Sunday, May 22, 2011

Joint Replacement Surgery: Solo Sport or Team Event?

Deciding to have total hip or knee replacement surgery and the timing of the surgery  is a personal and individualized process which can only made by the person experiencing the pain,  mobility and function deterioration.  Once the decided should “go it alone” or develop a carefully crafted plan to surround yourself with family and friends to assist you to reach your goals?  A recently released study supports previous findings that having a dedicated family member, significant other, or friend providing support every step of the way before, during, and after surgery positively impacts surgical outcomes.

This study included nearly 2000 patients who experienced joint replacement surgery.  The findings suggest that patients with strong social support, especially in the form of a “coach” experienced optimal outcomes including:
·         Shorter hospital stays
·         A greater likelihood to be discharged to their own home
·         Were more likely to achieve transfer out of bed and ambulation target goals
·         Reported feeling more ready and confident at the time of discharge
·         Were more likely to rate the overall quality of their care as excellent.

The findings replicate those of other studies which also found that preoperative education, as well as the use of coaches, positively impacts the quality and timeline for postoperative recovery from joint replacement surgery.

This particular study not only specifically explored the impact of a coach on outcomes, but also drilled down further to identify those time intervals that were most positively influenced by an active coach participating in the surgical experience:
·         Family or friend presence during the preoperative classes
·         Family or friend presence in the preoperative holding area while awaiting surgery
·         Family or friend presence during the last physical therapy session.

One additional finding was that the patient’s decision to use a coach for social support closely correlated with the view of his or her surgeon in this regard.  If the surgeon emphasized the importance of this role to the patient, this emerged as an important priority to the patient during the planning process.

One message is pervasive.  Once you have made the important decision to move forward with joint replacement surgery it is also important to identify those family members and friends who can function in the role of coach.  Discuss this with your physician early in the process.  When it comes to joint replacement surgery and rehabilitation these are no individual events, only team athletics.

Theiss, M.M., Ellison, M. W.l, & Tea, C.G.  The Connection Between Strong Social Support and Joint Replacement Outcomes.  Orthopedics.  2011; 34(5):357.

Sunday, May 15, 2011

LifeWings: A Commitment To Safety

The Orthopedic Team is eagerly anticipating the launch of the LifeWings Patient Safety Program at St. Joseph’s Hospital in early June.  Through our organized service line efforts we have made tremendous progress in improving operational efficiencies and patient outcomes over the years but also recognize that continued and sustained improvement requires ongoing effort and intervention.
Physicians, nurses, and other support team members will participate in intensive training sessions specifically designed for St. Joseph’s Hospital by LifeWings Partners.  LifeWings is a team of physicians, nurses, pilots, and former astronauts that have adapted for healthcare the teamwork training framework used by commercial aviation.  Through interactive exercises, experiential examples, evidence-based strategies, and tools and checklists we will learn how to avoid the mistakes that are occasionally made by teams and improve the safety for our patients.
We recognize that the system and environment of care at St. Joseph’s can be purposely and methodically redesigned to achieve results even better than those produced now.  We applaud the investment that St. Joseph’s Hospital has made to bring this program to us.  It truly demonstrates the commitment to creating and sustaining a culture of safety for our patients.

Sunday, May 8, 2011

Unicompartmental Knee Replacement: A Bone Sparing Alternative for Some Knee Arthritis Sufferers

Alternative Names:  Partial Knee Replacement, Unicondylar Knee Replacement, Unicompartmental Knee Replacement, Unicompartmental Knee Arthroplasty, Minimally Invasive Partial Knee Replacement
More than 500,000 people in the United States undergo total knee replacement each year.  Some of these patients and an additional gorup of other indivudals with knee arthritis might be candidates for partial knee replacement. 

Knee Anatomy
Three bones join together to form the knee joint
·         Thighbone (femur)
·         Shinbone (tibia)
·         Kneecap (patella)

The knee components are held together by muscles, ligaments, and soft tissue.  The shock-absorbing material inside the joint that cushions during weight-bearing activities is called the cartilage.
The knee is comprised of three separate section:
·         The medial compartment (inside part of the knee)
·         The lateral compartment (outside part of the knee)
·         The patellofemoral compartment (front part of knee between the kneecap and thigh bone)

Knee Arthritis
Osteoarthritis, or wear-and-tear arthritis, often results in symptoms such as stiffness, pain, and/or a sensation that the knee has “locked” during walking or other activity.  The cartilage in the knee degenerates over time until the surfaces are rubbing directly with each other without any cushioning (bone on bone).
Rheumatoid arthritis is an inflammatory process resulting in damage to the surface of the knee joint.  Partial knee replacement (PKR) is not indicated in rheumatoid arthritis.
Unicompartmental arthritis is wear and tear disease that affects only one of the three compartments of the joint instead of the entire knee.

Partial Versus Total Knee Replacement
Knee replacement surgery is intended to relieve knee pain and to imporve the function and motion of the knee. 
A total knee replacement (TKR) involves the complete repalcement of all three components in the knee.  Unicompartmental, or partial knee replacement, allows the surgeon to resurface (or replace) only the damaged compartment of the knee while preserving the health y bone in the other two compartments.
Patients suffering from osteoarthritis that is isolated to only one part/compartment of the knee might be candidates for partial knee replacement.  The healthy parts remain untouched during the surgery.  Patients also have the opportunity to undergo a standard total knee replacement in the future if the arthritis progresses and additional surgery is needed. 
Historical Perspective
Partial knee replecement actually predated Total Knee Replacement.  In the 1960’s when the idea of resurfacing an arthritic knee joint was first successfully accomplished, it was with a partial design.  It was only after the intial success of these designs that surgeon developers linked together two partials to make the first “Total Knee”-- the Duopatellar.  Over the years “total” knee designs have become more and more anatomic following the lead of nature.  At the same time partial knee replacement was overshadowed by the success of the “total” design despite the fact that it works so well in certain circumstances.  The continued improvement in material science has increased the longevity of both partial and total knee components.  Partial knee replacement, when applied to the correct patient, can have superior fuctional results when compared to”total” knee replacement.  The operative procedure remains more technically demanding for the surgeon, and is therefore usually provided only by orthopedic surgeons who are Joint Replacement Specialists.
The Procedure
Although the surgeon is able to predict with a high degree of accuracyby review of the x-ray if a patient is a candidate for PKR, the first step in the actual surgical procedure is to examine the three compartments of the knee directly to verify that cartilage damage is present in only one compartment of the knee.  If the damage is more significant than was visible on the preoperative x-ray, the surgeon will perform a total knee replacement instead.  He or she will discuss this possibility during the preoperative visit.
The term minimally invasive is often thought to relate to incision size.  In the hands of a skilled surgeon, the incision size is approximately half the size of the incision made during total knee replacement.  In terms of a partial knee replacement, the descripion of minimally invasive also correlates most closely to:
·         Preservation of two of the three compartments in the knee joint
·         Preservation of the stabilizing ligaments of the knee
o   Anterior cruciate ligament (ACL)
o   Posterior cruciate ligament (PCL)

During total knee replacement surgery these ligaments are usually cut or loosened.  Keeping these intact helps retain a more normal sensation of movement and range of motion.

If the intraoperative examination supports partially resurfacing the knee:
·         The damaged bone is removed and replaced with implants (prostheses) made of plastic and metal
·         The ends of the thigh and shin bones are cut and reshaped
·         The metal implants are secured in place with a fixative substance called bone cement
·         A plastic insert is placed between the two metal components to enable the surfaces to freely glide

Advantages of PKR
·         Quicker recovery and return to normal activities of daily living
·         Smaller incision
·         No disruption of the knee cap
·         Less pain
·         Improved range of motion
·         Little to no blood loss
·         Reports of a more natural feel in the knee

Disadvantages of PKR
·         Potential for additional surgery in the future (if other compartments become damaged by osteoarthritis)

As possible with any surgical procedure, complications can rarely develop:
·         Blood clots
·         Infection
·         Nerve injury
·         Persistent pain
·         Implant failure

Most patients can resume normal activities after partial knee replacement when they have regained adequate strength and flexibility.  Most exercise and activity are acceptable after surgery including walking, swimming, biking, gardening.  Activities that result in repetitive joint trauma such as running, jumping, or twisting should be avoided.

Partial knee replacement can achieve excellent results when performed on the appropriate population of patients.  This procedure may be an option for patients who are experiencing significant lifestyle limitations as the result of osteoarthritis isolated to one part of the knee.

If you believe that you may be a candidate for PKR talk to your doctor to determine what treatment is best for you.  Since this procedure is technically more challenging and surgeon experience is a key driver of positive surgical outcomes, don’t be hesitant to discuss with your surgeon his or her experience with this procedure.


Berger RA, Meneghini RM, Jacobs JJ, et al.  Results of unicompartmental knee arthroplasty at a minimum of ten years of follow-up.  Journal Bone Joint Surgery Am.  2005; 87(5): 999-1006.

Smith & Nephew:

Sunday, May 1, 2011

The Power of Teams

Anyone who knows us well, knows our sentiment about “our team.” Being branded a team does not in itself make a team, in fact, far from it. The word “team” is overused and in fact often misused.  At worst, people can be brought together structurally and be nothing more than folks functioning independently without common goals or vision.  Conversely, assemble people who share a common belief in their own ability to create and contribute to exceptional patient outcomes and there you find constituent parts that work as a unified whole.   Take a close look at our team and you will quickly recognize how highly interdependent we all are to achieve the results that we do. Everyone wins on our team, most importantly the patient. The Total Joint Replacement Program at St. Joseph’s Hospital consists of clinical and nonclinical people from our office, the hospital, and homecare providers.  All of us are critically important to the care that our patients receive and the outcomes that they achieve.  The whole is greater than the sum of the parts.
Throughout the years scientists have researched why migratory birds such as geese fly in a V-shaped formation.  Recently a team of scientists from France had the opportunity to study great white pelicans that had been trained to fly behind aircraft and boats in preparation for a feature film.  The scientists found that the heart rates of these birds dramatically decreased when they were flying together and that they were able to glide for longer periods of time, thus reducing the energy they exerted during their journey.  These findings suggest that flight formation evolved as a means to allow birds to reduce their energy expenditure.  Birds flying in a V had lower heart rates and experienced less air resistance than birds flying solo.  The bird in the lead position of a V formation will experience greater air resistance, will work harder, and fatigue more quickly than the other birds.  The flight formation (or team process) then compensates for this.  When the lead bird wearies, it falls out of the lead and allows another bird to take its place.  This exchange takes only a second or two and is barely evident from the ground.  The process of the lead bird changing out each time it becomes exhausted continues throughout the entire migratory journey, with each new bird offering strength along the way.  This formation permits all the birds to benefit individually while they work harmoniously as a team.

Like those migratory birds, we all share a portion of ourselves with each other. Each of us is willing to pitch in and do whatever is needed. We share a sense of common goals, open communication, mutual trust, and individual accountability. It truly is a Herculean effort to accomplish what we do.
Thanks Team!

“Bird Flight Explained,” BBC News World Edition, December 16, 2002.