“Ask the Experts” Transcript with Orthopedic Surgeon Ian Duncan, M.D.

Transcript for “Ask the Experts” Live Chat with Orthopedic Surgeon Ian Duncan, M.D.  

Kaweah Delta Health Care District: We would like to welcome everyone to tonight's chat. We're going to start with a general question that has been asked a lot tonight. What is arthritis and why does my knee hurt?

Ian Duncan: There are several types of arthritis, such as rheumatoid that have unique traits, but the most common is osteoarthritis, or wear and tear arthritis. Basically, osteoarthritis describes wearing out of the cartilage on the ends of the bones within a joint. Rather than being a smooth low friction joint, the surfaces become rough and irregular, there is more friction and irritation, which leads to pain and swelling. There is a complex biochemical process that occurs that is far more complicated, and multiple medications are being developed that manipulate this system, but the basic idea is the cartilage is wearing down and the joint is wearing out.

Kaweah Delta Health Care District: The next question comes from Yvonne Arroyo Sweeney. I had a spiral fx in December. I was casted 13 days later the cast was removed after 4 weeks then I wore a "boot" for two more weeks. I feel my ankle is slowly FEELING better, but my ankle still swells daily. Like serious Stay-puff marshmallow swelling. Is this normal?

Ian Duncan: Yvonne: This is fairly normal with most leg fractures and surgeries for 2-3 months especially as you start becoming more active. In the early phases you are supposed to elevate so that minimizes the swelling. But as you start walking more people usually stop elevating so their feet and ankles swell quite a bit. Until the injury completely heals in the case of fractures, it takes 5-7 months. The swelling may persist.

Kimberley Jones-Sisson: How old is the minimum age for getting a total knee replacement? Ian Duncan There is no minimum age for any joint replacement. With that said, it is better to wait until you meet the criteria for one. My criteria for a knee or hip replacement is if it interferes with you're activities of daily living, if you can't walk a mile any more without resting, and if you've tried everything else. Even if you do meet these criteria at a young age, realize there are downsides to starting at a young age (anything under 60 is young in joint replacement terms). The biggest issue is most joint replacements don't last forever. I tell patients to expect 10-15 years out of a knee replacement, although there is a wide variation, so if you get a knee replacement at 50, and it wears out when you're 60 or 65, then what do you do. The answer is complicated, but basically you have the option to have a revision knee replacement, but the risks are higher with these, not to mention you're older now, the function isn't as good, the lifespan is shorter, so while the first lasted 10-15 years, the second may only last 5-10, and then you're looking at you're third knee replacement, another revision at age 70-75. so you can see this is a downhill spiral. This doesn't even touch on the fact that there are not a lot of doctors or hospitals that like to do revision joint replacements because the outcomes are worse, the implants cost more, but insurance doesn't pay much more, so you may have trouble finding a doctor to care for you. Currently there are very few doctors in Tulare county, even at Kaweah that are willing to see patients needing revision knees. We are looking to recruit a joint replacemetn specialist, but there are many orthopedists going into this speciality now since reimbursement isn't very good. As you can see, you don't want to be in the position where you need a revision without a doc to help you, so the key is to not start the replacement path until you absolutely need it. If you do, fine, I've done knee replacements on patients as young as 50, some of my partners on patients in there 30s, and I've done hip replacements in teenagers when needed, so we can do what is necessary.

Kimberley Jones-Sisson Thank you

Kimberley Jones-Sisson
 I love this. Thank you Dr. Ian Duncan

Ronda Werner Is there a limit to the number of cortrizone shots a person can have for an arthritic shoulder?

Ian Duncan
 Not exactly. Most people agree that you should minimize the number of cortisone shots you get each year. Every doctor's number is different. My personal treatment plan is every 3 months if needed, but not more often. If you need shots more often than that, then you are probably ready for a shoulder replacement. There is no yearly time frame, essentially you could get 4 shots a year for ever if you don't want or can't have surgery.

Ronda Werner Thank you very much for your answer.

Ian Duncan My pleasure! This online chat is new for us, but we're hoping to continue this on a regular basis.

María Miranda I have alot of pain on my back,neck,shoulder and the bottom of my feet to what can i do ?

Ian Duncan This is a little too broad of a question to answer online. The simple answer is you need to see a physician to get an exam, and come up with a tentative diagnosis so tests can possibly be ordered to confirm that diagnosis.

Ian Duncan My best advice is contact you're primary care physician and consult them regarding diagnostic possibilities, testing options, and who if anyone they can refer you to for help. This certainly doesn't sound like the typical orthopedic problems of the arms or legs I deal with as a sports medicine surgeon. If anything they may be coming from you're spine, or a more systemic illness, but without a full history and exam it is too hard to tell online.

Leigh-Anne Anderson Caudill Dr. Redd in Visalia is really good. He did a great job with my knee surgery.

Ian Duncan Wonderful, he is an excellent surgeon, a good friend, and I would happily have him operate on my friends and family too. I am a little biased as we are partners in the same group, but the above would hold true if he wasn't.

Ladonna Perkins I wish i had a Dr. to tell me why my feet,legs,and hip hurts so bad...tingling,numbness,tight,and a whole lot of other problems...i need help...but no where to turn...

Ian Duncan Hi Ladonna, it sounds like there is a systemic problem at work, like a nerve issue (peripheral neuropathy), or fibromyalgia (inflammation of the myofascial planes), but without an exam, understanding you're full history, and perhaps getting some tests it's hard to say. As above, you need to see a physician that can help figure this out with you. If you're question is who should you see, typically family practice and internal medicine docs are the first line to at least narrow the diagnosis enough that they can choose a specialist for you to go to.

Ladonna Perkins Thank you.. i will do that...

Kathie Obryan Great idea. Informative.

Julie Britten Bruns Thanks for all the information and your valuable time to post all this for all of us with bad joints.

Kaweah Delta Health Care District Here is another question for Dr. Ian Duncan. What are the results of total knee replacement?

Ian Duncan Patients with advanced arthritis can expect relief from the nagging joint pain and improved walking function. In general the worse the arthritis, the better the relief, which is why historically we have made patients wait until they are very bad. Patients with mild arthritis have a smaller margin to improve, but many of those patients will still improve. Our orthopedic research tells us about 90-95% of patients with knee replacements are very satisfied, and would have the surgery over again. It's not to say it's a a perfect surgery, there are several potential complications, and a few common limitations, even for the satisfied patients.

Kaweah Delta Health Care District Here is another question for you Dr. Ian Duncan. When should I have a joint replacement?

Ian Duncan The most basic answer is you should have a joint replacement when you are having difficulty doing your activities of daily living like getting dressed, bathing, shopping, having difficulty cleaning the house or doing your job. We used to tell patients they should wait until they're crippled and can hardly walk. Today patients expect more and our replacements are better so our criteria are more liberal. My personal recommendation is if you can no longer walk a mile without having to sit down and rest than you may be a candidate for a joint replacement.

Kaweah Delta Health Care District And here is our final question for the night. Please be sure to visit KaweahDelta.org tomorrow for more frequently asked questions and answers. Dr. Ian Duncan: What are the major risks of a knee replacement?

Ian Duncan 90-95% of knee replacement patients are happy about their replacements, those that are not are often due to the following general complications:
- Up to 50% of patients will get at least some degree of vein blood clots, most are no problematic. A few can break off and float to the lungs and become lethal. For that reason all knee replacement patients have some type preventative blood thinning medication.
- ~5% of patient suffer from some degree of troublesome stiffness
- ~5% deal w/ some instability or looseness.
- 1-2 % get infections, so several steps are taken to minimize this such as preventative antibiotics before and after surgery.
- Often the most concerning risks depend on your medical health and having anesthesia, such as your risk for stroke or heart attack

Kaweah Delta Health Care District Thank you Dr. Ian Duncan for joining us, and thank you everyone who asked questions. Kaweah Delta Health Care District Make sure to visit KaweahDelta.org for a transcript of tonight's questions and answers.
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