Vitamin D & Surgery Healing
I just read an interesting article in a surgical journal. The vast majority of studies in my scientific journals tend to focus on biomechanics, surgical techniques and implant methods. This caught my attention as it instead focused on health. More specifically, the researchers were asking whether Vitamin D deficiency is associated with failure to heal after surgery. They were looking specifically at rotator cuff tears that were surgically reattached. It turns out that more tendon repairs had to have surgery again in the group of people with low Vitamin D. We have known for a while that those over age 70 have less potential to heal repairs, possibly from diminished blood flow to the tendon. This information about Vitamin D may give people another method of maximizing healing potential in advanced age.Read the article
Hip Arthroscopy, What is it for?
Arthroscopic hip surgery is a minimally invasive method of looking into a hip joint to diagnose and treat certain hip disorders. The most common problem I treat is a so-called labrum tear. The labrum is a ring of cartilage around the hip socket that acts to stabilize and seal the ball and socket joint. When there is a labral tear, there are a number of problems that occur. Some people have dull or sharp pain in the groin with activities. Sometimes people will feel an ache that goes through the groin to the back of the hip like a stabbing sensation going from front to back. I also hear people who describe a popping/catching of the joint with certain positions of the leg or activities.
I will sometimes inject the hip joint under ultrasound guidance in the office with local anesthetic to help confirm that the hip socket is where the pain is coming from. You want to make sure that a separate issue, such as a pinched nerve in the back, is not the main issue. Pinched nerves are notorious for acting like hip problems.
If there has not been an MRI performed, I usually order one to get images of the labrum. The MRI shows the labrum more accurately if there is fluid injected into the hip that helps to reveal the labral tear.Read the article
Treating the Rotator Cuff Without Surgery
I see a number of rotator cuff injuries in my office. There are four different cuff muscles, and each muscle can have a few different types of injury severity and/or pattern. You can imagine that there are a myriad of recommendations for treatment options with such complexity around the shoulder joint. I will therefore focus on the most commonly injured cuff muscle, the supraspinatus. That particular muscle/tendon complex is involved in around 90% of shoulder muscle injuries I see in the office. Sometimes, there is no tear of the tendon, but rather severe inflammation, often called bursitis.
The supraspinatus controls a great deal of overhead strength, especially for lifting items above the head while the arm is in front of you. This obviously affects a great deal of daily activities and can therefore be quite debilitating when not functioning properly. Many times, the injury can be attributed to an imbalance of the muscle forces around the joint that chronically stress the shoulder muscles. This imbalance eventually will lead to failure of tissues at some point. Read the article
What is PRP?
PRP stands for ‘Platelet Rich Plasma’. In short, it is taking a sample of your blood and separating out the components of the blood that can stimulate a healing response. That concentrated part of the blood is then injected into the injured part of the body.
The procedure itself involves an outpatient office visit that lasts up to 30 minutes. Just like a regular blood draw, the blood is taken from a vein in the arm. That blood is then placed into a centrifuge and spun down for 5 minutes. This separates the blood into two distinct layers. The lower layer is dark red and where the red blood cells are. The upper layer is yellow and more clear, and that is where the platelets and other healing factors reside.
The upper ‘platelet’ layer is then separated off within a self-contained sterile device. The fluid is then contained in a syringe, allowing it to be injected into the injured joint or tendon. I use ultrasound guidance to accurately target the site of injury and guide the injection.Read the article
Rotator Cuff Surgery, How it’s Done
The rotator cuff is a group of four muscles that surround the ball and socket. These muscles control much of your overhead function for daily activities. The most commonly injured of the four is called the ‘supraspinatus’. If it is torn, then it can cause trouble elevating the arm, and pushing things overhead. Sometimes it can be so severe that a person can experience ‘pseudoparalysis’, where the arm will not lift.
If the supraspinatus tendon (remember, then tendon is how the muscle attaches to the bone) is detached from the top of the ball, then we can typically re-attach it. The tendon can be reattached a few different ways, but the most common method these days is with a suture anchor. This is a small screw with stitches attached that can be screwed into the bone. The tendon is then laced up with the stitches and cinched down to bone. The screw can be made of metal or a non-metallic substance (plastic, calcium composite). The advantage of using non-metallic anchors is that future MRI scans show more detail in the event there is a new injury. As a general rule, the worse the tear, the more suture anchors may be needed to bring the tendon back to bone.Read the article
What is Anterior Hip Replacement?
There are a few options when it comes to hip replacement approaches. The approach is the location the surgeon places the incision to gain access to the hip joint. Traditionally, surgeons have used the so-called ‘posterior’ approach. From the patient perspective, there is a hockey-stick shaped incision over the buttock. Surgeons typically restrict bending the hip up and crossing legs when the posterior approach is used, as this may increase the risk of the hip dislocating out of the back of the socket. If you know someone who had to sleep with a foam wedge in between their legs after surgery, that means it was a posterior approach.
There are a few anterior approaches, but the most commonly used is the so-called ‘Smith-Peterson’. This describes the specific muscles that the surgeon goes between. The posterior approach detaches (and then later re-attaches) muscles from the hip that provide stability to the hip joint. The anterior approach aims to improve stability and function by going in between the front muscles and thus preserving the muscles in the back of the joint. Read the article
Gratitude and Relationship to Surgery Rehab
After you have taken care of enough people, you start to notice patterns in how some people bounce back quite quickly after a repair/reconstruction, and others have a very difficult time. As someone who is trying to improve outcomes and happiness among patients, I try to figure out what the differences are among these people, and how those differences may tie into how they recover. If I perform a couple hundred arthroscopic shoulder repairs in a year, there are usually enough people I see with a very similar problem and it becomes easier to then compare amongst them.
One of the factors that has stood out for me is gratitude. Time and again I see patients who are generally appreciative of the world around them and the opportunity to interact with people. These are people who are thankful for what they have, and tend not to rue what they are missing or wanting. They discuss issues in terms of where they are heading, not where they are stuck at. It seems obvious that a “happy” person would feel better, but it seems to be more than just a smile on a face. It is the attitude of really knowing that things will go well; if they don’t go well for a time, then there must be a reason for the bump in the road and it will be bypassed soon enough. It reminds me of actualization. That is to say, visualizing positive outcomes and general appreciation of those around you, and then the realization of that positivity becoming real in future experiences.Read the article
Hip/Knee Joint Replacement: What are the major risks?
There are different risks associated with different types of surgery. Each person has an individually different risk profile and many of the risks are worsened by overall medical issues. Hip and knee replacement tend to have a higher risk of blood clot due, in part, to the decrease in activity after the procedure. If the clot stays in the leg, then it is usually treated with anticoagulant medication for 3-6 months. If the clot travels into the lungs, then there are more involved treatments. Most surgeons use some form of blood thinner in the first few weeks after surgery to help reduce the chance of clotting. Read the article
Joint replacement: When should I do it?
It is a big decision when you are faced with a major joint (shoulder, hip or knee) that hurts on a daily and nightly basis. It gets to the point where the pain and stiffness affects many of your daily decisions and can significantly erode your overall health. Health problems result not only from the lack of activity, but also from the effects of various over the counter treatments that can cause their own problems.
It is important that you exhaust all of the non-surgical means to alleviate your pain and improve function. I will go into more depth on non-surgical treatment options for arthritis in another segment.
Your surgeon cannot tell you if you should get surgery, but merely can tell you whether you are a candidate based upon your story, your examination, and your imaging (x-rays most commonly).
Read the article