HIP – KNEE & LEG -- SHOULDER

HIP

Q: Who should have hip replacement surgery?
A: People with hip joint damage that causes pain and interferes with daily activities despite treatment may be candidates for hip replacement surgery. Osteoarthritis is the most common cause of this damage. However, other conditions, such as rheumatoid arthritis (a chronic inflammatory disease that causes joint pain, stiffness, and swelling), osteonecrosis (or avascular necrosis, which is the death of bone caused by insufficient blood supply), injury, fracture, and bone tumors also may lead to breakdown of the hip joint and the need for hip replacement surgery.

Q: Why do people have hip replacement surgery?
A: For most people who have hip replacement surgery, the procedure results in:

  • A decrease in pain
  • Increased mobility
  • Improvements in activities of daily living
  • Improved quality of life

Q: What’s the difference between an anterior hip replacement and a traditional hip replacement?
A: With an anterior hip replacement, the surgeon uses a small incision to reach the hip joint from the front of the hip joint (anterior) rather than the side (lateral) or back (posterior). This allows the hip implant to be placed without detaching the muscle from the hip or thigh bone – potentially causing less tissue disruption, reduced pain and faster recovery.

 Anterior ApproachTraditional Surgery
Avg. Hospital Stay2 to 4 days3 to 10 days
Small Incision4 to 5 inches10 to 12 inches
Less Muscle TraumaNo muscle detachmentMuscles cut
Faster Recovery2 to 8 weeks2 to 4 months

Q: What happens during an anterior hip replacement procedure?
A: You are place on a special table. The carbon-fiber arms support and manipulate the leg during surgery. Sterile robotic attachments reach inside the wound and lift the femur so that the surgeon can access it easier.
The hip is exposed by following a natural line between muscles so that the surgeon does not have to detach muscles or tendons from the bone. The femoral neck is cut and the arthritic femoral head and neck are removed.

With special tools called reamers, the surgeon scraps the burrs of the arthritic acetabulum so that it is smooth and can accept the new acetabular prosthesis.

Q: What exercises are best for someone with a total hip replacement?
A: Activity is important. It can reduce stiffness and increase flexibility and muscle strength. We will talk with you about developing an appropriate exercise program. Most programs begin with safe range-of-motion activities and muscle-strengthening exercises. Activities such as walking, stationary bicycling, swimming, and cross-country skiing can increase muscle strength and cardiovascular fitness without injuring the new hip.

Q: What’s hip arthroscopy?
A: It’s a procedure performed through small incisions using a camera to visualize the inside of the hip joint. Through small incisions less than ½-inch wide the surgeon inserts a camera into one incision, and small instruments through the other incisions.

Q: What conditions can be treated with hip arthroscopy?
A:  Hip arthroscopy is used for:

  • Labral Tear
  • Loose Bodies
  • Snapping Hip Syndrome
  • Cartilage Damage
  • Early Arthritis

Q: What is femoroacetabular impingement (FAI)?
A: It’s a condition where the hip bones are abnormally shaped. Because they do not fit together perfectly, the hip bones rub against each other and cause damage to the joint.

Q: What causes FAI?
A: FAI occurs because the hip bones do not form normally during the childhood growing years. It is the deformity that leads to joint damage and pain. When the hip bones are shaped abnormally, there is little that can be done to prevent FAI.

Because active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise does not cause FAI.

Q: What are some of the symptoms of FAI?
A: People with FAI usually have pain in the groin area, although the pain sometimes may be more toward the outside of the hip. Sharp stabbing pain may occur with turning, twisting, and squatting, but sometimes, it is just a dull ache.

Q: How do I know if I have FAI?
A: FAI requires a diagnosis. During your first appointment, we will discuss your general health and your hip symptoms. We will also examine your hip.

We will conduct an impingement test where we bring your knee up towards your chest and then rotate it inward towards your opposite shoulder. If this recreates your hip pain, the test result is positive for impingement.

We may also order imaging tests to help determine whether you have FAI.

  • X-rays will show whether your hip has abnormally shaped bones of FAI. X-rays can also show signs of arthritis.
  • Computed tomography (CT) scans provide more details than an x-ray.
  • Magnetic resonance imaging (MRI) scans create better images of soft tissue. They will help us find damage to the labrum and articular cartilage. Injecting dye into the joint during the MRI may make the damage show up more clearly.

Q: Do I need surgery if I have FAI?
A:
If tests show joint damage caused by FAI and your pain is not relieved by nonsurgical treatment such as changing activity or physical therapy, we may recommend surgery.

Many FAI problems can be treated with arthroscopic surgery. Arthroscopic procedures are done with small incisions and thin instruments. We use a small camera, called an arthroscope, to view inside the hip.

During arthroscopy, we can often repair or clean out any damage to the labrum and articular cartilage. We may correct the FAI by trimming the bony rim of the acetabulum and also shaving down the bump on the femoral head.

Q: What is a labral tear?
A: Labrum is a ring of cartilage found on the rim of the shoulder or hip joint’s socket. A labral tear occurs when this cartilage somehow gets torn. It can take several forms.

Q: What are the symptoms of a labral tear?
A: Signs and symptoms include pain or a "catching" sensation in the joint.

Q: What is the treatment for labral tears?
A:
The treatment depends upon which kind of tear there is in the labrum.

KNEE & LEG

Q: What are some of the most common knee injuries for active people?
A: Many athletes experience knee-ligament injuries. Of the four major ligaments found in the knee, the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) are often injured in sports. The posterior cruciate ligament (PCL) may also be injured.

  • ACL injury -- Changing direction rapidly, slowing down when running, and landing from a jump may cause tears in the ACL. Athletes who participate in skiing and basketball, and athletes who wear cleats, such as football players, are susceptible to ACL injuries.
  • MCL injury -- Injuries to the MCL are usually caused by a direct blow to the outside of the knee. These injuries often occur in contact sports, such as football or soccer.
  • PCL injury -- The PCL is often injured when an athlete receives a blow to the front of the knee or makes a simple misstep on the playing field.
  • Torn cartilage -- When people talk about torn knee cartilage, they are usually referring to a torn meniscus. The meniscus is a tough, rubbery cartilage that acts like a shock absorber. In athletic activities, tears in the meniscus can occur when twisting, cutting, pivoting, decelerating, or being tackled. Direct contact is often involved.

Q: Do I need surgery to correct knee-ligament injuries?
A: Treatment will vary depending upon the patient's individual needs.
Most ACL, MCL and PCL tears cannot be stitched back together. To surgically repair the ligaments and restore knee stability, the ligaments must be reconstructed. We will replace your torn ligament with a tissue graft. This graft acts as a scaffolding on which  a new ligament can grow.

Because the regrowth takes time, it may be six months or more before you can return to sports.

The surgery to rebuild an anterior cruciate ligament is done with an arthroscope using small incisions. Arthroscopic surgery is less invasive. The benefits of less invasive techniques include less pain from surgery, less time spent in the hospital, and quicker recovery times.

Q: What is a torn meniscus?
A:
Meniscal tears are among the most common knee injuries. Athletes, particularly those who play contact sports, are at risk for meniscal tears. However, anyone at any age can tear a meniscus. When people talk about torn cartilage in the knee, they are usually referring to a torn meniscus.

Q: What are the symptoms of a torn meniscus?
A: You might feel a "pop" when you tear a meniscus. Most people can still walk, athletes keep playing with a tear. Over the next few days, your knee gradually becomes more stiff and swollen.

Common symptoms of meniscal tears are:

  • Pain
  • Stiffness and swelling
  • Catching or locking of your knee
  • The sensation of your knee "giving way"
  • You are not able to move your knee through its full range of motion

Without treatment, a piece of meniscus may come loose and drift into the joint. This can cause your knee to slip, pop or lock.

Q: How is a torn meniscus treated?
A: It depends on the type of tear, its size, and location. The outside one-third of the meniscus has a rich blood supply. A tear in this zone may heal on its own, or can often be repaired with surgery. The inner two-thirds of the meniscus lacks a blood supply. Without nutrients from blood, tears in this area cannot heal. Because the pieces cannot grow back together, tears in this area are usually surgically trimmed away.

Arthroscopy is the preferred technique for treating a torn meniscus. We insert a miniature camera through a small incision to give us a clear view of the inside of the knee. We will then insert miniature surgical instruments through other small incisions to trim or repair the tear.

SHOULDER

Q: Could I have a torn rotator cuff?
A: Usually people with rotator cuff injuries feel pain over the deltoid muscle at the top and outer side of the shoulder. Motions like those involved in getting dressed can be painful. The shoulder may feel weak, especially when trying to lift the arm into a horizontal position. Individuals may also feel or hear a click or pop when they move their shoulder. Pain or weakness when rotating their arms outward or inward may indicate a tear in a rotator cuff tendon. Individuals also feel pain when lowering their arms to the side after they move their shoulders backward and raise their arms.

Q: How are torn rotator cuffs treated?
A: Patients with rotator cuff tendinitis or bursitis that does not include a complete tear of the tendon can usually be treated without surgery. Nonsurgical treatments include the use of anti-inflammatory medication and occasional steroid injections into the area of the inflamed rotator cuff, followed by rehabilitative rotator cuff strengthening exercises.

Surgical repair of rotator cuff tears is best for:

  • Younger patients, especially those with small tears. Surgery leads to a high degree of successful healing and reduces concerns about the tear getting worse over time.
  • Individuals whose rotator cuff tears are caused by an acute, severe injury. These people should seek immediate treatment that includes surgical repair of the tendon.

Q: What is shoulder impingement?
A:
Impingement occurs when the rotator cuff tendons become compressed and/or worn. The rotator cuff is actually a series of four muscles connecting the scapula (shoulder blade) to the humeral head (upper part of the shoulder joint).

The rotator cuff is important in keeping the upper shoulder join within the socket during normal shoulder function and also contributes to shoulder strength during activity. Normally, the rotator cuff glides smoothly between the undersurface of the bone at the point of the shoulder and the upper part of the shoulder joint.

Any process that compromises this normal gliding function may lead to impingement. Common causes include weakening and degeneration within the tendon due to aging, the formation of bone spurs and/or inflammatory tissue within the space above the rotator cuff and overuse injuries. Overuse activities that can lead to impingement are most commonly seen in tennis players, pitchers and swimmers.

Q: How do I know if I suffer from shoulder impingement?
A:
We can diagnosis shoulder impingement through a careful history and physical exam. Patients with impingement most commonly complain of pain in the shoulder, which is worse with overhead activity and sometimes severe enough to wake them during the night.

Manipulating the shoulder in a specific way during the exam will usually reproduce the symptoms and confirm the diagnosis. X-rays can also help in evaluating the presence of bone spurs and/or the narrowing of the subacromial space. MRI (magnetic resonance imaging), a test that allows us to see the rotator cuff, is usually not necessary in cases of shoulder impingement, but may be used to rule more serious problems.

Q: Is surgery necessary for shoulder impingement?
A:
Surgery is not necessary in most cases of shoulder impingement. But if symptoms persist despite nonsurgical treatment, surgery may help. Surgery involves removing tissue that is irritating the rotator cuff. This can typically be done using arthroscopic techniques.