Advancements in Orthopedic Surgery

Whether stemming from a disease or an injury, many of us have orthopedic conditions that affect our joints, bones, and ligaments. Fortunately, recent advances in orthopedic care are making a difference for many Chicagoans.

Orthopedic surgeons are innovators, constantly adopting new technologies — whether robotic-assisted surgery or 3D motion-analysis technology — to refine their approach, giving their patients the best function with optimal recovery.

Knee and hip replacements reduce pain and grant mobility to people with severe arthritis. And advancements in shoulder and elbow replacements increase function, so people can return to the activities they enjoy.

We asked four local leading orthopedists to talk about what these advancements mean. Read on for answers from:

Q: What new developments are you excited about in the field of orthopedics?

Nam: One innovation that continues to receive increased attention in hip and knee replacement is the use of robotic-assisted surgical systems to perform the procedure. The volume of robotic-assisted surgeries has grown on an annual basis in the United States and worldwide.

Most major implant companies are now introducing robotic systems that provide advantages in the accuracy and precision of placing components during joint-replacement surgery.

Finn: I believe we are in an era where robotic-assisted surgery is becoming an option for many people. While we are still in the evaluation period as to the significance of the impact this might have on patient outcomes, robotic-assisted surgery offers patients smaller incisions, which can lead to less blood loss, smaller scars, and faster recovery.

Romeo: Technological advances in imaging, preoperative 3D planning with virtual implant positioning, and intraoperative tools — such as robots or custom guides — are greatly improving our ability to ensure the implants we use are matched to the patient and precisely placed during the surgery.

I am thrilled to see the development and acceptance of stemless shoulder replacements — which means less bone is removed to secure the implant — for people with osteoarthritis, as well as unique designs of reverse total shoulder implants for people with arthritis and rotator cuff problems. It’s amazing that we can now successfully treat the problems related to cartilage, bone, and tendons with reverse total shoulder replacement.

Also, patient-centered apps and accessible websites allow me to provide individuals with education and expectations before surgery, a better understanding of the surgical procedure, clearly defined rehabilitation exercises, and an effective way to stay in touch after surgery.

Davidson: A growing area in sports medicine is using 3D motion-analysis technology to detect movement errors that are hard to see with the naked eye. For young athletes, minimizing the risk of injury is important to protect the long-term health of joints. One way to do this is to analyze how an individual moves, as certain body positions place increased stress on the joints.

At Shriners Children’s Chicago, our motion analysis center provides return-to-sport testing to identify subtle areas of weakness that may increase the risk of reinjury. The information that we provide to the patient can guide rehab and help them safely return to sports.

Q: What questions should I ask my doctor prior to joint repair surgery?

Finn: For hip and knee replacements, the most basic question is to ask the surgeon about their level of experience with joint replacement surgery. In addition, you should discuss with your doctor any questions regarding preoperative protocols, techniques used in surgery, and post-surgery protocol for rehab and recovery.
Finally, it is not unreasonable for the patient to ask the surgeon about his or her complication rates. For example, consider asking about the percent risk of infection after surgery.

Nam: It is important that people feel comfortable and confident with their plan for surgery and their journey through recovery. Studies have shown that patient education is critical and that setting appropriate patient expectations is a big factor to ensure satisfaction after surgery.
People should ask surgeons about their specific surgical technique, anesthesia preference, medications, expected road to recovery, and any limitations that they might have after undergoing the surgical procedure. Every physician who performs knee or hip replacement surgery should provide an education class to address patients’ concerns.

Romeo: Before making a decision about surgery, people should ask questions to weigh the potential risks and benefits. If one of my relatives required a joint replacement, I’d encourage them to ask:

• Are you able to do this as a same-day or outpatient surgery?

• Can this procedure be performed in an ambulatory surgicenter instead of a hospital?

• What are the possible complications of this surgery?

• What is the average recovery time with this type of surgery for your patients?

• How long do joint replacements last with your patients?

• Do I have any health conditions that might complicate my surgery or recovery?

• What restrictions will you suggest after I have the joint replaced?

• What help will I need to care for myself after surgery?

• What are my treatment options if I choose not to have surgery?

• How will my condition change or deteriorate if I do not have surgery?

• How many joint-replacement surgeries have you done?

Davidson: It’s important to know how to prepare
for surgery to minimize stress afterward. Ask your surgeon and care team if you will need equipment to assist with mobility, using the bathroom, or sleeping. Find out if there are devices that can help with surgical pain. In addition, ask how to optimize your health before surgery to aid your recovery afterward.
Having surgery can be very stressful, both physically and mentally. Make certain you understand the goal of the surgery and feel comfortable with the plan. If not, ask your care team about other options or getting a second opinion. This way you can feel confident and prepared for surgery.

Q: Considering the risks that opioids pose, what’s the best way for people to manage pain before and after surgery?

Romeo: Before surgery we encourage patients to use over-the-counter medications such as extra-strength Tylenol and ibuprofen for pain relief. If patients have received opioid medications from another physician, we encourage them to discontinue the medications as soon as possible to prepare for the surgery. Sometimes, working with a pain management specialist is indicated.

For the surgical procedure and immediately after surgery, my patients follow Enhanced Recovery After Surgery (ERAS) protocols to minimize the effects of anesthesia, reduce post-op pain, and speed recovery. These protocols include best practices from just before surgery to afterward.

Another important aspect includes good nutrition before surgery, so the body has what it needs to heal. Working with our anesthesiology team, my patients drink an electrolyte drink four hours before surgery since this has been shown to help with post-op recovery.

Also, for most upper extremity surgery including shoulder replacement surgery, I use nerve blocks whenever possible, so individuals have up to 12 hours of a painless shoulder after they are discharged home on the day of surgery. This enables them to return to the comfort of their home and settle in the same day as their procedure.

Finn: Prior to surgery, people may use nonsteroidal anti-inflammatory medications (such as naproxen or ibuprofen), activity modifications, and periodic cortisone injections. In addition, acetaminophen (Tylenol) may be helpful, as well as Tramadol, a prescription pain medicine.

Following surgery, a multimodality approach to pain control includes neuraxial anesthesia (spinals and blocks), anti-inflammatories, intravenous Tylenol, inhibitors of neurologic pain such as Lyrica, systemic steroids, and local infiltration of the tissues with medications that fight pain, swelling, and inflammation. The judicious use of opioids may be considered, being mindful of their complications and risks.

Nam: Prior to surgery, one of the best ways to manage pain is through activity modification — avoiding activities that can aggravate the joint’s condition, but keeping a balance of activity to preserve some function and mobility of that joint.

Other modalities include the use of ice, elevation, injections, physical therapy, and also anti-inflammatories. Your physician should provide you with recommendations on what approaches may be most appropriate based on your condition.

Following surgery, one of the greatest advancements has been the use of multimodal analgesia protocols that may include regional anesthetic blocks and a combination of medications that act together to reduce pain through different pain-generating pathways.

Davidson: It’s best to take a multipronged approach to treating pain. Pain medications, if prescribed, can often be supplemented with acetaminophen (Tylenol) or ibuprofen. The old acronym RICE — rest, ice, compression, and elevation — provides a helpful approach for both pain and swelling.

Another technique is using braces, splints, or assistive devices — such as crutches or a cane — to decrease the pressure on the affected area. If allowed, gentle joint motion is better than keeping a joint stiff without movement.

Finally, our mind is a powerful tool in managing pain. Meditation and other mindfulness techniques can help reduce stress, calm anxiety, and regulate the response to pain.

Q: What should young athletes know about sports overuse injuries and how to treat them?

Davidson: It is important to treat overuse injuries early, as they can affect healthy bone and joint development. Overuse injuries are typically caused by two main things: overuse and poor technique. Therefore, treatment and prevention are focused on these areas.
Avoiding overuse means taking periods of rest. This can range from decreasing the time spent practicing the painful activity, to spending more time cross-training, to taking time off from the sport.

Poor technique means that extra stress is inappropriately placed on joints or muscles, leading to pain. Deficits are often seen in joint motion and surrounding muscle strength, which can contribute to poor technique.

Nam: Sports overuse injuries have clearly been a growing area of interest, with the increased intensity and duration in which young athletes participate in sports. The first step is making sure young athletes recognize that having soreness or achiness around a joint or muscle may be more serious than it initially appears.

If symptoms do not resolve with simple rest or activity modification, or seem to reoccur with greater frequency, then young athletes should be evaluated by a medical professional. Often, these types of injuries can be managed with rest and physical therapy, but it is critical for young athletes to also be evaluated for underlying organic or mechanical issues that may predispose them to these types of injuries.

Finn: Generally, overuse syndrome occurs when musculoskeletal tissues are stressed beyond their reparative capabilities. Often, this results in pain, which is protective to the patient and suggests minimizing their activity. If the symptoms do not improve, they should seek the care of an orthopedic sports medicine physician.

Romeo: Currently, there is an epidemic of young pitchers needing Tommy John surgery — a surgery named after a former baseball pitcher — to repair a torn ulnar collateral ligament, a ligament inside the elbow. We have also seen a significant rise in leg injuries and knee ligament tears in sports such as soccer and women’s basketball.

This unexpected increase in injury is rooted in the idea that for the athlete to reach their full potential, they have to play the same sport throughout the year. The lack of cross-training — young athletes are increasingly specializing early in a single sport — and time to rest and recover from their training has led to injuries associated with overuse and fatigue.

Participating in more than one sport throughout the year allows for the development of other physical attributes and hand-eye coordination, while reducing stress and resting the areas that are prone to injury in specific sports.