Knee1 Discussion with Dr. James Lubowitz January 16, 2003 Note to our users: This interactive
feature is in no way a substitute for the examination and advice of a
physician. You are responsible for all actions you take after reading material
on this site. Always seek the advice of a doctor for concerns about your health
or a specific condition. Dr. Lubowitz: Hello Dr. Lubowitz: The plica is a band that can
become irritated. Treatment is ice and NSAIDs and quadriceps rehabilitation. If
this fails, the plica can be arthroscopically excised with good outcomes. Sue: Hi Doc, I was recently diagnosed with a possible medial
meniscal tear or perhaps chondromalacia - in either case what is the treatment
for this?? Any advice would be greatly appreciated. Karen: How quickly can one generally return to heavy
athletic activity after arthroscopy? Dr. Lubowitz: The recovery from surgery is
individualized, but rare patients reveal they have already gone for a hike
before I remove stitches (1 1/2 weeks). This is not recommended. Natalie: Dr I had a ski accident last Saturday. My right
knee has been swollen and I have difficulty walking. Unfortunately I have just
started a new job and don’t have insurance. Do you have any suggestions for me? gini: Should one still experience severe pain 4 months after
partial meniscus removal? maj: If the natural patella is not replaced during a tkr, is
it somehow resurfaced where it is heavily worn? Dr. Lubowitz: Overuse, especially impact sports
or high impact sports can make things worse. Follow the advice of the
therapist, and gradually increase activity. Let comfort be your guide. This
means, if the knee hurts or swells the night after your activity, or the next
day, you are overdoing things. Karen: What side effects (especially negative ones) can
occur with a cortisone injection? Knee1: Dr. Lubowitz, we get a lot of questions regarding the
accuracy of MRIs. Is it possible for an MRI to ever "miss" a tear or
other damage? maj: is the zirconium implant glued in or is the shaft a
rough metal which would adhere to the bone and the bone eventually
"grow" onto the implant? Paul: I'm 34. Have had 4 ops in 8 years on my left knee My
last op was to remove a lump on the inside of my knee, a sort of abscess. But
the abscess is still there & still painful 18 months after the operation.
1) Should I have yet another operation to try & fix the problem or just
continue with physiotherapy exercises & hope the pain goes away? 2) How
many operations can the knee sustain before a knee replacement is required? sportgirl: Is it possible to re-graft cartilage in the knee?
Or is there an over-the-counter medicine that can help cartilage restoration? Dr. Lubowitz: It is possible to re-graft
cartilage in the knee--definitely. Glucosamine is over the counter. It is not a
medication but a supplement. It may or may not help restoration, we are not
sure how it works, but excellent research shows it reduces pain from cartilage
damage. There are other supplements that have not yet been fully tested. Karen: What strengthening exercises do you recommend for
post-op rehab? kasmay: Why is the ACL so important and why so commonly
injured? Dr. Lubowitz: ACL reconstruction is done
arthroscopically, through tiny incisions. A cadaver graft requires a 1-2 cm.
(less than one inch) incision to put in the tunnels, and a patella tendon or
hamstring autograft (from your own knee) can be harvested from a 2-3 cm
incision. Maybe 4 for the patella tendon. When I do the patella tendon, I also
make the arthroscopic portals through the same incision, so the 3 cm incision
is all! jaburo: I once had a friend tell me that certain weight
routines, like leg extensions that work the quadriceps, can help prevent knee
injuries. Is there any truth to this? Dr. Lubowitz: I believe this to be true. I
wanted to research this during my fellowship, but we didn't have the necessary
resources at the time. Personally, I sometimes try this. newman: How do you tell the difference between plica
syndrome and anserine bursitis? mikey: Is it possible for a surgeon to hit a vein during
arthroscopy? My mother had arthroscopy and her first day out, she bled quite a
bit (almost to the point it was alarming). Dr. Lubowitz: It is possible. The veins in the
skin can bleed but the stitch at the end usually stops them. Sometimes, the
inside of the knee bleeds, such as a small vein or artery, which often occurs
in the fat pad. After a lateral release, the superior lateral geniculate artery
can bleed a lot. Either the knee swells, or the blood leaks out, alarmingly, or
both. Knee1: Thank you, Dr. Lubowitz, for joining us tonight.
Back
Knee1: Welcome to tonight's chat with Dr. James Lubowitz of
Taos, New Mexico.
Knee1: Dr. Lubowitz is the founder of the Taos Orthopaedic Institute and a
member of the medical staff for the U.S. Ski and Snowboard Team. He also holds
the prestigious position of Associate Editor Arthroscopy: The Journal of
Arthroscopic and Related Surgery. He is currently practicing medicine in New
Mexico, specializing in knee injuries and arthroscopy at the Institute that he
founded.
Knee1: Dr. Lubowitz, thank you for joining us. Users, we welcome your
questions!
Knee1: Dr. Lubowitz, perhaps we can start by having you tell us a little
about how you got started in orthopedics.
Dr. Lubowitz: I always considered medicine as a profession and was an
athlete. The only doctors I saw were orthopaedic sports specialists in the
training room. They were role models.
Dr. Lubowitz: I love that orthopaedic patients are often healthy. They
have a specific problem and our outcomes are usually good or excellent. So
patients can get back to normal. This is rewarding.
west330: Can you tell me more about plica problems? I have an as-yet
undiagnosed knee problem – lots of stiffness and swelling in my right knee, but
all bloodwork has come back negative for rheumatoid arthritis. My doc now
thinks it’s a plica problem. What are the possible treatments?
Dr. Lubowitz: An MRI could be an important diagnostic test.
Dr. Lubowitz: A medial meniscus tear will generally not heal without
arthroscopic treatment. If it does not get better with a few weeks of relative
rest, ice and possibly NSAIDs, an MRI could be diagnostic and an arthroscopic
partial menisectomy (or occasionally repair) could be curative.
Dr. Lubowitz: For chondromalacia, NSAIDs, glucosamine, strengthening the
muscles around the knee or even viscosupplementation injections can help.
Arthroscopy can smooth the cartilage if non-operative measures fail.
Dr. Lubowitz: Actually, return to sport after arthroscopy is a research
study we are initiating. Often, my patients return to skiing in less than two
weeks.
Dr. Lubowitz: Natalie, with regard to your insurance problems, I wish I
could help. With regard to your knee, swelling is a sign of significant
internal derangement. You could try ice and rest and compression with an ACE to
take the swelling down, but I recommend orthopaedic or primary care sports
medicine consultation.
Dr. Lubowitz: Generally, no. However, if in addition to the meniscus
surgery, you have articular cartilage (joint lining) damage, some pain will
persist.
Dr. Lubowitz: The most common cause of persistent pain after
arthroscopic partial menisectomy is inflammation. Aggressive anti-inflammatory
treatment may help. If not, your surgeon could look for other causes of the
pain.
Dr. Lubowitz: maj, the answer to your question is no. Research shows that
taking all patients having total knees, the results are equal with and without
resurfacing. This is a controversial point. Some prostheses are designed with a
deep femoral groove especially to allow retention of the patella, regardless of
heavy wear.
Knee1: Back to a previous user...
Sue: I am presently on naproxen 2x a day and have just started PT with advice
from my doc, what activities if any could make this condition worse?
Dr. Lubowitz: Occasionally patients have a "flare" reaction
with increased pain and swelling and redness. In my experience, this is rare.
Diabetics may have increases in their blood sugar. Any injection can cause an
infection and steroids lower your ability to fight infection. Again, in my
experience, we have never had this problem from an injection at Taos
Orthopaedic Institute. Finally, steroid injections must be used judiciously--3
a year are my limit and at least 2 weeks apart. More than this can accelerate
cartilage loss.
Dr. Lubowitz: Absolutely. MRIs are extremely sensitive and specific for
ligament tears. They are less so for meniscus. The published studies show about
90% accuracy. So one in 10 could be missed. And published studies are usually
the best results by the most specialized people. In the community, accuracy may
be as low as 70-80% as a rough estimate.
Dr. Lubowitz: For articular cartilage, MRI has even lower accuracy,
historically, but much improvement is occurring in this area.
Dr. Lubowitz: This implant may be implanted using cementless or cemented
technique
Dr. Lubowitz: An abscess or infection should be gone but could increase
your risk for future infection. To answer question 1 I would need much more
information and an exam. You should see a superspecialist. Question 2, knee
replacement is for painful arthritis. The knee can have many operations without
the development of arthritis. Professional athletes sometimes have arthroscopy
after each season. This is rare and not a recommendation.
Dr. Lubowitz: Rehabilitation is surgery specific. For sure. What
operation?
Knee1: Dr. Lubowitz, our users often ask about the safety of yoga. While it
is obviously not high-impact, are the stretching/lunging poses tough on the
knee?
Dr. Lubowitz: I think that in general, yoga is not too tough on the knee. A
hyperlax individual (very loose joints) can have increased risks of knee
problems. Like many sports and activities, with proper technique, yoga is not a
common cause of knee problems.
Dr. Lubowitz: To add, yoga is very, very popular in Taos. I rarely see
knee problems from this, and generally the problems I see do not require
surgery.
Dr. Lubowitz: The ACL is important because it is the primary stabilizer
preventing anterior subluxation or dislocation (where the tibia or leg bone
comes out from under the femur or thigh bone). If this occurs, pain and a
swollen knee result. If this occurs, the meniscus often tears, and the meniscus
prevents arthritis.
kasmay: And following up - for ACL reconstruction, how long does that
procedure last? And how many incisions (and how large) are required for this
procedure?
Dr. Lubowitz: The ACL is commonly injured when people are very active in
pivoting sports with a fixed foot (like a football cleat or basketball shoe) or
with a long lever arm (like skiing). Because the popularity of sport is
increasing, ACL injuries are common. Skiing and college football are the number
one causes. Surgeons also know a lot more about a torn ACL. Maybe we miss the
diagnosis less.
Dr. Lubowitz: An ACL reconstruction can last a lifetime. But you can
tear the graft just like you can tear your own ACL. If it is done right,
technically, and if future trauma is avoided, I would expect it to last a
lifetime.
Dr. Lubowitz: jaburo, I believe that strong quads are very important to
knee injury prevention and rehabilitation. This is especially important with
kneecap and anterior knee pain. But if there is kneecap (patellar) cartilage
damage (chondromalacia), resisted extension can make this worse. In this case,
isometric quad exercises like straight leg raises, are ideal.
gini: What kinds of tests are used to diagnose articular cartilage damage?
Dr. Lubowitz: As above, MRI has come a long way in this area. Arthroscopy
is diagnostic as well as therapeutic. You look right at the damage with the
camera...this is the gold standard. Regular x-rays don't show the damage until
arthritis becomes advanced.
Dr. Lubowitz: With diagnostic arthroscopy, the treatment or therapeutic
part comes at the same operation, of course.
Paul: When performing a leg extension on a weight machine, is it true that
you can target the inside of the thigh more if you turn your foot outwards?
Dr. Lubowitz: Again, as above, I try to recommend this type of exercise
in an isometric fashion, holding the weight up, but with the knee straight, and
not letting the weight move.
Dr. Lubowitz: newman, the pes anserine bursa is below the medial joint
line, on the top of the medial tibia. The plica is medial to the kneecap. The
location of the tenderness is the best clue.
Dr. Lubowitz: Trivia: pes anserine means goose's foot. The three tendons
converge with this appearance.
Dr. Lubowitz: More trivia: the pes anserine tendons are the
semi-tendinosis, the semi-membranosis, and the gracilis. The first two are used
for hamstring tendon ACL grafts
Knee1: Dr. Lubowitz, many of our users suffering from bursitis ask about
their options. Is it possible to actually remove the bursa? What other
treatments are available for chronic bursitis?
Dr. Lubowitz: Surgical bursectomy is possible and effective. Other
non-surgical methods are anti-inflammatory treatments such as NSAIDS, ice and
compression. A steroid injection is excellent in many cases, so long as there
is not infectious bursitis.
Dr. Lubowitz: A bursa is a fluid filled shock-absorbing sack. There are
many in the body and in the knee. The most commonly problematic is the
prepatellar bursa, not IN the knee but in front of the kneecap.
Knee1: We're getting ready to close the discussion for the night. Dr.
Lubowitz, do you have any closing thoughts or tips to share with our audience?
Dr. Lubowitz: The audience is obviously quite sophisticated. I think that a
good tip is that swelling is a sign of serious internal derangement, and formal
consultation could be sought.
Dr. Lubowitz: Another tip, as I am a ski doc, is that proper binding
adjustment definitely reduces the risk of ACL tear.
Dr. Lubowitz: The January Arthroscopy Journal arrived today. A review of
The Skier's Knee by my associate Dr. Guttmann, our former Fellow Dr. Rossi, and
I is a personal highlight!
Dr. Lubowitz: And, thank you Knee1
Knee1: And thank you, audience, for joining us. Tune in next month when we
chat with Dr. Dinesh Patel, Thursday, February 13.