♪ >> GOOD EVENING AND WELCOME TO DOCTORS ON CALL.

I AM DR. PETER NALI, PROFESSOR ANDN BIO BEHAVIOR HEALTH.

COLEADER OF THE DULUTH CAMPUS OF THE UNIVERSITY OF MINNESOTA MEDICAL WILL -- MEDICAL SCHOOL.

I'M YOUR HOST FOR TONIGHT'S PROGRAM ON SPORTS AND OUTDOOR INJURIES AND JOINT REPLACEMENTS.

THE SUCCESS OF THIS PROGRAM IS VERY DEPENDENT ON OUR VIEWERS.

PLEASE CALL OR EMAIL YOUR QUESTIONS AND WE WILL DO OUR BEST TO ADDRESS THEM.

THE TELEPHONE NUMBERS AND EMAIL ADDRESS FOR YOUR QUESTIONS CAN BE FOUND AT THE BOTTOM OF YOUR SCREEN.

OUR PANELISTS THIS EVENING INCLUDE DR. PATRICK HALL, AN ORTHOPEDIC SURGEON WITH ORTHOPEDIC ASSOCIATES OF DULUTH AND DR. CARL RASMUSSEN, A FAMILY MEDICINE PHYSICIAN WITH ST. LUKE'S MOUNT ROYAL MEDICAL CLINIC.

EMBERS OF THE WDSE STAFF ARE STANDING BY TO TAKE YOUR PHONE CALLS.

NOW, ONTO TONIGHT'S PROGRAM.

OUR FIRST QUESTION IS FROM DULUTH.

DR. HALL, WHAT ARE THE MOST COMMON SPORTS INJURIES?

DR. HALL: FORTUNATELY, MOST SPORTS INJURIES ARE MINOR.

THEY INVOLVE A LOT OF SPRAINS AND STRAINS AND A LOT OF THOSE CAN BE TREATED CONSERVATIVELY WITH THE TYPICAL HOME READIES WITH ICE AND COMPRESSION AND IBUPROFEN.

A LOT OF THOSE THINGS GET AT HER WITH CONSERVATIVE MANAGEMENT.

SOME OF THEHELP US UNDERSTAND TE DIFFERENCE BETWEEN A SPRAIN AND A STRAIN.

>> IT IS MAINLY A TERMINOLOGY DIFFERENCE.

A STRAIN IS REFERRING TO MUSCLE TISSUE OR A TENDON INJURY.

A SPRAIN IS A LIGAMENTOUS INJURY AS DR. HALL WAS DISCUSSING.

THESE ARE NONOPERATIVE OR INJURIES THAT CAN BE TREATED CONSERVATIVELY.

MOST OF THEM DO WELL JUST WITH SOME TIME TO REST AND CARE FOR THEM CONSERVATIVELY.

>> WHAT IS TURF TOE AND HOW IS IT TREATED?

>> TURF TOE IS AN INJURY MOST COMMONLY TO THE FIRST TWO.

TO THE LARGE JOINT OR THE FIRST TOE.

IT IS AN INJURY TO THE JOINT CAPSULE.

ANYWHERE FROM AN IRRITATION OF THE CAPITAL TO A TEAR IN THE CAPSULE.

IT IS MOST COMMONLY SEEN IN FOOTBALL PLAYERS AND SPECIFICALLY ALL OFFENSIVE LINEMAN WITH HAVING TO PUSH OFF WITH A LOT OF WEIGHT ON THE FOOT.

ANY ONE COULD POTENTIALLY GET TURF TOE FROM PUSHING OFF WITH A LOT OF WEIGHT ON THE FIRST BIG TAUPE.

DARK -- >> HOW DO SURGEONS CONFIRM THE FIRST SIDE OF SURGERY BEFORE STARTING?

DR. HALL: WE ALWAYS WANT TO MAKE SURE WE DO THE CORRECT SIDE.

THERE IS A COMMON WAY TO DO THAT.

IN THE PAST, IT HAS BEEN DIFFERENT.

IF IN HOSPITALS HAD DIFFERENT WAYS TO CONFIRM THE PROPER SURGICAL SITE PRIOR TO SURGERY.

THE AMERICAN ACADEMY OF ORTHOPEDIC SURGERY A FEW YEARS BACK TRIED TO STANDARDIZE THE PROTOCOL FOR CONFIRMING THE PROPER SURGICAL SITE.

WHAT THEY CAME UP WITH WAS THE SURGEON WOULD PUT THEIR INITIALS ON THE SURGICAL SITE AND BEFORE THE SURGERY STARTS, WE WOULD HAVE WHAT WE CALL A TIMEOUT IN THE OPERATING ROOM WHERE EVERYBODY STOPS WHAT THEY ARE DOING AND EACH PERSON CONFIRMS THE PROPER PATIENT SURGICAL STATE -- SURGICAL SITE AND PROCEDURE BEFORE PROCEEDING WITH THE SURGERY.

NOW IT IS STANDARDIZE AND THERE IS MUCH LESS WRONG SITE SURGERY BECAUSE OF THAT.

IT HAS BEEN UNIFORMLY STANDARDIZED ACROSS THE COUNTRY TO DO A CERTAIN WAY AND EVERY HOSPITAL DOES IT THE SAME WAY.

DR. NALIN: GOOD TO KNOW.

DR. RASMUSSEN, WHAT ABOUT THE PNEUMONIC WITH THE LETTERS RAISI?

HOW DOES THAT RELATE TO THE TREATMENT OF INJURIES?

DR. RASMUSSEN: THAT IS THE MAINSTAY FOR THE CONSERVATIVE MANAGEMENT THAT WE HAVE DISCUSSED, ESPECIALLY FOR SPRAINS AND STRAINS.

R'S FOR REST.

I IS FOR ICE.

C IS FOR COMPRESSION.

E IS FOR ELEVATION.

THERE WILL WAYS TO CUT -- THOSE ARE WAYS TO DECREASE SWELLING AROUND THE INJURY.

DR. NALIN: THANK YOU.

DR. HALL.

HOW ABOUT THE REASON OR CAUSES FOR THE NEED FOR HIP REPLACEMENTS?

DR. HALL: THE MOST COMMON CAUSE FOR HIP REPLACEMENT IS JUST WEAR AND TEAR ARTHRITIS OF THE HIP.

IN PEOPLE WHO HAVE ARTHRITIS, THE MAIN PROBLEM IS THE CARTILAGE WEARS OUT.

THERE IS SMOOTH CARTILAGE ON BOTH SIDES OF THE JOINT AND IT CAN WEAR OUT EVENTUALLY.

WHEN IT WEARS OUT, IT CAN CAUSE PAIN AND INFLAMMATION AND NEED TO BE REPLACED.

OTHER REASONS FOR HIP REPLACEMENT INCLUDE FRACTURES.

WHEN PEOPLE HAVE A FEMORAL NECK FRACTURE THAT IS DISPLACED, OFTEN TIMES THE BLOOD SUPPLY GETS DISRUPTED AND IT IS NOT USUALLY SUCCESSFUL TO TRY TO PUT IT BACK TOGETHER AND FIX IT BECAUSE THAT WILL NOT HEAL.

OFTEN TIMES AND ELDERLY PATIENTS, WE DO A HIP REPLACEMENT.

THERE ARE OTHER REASONS WHY PEOPLE MIGHT NEED A HIP REPLACEMENT.

AVASCULAR NECROSIS IS ONE.

THAT CAN SOMETIMES AFFECT YOUNGER PEOPLE.

ONE OF THE REASONS WHY WE MIGHT DO A HIP REPLACEMENT AND A YOUNGER PERSON IS THEY GIVE SOMETHING CALLED AVASCULAR NECROSIS, WHICH MEANS THE BLOOD SUPPLY TO THE FEMORAL HEAD GETS DISRUPTED FOR WHATEVER REASON AND THE FEMORAL HEAD COLLAPSES AND BECOMES ARTHRITIC AT A YOUNG AGE.

UNFORTUNATELY, THAT CAN AFFLICT PEOPLE INTO THEIR 20'S SOMETIMES.

IDEALLY, IF I WANT TO DO A HIP REPLACEMENT NOW IN THEIR 20'S BUT THAT IS THE ONLY OPTION FOR PEOPLE WHO HAVE A REALLY BAD HIP.

DR. NALIN: THANK YOU.

DR. RASMUSSEN, WHAT ABOUT THE OTTAWA ANKLE RULES AND HOW DO THEY HELP YOU IN THE TREATMENT OF PATIENTS?

DR. RASMUSSEN: THE OTTAWA ANKLE RULES ARE A CLINICAL DECISION ALGORITHM THAT WAS DEVELOPED TO HELP PRIMARY CARE DOCTORS AND EMERGENCY ROOM PHYSICIANS DETERMINE IF AN ANKLE INJURY NEEDS TO BE X-RAYED TO DETERMINE IF IT IS FRACTURED OR NOT.

THEY ARE RULES THAT ARE BASED OFF OF A NUMBER OF TENDER POINTS THAT CAN BE EVALUATED AROUND THE ANKLE.

THE BIG ONE IS WHETHER A PATIENT CAN BEAR WEIGHT ON THE ANKLE AFTER AN INJURY OR NOT.

IF THE PATIENT CAN BEAR WEIGHT AND WALK ON IT WITHOUT SIGNIFICANT PAIN, THAT DECREASES THE LIKELIHOOD THERE IS A FRACTURE.

WITH ANY ANKLE INJURY, IF THERE IS ONGOING PAIN OR SPECIFICALLY, IF THERE IS TROUBLE BEARING WEIGHT OR WALKING AFTERWARDS, THOSE SHOULD BE EVALUATED IN -- EITHER IN A OR EMERGENCY ROOM SETTING.

DR. NALIN: DR. HALL, ABOUT KNEE REPLACEMENTS, A CALLER IS ASKING ABOUT A 51-YEAR-OLD MAN ANTICIPATING BOTH KNEES BEING REPLACED AT THE SAME TIME.

WHAT ARE YOUR THOUGHTS ABOUT KNEE REPLACEMENT ONE AT A TIME OR BOTH IN THE SAME SURGICAL DAY?

DR. HALL: THERE ARE PROS AND CONS TO DOING BOTH AT THE SAME TIME OR DOING ONE KNEE AND STAGING THEM.

WITH BOTH KNEES DONE AT THE SAME TIME, YOU GET BOTH KNEES AT THE SAME TIME AND THE RECOVERY IS ONE TIME PERIOD.

YOU DON'T HAVE TO GO THROUGH SURGERY TWICE AND TWO SEPARATE ANESTHETICS.

THE DOWNSIDE IS THE INCREASED RISK OF COMPLICATIONS IS A REAL.

THE INCREASE RISK OF BLOOD CLOTS AND PULMONARY EMBOLISM, THERE IS AN INCREASED RISK OF BLOOD LOSS AND REQUIRING A BLOOD TRANSFUSION.

PLUS, THE RECOVERY IS A LOT TOUGHER WHEN YOU HAVE BOTH DONE AT THE SAME TIME BECAUSE YOU ARE TRYING TO RECOVER ON TWO NEEDS AND BOTH LOWER EXTREMITIES ARE EFFECTIVE.

I TRY TO ENCOURAGE PEOPLE TO PICK THE WORST KNEE FIRST AND DO THAT KNEE AND ONCE THEY ARE RECOVERED FROM THE INITIAL KNEE REPLACEMENT, IF THEY ARE STILL SOME TO MEDIC ENOUGH, STAGE IT AND DO THE OTHER ONE LATER.

I HAVE DONE IT -- DONE BOTH AT THE SAME TIME AND SOME PEOPLE GET RICH JUST FINE.

THERE IS A HIGHER RATE OF COMPLICATIONS.

IF PATIENTS CAN DO -- PATIENTS CAN DO BOTH AT THE SAME TIME.

THEY JUST HAVE TO REALIZE THERE IS MORE RISK.

DR. NALIN: YOU MENTIONED THE RISK FOR BLOOD CLOTS.

WHAT ARE SOME OF THE PREVENTIONS FOR BLOOD CLOTS AROUND SURGERY?

DR. HALL: THE CONCERN WITH A BLOOD CLOT IS PATIENTS WHO HAVE A HIP OR NEW REPLACEMENT ARE AT A INCREASED RISK TO HAVE A BLOOD CLOT IN THEIR LEG FOLLOWING SURGERY.

THE DANGER IS IF IT GETS BIG ENOUGH AND WAKES UP AND TRAVELS TO THE HEART AND LUNGS, IT CAN CAUSE WHAT IS CALLED A PULMONARY EMBOLISM.

A BIG ENOUGH PULMONARY EMBOLISM CAN BE FATAL.

MOST ARE NOT TIERED STAR TREATABLE.

THEY CAN BE SERIOUS.

WE DO A LOT OF THINGS TO PREVENT BLOOD CLOTS.

WE PUT PEOPLE ON AN ANTICOAGULANT POSTOPERATIVELY AND THERE ARE SEVERAL AVAILABLE.

WE TEND TO USE ASPIRIN IN OUR PRACTICE.

WE ALSO HAVE PEOPLE WEAR THE WHITE STOCKINGS.

THAT HELPS KEEP THE BLOOD FROM CLOTTING AND PULLING IN THE VEINS.

WE ALSO GET PEOPLE UP AND GET THEM STANDING AND WALKING AS SOON AS POSSIBLE.

THAT IS PROBABLY THE BEST PREVENTION FOR A BLOOD CLOT AFTER A KNEE OR HIP REPLACEMENT, TO GET UP AND WALK OR MOVE.

WHEN PEOPLE WALK, EVERY TIME THEY TAKE A STEP, THEY CONTRACT THEIR CALF MUSCLES.

THAT HELPS MOVE THE BLOOD THROUGH.

THAT IS WHY SOMEBODY UP AND WALKING AND ACTIVE RARELY EVER GETS A BLOOD CLOT.

IT IS PEOPLE WHO ARE DEBILITATED FROM SOME MEDICAL CONDITION AND HAD TO HAVE SURGERY AND THEY ARE NOT WALKING AS MUCH AS THEY NORMALLY DO.

THE BEST PREVENTION IS TO GET UP AND WALK AND MOVE.

WE USE ALL OF THE ADJUNCT METHODS TO TRY TO PREVENT BLOOD CLOTS AS WELL.

MOST OF THE TIME WE CAN PREVENT THE BLOOD CLOTS.

WE TAKE IT SERIOUSLY.

IF SOMEBODY SHOWS SIGNS OF A BLOOD CLOT, WE EVALUATE THEM WITH AN ULTRASOUND AND IF THEY HAVE A BLOOD CLOT, WE TREAT THAT APPROPRIATELY.

DR. NALIN: SOUNDS LIKE LOTS OF WAYS TO PREVENT IT INCLUDING GETTING UP PROMPTLY AND MOVING.

DR. HALL: THAT IS WHERE THERAPY IS IMPORTANT.

DR. NALIN: DR. RASMUSSEN, HOW ABOUT THE STINGER INJURY OF THE NECK?

WHAT IS THAT AND HOW IS IT TREATED?

DR. RASMUSSEN: THAT IS A GOOD QUESTION.

IT CAN BE A SCARY INJURY.

IT IS CAUSED BY A SUDDEN INJURY TO THE HEAD OR NECK.

IT WOULD CAUSE PAIN GOING DOWN ONE ARM.

IT IS A SHARP BURNING NERVE PAIN AND THAT IS WHERE THE TERM STINGER COMES FROM.

IN ADDITION, YOU CAN ALSO SEE LOSS OF FUNCTION OF AN ARM AND HAND WITH A STINGER.

SO NERVE SYMPTOMS SUCH AS NUMBNESS OR WEAKNESS.

WITH A STINGER, THAT SHOULD RESOLVE IN A SHORT TIME.

OFTEN IN A MATTER OF MINUTES.

IF THE SYSTEM -- THE SYMPTOMS WERE TO PERSIST, THAT WOULD BE SOMETHING THAT WOULD NEED TO BE EVALUATED WITH IMAGING OF THE CERVICAL SPINE OR NECK.

DR. NALIN: THANK YOU.

DR. HALL, A CALLER WANTS TO KNOW, ARE THERE AGE LIMITS TO A KNEE REPLACEMENT?

COULD A PATIENT OVER THE AGE OF 80 HAVE A KNEE REPLACEMENT DONE?

DR. HALL: THERE IS NO ABSOLUTE AGE CUT FOR JOINT REPLACEMENT.

WE DO PATIENTS, WE DO THE REPLACEMENTS ON PATIENTS IN THEIR 80'S.

WHAT IS MORE RELEVANT IS THE PATIENT'S OVERALL HEALTH AND IF THE PATIENT'S OVERALL HEALTH WOULD SUPPORT A KNEE REPLACEMENT AND THEY ARE ACTIVE AND HEALTHY AND THEIR NEEDS ARE WORN OUT AND IF THE KNEE IS THE THING HOLDING THEM BACK FROM BEING MORE ACTIVE, THEY ARE GOOD CANDIDATES FOR KNEE REPLACEMENT.

THE PATIENT'S THAT WE SEE ARE MOSTLY IN THEIR 70'S AND 80'S.

THAT IS -- IF YOU GET TO BE OLDER AND HAVE MORE IN MEDICAL COMORBIDITIES, THAT MIGHT BE AN INDICATION TO DOING KNEE REPLACEMENT.

I DO NOT THINK THERE IS AN ABSOLUTE CUT OFF.

DR. NALIN: HOW ABOUT GLUCOSAMINE?

IS IT GOOD FOR BUILDING UP CARTILAGE AND STRENGTHENING BONES?

DR. RASMUSSEN: THERE IS MIXED EVIDENCE.

OVERALL, THE EVIDENCE IS WEAK.

IT IS USED BY PATIENTS.

TO TRY TO PRESERVE CARTILAGE.

IT IS NOT SOMETHING THAT IS GOING TO BUILD THAT CARTILAGE.

I USUALLY TELL PATIENTS, IT IS WORTH A TRY IF YOU HAVE ARTHRITIS OF A MAJOR JOINT SUCH AS A KNEE.

IT IS PROBABLY WORTH A TRY, MAYBE A MONTH'S TRIAL TO SEE IF IT HELPS WITH YOUR SYMPTOMS.

IF IT DOES NOT HELP, IT MIGHT NOT HE WORTH CONTINUING TO TAKE.

DR. NALIN: A CALLER FROM MINNEAPOLIS WANTS TO KNOW, AFTER HAVING TWO HIP REPLACEMENTS YEARS AGO, HOW MIGHT THEY KNOW WHETHER THEY NEED TO GET ONE OF THEM REPLACED?

WHAT ARE SOME SIGNS AND SYMPTOMS?

DR. HALL: IF THE HIPS ARE STILL FUNCTIONING WELL AND THE PIT -- AND THE PATIENT IS A PERCENT TO MEDIC, -- IS ASYMPTOMATIC, THEY PROBABLY DON'T NEED TO HAVE A REVISION.

IF THEY START TO HAVE PAIN THAT WAS NOT THERE BEFORE AND THERE IS SOME DRASTIC CHANGE AND IT A LEVEL OF FUNCTION, THEN I THINK IT IS WORTHWHILE TO HAVE IT EVALUATED.

THE FIRST STEP IN EVALUATING THE HIPS WOULD BE TO GET X-RAYS.

IF THERE IS ANY CONCERN ON THE X-RAYS, MAY BE FURTHER IMAGING WITH A CT SCAN.

IF THE PATIENT IS ASYMPTOMATIC AND THEY HAVE HAD HIP REPLACEMENTS, THERE IS NOT LIKELY ANYTHING WRONG.

IF THEY HAVE NOT BEEN SEEN OR EVALUATED FOR A LONG TIME, IT MIGHT BE WORTHWHILE TO SEE AN ORTHOPEDIC SURGEON, GET A SET OF X-RAYS AND BE SURE EVERYTHING LOOKS GOOD ON THE X-RAY.

THEY HIP REPLACEMENTS NOWADAYS CAN LAST A LONG TIME.

A PATIENT THAT IS 20 YEARS OUT FROM A HIP REPLACEMENT MIGHT BE DOING JUST FINE AND IF THEY ARE A SYMPTOM MEDIC, THEY PROBABLY WOULD NOT NEED ANYTHING FURTHER DONE.

DR. NALIN: DR. RASMUSSEN, A CALLER WANTS TO KNOW, WHAT ARE THE BEST WAYS TO TREAT SHINS POINTS?

>> SHIN SPLINTS ARE ACTUALLY ON KIND OF A CONTINUUM OF STRESS INJURY TO THE BONE, TO THE TIBIA.

IN THE LOWER LEG.

SHIN SPLINTS THEMSELVES CAN BE TREATED CONSERVATIVELY WITH WHAT WE DISCUSSED EARLIER.

REST, ICE, COMPRESSION, ELEVATION.

AND ALTERING THE AMOUNT OF ACTIVITY YOU ARE DOING.

FOR EXAMPLE, IF YOU JUST PICKED UP RUNNING AND YOU HAVE DEVELOPED SHIN SPLINTS, YOU'RE GOING TO WANT TO RUN OFF ON THE VOLUME OF RUNNING YOU ARE DOING.

TAKE A BREAK.

REST.

ROGER LABELED BACKUP.

IT IS A INJURY THAT CAN BE MANAGED CONSERVATIVELY.

MODIFICATION OF YOUR ACTIVITY SHOULD GO A LONG WAY.

DR. NALIN: A QUESTION NOW.

OUTSIDE INJURIES.

WHAT ARE THE OUTSIDE INJURIES ASSOCIATED WITH THE EYES?

DR. RASMUSSEN: A PRIMARY ONE WOULD BE I TRIM APPEARED YOU'RE STRUCK WITH AN OBJECT IN THE EYE, IF YOU ARE POKED WITH SOMETHING IN THE EYE, THOSE ARE THINGS WE ARE CONCERNED ABOUT.

IN THAT SCHEME OF THINGS, ADVICE WE GIVE TO PATIENTS WOULD BE IF YOU HAVE ANY SORT OF PERSISTENT BLURRY VISION AFTER AN INJURY LIKE THAT OR PAIN ASSOCIATED, THAT IS AN INJURY THAT SHOULD BE EVALUATED.

THAT WOULD BE A PRIMARY CONCERN FOR OUTDOOR INJURIES INVOLVING THE EYE.

DR. NALIN: DR. HALL, WHAT ABOUT KNEE DISLOCATIONS?

HOW DO THEY OCCUR AND HOW DO YOU TREAT THEM?

DR. HALL: KNEE DISLOCATIONS ARE A VERY SERIOUS INJURY.

IF YOU HAVE A TIBIA FEMORAL DISLOCATION, THAT USUALLY INVOLVES A HIGH ENERGY INJURY.

THAT MEANS USUALLY, FROM A CAR ACCIDENT OR SERIOUS ALL OR SPORTS INJURY.

A MORE COMMON DISLOCATION IS A PATELLA DISLOCATION.

THAT IS LESS SERIOUS.

IT IS A DISLOCATION OF THE KNEECAP.

THAT IS A MORE COMMON SPORTS INJURY.

IF THIS IS THE WAY THE KNEE IS LINED UP, THE PATELLA CAN DISLOCATE TO THE LATERAL SIDE.

IF IT DOES, SOMETIMES IT WILL SPONTANEOUSLY REDUCE AND GO BACK IN PLACE.

SOMETIMES IT REMAINS DISLOCATED TO THE SIDE.

IF IT DOES, THAT NEEDS TO BE SEEN PROBABLY IN AN EMERGENCY ROOM AND BE PUT BACK IN PLACE.

THAT IS A LESS SERIOUS INJURY THAN A KNEE DISLOCATION.

THE DANGER WITH AN ACTUAL KNEE DISLOCATION AS IT CAN DISRUPT THE ARTERIAL SUPPLY THAT RUNS DOWN THE BACK OF THE NEED.

THE BIG WORRY WITH A KNEE DISLOCATION IS AN INJURY THAT WOULD COMPROMISE THE CIRCULATION TO THE LEG.

THOSE ARE TWO DIFFERENT THINGS.

THEY ARE BOTH CONSIDERED KNEE DISLOCATIONS.

A MORE COMMON SPORTS INJURY WOULD BE A PATELLA DISLOCATION BY FAR.

THAT IS A COMMON THING.

WE SEE THOSE FREQUENTLY.

WE USUALLY PUT IT BACK IN PLACE AND TREATED CONSERVATIVELY.

IF IT WERE TO BECOME A RECURRENT PROBLEM, SOMETIMES SURGERIES REQUIRE TO STABILIZE THE PATELLA AND KEEP IT FROM HAPPENING.

DR. NALIN: A CALLER WHO WORKS STANDING ON HIS FEET QUITE A LOT WONDERS ABOUT BUNIONS AND HOW THEY MIGHT BE SYMPTOMATIC AND CAN BE TREATED.

DR. RASMUSSEN: BUNIONS ARE BONY PROTRUSIONS OR MALFORMATIONS.

OFF OF THAT FIRST BIG TOE JOINT.

THEY CAN DEVELOP OVER TIME.

THEY WOULD CAUSE PAIN RIGHT AT THAT SITE.

MOST OF THEM CAN BE MANAGED CONSERVATIVELY WITH TRYING TO WEAR A WIDER TOE BOX SHOE AND SOMETIMES PROVIDING SOME ADDITIONAL SUPPORT UNDERNEATH THE BUNION.

IF SOMEBODY WERE TO HAVE PERSISTENT PAIN BEYOND THOSE CONSERVATIVE MEASURES, IT MIGHT BE A GOOD IDEA TO GET X-RAYS AND TO BE EVALUATED EITHER BY AN ORTHOPEDIC SURGEON OR A PODIATRIST.

DR. NALIN: A CALLER ASKS ABOUT LOCAL KNOWLEDGE OR EXPERTISE REGARDING METAL ALLERGIES IN ANTICIPATION OF JOINT REPLACEMENT.

>> METAL ALLERGIES ARE RARE.

IT IS A CONSENT SOMETIMES BECAUSE SOME OF THE PROSTHESES WE USED TO HAVE NICKEL IN THEM.

THAT HAS BEEN RECOGNIZED AS A COMMON ALLERGY.

THERE ARE ALTERNATIVE PROSTHESES THAT DO NOT HAVE NICKEL.

IF SOMEBODY IS REALLY CONCERNED OR HAS A HISTORY OF A METAL ALLERGY, WE DO ALLERGY TESTING AHEAD OF TIME.

IF THEY DO HAVE A TRUE ALLERGY TO SOME OF THE METALS USED, WE LOOK FOR OTHER ALTERNATIVES.

AND SO A LOT OF PATIENTS THAT MAY HAVE HAD A REACTION TO SOME TYPE OF JEWELRY OR SOME OTHER METAL, A LOT OF TIMES THAT IS A NICKEL ALLERGY.

WE TEST THEM FOR THAT.

IF THEY HAVE A NICKEL ALLERGY, WE HAVE ALTERNATIVES WE CAN USE THAT DO NOT HAVE NICKEL AND WE CAN WORK AROUND A LOT OF THE METAL ALLERGIES.

DR. NALIN: CONSIDERING THE INCIDENCE OF CONCUSSION IN SPORTS, HOW IS THE EVALUATION AND TREATMENT OF CONCUSSIONS IMPROVED IN RECENT YEARS?

DR. RASMUSSEN: IT HAS IMPROVED QUITE A BIT.

OUR UNDERSTANDING OF IT HAS IMPROVED A LOT.

IT HAS BEEN A LOT OF RESEARCH DONE ON CONCUSSION OVER THE LAST 5, 10 YEARS.

THE OLD STANDARDS OF PRACTICE WHERE WHEN SOMEBODY WOULD GET A CONCUSSION AND WOULD OFTEN TIMES BE TOLD TO GO IN DARKROOM AND BASICALLY REST UNTIL THE CAUTION -- THE CONCUSSION HAD RESOLVED OR THE FLIPSIDE, THE CONCUSSION GOING UNNOTICED.

AN ATHLETE OR SPORTS PARTICIPANT BEING PUT BACK INTO A GAME, WE DON'T DO THOSE THINGS ANYMORE.

NUMBER ONE, IF SOMEBODY IS SUSPECTED OF HAVING A CONCUSSION DURING AN ATHLETIC EVENT, WE WILL IMMEDIATELY REMOVE THEM FROM PARTICIPATION AND MANAGE IT AS SUCH.

THE MAINSTAY FOR CONCUSSION MANAGEMENT IS STILL REST.

IT IS BRAIN REST.

CONCUSSION IS NOT A STRUCTURAL INJURY TO THE BRAIN.

IF WE DO NEUROIMAGING.

EITHER A CT OR MRI OF A PATIENT WITH A CONCUSSION, WE DO NOT SEE ANY DAMAGE.

IT IS A FUNCTIONAL INJURY TO THE BRAIN WHERE THE BRAIN HAS BEEN JARRED WITHIN THE SKULL AND IT NEEDS TIME AND REST TO GET BACK UP TO FULL PROCESSING SPEED.

YOU CAN THINK OF IT LIKE A COMPUTER THAT HAS LOCKED UP ON YOU AND YOU NEED TO REBOOT IT AND YOU NEED TO GIVE IT TIME TO RESTART.

THE MAINSTAY IS STILL REST.

NOWADAYS, RATHER THAN SAYING YOU GOT TO REST IN DARKROOM FOR TWO WEEKS, WE SAY REST BUT AS SOON YOU FEEL LIKE YOU CAN TOLERATE IT, WE LIKE TO ADVANCE PEOPLE BACK TO ACTIVITY AND THEIR NORMAL DAILY ROUTINE.

WE STILL HAVE WHAT WE CALL A GUIDED RETURN TO PLAY PROTOCOL FOR YOUTH AND FOR ATHLETES WHERE WE WILL NOT ALLOW THEM TO GET BANK INTO SPORT USUALLY WITHIN A SEVEN DAY TIMEFRAME.

THAT ALLOWS FOR A STEPWISE FASHION TO MAKE SURE THEY ARE TOLERATING A GRADUATED ADVANCEMENT OF THEIR ACTIVITY BEFORE WE ARE PUTTING THEM AT RISK FOR POTENTIALLY GETTING -- TO BE IN CONTACT SITUATION AGAIN WHERE THEY MIGHT GET THEIR HEAD INJURED.

DR. NALIN: A FEW BRIEF QUESTIONS TO WRAP UP.

ONE CALLER DESCRIBED AN INJECTION OF FAT INTO THE KNEE JOINT.

CAN IT OCCUR AGAIN AND HOW OFTEN?

>> AN INJECTION OF FAT INTO THE KNEE JOINT.

I AM NOT SURE.

>> I THINK WITHIN THE FIELD OF WHAT IS CALLED REGENERATIVE MEDICINE, THERE ARE PEOPLE THAT ARE EXPLORING THE IDEA OF USING FAT CELLS.

AS A WAY TO PRESERVE CARTILAGE.

I DON'T KNOW IF THERE IS ANY GOOD EVIDENCE SUPPORTING THAT.

DR. NALIN: DR. HALL, WHAT KEEPS THE BALL IN THE SOCKET OF A HIP THAT HAS BEEN REPLACED?

DR. HALL: YEAH, SO PART OF IT IS THE GEOMETRY OF THE HIP THAT KEEPS IT STABLE.

PART OF IT IS THE MUSCLE TENSION.

YOUR MUSCLES CONTRACT AND IT HOLDS THE HIP INTO PLACE.

WHEN YOU DO HIP REPLACEMENTS, IT IS IMPORTANT TO GET THE PARTS POSITIONED CORRECTLY BECAUSE IF THE PARTS ARE NOT POSITIONED CORRECTLY, IT CAN LEAD TO MORE PROBLEMS WITH INSTABILITY.

IT IS POSSIBLE TO DISLOCATE A TOTAL HIP REPLACEMENT AND THAT HAPPENS SOMETIMES.

WHEN IT DOES, WE CAN PUT IT BACK IN PLACE.

IF THERE IS A STRUCTURAL REASON SUCH AS THE ARTS AND MALL POSITION, SOMETIMES YOU HAVE TO REVISE IT TO GET IT BACK INTO PLACE.

MOST OF THEM ARE PRETTY STABLE.

AND MORE STABLE THAN THE OLD VERSIONS OF HIP REPLACEMENTS USED TO BE.

PEOPLE CAN BE PRETTY ACTIVE.

THEY CAN DO A LOT OF THINGS WITH HIP REPLACEMENTS.

WE USUALLY TRY TO RECOMMEND PEOPLE DO NOT GET THEIR HIP IN AN AWKWARD POSITION BECAUSE IF YOU GET INTO AN EXTREME POSITION, IT CAN PUT YOU AT RISK TO DISLOCATE THE HIP.

THE MUSCLE TENSION IS WHAT KEEPS IT TOGETHER.

DR. NALIN: GREAT.

I THANK YOU VERY MUCH AND I WANT TO THANK OUR PANELISTS.

DR. PATRICK CALL AND DR. CARL RASMUSSEN AND OUR PHONE VOLUNTEERS FROM WDSE.

PLEASE JOIN HOST DR. RAY CHRISTENSEN FOR A PROGRAM ON END OF LIFE AND ADVANCED CARE PLANNING WHERE HAS IT -- WHEN HIS PANELISTS WILL BE DR. JEFF COPEMAN AND DR. AMY GREMINGER.

THANK YOU FOR WATCHING.

GOOD NIGHT.

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