000 knee replacement surgeries using cross-linked polyethylene. While all three materials—metal, ceramic, and polyethylene—appear to perform fairly evenly in hip replacement surgery, cross-linked polyethylene is less expensive than ceramic on ceramic. Although the individual patient does not experience a cost difference, this is a benefit to the industry as a whole. Our goal is to develop improved materials that will result in better outcomes and be cost-effective.

If you’re having knee or hip surgery, you can trust your doctor to choose the most effective material for you. Regardless of whether it’s metal on metal, ceramic on ceramic, or cross-linked polyethylene, with all of these new biomaterials, we are cautiously optimistic that wear may no longer be a problem.

Have you had or are you going to have hip or knee replacement surgery? Have you had experience with any of the new biomaterials? We’d like to hear from you. Please take a moment to give us feedback in the comments section below.

About James R. Roberson, MD:

James R. Roberson, MD, chairman of the Department of Orthopaedics and professor of Orthopaedic Surgery, specializes in treating hip and knee arthritis and has performed more than 10,000 hip and knee replacements over the course of his career. Dr. Roberson has practiced at Emory since 1982.

Getting In Shape For Surgery

In this post, I’ll discuss the importance of “getting in shape” for surgery. When conservative nonsurgical measures fail, and we’re considering joint replacement surgery for the treatment of end stage arthritis of the hip or knee, it’s important to take measures to increase your chance of success and reduce the risk of complications. Ideally, these steps should take place well before the actual procedure, and can be compared to “training for a marathon”. Generally, we look at three things in particular: Are you close to your ideal body weight? Are you aerobically conditioned? Are you a nonsmoker? If the answer to each of these questions is yes, you’re probably an excellent candidate for surgery. If not, we suggest that you take the following steps prior to scheduling surgery:

Lose weight

Being at or close to your ideal weight enhances your chances of surgical success. (You can calculate your BMI here.) If your BMI is 30–39, you have a higher risk of complication from surgery. If your BMI is 40 or above, you may not be a candidate for surgery right now, but we have resources at Emory to support you in your weight-loss efforts. Emory Family Medicine offers weight-loss counseling services, and the Emory Bariatric Center provides both surgical and nonsurgical weight-loss options. Weight loss is among the most important steps toward improving overall health and quality of life. In most cases, weight loss will improve the pain and loss of function associated with arthritis of the hip and knee. This improvement can be significant enough to obviate the need for surgery.  If surgery is necessary, appropriate weight loss prior to surgery will dramatically reduce the risk of complications including infection and dangerous blood clots. In addition, it will speed the recovery process and help prevent future orthopedic problems.

Get active

Patients who exercise regularly tend to recover from surgery more quickly than patients who don’t. If you’re preparing for orthopedic surgery such as knee or hip replacement, weight training and cardiovascular exercise can smooth the recovery process. When your muscles and soft tissues are strong and well conditioned, they help stabilize the knee and protect the joints, helping you get moving again more quickly.

Further, if you‘ve been diagnosed with hip or knee arthritis, don’t discontinue exercise and aerobic conditioning. Exercise has been scientifically proven to improve the pain and loss of function associated with arthritis of the knee. If you aren’t currently active, you can start now by slowly introducing exercise into your schedule—even just three times a week is helpful. Choose an exercise that does not cause pain. In general, lower impact exercises such as swimming, cycling, and the elliptical machine will allow elevation of heart rate while minimizing pain associated with hip or knee arthritis. There’s no evidence that increasing activity level will cause worsening of knee arthritis.

If you need help creating an exercise plan, the physical therapists at the Emory Orthopedics & Spine Center can work with you. Having professional support and/or a partner to exercise with can make it easier to begin and stick with an exercise program.

Stop smoking

Smoking cigarettes increases the risk of complication after orthopedic surgery. If you’re a smoker, cessation from smoking for at least one month before and one month after surgery can significantly reduce the risk of complications after surgery. Smoking can inhibit bone’s ability to heal itself, slow surgical wound healing, and increase the risk of infection following surgery. Smokers also have an increased chance of having lung problems, such as pneumonia, after surgery. One study demonstrated that smoking cessation prior to and after surgery could reduce the risk of complication by more than 50%.

If you need help quitting, Emory Family Medicine offers smoking cessation counseling services.

Are you getting in shape for orthopedic surgery? We welcome your questions and feedback in the comments section below.

Thomas Bradbury, MD, is an assistant professor of orthopedic surgery. He holds clinic at Emory Orthopaedics & Spine Center at Executive Park and performs surgery at Emory University Orthopaedics & Spine Hospital (EUOSH). Dr. Bradbury’s professional goal is the improvement in quality of life for patients with pain secondary to hip and knee problems. He started practicing at Emory in 2007.