[Music] and welcome to doctors on call i'm dr peter nalin professor and department head of family medicine and biobehavioral health associate dean for rural medicine and co-leader of the duluth campus of the university of minnesota medical school i am your host for our program tonight on lower extremity knee foot and hip problems the success of this program is very dependent on you the viewer so please call in your questions or email them to ask wdse.org the telephone numbers can be found at the bottom of your screen our panelists this evening include dr joshua rother an orthopedic surgeon with orthopedic associates of duluth and dr william uffman an orthopedic surgeon with essentia health our medical students answering the phones tonight are katie benson from staples minnesota claire buntrock of rochester minnesota and megan serratore from bemidji minnesota and now on tonight's program on lower extremity knee foot and hip problems the first question dr rother why is osteoarthritis called wear and tear arthritis osteoarthritis is called the wear and tear thrace because it's simply a loss of cartilage on both sides of the joint there's a clear genetic basis to the development of that there's a difference from patient to patient in terms of severity of that treatment uh in terms of managing that can be lots of not a conservative non-operative when it gets to the end stage of arthritis where it's bone on bone certainly looking at things like joint reconstruction are a useful tool to get patients back to good quality life and living thank you dr uffman for you the question is what new technologies are improving hip replacement surgeries sure that's a great question so i think things that we've been learning since they started doing hip replacements in the 60s is improving the biomechanical properties of the materials that we actually implant in people the way that they're fixated into the bones instead of using cement we now you know use in-growth prosthesis where it's special metal that our body can actually grow into also in terms of the polyethylene plastic liners and the approaches that we use uh improve the way that uh patients recuperate um we think that it you know helps them improve even more quickly wonderful and very interesting what would uh one expect to experience if a patient needed hip replacement surgery wdsc's jason sibo shares more on his decision to have surgery in this clip recorded earlier this week i think when it finally came time to finally make the decision to have my hip replaced was when it became unbearable i saw doctors i saw the x-rays and if you look at the x-rays there's supposed to be a gap between major bone groups and that's the cushion that allows you to to function while that was gone and it had progressed into other areas my gait was different i had a bit of a limp all the time well what that does is it messes with other systems and i finally got to the point where i i just couldn't take it anymore it was a decision that talking with my wife yeah you've got to do this now most people have to go through um pre-surgery prep they have to exercise that the muscle groups in order to get them strong enough so when you are recovering those muscle groups don't atrophy or um they're able to come back faster as far as prep work relatively easy you know you go into the hospital you you go through the normal procedures you get a shave because that happens you have your ivs and you're dressed and you're wheeled into the operating room i specifically had a spinal block after that um within a week within a week i was not using a walker and not using a cane that's how fast i came back from this and that was just on the left side i was in a lot of pain for a long time this wasn't something that was just happened on a whim because of an injury this was 10 15 years worth of pain and hobbling and not feeling like myself and just being held prisoner by my joints after the fact much happier pain is so far less and what i mean by that is there are twinges like i said when it gets cold outside it hurts but comparatively speaking night and day and i'm a much happier camper my wife will attest to this my kids will attest to this i'm not a patient person but you've got to be patient and that helps you um and motivates you to continue with your pt to continue using caution but also to start living again and that's for me that was the the biggest thing is i wanted to get back to my active lifestyle when before i didn't have one we're fortunate to hear this firsthand account from a patient dr uffman how does this story compare to what you hear well i think it rings really true with what i experienced in my own uh practice that uh i wish that all the surgeries that that i do have as good of outcomes as the total hip replacement i i tell my patients i think that's the best surgery that we can do for patients 98 satisfaction rate people are up and walking the same day all that pain like like jason said all that pain that he had is completely gone as soon as he wakes up from the surgery and that's really powerful to be able to give that to people wonderful dr rother how do orthopedic surgeons participate in preventing wrong side surgeries i think that's a great question it's something that can be an issue and and there's accepted standards at every hospital that's very universal we mark the site and the patient's presence uh before we bring them back to the operative suite when we are in the operative suite we also do a time out where the circulating nurse reads off the consent verified by anesthesia as well as a circulating tech in addition to myself to confirm that because a lot of what we deal with is laterality and it's very important to to get this right and households have very established protocols to prevent this important issue that's uh it's very reassuring and an important protocol dr uffman let's uh traverse further down the down the lower extremity this question is what is the recovery time for an achilles tendon repair and why so i would say that you know you can almost apply a principle on any orthopedic injury that there is sort of about a you're looking at a year of total recovery and i think about it as sort of if you're a mathematical person then you can almost apply it to a logarithmic logarithmic graph where you have pretty rapid progress that sort of slows down over time where the very high slope area is kind of the first six weeks to three months all injuries or surgeries we try to protect people for six weeks to sort of foster the real strong healing encourage range of motion over the next six weeks so that by about three months we as orthopedic surgeons feel more comfortable with actually letting you start to strengthen return to activities sometime in the four to six month ballpark uh kind of based on what your demands that you're going to place on that you know i guess in this case your achilles tendon so thank you for that dr rother how does range of motion impact your clinical advice about knee replacements well range of motion is a very important thing that patients want to achieve post-surgery oftentimes what they start out pre-operatively before knee replacement we can gain 15 to 20 degrees on it does give us a little reflection of things that we may have to do intraoperative to account for those deficiencies contractures by different bony resections to help balance out that knee so they have a stable platform that has improved range of motion better function and certainly less pain so it's it's an important factor we look at in the pre-op assessment that's going to ultimately kind of determine the course and and how hard they got to work on their therapy afterwards dr uffman a patient asks could you say a bit about morton's neuroma and metartalgia and some of the treatment or or diagnosis of it sure so morton's neuroma or metatarsalgia are kind of pain in the forefoot you know a morton's neuroma is typically in between your second and third bones of the foot and basically it's typically symptomatic when people walk there can be some radiating or shooting pain from kind of the forefoot area into your toes metatarsalgia being kind of very similar maybe the characteristic of the pain is slightly different um and typically the treatment is kind of the same it's getting good inserts for your shoes having shoes that fit you well if you can't find shoes that fit you well going to some place that can perhaps make you custom inserts or get you the right kind of shoes if if that doesn't get you where you need to be you know then you step it up with anti-inflammatories potentially local injections sometimes you know stretching and probably the last resort would be you know resection of the neuroma or potentially if it's metatarsalgia and there's some way that the you know your foot is acting like a platform correcting bone angles shape so that you don't put as much weight through that area of your foot and dr rother also a condition of the feet what are some of the findings that might indicate peripheral neuropathy well the most common finds can be numbness and tingling there's going to be a lot of different reasons for that certainly diabetes being one of the prevailing reasons for that to develop occasionally you can get that if you had a compressive neuropathy in the back but numbness and tingling would be the predominant finding you could see some weakness on exam as well and the treatments can be aimed at the true ideology of that in some scenarios you don't know exactly what the cause is but most commonly diabetes can be one of the top ones on the list in good diabetic control being important to manage that and dr uffman also about the feet what is plantar fasciitis and why might it hurt more in the morning sure so uh plantar fasciitis so the plantars fascia is sort of like a windless mechanism if you're a sailor it basically kind of helps to sheet in a sail in this case the plantar fascia attaches from your heel bone and runs out to the very ends of your metatarsal bones and it almost creates a stable arch for the bones of your feet so it's under constant stress during weight bearing and it just happens to either bother you at one end or the other it's more common that it happens at the heel end and so typically it's like anything it's going to be more painful in the morning because when we sleep our feet go into sort of a toes down position and when you go and stand up you stretch and put that fascia on stretch and that can be quite painful so good treatments for that are sleeping with special socks that will actually stretch your feet at night and then just doing stress stretch exercises in the morning and it has a very good successful outcome without surgery and dr rother this question is about knee surgery why might a patient be advised to get their bmi under 40 before undergoing knee surgery i think that's a great question and certainly a hot topic too as well uh we look at a lot of risk factors perioperatively and the whole drive at this moment to you know get bmis less than 40 optimize other conditions like diabetes and anemia you know you know stop smoking and things of that nature just to improve outcomes quite honestly with joint reconstruction it's been clear and proven that the uh complication rate with respect to infections is significantly lower when we have these other modifiable risk factors under control bmi being one of those big ones on that list in terms of wound healing and it's an important topic that you know both st luke's essentia and all the other major hospitals up here look at perioperative ensure that we're going to have a good outcome on what is generally a very successful procedure aim for those best outcomes absolutely for the for the patient optimization thank you dr uffman um a new question how how would you evaluate a patient with pain behind the kneecap sure so pain behind the kneecap um i guess you you think about you know what is the patient doing when does it hurt um typically pain behind the kneecap at least in my experience comes about when people are going up and down stairs going down steep hills hiking that kind of stuff obviously you want to get some x-rays and potentially based on their age or what the x-rays show and mri to kind of see what what is going on what their cartilage looks like is this a more of an arthritis kind of a picture or is this more of a focal cartilage lesion that could maybe be treated with some kind of arthroscopic procedure talk about injections talk about potentially physical therapy if you can find some correctable muscular imbalance or flexibility imbalance that you can you know correct to try to take the stress off of the kneecap because the kneecap sees about anywhere from six to 12 times our body weight with activities of daily living it's the thickest cartilage but also has the most shear of any part of our body so it really takes a bad beating so anything we can do to kind of make its mechanical environment more healthy for it is going to do good for your knee dr rother also in the vicinity of the knee what is osgood slaughter disease and why does it arise in athletes good question it's a very common condition we see in adolescents it's where the growth plates open where the patellar tendon inserts and athletes as they're doing running and exertion it can cause a lot of traction and strain on that insertional point with that open growth plate it can be very painful it's generally well managed with conservative treatment including anti-inflammatory stretching sometimes you use patellar tendon straps or braces to protect against that it is a very common entity unfortunately and the pretty much vast majority of the cases this will resolve without with time and and rarely if ever is surgery recommended or necessary for that it's generally just a conservative management and you can push through on the play but yeah a very common condition we see in treat all the time dr uffman also in the vicinity of of the knee what are shin splints and their potential treatments sure so uh shin sprints shin splints is kind of a spectrum of things and it's typically a an overuse injury it occurs in the tibia which is obviously your shin or your leg bone it's the main weight-bearing bone of your lower limb and it's typically seen in people who are trying to do something too much too soon so we see it a lot in uh young people that go out for cross-country or you know start playing sports and they're not very well conditioned and they're running or you know doing too much weight-bearing activity or military recruits it's a very common thing it's basically just the bone is not strong enough to react to the stress that it's being applied so typical treatments are rest relative rest sometimes it can be as strict as non-weight-bearing but it's typically very well managed with you know modifying your activity uh and then in some cases it's metabolic you know so trying to get people to eat better be more healthy take vitamin d that kind of stuff dr rother what are a few common reasons for recommending or or needing a knee brace yeah knee bracing we use for a whole host of entities in one respect for arthritis we can use unloader braces to take some strain off that compartment that is showing signs of wear especially in the earlier stages i will say that patients compliance is maybe not the best for that but when they are compliant i do think it's effective we oftentimes will use bracing posts like say acl surgery to help you know support that ligament that's been reconstructed just to ensure that's not going to take undue stress another real common reason for bracing would be for kneecap related issues like we had talked about before when you're having some kneecap instability those braces can help to support that kneecap mechanics and keep things in alignment as they're going through the recovery and rehab and and re-strengthen the knee to help improve those uh patellofemoral dynamics dr uffman what makes a vascular necrosis a serious condition sure it's uh basically a vascular necrosis is sort of a disorder of your bone that usually kind of an end stage leads you to a knee replacement or a hip replacement depending on where you have it so i think it's serious in that regard in that the sort of downstream effect of it can lead to your bone collapsing which there really is nothing other to do at that point than to replace your hip which while or a knee in this case so in that regard those procedures while good do have some serious consequences but it does kind of handcuff a surgeon in terms of how they can help you thank you dr rother a patient had a total knee replacement recently and now has baker's cysts what might be done about baker's cysts well it's a great question and baker cysts are very common entity typically as a knee is arthritic you're building up a lot of fluid pressure and some scenarios that can escape out into the back of the knee and form a cyst or a pocket there generally the remedy is going to be doing exactly what she had done with the knee replacement and in time it's fully expected that that cyst will resolve in some unusual scenarios we will remove that if it persists but in most scenarios if you address the issue within the knee joint that cyst will will run its course and and and dry up and the symptoms will improve after that's all said and done good to know and and encouraging dr uffman what can be done for treating bone spurs in the ankle or foot so i think it it probably depends one on the location and to whether or not they're symptomatic so you know heel spurs so spurs on the heel can be difficult or painful with shoe wear they can be removed if you can't find shoes that are comfortable if you have bone spurs in your ankle and they potentially cause decreased range of motion those can sometimes be removed either in an open surgical fashion or sometimes in an arthroscopic camera driven fashion so i guess it it all kind of like everything in orthopedics it boils down to what's your real complaint is it pain is it range of motion is it weakness uh or you know because sometimes you have bone spurs and they don't bother you uh and so we we try not to do no harm if it doesn't harm you then you know we try to let it be thank you and dr rother what can patients expect about infection control and prevention a few examples if they're anticipating surgery ahead yeah that's an important topic you know for us infection control starts with some of these perioperative uh factors for patients too so if they are diabetic good diabetic control is important things we do personally in the operating room include you know a given anabox beforehand sterile technique being really cognizant on those important factors but i think it's kind of a combination of effect with what we do perioperative with good nutrition good diabetic control and then the other measures that we take intraoperative and because an infection is a very serious consequence of some of the surgeries that we potentially do and it's not as if it's a zero risk it is a risk and and once it happens it's a matter of how we address that and take care of that issue to get them back on track thank you and dr uffman a patient reports tendinitis and tenocinovitis brachy metatarsa what are some approaches to a patient with those symptoms and conditions i feel like you have to speak greek fluently on this show in order to be able to understand what we're talking about here but so tendinitis tenocinovitus brachymediobrachymetotia so those are all sort of conditions of the feet um you know inflamed tendons uh inflamed tendon sheaths and of course short metatarsal bones which all would basically kind of affect you know pain when you put your foot down or pain when you move your toes and so it kind of comes back to the same orthopedic principles of rest ice you know activity modification uh if if we do feel that you know we can't calm down your your tendons or your tendon sheaths with you know those sorts of things sometimes there are um you know tendon diverting surgeries or bone lengthening procedures that can you know be considered but most of the time foot conditions can kind of be treated non-operatively dr roth you mentioned the patient's participation in their recovery anything about casting materials or the care of casting that patients can be helpful and positive about yeah i mean when we have to apply cath which isn't infrequent it's important that they take care of the skin around they control swelling um you know if they're having itchiness you know using antihistamines to help with that rather than scratching that skin surface because you know i've seen scenarios where they've gotten infections from that but it's important to take good control and care of the cats you know oftentimes we have to change casts out during the process of you know fracture management and that's not an uncommon thing as you know the swelling does go down the cast can become a little more loose and there can be issues with how it's uh holding that fraction position or causing skin related issues so cast care is important it's a hassle but generally it's a short-lived hassle in most scenarios and and it's uh something that we certainly watch seriously dr uffman a swimmer is experiencing swelling right below the knees that then goes away what might be contributing that is a difficult question to answer i would say you know um i guess depending right below the knee um yeah it would that would almost be after something they have to come in and sort of be looked at i would imagine i guess you could think you know is that some sort of patellar tendonitis or inflammation i guess particularly if they're doing a lot of kicking um that'd probably be my best guess but i agree with you i think a good clinical exam and you'll see their pressure points are and and from their determined but i agree i think it's probably more patellar tendonitis i would suspect if it's right below the knee so a good clinical exam would be a good next step that'd be the best way to determine that best thing for every for all orthopedic conditions is a good clinical exam yes and a patient is experiencing numbness of the entire leg at times any other thoughts beyond uh certainly a good physical exam yeah i think it's getting to the source of what may be causing it there could be a multitude of reasons for that i would say if it's the entire leg the most common thing that would come in my mind would be a compressive neuropathy in the back whether it's from bone spur formation there or a disc herniation there could be peripheral entrapment but if it's the entire leg i would think it more would line back into the back so a good history will help you know exams going to help and probably some diagnostic studies to follow uh if the exam supported the initial thoughts and and ideas about what was causing it well i'd like to thank our panelists dr joshua rother and dr william uffman and our medical student volunteers katie benson claire buntrock and megan serratore please join dr ray christensen next week for a program on men's health and kidney stones when his panelists will be dr e toga hanhan and dr benjamin marsh thank you for watching good night [Music] so [Music] it's kind of standard stuff you don't got to soak it just got to clean