March 21, 2014
Transcript for “Ask the Experts” Live Chat with Orthopedic
Surgeon Ian Duncan, M.D.
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?
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.
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?
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.
Jones-Sisson: How old is the minimum age for getting a total knee
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.
Jones-Sisson Thank you
Jones-Sisson I love this. Thank you Dr. Ian Duncan
Werner Is there a limit to the number of cortrizone shots a person can
have for an arthritic shoulder?
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.
Werner Thank you very much for your answer.
Duncan My pleasure! This online chat is new for us, but we're hoping
to continue this on a regular basis.
Miranda I have alot of pain on my back,neck,shoulder and the bottom of
my feet to what can i do ?
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.
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
Anderson Caudill Dr. Redd in Visalia is really good. He did a great
job with my knee surgery.
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
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...
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.
Perkins Thank you.. i will do that...
Obryan Great idea. Informative.
Britten Bruns Thanks for all the information and your valuable time to
post all this for all of us with bad joints.
Health Care District Here is another question for Dr. Ian Duncan.
What are the results of total knee replacement?
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.
Health Care District Here is another question for you Dr. Ian Duncan.
When should I have a joint replacement?
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.
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
Duncan 90-95% of knee replacement patients are happy about their
replacements, those that are not are often due to the following general
- 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
Health Care District Thank you Dr. Ian Duncan for
joining us, and thank you everyone who asked questions.
Health Care District Make sure to visit KaweahDelta.org for a
transcript of tonight's questions and answers.