A New Decade As we enter a new decade, reflecting on the past sets the stage for what’s next. OAD looks forward to offering new services, locations and specialists, but OAD’s patient-focused orthopaedic and musculoskeletal care of unsurpassed quality remain our top priority. For those familiar with OAD’s history, the practice’s growth and prominence throughout DuPage County are remarkable. OAD began in 1981 when Douglas B. Mains, MD, started practicing in Carol Stream’s Mona Kea Medical Park. Today we are a six-location orthopaedic and musculoskeletal practice with on-site therapy and diagnostic testing services, MRI Centers and outpatient surgery center—the DuPage Orthopaedic Surgery Center. In keeping with OAD’s mission of providing a Center of Excellence for comprehensive orthopaedic care, we recently welcomed Marjorie Delaney, APN-FNP/BC, our first Advanced Practice Nurse and Research Coordinator. Marjorie’s nursing expertise and clinical research background offers enhanced patient care, in-depth research and a specialized skill set wellsuited for OAD. We’re also pleased to announce the addition (August 2010) of our 23rd physician, Mir Haroon Ali, MD, PhD, a spine/back and neck specialist, who is fellowship trained in orthopaedic spine surgery. Dr. Ali earned his undergraduate and medical degrees, in addition to a PhD, from the University of Chicago. He completed a surgical internship and orthopaedic surgery residency at the eminent Mayo Clinic in Rochester, Minn. In this ninth issue of OAD Orthopaedics Review, renowned knee and hip joint replacement, reconstruction and revision specialist, David M. Mochel, MD, describes how patients can experience rapid-recovery total knee and hip replacement with improved pain control (page 4). On page 6, Aaron A. Bare, MD, a shoulder, knee, and sports medicine specialist, explains the role platelet rich plasma can have in promoting healing. Kimberly Lueken, DPT, presents the goals of physical therapy for degenerative arthritis on page 11. In the Patient’s Perspective an OAD patient shares her total knee replacement success story and how she resumed an active lifestyle. We are grateful to our vendors and business partners for their generous support of OAD’s educational publication. With each issue, we keep discovering how respected and valued OAD Orthopaedics Review is as a source of orthopaedic information. Turn the page and see what’s next!
The Physicians of OAD Orthopaedics Mir H. Ali, MD,PhD (August 2010) Spine-Back and Neck Specialist
Stephen E. Heim, MD Spine-Back and Neck Specialist
David M. Mochel, MD Hip and Knee Specialist
John L. Andreshak, MD Spine-Back and Neck Specialist
Thomas W. Kiesler, MD Hand/Upper Extremity Specialist
Mary T. Norek, MD Physical Medicine and Rehabilitation Specialist
Aaron A. Bare, MD Shoulder, Hip, Knee and Sports Medicine Specialist
Jerome L. Kolavo, MD Spine-Back and Neck Specialist
Anup A. Bendre, MD Hand/Upper Extremity Specialist
Lenard W. LaBelle, MD Shoulder, Knee and Sports Medicine Specialist
David K. Chang, MD Hip and Knee Specialist
Mary Ling, MD Hand/Upper Extremity Specialist
Rachel A. Cisko, DPM Podiatric Physician and Surgeon
Richard L. Makowiec, MD Hand/Upper Extremity Specialist
Beth B. Froese, MD Physical Medicine and Rehabilitation Specialist
Vinita Mathew, MD Physical Medicine and Rehabilitation Specialist
Gregory P. Witkowski, MD Foot and Ankle Specialist
Matthew D. Gimre, MD Nonsurgical Sports and Orthopaedic Medicine Specialist
Steven E. Mayer, MD Physical Medicine and Rehabilitation Specialist
Emeritus Physicians Douglas B. Mains, MD John F. Showalter, MD
Jeffrey A. Senall, MD Foot and Ankle Specialist William R. Sterba, MD Shoulder, Hip, Knee and Sports Medicine Specialist Richard K. Thomas, MD Hand/Upper Extremity Specialist David H. Watt, MD Shoulder, Knee and Sports Medicine Specialist
In this issue
Vol. 5, No. 9
4 Knee & Hip Replacement Recovery Making recovery smoother for joint replacement surgeries 6 Platelet Rich Plasma (PRP) to Improve Soft Tissue Healing Using our own cells to promote healing 8 Patient’s Perspective: Total Knee Replacement 11 Healing Knees Physical therapy for degenerative arthritis
A publication from
Warrenville ■ Wheaton ■ Naperville Carol Stream ■ Bartlett ■ Winfield (630) 225-BONE (2663) ■ (630) 225-2399 Fax www.OADortho.com Main OAD Office Medical Offices at Cantera 27650 Ferry Road, Suite 100 Warrenville, IL 60555-3845 Medical Offices at Danada 7 Blanchard Circle, Suite 101 Wheaton, IL 60189-2038 Medical Offices at Naperville 101 East 75th Street, Suite 100 Naperville, IL 60565-1469 Mona Kea Medical Park 515 Thornhill Drive, Suite A Carol Stream, IL 60188-2703
OAD Orthopaedics Review is an educational and informative resource for physicians, health care professionals, employer groups, and the general public. This publication provides a forum for communicating news and trends involving orthopaedic-related diseases, injuries, and treatments, as well as other health-related topics of interest. The information contained in this publication is not intended to replace a physician’s professional consultation and assessment. Please consult your physician on matters related to your personal health.
Physician Offices & Convenient Care Center at Bartlett Commons 820 Route 59, Suite 320 Bartlett, IL 60103-1694
OAD Orthopaedics Review is published by Oser-Bentley Custom Publishers, LLC, a division of Oser Communications Group, Inc., 1877 N. Kolb Road, Tucson, AZ 85715. Phone (520) 721-1300, fax (520) 721-6300, www.oser.com. Oser-Bentley Custom Publishers, LLC specializes in creating and publishing custom magazines. Editorial comments: Karrie Welborn, firstname.lastname@example.org. Please call or fax for a new subscription, change of address, or single copy. This publication may not be reproduced in part or in whole without the express written permission of Oser-Bentley Custom Publishers, LLC. To advertise in an upcoming issue of this publication, please contact us at (520) 721-1300 or visit us on the Web at www.oser-bentley.com. May 2010
Medical Offices at Central DuPage Hospital 25 North Winfield Road, Suite 507 Winfield, IL 60190-1295
OAD ORTHOPÆDICS Review 3
KNEE & HIP REPLACEMENT
Knee & Hip Replacement Recovery with David M. Mochel, MD, FACS Knee and hip replacement surgeries are among the most common orthopaedic procedures performed today. Over the years, these surgeries have become less invasive and physicians are focused on easing recovery for the patient. OAD Orthopaedics tries to make the road to recovery smoother for each patient. This is done through comprehensive pre-operative planning and exercise, choosing minimally invasive methods during surgery, and minimizing post-operative pain and providing an individualized rehabilitation plan for after surgery.
BEFORE SURGERY The road to a smooth recovery begins before surgery. Prior to surgery, a patient must be evaluated by their primary care physician to determine if the patient is healthy enough to undergo surgery, and to determine if evaluations by other specialists are necessary. The patient’s overall health prior to surgery can have an impact on recovery time post-surgery. In order to speed and ease recovery, a preoperative exercise plan might be developed for the patient, depending on their physical abilities. The exercise plan would ideally begin at least a couple of months prior to the scheduled surgery. “The better shape 4 OAD ORTHOPÆDICS Review
people can get themselves in prior to surgery, the quicker their recovery will be,” said Dr. David Mochel, an orthopaedic surgeon with OAD. It can sometimes be too painful for the patient to exercise, but Dr. Mochel suggests non-pounding exercise, such as water exercise and biking. The surgeon will also go over a postoperative care plan with the patient prior to surgery. The preferred option is to release the patient to recover at home after surgery, but Dr. Mochel stressed the importance of having a willing and able caregiver. Without a caregiver, a patient goes to a rehabilitation facility to begin the recovery process.
SURGERY Knee and hip replacement surgeries have become less invasive with smaller deep incisions, said Dr. Mochel. He said the skin incision is irrelevant, what matters is the deep incision. Advancements have also been made in the implants used for hip and knee replacements. The implants have become more gender specific, with improved sizing for female patients. Also, better materials have increased the life span of artificial hips and knees. Surgeons are using a multimodal anesthesia method to attempt to reduce the amount of drugs a patient receives as well
as minimize post-operative nausea and vomiting. With multimodal anesthesia, patients recieve a combination of nerve blocks, IV sedation or spinal/regional anesthesia. Better pain medications and anti-inflammatory medications help control nausea and vomiting. After a two- or three-day hospital stay, the patient is allowed to go home with a caregiver, or the patient moves to an acute or subacute rehab facility. A rehabilitation medicine physician may evaluate the patient in the hospital to determine rehab placement. Acute rehab tends to be more intense and is an option for healthier patients. Insurance is also a determining factor in choosing the type of rehabilitation facility.
RECOVERY In the ideal world, a patient would return home following surgery, but the key is they have to have a willing and able caregiver, said Dr. Mochel. Healthier, younger patients are usually able to go home from the hospital sooner. Patients who go directly home have home therapy and home nursing for two to three weeks. After home therapy, the patient converts to outpatient therapy. A rehabilitation plan, whether at home or in a facility, focuses
on helping the patient walk better with their new knee or hip by working on their range of motion and building strength. Hip replacement patients typically recover a little faster than knee replacement patients, and as after any major surgery, may take six to 12 months to fully recover. The replaced joint tends to feel more normal as time progresses. Returning to work and sports depends on an individual’s personal work and activity demands. Patients returning to desk work often go back to work between two and four weeks, and patients with a physically demanding job return to work between six and 12 weeks. Patients can begin light sports, such as golf, swimming and a normal workout, after about six weeks. They are able to begin playing more strenuous sports, such as tennis and racquetball, after about 12 weeks. Recovery from hip or knee replacement is a very individualized process and is different for every patient. “It’s important not to compare yourself to your neighbor,”
said Dr. Mochel. Through physical therapy, patience and a bit of hard work, the vast majority of patients recover and return to a normal, active lifestyle. David M. Mochel, MD, FACS, earned his medical degree from the University of Illinois College of Medicine in Rockford and completed his postgraduate training at the Grand Rapids Orthopaedic Surgery Residency Program in Grand Rapids, Mich. Dr. Mochel specializes in adult reconstructive surgery, with expertise in hip and knee total joint replacement, revision and arthroscopic procedures. Board certified by the American Board of Orthopaedic Surgery, he is a member of the American Academy of Orthopaedic Surgeons, and a Fellow of the American College of Orthopaedic Surgeons, the American College of Surgeons, and the International College of Surgeons.
OAD ORTHOPÆDICS Review 5
PLATELET RICH PLASMA
Platelet Rich Plasma (PRP) to Improve Soft Tissue Healing Using our own cells to promote healing By Aaron A. Bare, MD An injured extremity, either a bruise or tear to a muscle or tendon, requires our body’s innate ability to heal or repair the damaged structure. Most acute injuries, such as sprains or contusions (bruises), incite an inflammatory cascade that begins the healing process. The inflammatory process recruits specialized healing cells that mend our damaged tissues. Inflammation is our body’s normal healing response to an injury. The by-product of healing produces warmth, swelling and discomfort in the involved extremity. Fortunately, most soft tissue injuries heal without difficulty or the need for intervention (i.e., sprains, strains). These injuries may benefit from modalities such as ice, elevation or medications to treat our symptoms during the healing process. Some injuries, however, are not capable of healing without assistance and require surgical repair or reconstruction of the damaged ligament or tendon. One example of this is a full or complete rotator cuff tear (Fig. 1). The rotator cuff is an important tendon in our shoulder that assists in arm elevation. An injury to this tendon will typically cause weakness and pain with reaching and lifting. For appropriately selected situations, an arthroscopic repair of the torn tendon re-establishes the connection (Fig. 2a, 2b) of the tendon to the bone. As the tendon is sutured or repaired to the bone, our body must develop a union between the tendon and the bone once it is reattached (via sutures). The repair begins the inflammatory pathway, ultimately resulting in a healed tendon. The majority of soft tissue injuries heal properly with our body’s normal
biological response and most sprains and strains will resolve on their own. Some situations such as large rotator cuff tears or chronic elbow tendonitis create a biologically unfavorable healing environment. For instance, large rotator cuff tear repairs have a relatively high re-tear rate (ranges 30-70 percent). In an effort to improve or assist our body’s ability to heal, biological adjuncts are now available to treat select musculoskeletal injuries, especially those that may not heal well on their own. PRP, platelet rich plasma, can enhance or improve our healing response. PRP is a concentrated dose of platelets from our own blood that stimulates a supra-physiological healing response. Platelets are the key cells involved in our healing response. These cells recruit or signal other specialized cells to the injured area to maximize healing potential. PRP delivered in a concentrated fashion will increase the platelet concentration more than 10 times seen in the body’s normal healing response. PRPs’ potential benefit is twofold. First, the time for soft tissue healing may decrease. This can be advantageous in returning an active individual or athlete back to their sport or normal activities earlier than traditional healing times. Also, the strength of a surgically repaired tendon or healing structure may improve. These potential advantages have been shown in both laboratory and human studies, which are currently being conducted to verify these beliefs.
Fig. 2a & 2b Rotator cuff tendon repaired to bone Fig. 2a
Fig. 1 Rotator cuff tendon detached from bone Fig. 1
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PLATELET RICH PLASMA
Fig. 3 Centrifuged blood creates a clear layer (on top) of platelet rich plasma Fig. 5
Fig. 4a Arthroscopic insertion of two platelet rich clots under rotator cuff tendon
Fig. 4b Tendon reattachment to bone with platelet between tendon and bone
For example, a 60-year-old male with a previously repaired arthroscopic rotator cuff has a tear that did not fully heal but instead re-tore. During the second arthroscopic procedure, platelet rich biological clots were inserted between the torn tendon and bone to facilitate healing of the rotator cuff. For situations such as these, when an injury has a tenuous healing environment, it may benefit from PRP and improve the healing response. The delivery of the substance is typically minimally invasive. Platelets can be delivered either through an injection (Fig. 3) or clot-delivered arthroscopically during surgery (Fig. 4a, 4b). The technique delivers platelet rich plasma, produced from a patientâ€™s own blood via a centrifuge process (Fig. 5), directly to the healing area without creating additional trauma to the injured area. Other injuries that may benefit from biological augmentation are elbow epicondylitis, ACL reconstructions and ligament sprains failing traditional conservative measures. Most soft tissue sprains, strains and tears do not require PRP to heal well. However, in situations where healing is a concern, a biological augmentation (platelet rich plasma) can increase the healing potential of the injured structure. PRP is a safe and inexpensive treatment and holds the future of improved healing.
Fig. 5 Whole blood centrifuge isolates platelet rich plasma and suturable clots can be produced
American Board of Orthopaedic Surgery, he is a member of the Arthroscopy Association of North America, the American Orthopaedic Society for Sports Medicine and the American Academy of Orthopaedic Surgeons.
Aaron A. Bare, MD, earned his medical degree from Northwestern University Medical School and completed his surgical internship and orthopaedic surgery residency at Northwestern. Fellowship trained in sports medicine from the Southern California Orthopedic Institute in Los Angeles, Dr. Bare has treated a wide variety of amateur and professional athletes and specializes in comprehensive care of the shoulder and knee. His areas of expertise include shoulder and knee arthroscopy and joint replacement, advanced reconstruction of the shoulder, and hip arthroscopy. Board certified by the
OAD ORTHOPĂ†DICS Review 7
Total Knee Replacement Continuing an active life By Karrie Welborn In 1968, when Cecille Gerber was in her first year of teaching high school English at Glenbard East High School in Lombard, Ill., her little Chevy was hit by another driver and slammed into a tree. Her right knee, which hit the gear shift on the floor, was seriously injured. In emergency surgery at Elmhurst Hospital, Dr. Alvin Kanter reattached the severed ligaments and for the next 37 years, she lived, worked and played without any serious knee problems. There was a 7-inch diagonal scar, but other than this minor cosmetic flaw, the knee was good for pretty much all knee-work necessary over the years. Throughout those 37 years, Cecille gardened, golfed, roamed her Glenbard classroom in heels, and enjoyed other activities. If, occasionally, the knee twinged, or ached, basic common sense behaviors were enough to retain ease of mobility and strength. 8 OAD ORTHOPÆDICS Review
Cecille Gerber in Alaska
As Cecille approached her 60s, the little aches and twinges became more problematic and less comfortably eased. To top that off, she helped a friend clean and paint a country house, which meant she spent the day running up and down stairs, among other tasks. As she was getting out of the car after the busy day, her foot caught, her knee locked, and she knew she was going to have to review the health of the knee and her own activities. Even so, it took a good two years and an occasional cortisone shot for her to act upon the realization that her knee really did need surgery. Her first inquires into surgical solutions brought comments like, “Well, you’ll never kneel again,” along with the prospect of a seriously curtailed activity roster. This was not something Cecille was willing to accept. In search of a second
opinion, she arrived at the office of Dr. David K. Chang, of OAD Orthopaedics. At Dr. Chang’s office she found a physician whose professional demeanor included a kind gentleness that blended with his expertise. However, it was his willingness to listen to questions and relay clearly what he saw as necessary that clinched the decision for Cecille. She felt immediately that she had found her surgeon. Cecille said, “He was so personable, and there was never any condescension in his voice. In fact,” she continued, “on my second visit or so I said, ‘Dr. Chang, I have a few questions for you.’ And you know what he said? ‘Good! Let’s hear them!’” The surgery was set for mid-February 2007. The scar tissue from her emergency surgery in 1968 meant the surgery in 2007 was a little more complex than
most total knee replacement surgeries, but the complexity was not an issue for Dr. Chang. The surgery was successful. Following her release from the hospital, Cecille had two weeks of in-home physical therapy followed by three weeks of outpatient physical therapy at Marianjoy Rehabilitation Hospital in Wheaton, Ill. Cecille also utilized a Continuous Passive Motion (CPM) machine several hours a day, at home. CPM is a prescribed, aftersurgery total knee therapy. The machine moves the joint automatically, through a range of motion for a specified period of time. The movement and the length of time is set (prescribed) by the surgeon. Cecille was driving herself around as early as three weeks after the surgery. A year later, almost to the day, Cecille was on her way to Alaska to see the Aurora Borealis and experience Alaskan sports such as snowshoeing and mushing a dog sled. She admits to requesting only three dogs to mush rather than the usual four-dog team, in order to go slightly slower. During this
first year post-surgery, Cecille had been conscious of a new vulnerability in herself regarding the knee, but this Alaskan debut of sports activities clearly proved that she not only could kneel, at will, she had the strength and flexibility to continue a very active life. Since her first total knee replacement surgery Cecille has had occasion to refer friends to Dr. Chang. Interestingly enough he does not always recommend surgery as the treatment of choice. With one referral he recommended specific exercises, for another he recommended arthroscopic surgery. A third referral was told that the problem was her back, not her knees. Surgery is not always the treatment needed. When it is, Dr. Chang is clear David K. Chang, MD about the risks and the timing. During Cecille’s first surgical consultation, Dr. Chang informed Cecille that her left knee would ultimately need surgery,
but that there was no immediate hurry. This gave Cecille not only time to heal from and experience the positives of her first surgery, but also to cultivate an awareness of the left knee so she would know when it was the right time to address the surgical need. In March 2010 Cecille returned to the hospital for a total knee replacement surgery—but on the left knee. The procedure itself holds no fears for Cecille, after the positive experience of three years ago, she knows that although surgery may bring initial discomfort, the bottom line is that the surgery works. Cecille can kneel (or snowshoe, or mush dogs in Alaska) whenever she likes! Cecille’s story was suggested for OAD Orthopaedics Review by Jeanne (Gigi) DiPirro, RN, Dr. Chang’s nurse. Jeanne felt that sharing Cecille’s positive experience would be an excellent way to ease fears and educate readers regarding the total knee replacement procedure. That Cecille’s story is also an inspiring one, is certainly a bonus!
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Healing Knees Physical therapy for degenerative arthritis By Kimberly Lueken, PT, DPT, CSCS Degenerative arthritis of the knee can be problematic for a large majority of the population. Not only can these conditions cause the knee to be painful, they may bring about muscle imbalances, loss of motion and pain in the joints above and below the knee. For example, many people with degenerative knee conditions will lose knee extension (straightening), forcing them to walk with a flexed (bent) knee. This may be due to a weak quadriceps muscle or pain. Changes in the biomechanics of the knee
may result in loss of ankle dorsiflexion range of motion and plantarflexion strength, along with increased hip flexor tightness and decreased hip extension strength. Biomechanical changes in the lower extremity can cause the lumbar spine to compensate and may result in low back pain. A total knee replacement (arthroplasty) is a surgery most commonly performed on people who have degenerative arthritis and limited function due to pain or weakness. Many patients find they are unable to participate in activities they previously enjoyed,
such as regular exercise, golf and playing with their grandchildren. Conservative treatment methods, including medications, injections, rehabilitation and the use of an assistive device, are not always enough to restore prior function. Once the patient and surgeon have decided that a total knee arthroplasty is indicated, surgical procedure and post-operative expectations are explained to the patient by the medical team. One of the most important factors in the surgical outcome is the rehabilitation following a total knee replacement. OAD ORTHOPĂ†DICS Review 11
Fig. 1 Measurement of patient’s knee flexion range of motion
The goal of physical therapy following a total knee replacement is to restore a functional and healthy lifestyle. The rehabilitation program will be designed to allow the patient to ambulate safely with or without an assistive device, improve range of motion, increase strength and restore balance. Improvement to each of these areas will permit the patient to stand longer, walk further and participate in activities they enjoy. The physical therapist will also use modalities such as ice, heat, ultrasound or electrical stimulation to help control pain that may occur after surgery. Typically, after the patient is released from the hospital, a physical therapist will go to their home for approximately two weeks. The home health care physical therapist will instruct the patient on safe ambulation, proper stair climbing and exercises to increase range of motion and strength. Once the patient is more mobile and comfortable, outpatient physical therapy is scheduled. During the patient’s first outpatient physical therapy visit, the therapist discusses goals the patient would like to 12 OAD ORTHOPÆDICS Review
Fig. 2 Patient performing functional quadriceps strengthening exercise
achieve and prepares an individualized plan of care. Measurements for swelling, range of motion (Fig. 1) and strength are recorded. These measurements are rechecked regularly to chart progress and allow the physical therapist to communicate with the surgeon regarding the patient’s improvement. A biomechanical analysis of the patient’s gait is used to assess any other areas (i.e., hip, foot) that need to be stretched and strengthened to contribute to optimal recovery. Return visits may include soft tissue massage, electrical stimulation and ice to help reduce pain and swelling. Stretches (passive range of motion) will be performed by the therapist to increase knee flexion and extension. How much range of motion a patient can achieve is dependent on what the patient’s range was prior to surgery. However, most physicians would like zero degrees of extension to approximately 120 degrees of flexion. Patients will be instructed in strengthening (Fig. 2) and proprioceptive exercises using different equipment in the therapy gym. Once adequate strength is obtained, the therapist will work to
progress the patient off their assistive device and ambulate stairs normally. Most patients will be in outpatient physical therapy for up to six weeks. Prior to being discharged from physical therapy the therapist will review any exercises the patient may need to do in order to maintain good strength and range of motion. Overall, with hard work and dedication, each patient should be able to achieve all the goals initially set in physical therapy. Upon completion of outpatient physical therapy, patients will have received the appropriate tools to allow them to continue a full and productive life. Kimberly Lueken PT, DPT, CSCS, joined OAD Orthopaedics in 2005. She earned her Master’s degree in Physical Therapy from Clarke College in Dubuque, Iowa in 2002. She recently finished her Doctorate of Physical Therapy degree from A.T. Still University in Mesa, Ariz.
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