Knee1 Discussion with Dr. David Golden
November 20, 2002

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Today's Guest
David Golden, M.D. is an orthopaedic surgeon, specializing in knee reconstruction, shoulder reconstruction, and sports surgery. His emphasis is on minimally invasive techniques. He earned his BA and MD from The Ohio State University and completed his orthopaedic residency at Harvard University. He remained at Harvard/Massachusetts General Hospital for a trauma fellowship followed by a sports medicine fellowship. He is a member of the American Academy of Orthopedic Surgeons (AAOS), the American Orthopedic Society of Sports Medicine (AOSSM) and the Arthroscopy Association of North America (AANA). He is in private practice at Cedars Sinai Hospital in Beverly Hills, California.

Knee1: Welcome to the Knee1 moderated chat. Tonight we are happy to introduce Dr. David Golden as our guest orthopaedic surgeon. We welcome your questions and your input.

Knee1: Please be advised that we receive more questions than can be answered, so we thank you in advance for your patience if your question is not immediately answered.

Knee1: Today's guest is David Golden, M.D. , an orthopaedic surgeon specializing in knee reconstruction, shoulder reconstruction, and sports surgery. His emphasis is on minimally invasive techniques.

Knee1: Dr. Golden earned his BA and MD from The Ohio State University and completed his orthopaedic residency at Harvard University. He remained at Harvard/Massachusetts General Hospital for a trauma fellowship followed by a sports medicine fellowship.

Knee1: He is a member of the American Academy of Orthopaedic Surgeons (AAOS), the American Orthopaedic Society of Sports Medicine (AOSSM) and the Arthroscopy Association of North America (AANA). He is in private practice at Cedars Sinai Hospital in Beverly Hills, California.

Knee1: Dr. Golden, thank you for joining us. Perhaps we could start by having you tell us a bit about what trends in knee surgery you have noticed since you began practicing.
Dr. Golden: The most notable change is rather a progression. Smaller incisions and more advanced technology allow advanced procedures and quicker recovery. More and more, patients are going home the same day of surgery and rehabilitation can be hastened sometimes.

KK: My 13 year old son was diagnosed with OCD about 1 month ago. He is not playing any sports at the time due to this. He is a wrestler and would like to wrestle in the last three matches. What would you advise us to do?

Dr. Golden: It's dependent on the lesion. An MRI will give the extent of the OCD and the location. Those are two important factors to determine long-term outcome. If surgery is recommended, he'll be out the season. If non-operative treatment is the plan, then weight bearing is modified for some time and return to sport is pain related. Be sure to talk with your surgeon. Sometimes it's frustrating, especially to a 13 year old, but additional time may allow him to heal and not have future problems.

KM: My 19 yr old daughter has hypermobility issues, which cause recurrent knee dislocations. She has had lateral release, medial repair, which failed. She then had a Fulkerson, which has also failed. We've done much PT, bracing, tried protonics and acupuncture. Her surgeon now recommends a modified galeazzi. Any thoughts?
Dr. Golden: Patella dislocations can have a number of reasons for happening. The right procedure is dependent on the right diagnosis. Be sure to get a second and even third opinion, as the case becomes more complex with each intervention. Though I'm sure it was checked, a full length standing x-ray of both lower extremities may give some additional information. In the meantime, activity modification will help control the dislocations.

brano: What is ACL shrinkage? A friend told me a little bit about it, but I would like to know more.

Knee1: A quick note to our users: "dx" means "diagnosed"

Dr. Golden: With a specialized instrument, the fibers of the ACL are changed and attenuated, thereby shrinking the ACL. Theoretically, it may correct laxity but has not been well established in the literature. Currently, ACL deficiency causing symptoms is treated with reconstruction, not shrinkage.

Bryan: I was in a car accident in 1999 (knee hit dashboard). I had arthroscopic surgery later that year to repair ACL & something with my meniscus. I was a VERY avid runner before the accident, and even with the surgery, I experience daily pain. I have had multiple x-rays & MRIs but the doctors tell me there is nothing else that can be done, because the back of my kneecap is jagged and there is nothing to correct this problem. Are there any new procedures that can be done to fix my kneecap?
Dr. Golden: Some recent work has focused on patella replacements. Few patients have isolated patellofemoral arthritis and if they have it, it's usually caused by trauma, such as yours. There are some early reports that the patella replacements work well but there are only short-term outcomes as of yet. The long-term outcomes will be the real test (by the way, only the surface of the patella is replaced with plastic, not the entire patella). Talk to your doctor to see if he or she has experience with it.

Knee1: Dr. Golden, we have a follow-up question to the wrestling question...
KK: The surgeon said the plan is for non-operative healing. He said if it doesn't heal within a year then he will do surgery. If he does go ahead and wrestle can it make this condition worse?
Dr. Golden: Yes, potentially it can. The piece of cartilage could become more symptomatic or even break off into the joint. This certainly doesn't always happen but potentially could. That is why the location and size are so important.

andrea: my 10 year old daughter has knee contracture and unable to bend her knee past 70%. She has had an exploratory arthroscope, which found she had a lot of scar tissue but still had her tendon lengthened during surgery to be able to bend. After two more surgeries to clean a staph infection and to manipulate her knee, she can neither bend nor straighten her knee. Any suggestions on where to go from here?

Dr. Golden: There is no simple answer. After infections, the knee cartilage is rarely again totally normal. It does not always cause problems in the future but can limit the range of motion. Scar tissue and pieces of bone can cause the same problem. Allow time for the knee to heal, assuming the infection is cleared and physical therapy is the mainstay of treatment. As long as your surgeon says it is alright, aggressive therapy is the best process for now until it is reevaluated in a few months.

Knee1: Dr. Golden, we have also had numerous questions from users asking how they should best go about choosing an orthopaedic surgeon. What advice would you give to patients when they are exploring their options?

Dr. Golden: Don't be afraid to ask EXACTLY what you want to ask. Ask where they trained (if you care), ask what their specialty is, ask if they are fellowship trained in a particular subspecialty, and ask how many procedures (or whatever) have they performed. Be sure to ask if they are Board Certified or Board Eligible (the latter precedes the former) and be sure you feel comfortable. If surgery for whatever reason is recommended, ask them for names for second opinions. If they balk, walk out the door and don't come back. More often, there are more sub-specialized surgeons in larger cities and/or larger or academic settings.

rpt: I've recently had my left knee replaced, 8 weeks today. How far along should my muscles be? They still hurt…especially with precipitation.

Dr. Golden: Recovery from total knee replacement can be lengthy. At 2 months, you won't be normal, but you should be getting stronger, even if it is a slow progression. If you are having problems straightening or bending the knee and the issue is worsening, be sure to see your operating surgeon to be sure there are no problems developing.
  

brano: Why do women experience more knee problems than men?

Dr. Golden: That is a question that, if I could answer, I'd win the Nobel Prize. There are too many theories to list here. They range from different anatomy to different ratios of ligament sizes, to different muscle tone and size, to different shapes of bones, etc., etc., etc. There are, undoubtedly, more ACL tears in women (proportionately) compared to men. But that may be a function of more involvement in activities that lend themselves to injury or may have to do with the above listed reasons. Research is also focusing on hormonal effects on bones, joints, tendons and ligaments. The preliminary results are interesting and will require follow up studies.

Rob: I am scheduled for a LR and MR on my right knee in Jan. As a general rule, about how long will I be laid up? My PT laughed at me when I said possibly back to work in 6 weeks (cabinet builder).

Dr. Golden: I'm assuming LR and MR mean lateral and medial menisectomy. If so, it depends on the intraoperative findings. If resection is performed, usually recovery is governed by comfort. If the meniscii are repaired, the recovery is different as it requires more time and usually requires crutches for some time.
  

asiamoya: my daughter was born with her popliteal tendons traversing in the opposite direction of normal ones. Can this be fixed?

Dr. Golden: I'm not quite sure what that means. The question to ask your pediatric orthopaedic surgeon is "does it need to be fixed." Do not fix something that will neither cause pain nor functional disability now or in the future. If this problem involves the knee, be sure to see a pediatric specialist.
  

A.C.: Dr. Golden, have you ever had a patient experience a literal breakage of their bio-interference bone screw post-op an ACL reconstruction? If so, is this an expected risk?
Dr. Golden: One of the risks of bioabsorbable screws is breakage. Most often, if it occurs, it happens during the placement in operating room. Graft failure, for whatever reason, is always a risk of ACL reconstruction. I have not seen any particular increase in breakage postoperatively in the bioabsorbable versus the metal screws.
  

goat: I am being treated for OCD of my knee. I have had arthroscopic surgery, supartz injections, and physical therapy since April 2001. I am still in pain and have locking in the knee. Doctor is recommending another MRI, possible cartilage harvesting. Have you heard of ECSWT? Please help with any info.

Dr. Golden: Cartilage grafting is a consideration for OCD if it is large enough and only in a focal (concentrated) area. The locking of the knee is a mechanical problem inside the knee and may be a result of the OCD breaking off and causing a problem. An arthroscopy will be recommended for the mechanical problems but it sounds like your surgeon wants to address the larger issue of OCD. It's not unreasonable to recommend cartilage transfer for the appropriate patient. The cartilage is often taken from inside the knee from areas that are not weight bearing dependent. Knee alignment is another important factor to consider.
 

big blue: Hello Dr. Golden, What is your opinion of cartilage transplants? How well do they work for active 35-45 yr. old males and is there another alternative to consider for cartilage defects? Thank you.

Dr. Golden: Cartilage defects are a challenge for patients and surgeons both. They can work for the appropriate patient but not for everyone. The older we become, the more trauma our knees see. If there is arthritis, cartilage transplant is not usually recommended. As far as alternatives, there are not any for small areas of cartilage loss. For larger lesions, a total knee implant may even be required. Be sure to discuss all possibilities with your surgeon.
  

Knee1: Dr. Golden, we're about ready to end our discussion. Do you have any closing thoughts for our users?
Dr. Golden: Even though humans are animals, our cousins in the wild are often smarter than we are. When they are hurt, they limp. Or they don't walk (if the pain is in their lower limbs). They modify their activity to pain and allow healing time. Humans are busier more now than ever. But if you don't take great care of your knees now, they will never forgive you and they will get even, guaranteed. If you have pain or injury, see your doctor and, if needed, see an orthopaedic specialist for an evaluation. Until that time, treat injuries with respect and give them time to heal. Use the knowledge that ice, rest, elevation and compression can go a long way in initial treatment of knee injuries. Keep your knees healthy and try to train with no or low impact activities. We'll speak soon. Thank you for your excellent questions.
  

Knee1: Users, thank you for participating. We had more questions than Dr. Golden could answer tonight, but we will be saving your questions and addressing them in upcoming chats.
  

Knee1: If you are a registered Knee1 user, you will receive notification of these chats through our newsletter, the Knee1 Beat. You may also further share your stories and questions with other users in our Knee1 forums. Thank you for joining us, and Dr. Golden, thank you for participating.