Minimally Invasive Anterior Approach to Total Hip Replacement

For the past 20 years, since the beginning of my residency, I have been using the posterolateral approach for total hip replacements. While this approach is extremely common, very useful, and works well, it does have the drawback of having a higher potential for dislocation than some of the other approaches.

One of these approaches involves coming from the front, or “anterior” side of the hip. Dr. Phil Downer, one of my partners in Orthopedic Specialists of Seattle, has been using this approach for 3-4 years, and has been very pleased with the results. I have been performing the approach with him recently, and I, too have been impressed with the simplicity of the technique, and the more rapid recovery it provides.

I will therefore now be offering this exciting new technique to my patients. Should you be a candidate for hip replacement, I look forward to discussing this with you personally in clinic.

– Charles Peterson II, MD

Hand Masses-Lumps and Bumps on the Hand and Wrist

I see many patients with different types of lumps and bumps of the hand and wrist. The vast majority of hand and wrist tumors are benign (non-cancerous), but they should all be evaluated by an orthopedic hand specialist. Any abnormal mass or growth is considered to be a “tumor”. These can occur on the skin, like a mole or a wart, or can be underneath the skin in the soft tissue, the fat layer, the muscle, or even the bone. There are many different types of tissues in the hand and wrist, so many types of tumors can occur.

What are the most common hand and wrist masses?

Ganglion cysts – These are the most common type of mass that represents around 50% of all hand and wrist growths. A ganglion cyst occurs when the tough lining of the small joint forms a pouch where joint fluid collects resulting in a “ballooning-out” of the lining of the tendon sheath or joint. This fluid is very thick, with a molasses-like consistency and when it fills the cyst, it makes it feel very firm. These cysts can also form as pouches off a knuckle joint or tendon sheath and are often referred to as mucous cysts. The treatment options I offer for these include aspiration, where the mass is punctured and the fluid is removed with a needle, or removal by means of surgery.

Giant Cell Tumor of the Tendon Sheath – Giant cell tumors are not true tumors as much as they are firm masses, and they are the second most common types of hand and wrist masses. These masses develop from joint lining known as synovium or from a tendon sheath. Giant cell tumors grow slowly and are quite painful. I can usually easily remove these lesions, but they often come back. Though these growths sound bad but they are slow growing and benign.

Epidermal Inclusion Cysts – I see these masses after an injury to the hand or finger and they often show up years later. An inclusion cyst develops just underneath the skin and is often quite firm. When an injury such as a deep cut occurs, the surface cells are pushed into the deep layers of the palm or finger resulting in the formation of a cyst in the area of injury. Skin cells produce a protective, way substance called keratin and when skin cells get trapped under the surface, they will continue to grow and make this keratin, which forms the cyst.

Carpal Boss – This common type of mass isn’t a tumor, but rather is an overgrowth of bone on the back of the hand. Carpal bosses are similar to bone spurs and often are often misdiagnosed as ganglion cysts. This type of mass is firmer and not movable, however. Occasionally the bump of a carpal boss is problematic, I might recommend removal of the symptomatic bone spur.

Enchodroma – When the cartilage grows inside the bone, an enchodroma occurs. These masses are non-cancerous but can present a problem when the bone becomes weakened and can lead to a fracture from weak bone. Usually I can fix the fracture while bone grafting the lesion to treat the lesion. Again, these are usually benign.

Lipomas, Neuromas, and Fibromas – These masses are all usually benign growths. Lipomas are fatty tumors, neuromas are nerve tumors, and fibromas are tumors of the fibrous connective tissue material of the hand and wrist. They can occur on the hand and wrist regions and are usually benign but often symptomatic. Many patients request removal of these lesions which not only treats the lesion, but provides a firm diagnosis.

Should I worry about cancer?

Though uncommon, the most common kinds of cancer that affects the hand and wrist include squamous cell carcinoma, basal cell carcinoma, and melanoma. While cancer seldom originates in the hand and wrist region, there are rare cases of bone and cartilage tumors that could result. When cancer originates in the hand, it is called sarcoma and is due to abnormal growth of the bone, cartilage, or soft tissues. While sarcomas are rare, it is always best to come to my office for an evaluation if you have a concerning mass of the hand or wrist.

What will an orthopedic specialist do for a lump or bump of the hand or wrist?

First of all, I will perform a careful history and physical examination to help determine the type of hand or wrist tumor you have. Often, x-Rays may be necessary to evaluate the bones, joints, and soft tissues. Further diagnostic studies, such as CT, MRI, or Bone Scan, might narrow down the diagnosis. Treatment will depend on the type of mass you have. Generally, definitive treatment with the lowest recurrence rate involves the surgical removal of the mass. This will allow me to send the tissue off to a pathologist to analyze it and determine what exact type of growth you have.

In general, I recommend evaluation of all hand masses to establish a firm diagnosis and a reasonable treatment plan. Most tumors are benign, but can often be symptomatic. Usually excision of the lesion is curative and can help provide a reassuring diagnosis.

Common Knee Problems

Almost everyone will have a minor knee problem during their lifetime. Our body movements don’t cause us problems most of the time, but some symptoms related to the knee can develop from every day wear-and-tear, injury, or simply from over use of the knee joint. These knee problems often happen during sporting activities or work-related tasks.

Some people are more likely than others to develop knee injuries andproblems. There are factors that increase your chances of having these issues such as certain jobs, sporting and recreation activities, getting older, or having a disease like arthritis or osteoporosis. Knee problems are the most common reason for visiting an orthopedic specialist’s office. … read more

Cubital Tunnel Syndrome and Surgery

Cubital Tunnel Syndrome is a condition where the ulnar nerve of the upper extremity is pinched as it passes behind the elbow. Nerve compression from increased pressure leads to numbness, tingling, pain, and weakness of the affected arm and hand.

Cubital tunnel syndrome often presents as a tingling sensation in your hand like you have hit your “funny bone.” When you do hit your elbow a certain way, the sensation you feel is the result of irritation to the ulnar nerve. This leads to a shooting sensation of tingling, pain, and numbness into the small finger and the ring finger. Your ulnar nerve will transmit a signal to your brain to allow these sensations to be felt.

What causes Cubital Tunnel Syndrome?

Cubital Tunnel Syndrome is the result of some form of pressure on the ulnar nerve. Pressure on the ulnar nerve develops in several different ways. The ulnar nerve is located right next to the bone and doesn’t have much padding over it. When pressure is put on this nerve, the syndrome develops.

Pressure on the ulnar nerve can also occur when you keep your elbow bent in a certain position for a long time. This stretches the nerve as it crosses through the cubital tunnel and narrows the tunnel itself. This often occurs during sleep. It may also occur when holding a phone for a prolonged period of time.

For some people, the connective tissue over the nerve gets thicker and this causes pressure on the nerve. Cubital Tunnel Syndrome occurs when the pressure is significant enough and sustained enough to interfere with the way this particular nerve functions.

What are the symptoms of Cubital Tunnel Syndrome?

If you have this syndrome, you will have pain, numbness, and tingling in the small finger and the ring finger. These symptoms are generally felt when you have pressure on the nerve such as sitting with the elbow on an arm rest or during a repetitive motion of moving the elbow in a bending position and then straightening it.

In addition, you will have weakness of the muscles in the hand or clumsiness with use of the hand. These weakened muscles are called the intrinsic muscles of the hand, and they help with finger movements. People who have more severe symptoms will frequently drop objects that they pick up and also have difficult with the fine motor movements of the fingers.

How is Cubital Tunnel Syndrome diagnosed?

The diagnosis of Cubital Tunnel Syndrome is concluded after a complete history and examination is done by an orthopedic specialist. If there is a concern that something abnormal may be causing the nerve compression, X-Rays and other imaging may be necessary to evaluate this elbow, arm and hand. Nerve conduction studies, called EMGs, will help the doctor determine the extent and location of the nerve compression.

How is Cubital Tunnel Syndrome treated?

Many people can be treated for Cubital Tunnel Syndrome with anti-inflammatory medications, especially if the EMG test shows that the pressure is only minimal. Sometimes, the orthopedic specialist will splint the elbow, especially at night. Another treatment option is the use of padding for the elbow during work or sporting activities. If these non-operative treatments fail to provide relief, surgery will be necessary to eliminate the pressure from the ulnar nerve.

Surgery for Cubital Tunnel Syndrome

The goal of surgical treatment for Cubital Tunnel Syndrome is to alleviate the pressures on the Ulnar Nerve. This can be accomplished through a minimally invasive technique called Endocscopic Cubital Tunnel Release. Dr. Weil is currently the only surgeon at Swedish Hospital performing this type of surgery. It involves a small incision behind the elbow in order to insert the camera into the tunnel and to release the nerve.

Post-operatively, patients are placed in a soft bandage for 4 days and can resume light activities immediately after surgery. The recovery from this type of surgery is much faster than traditional open surgical approaches.

Patients who are not candidates for this procedure can be treated with open procedures such as an ulnar nerve transpostion. This involves moving the ulnar nerve from the back of the elbow to the front of the elbow. The nerve may be put under a layer of fat, under the muscle tissue, or deep within the muscle. Following surgery, recovery depends on what the surgery entailed and what needed to be done. Most people recover well in a couple of months.

Hand Numbness – Common, but Usually Worth Investigating

Many people, both young and old, find hand numbness quite bothersome. Hand numbness is sometimes persistent, but often becomes worse in specific situations – waking up at night, driving, talking on a cell phone, sporting events, fishing, at work, ect. Usually, patients come to my office thinking that a numb hand is a part of life, but in reality, a numb hand usually means that a nerve is being choked off by abnormal positions and usually abnormal anatomy.

Though many feel that the numbness can be managed, my concern is that the same nerves which provide sensation, also provide valuable strength and dexterity for hand function, which often is already compromised by the time that a patient comes in for evaluation.

How is it diagnosed?

The two most common nerves that are compressed are the median nerve at the wrist, typically known as Carpal Tunnel Syndrome, and the ulnar nerve at the elbow, called cubital tunnel syndrome. There are certainly many other areas of nerve compression which can give a sense of numbness, which can be evaluated with a simple clinical exam or an electrical nerve study. Typically, I perform a full examination of all the nerves of the upper extremity and based on the findings, may order further studies such as a nerve conduction test, X-ray or an MRI to confirm or rule out my diagnosis.

What can be done?

The first key in treatment is to establish the correct diagnosis. Based on the particular nerve at risk, sometimes simple activity modifications or splinting can prevent a particular nerve from being susceptible to compression.

Sometimes, the nerve has been compressed for a long period of time or the nerve is at particular risk and I may offer a nerve decompression to permanently relieve the damaging effects of nerve compression and the numbness and muscle dysfunction that is likely to worsen if left untreated. These surgeries are day surgeries and usually are quite well tolerated.

Most of my patients compare them to dental type procedures, where soreness for several days occurs, but you are able to continue with your routine life. The decompression surgeries can be performed with modern minimally invasive techniques that can greatly minimize the pain and disability resulting from the procedure.

If you have numbness symptoms that you would like evaluated, do not hesitate to contact my office at 206-633-8100