Switching to Anterior Approach for THR

I initially looked at switching to the anterior approach (going into the hip from the front rather than the side or back of the hip) because the PAs (physician assistants), nurses, and physical therapists in my hospital all told me that they felt that the patients who had anterior approaches were having significantly less pain and were able to rehabilitate faster.

I have a partner who was one of the first people in the Seattle area to do anterior approach THR and the hospital staff could watch the difference in how the patients recovered after their surgery.

Anterior Approach

Finally one day I asked our head PA how she would want her total hip done and she said definitely by the anterior approach. At that point I knew I had to learn more about it and whether it was reasonable for a surgeon that has always done THR through a posterior approach to change to a dramatically different technique and still be confident that my patients would benefit.

I first observed the technique in the operating room and then studied the anatomy of the anterior approach. The first obvious benefit is that the approach to the hip from the front is anatomically easy and does not involve cutting any major structures to get to the hip. You simply spread the interval between two muscles and you are down onto the hip capsule.

When you go in from the back you have to divide the gluteus maximus (butt) muscle and split part of the ilio-tibial band on the side of the hip and then cut several small tendons off the back of the hip.

The thing that stops a lot of surgeons from doing this approach is that it is so different from what they are used to. The other thing that stops them is the special technique that is necessary to place the stem into the femur (upper thigh bone). When you approach the hip from the back, it is fairly easy to place the stem of the implant into the femur.

From the anterior approach most surgeons use a special table called a fracture table that allows you to position the leg in a very specific way. In my case, all of the operating room staff and my assistants were used to doing this approach and that made my job a lot easier.

Once I decided that I wanted to learn this technique, I went to a lab where you can practice on cadavers. I was surprised at how easy the approach was and how well I could get good exposure of the socket and the femur to do the surgery. Once I had the exposure, the actual placement of the implants was exactly what I had been doing from the posterior approach.

I have now been doing all of my hips using the anterior approach, and although the first few that I did made me a little anxious, after about 10 hips I knew that I would never go back. For me to switch, I had to feel that it was an advantage to my patients and that I could do as good or better job implanting the components. I have definitely found both to be true.

I have found that my patients have less pain and are ready to leave the hospital sooner. After an anterior hip there are no hip position precautions like there are after a posterior approach. This means no pillows between the legs and you can bend over as far as you want.

My patients who have had one hip done through the posterior approach and one through the anterior approach tell me that not having to follow specific hip position precautions is one of the biggest positive differences that they noticed and they feel that it helped them recovery more quickly.

From my standpoint as a surgeon, I love the approach because I don’t have to cut any major structures to get to the hip, and also when it is done through the anterior approach it is easy to use fluoroscopy (real time x-ray) to check the position of the hip components while you are putting them in. This allows the cup position to be optimal and allows the surgeon to check the leg length to be sure it is the same as the other leg.

I am very happy that I was pushed to learn this new approach to THR. Total hip replacement surgery is one of the most rewarding surgeries that we do. No matter how it is done, as long as it is done well, patients have wonderful results. This is exactly why many surgeons don’t feel the need to change. They are doing an operation with excellent results and they don’t want to take a chance on having problems while learning a new way of doing it.

Fortunately for me, I was able to see a good surgeon and support staff doing this procedure and it convinced me to change.

My last thoughts for anyone reading this who is contemplating having their hip replaced is to know that the most important thing for a successful hip replacement is having a good surgeon and a hospital that does hip replacement surgery routinely. I do think the anterior approach has advantages over the posterior approach for both the patient and the surgeon and that’s why I switched.

Treatment of Cubital Tunnel Syndrome (Cell Phone Elbow)

Ulnar nerve entrapment at the elbow, also known as cubital tunnel syndrome is a condition where the ulnar nerve in your arm becomes irritated or compressed. This nerve is one of the three important arm nerves that travel from your neck all the way down into your hand. Constriction can occur in a number of places along this path, and depending on the site of irritation or compression, this pressure causes numbness, elbow pain, hand and wrist discomfort, or finger pain. When the ulnar nerve is compressed at the elbow, it is called, Cubital Tunnel Syndrome.   This condition is now also commonly called “cell phone elbow”.

Causes of Cubital Tunnel Syndrome

The ulnar nerve gives you feeling in your little finger and half of your ring finger. Additionally, it controls the muscles of the hand that allow you to pick stuff up and do other fine movements. It also controls bigger muscles of the forearm that allow you to grip objects.  The exact cause of cubital tunnel syndrome is not completely understood, but it is believed that the ulnar nerve is susceptible to compression at the elbow because it passes through a narrow space where there is not much tissue for protection.

Keeping your elbow bent for long periods of time (like when you hold a cell phone to your ear) may cause ulnar nerve irritation and symptoms.   Other common reasons for this condition include:

  • -A direct blow to the inside of the elbow or “hitting the funny bone”
  • -Fluid buildup in the elbow that leads to swelling and nerve compression
  • -Irritation when the nerve slides in and out of place with bending
  • -Pressure on the nerve from prolonged leaning on your elbow
  • -Sleeping with your elbow bent

Home Remedies for Cubital Tunnel Syndrome

The simplest thing you can do is to lay down your cell phone and avoid other activities that require you to bend your arm for long periods of time. Also, make sure your computer chair is not too low, and do not rest your elbow on the armrest a lot. Keep your elbow straight when sleeping, if possible, by wrapping a towel around your elbow region or wear an elbow pad backwards.

What the Doctor May Do at Your Visit

If the orthopedic specialist suspects you have cubital tunnel syndrome, he may order special X-rays to see if bony deformities are the cause of the problem.  Additionally, he may order electrical nerve conduction studies to determine how well your ulnar nerve is working and to identify exactly where the compression site is located.

Nonsurgical Treatment

Sometimes, non-steroidal anti-inflammatory medicines can alleviate your symptoms. The orthopedic specialist will want to decrease the swelling around the nerve with these medications. Also, he may inject a “steroid”, like cortisone around the ulnar nerve area of compression. It is not uncommon for the doctor to recommend a brace or splint for you to wear at night to keep your elbow straight. Finally, there are certain nerve gliding exercises that may help your nerve slide through the cubital tunnel so that symptoms can improve or resolve completely. These special exercises help keep the wrist and forearm from getting stiff and sore.

Surgical Treatment

For some people, nonsurgical measures are not enough to relieve the symptoms of cubital tunnel syndrome. In these cases, the orthopedic specialist recommends surgery to take the pressure off the ulnar nerve. Also, surgery is indicated for those who have severe nerve compression or muscle wasting due to the condition. The surgical procedures available include:

Endoscopic or Open Cubital Tunnel Release:  In this surgery, the ligament “roof” of the cubital tunnel is divided. This allows for an increased tunnel space and a decreased nerve pressure.   This procedure minimizes the dissection around the nerve and allows for the quickest recovery.  Dr. Weil is one of the only surgeons in the northwest performing Endoscopic Cubital Tunnel Ulnar Nerve Decompression surgery.  This method is the least invasive and allows for the fastest recovery of all ulnar nerve decompression surgeries.  Dr. Weil was highlighted on King 5 news Health Link for his treatment of cubital tunnel syndrome.

Ulnar Nerve Anterior Transposition:  With this procedure, the nerve is moved from the cubital tunnel and placed in front of that region. Ulnar nerve anterior transposition allows the nerve to lie under the skin and fat but on the muscle, within the muscle, or under the muscle. Placement will depend on your particular problem and the surgeon’s choice.

Medical Epicondylectomy:  One great option to release the ulnar nerve is to remove part of a bony section called the medial epicondyle. This technique prevents the nerve from becoming caught on one of the bony ridges so that it can adequately stretch with bending motions.

Surgical Recovery

If you must undergo a surgical procedure, the orthopedic specialist may put you in a splint following the surgery. For the endoscopic technique no splint is required, for the transposition technique, you may have to wear it as long as 6 weeks. Also, your doctor may recommend that go to physical therapy to learn exercises that will help you regain strength and motion in your arm.

Common Forearm Fractures in Children

Fractures of the forearm in children can occur near the wrist (at the distal bone end), in the middle of the bone, or near the elbow (at the proximal bone end). The two forearm bones are the radius and the ulna. A child’s bones are at risk for growth plate fractures because these sections are made of cartilage. Fortunately, children’s bones heal faster than adults’.

Forearm fractures make up around 50 percent of all childhood fractures, and the majority of these involve the wrist-end of the radius bone. Most forearm fractures in children occur from a fall onto an outstretched arm.

Types of Childhood Forearm Fractures

The main categories of fractures are non-displaced or displaced fractures and closed or open fractures. Displaced fractures involve the bone snapping into two or more parts and these parts do not line up. A non-displaced fracture is one in which the bones break but are still in anatomic position.

These fractures require a procedure to re-align the bones. A closed fracture is where the bone breaks but does not protrude through the skin. An open fracture, however, involves the bone breaking through the skin.

Torus Fracture

A torus fracture, is also called a “buckle” fracture, results in the top layer of the bone on one side compressing and buckling away from the growth plate. This is a stable fracture, with the broken segments not separated or displaced. These breaks hurt but do not cuase a deformity.

Metaphyseal Fracture

With a metaphyseal fracture, the break is across the upper or lower portion of the bone shaft. With this type of injury, the growth plate is not affected.

Greenstick Fracture

A greenstick fracture runs through a portion of the bone, causing it to bend on the other side. This term came about because doctors described this fracture like a green stick breaks. These types of injuries occur only in children, as adult bones won’t break in this manner.

Galeazzi Fracture

The Galeazzi fracture affects the radius and the ulna bones. These types of injuries are usually displaced with dislocation of the ulna at the wrist area.

Monteggia Fracture

With a Monteggia fracture, both forearm bones are affected. The ulna breaks and the top and the radius dislocates. This is a severe injury that requires immediate urgent care.

Growth Plate Fracture

Growth plate fractures, also called physeal fractures, occur at or across the growth plate, typically in the area where the radius attaches with the wrist. This area heals well, with less than 5 percent having complications.

Symptoms

Symptoms really depend on the type of fracture, but most fractures cause severe pain and numbness of the hand and forearm. Sometimes, the fracture causes a bent appearance of the forearm. Other symptoms include swelling, bruising, and inability to rotate or turn the arm.

Treatment

Treatment depends on the degree of displacement and the specific type of fracture. The severity of a fracture depends on the location and the amount of damage done to the tissue and bone. A minor fracture could heal within a few weeks, whereas a serious fracture could take months to heal.

Treatment also depends on the age of the child, the degree of deformity, and the stability of the break. The goal of treatment to a fracture involving the growth plate is restoration of normal alignment with minimal trauma.

Nonsurgical Treatment

Many fractures of the forearm in children can be treated without surgery. Casts and immobilizing devices protect the bones while they heal. Sometimes it is necessary for the orthopedic specialist to manipulate the bones into proper alignment, a process called reduction.

Surgical Treatment

Surgery to realign the bones and secure them in place is necessary if the skin is broken, if the fracture is unstable, if bone segments have been displaced, and if the bones cannot be manipulated to realign through reduction. Once the surgeon aligns the bone segments, he may use metal implants, pins, or a cast to hold these in place.

Long-Term Outcome

Once your child’s cast comes off, the wrist joint or elbow joint may be stiff for a few weeks. This will resolve without the need for physical therapy in most cases. Your child’s healing bones will be temporarily weak following immobilization, so you should not allow rough play, climbing, or contact sports for 3 to 4 weeks after the cast comes off.

Knee Pain and Skiing

Knee pain is a common complaint among skiers, and often knee pain in skiers is the result of an injury. The location and severity of the pain depends on the cause of the problem. Signs and symptoms that often accompany knee pain include redness, warmth, weakness, instability, swelling, stiffness, œlocking, and œpopping.

Be sure to notify your orthopedic specialist if you have knee pain accompanied with swelling, cannot fully extend of flex your knee, notice a deformity, have a fever, or if the knee œgives out.

Knee Injuries from Skiing

Because of the mechanics of the sport, knee injuries are quite common for skiers. These injuries can range from simple to complex, with 25% of all ski injuries affecting the knee.

MCL Injury – The most commonly injured knee structure is the medial collateral ligament (MCL). This is because of the type of stance and turn skiers use that places serious stress on the inside of the knee.

ACL Injury – The anterior cruciate ligament (ACL) is injured in more advanced skiers or from those who have a specific type of fall. ACL injuries are associated with sudden direction change with a twisting injury accentuated by the long lever arm of the ski.

Torn Meniscus – Another common skiing injury is a torn meniscus. The meniscus is a rubbery tough cartilage that acts a shock absorber for the joint. It is torn when you suddenly twist your knee with weight on it or from a direct contact blow during a fall.

Knee Bursitis – Certain knee injuries lead to inflammation of the bursae, the small sacs of fluid that cushion the knee joint. This condition is painful, especially with bending of the knee, and swelling is common.

Patellar Tendinitis – When one or more tendons are irritated and inflamed, patellar tendinitis develops. The tendons are the thick fibrous cords that attach bone to muscle. Skiers are prone to inflammation of this tendon that connects the quadriceps muscle on the front of the thigh to the tibia (shinbone).

Knee Dislocation – Pain from dislocation of the knee joint is rare and is a true emergency. The displacement of the leg stretches and tears the knee ligaments and may involove injuries to the arteries and/or nerves. This painful condition often produces an obvious knee deformity and requires immediate medical attention.

Kneecap (Patella) Dislocation – Dislocation of the patella is caused from direct trauma or forceful twisting of the knee. Obvious patella deformity occurs with this condition, and you should seek medical care immediately.

Runner’s Knee (Patellofemoral Pain)

Skiers put heavy stress on their knees that causes a condition called runner’s knee. This knee pain syndrome causes pain around the front aspect of the knee. The pain occurs with walking up or going down stairs, squatting, kneeling, or sitting.

Patellofemoral pain is caused by malalignment of the knee, partial dislocation, injury, flat feet, or tightness and weakness of the thigh muscles. Runner’s knee can be the result of soft tissue irritation in the front of the knee.

Treatment for Knee Pain

Treatment of your knee pain will depend on the particular problem that is causing the pain.

Basic First Aid for Knee Pain

Stop skiing and use the RICE formula:

Rest – Avoid putting weight on the painful knee.

Ice – Apply cold packs or ice wrapped in a towel for short intervals of time frequently.

Compression – Use an elastic bandage, like a simple knee sleeve with the kneecap cut out that fits snugly.

Elevation – Keep the knee raised up higher than your heart.

Nonsurgical Treatment

If you have knee pain, you should see an orthopedic specialist. The doctor may recommend physical therapy for you to learn reconditioning to regain full range of motion, power, strength, speed, and endurance. These exercises help the front thigh muscles (quads) and the back thigh muscles (hamstrings).

Another thing the doctor may recommend is a special brace to help protect and support the knee. Certain knee pain syndromes respond to injections of corticosteroids to reduce inflammation. The doctor may recommend a hyaluronic acid injection for joints that need extra lubrication.

Surgical Treatment

There are several surgical knee procedures for knee pain.

Arthroscopy – This is done when there is significant damage to the cartilage or meniscus. The orthopedic specialist uses a pencil-sized instrument (called an arthroscope) to look inside the knee joint to diagnose and repair your condition.

Realignment – This is done to reduce the pressure on the cartilage and supporting structures of the front aspect of the knee.

Partial Knee Replacement Surgery – This procedure is done when there is serious damage to the knee. The orthopedic specialist replaces the damaged portion with parts made of metal and plastic.

Total Knee Replacement – This surgery is done when the doctor must remove significant damaged bone and cartilage and replace it with an artificial joint.

Knee Pain Prevention

Keep weight normal – Maintaining a healthy weight is the best thing you can do to prevent knee pain and injury.

Get strong and stay limber – Weak muscles lead to knee injuries, so keep your quads and hamstrings strong. Balance and stability training allows the muscles of the knees to function properly. Also, avoid injury by stretching to increase flexibility.

Stay in shape – Prevent knee pain and injury by keeping yourself well-conditioned.

Use proper gear – Make sure your skiing shoes are good shock absorbers and of quality construction. Also, be sure your shoes fit properly.

Elbow and Shoulder Arthritis

I see three major types of arthritis that affect the elbow and shoulder joints. Osteoarthritis is the “wear-and-tear” arthritis caused from degenerative conditions, and occurs most frequently. Rheumatoid arthritis is less common and is a systemic inflammatory condition of the joint lining (the synovium). Posttraumatic arthritis is a form of arthritis that develops from an injury, such as a dislocation or fracture.

Elbow Arthritis

Many patients wonder, “What is arthritis”. For any joint, arthritis means, “joint inflammation”. In the case of the elbow, if the cartilage surface of the elbow becomes worn from age or damaged, elbow arthritis occurs. If you have elbow arthritis, you probably have pain, swelling, stiffness, and loss of normal range of motion. Some people complain of a “locking” or “grating” sensation in the joint.

These sensations are related to the loss of normal smooth joint surface and when pieces of loose bone or cartilage lodge between the joint surfaces interfering with normal movement. Often, my patients may notice numbness of the ring finger and pinky finger. This is related to the pressure placed on the ulnar nerve or funny bone from the swelling.

How is elbow arthritis diagnosed?

I can diagnose elbow arthritis based on your symptoms, a simple physical examination, and standard X-rays. This disease tends to be more common in men than women, and it generally occurs in people over the age of 50 years. You are at increased risk for elbow arthritis if you have a history elbow injury, inflammatory arthritis, or a family history of arthritis. Others at risk for elbow arthritis include people who have jobs or participate in activities that place demands on the elbow joint, such as professional baseball pitchers.

How is elbow arthritis treated?

I treat elbow arthritis predominantly based on your symptoms. Factors to consider include the stage of the disease, patient goals, and your overall medical condition and physical health. Nonsurgical treatment for elbow arthritis involves measures to alleviate or reduce pain, increase range of motion, and restore function. This includes physical therapy, activity restrictions and limitations, and oral anti-inflammatory or pain medications. If these conservative measures do not work, many patients benefit from corticosteroid injections, which can give several months of relief and can be both therapeutic and diagnostic.

Surgery may be necessary if nonsurgical measures do not control and alleviate symptoms. If the damage is not too severe, I can do minimally invasive and sometimes even arthroscopic procedures to remove loose bodies and degenerative, inflammatory tissue from the joint. This smoothes out the irregular joint surfaces and provides symptom relief. If the joint space is severely worn, I may suggest a joint replacement for you.

Shoulder Arthritis

The shoulder is made up of two joints. One of these is the acromioclavicular (AC) joint, located where the collarbone (the clavicle) meets the tip of the shoulder blade (the acromion). The other is located at the junction of the upper arm bone (the humerus) and the shoulder blade (the scapula), and this is called the glenohumeral joint. Both of these shoulder joints are often affected by arthritis. The symptoms of shoulder arthritis include pain, stiffness, decreased or limited range of motion, and crepitus. Crepitus is a “clicking” or “snapping” sound made with shoulder movement.

How is shoulder arthritis diagnosed?

I diagnose shoulder arthritis based on a thorough physical examination, symptoms, and basic X-rays. Most people with shoulder arthritis have a narrowing of the joint spaces, formation of bone spurs, and changes in the bone structure. People over the age of 50 years are at increased risk for shoulder arthritis. Also, having a history of an injury to your shoulder joint puts you at risk for developing this condition.

How is shoulder arthritis treated?

I treat shoulder arthritis based on the severity of the disease, health status and overall condition, activity level and work responsibilities, and prior history. Nonsurgical measures include oral medications, physical therapy, and activity restrictions and limitations. Patients that do not respond to these methods could have a corticosteroid or hyaluronic acid injection. When the joint is severely damaged or worn, or if the patient does not improve with conservative measures, the glenohumeral joint can be replaced with a prosthesis in a procedure called a total shoulder arthroplasty.

If necessary, the head of the humerus is replaced. For arthritis of the AC joint, a resection arthroplasty could help. I do this by taking a small piece of bone from the collarbone to leave room for movement.