Posts By: Stuart Kozinn, MD

Partial Knees

Partial Knee replacement is becoming more popular because of the faster recovery. This photograph shows the difference between a partial (Unicondylar knee implant ) and a total knee implant which is  larger and covers both condyles of the femur and the entire tibial surface. The knee with the Uni maintains a normal ACL and PCL – Anterior cruciate ligament and Posterior cruciate ligament. This leads to better proprioception in the knee, or position sense.  A study done by Dr. Kozinn showed that more patients who have a a Uni on one side and a total knee on the other preferred the Uni- because it feels more like a normal knee ( sensory nerve feedback).

Uni Knee vs. Total Knee

Anterior Total Hip Replacement

Longer term follow up of anterior hip replacements are showing excellent results.  The greatest benefit may be a more rapid recovery for patients, and many will be able to have this hip procedure done as an outpatient.

Bilateral anterior hips can be done on the same day with rapid recovery!

Unicondylar (Partial Knee) Replacement

Many orthopedic surgeons who perform knee joint replacements are taking another look at Unicondylar Knee Replacements ( aka Partial Knee Replacement).  Uni knees are designed with either a fixed bearing design or a mobile bearing design. Both designs have shown good success, and your surgeon will explain the type he prefers and why.

Mobile bearing total knee and partial knee replacements allow patients to be very active.

There are many reasons, but some include : improvement in biomaterials that can resist wear and tear over time – i.e., the plastic spacers that serve to substitute for the worn out meniscus ; the ability to use better pain-management protocols that facilitate early rehabilitation ( most patients can walk on their new partial knee immedicately after surgery ); out-patient facilities  ( the rise of ambulatory surgery centers or ASCs) that can perform these partial knee replacements in the same day as discharge to home.  Patients desire to return to work and athletic activities as soon as possible.  The incision and muscle disruption is less compared to a “Total” Knee Replacement, so in general, recovery is faster.  Typically, formal post-operative physical therapy is not required, although some patients choose to do it.  A comprehensive home exercise program appears to give similar range of motion results over time.  Lastly, studies that have compared the satisfaction of a total knee vs. a partial knee ( in the same patients ), hve shown a predilection to prefer the partial knee.  The easiest way to explain this, is a partial knee does not remove many of the “normal structures” – such as the ACL ( anterior cruciate ligament, PCL (posterior cruciate ligament), lateral meniscus: structures that remain in the knee and continue to “transmit” neural feedback ( proprioception) to the brain – this feedback includes “positional sense”, that makes it more effective for athletes to “react” with reflexive action.   Not all patients with knee arthritis are candidates for a partial knee.  Talk to your knee surgeon to find out if you are a possible candidate for Unicondylar Knee Replacement.

Surgeon Education

Most patients are not aware that even experienced orthopedic surgeons are constantly updating their knowledge base, and attending educational courses and lectures.

I ( Dr. Stuart Kozinn MD) am going to just such a course today, held at Science Care in Phoenix.  This facility allows surgeons to use cadaver specimens to “practice on”, before using new implants in their alive human patients!  This particular course is being sponsored by DJO, a leading provider/manufacturer of Total Knee and Total Shoulder Replacement implants.  Their Altivate Reverse Shoulder Arthroplasty system has some particular advantages in its modularity ( allowing customization at the surgical table for individual anatomy differences ), and the Empower Total Knee System has state of the art design and component bio-compatibility.  I particularly like the Vitamin E treated polyethylene components which leads to longer plastic life and less wear from oxidative degradation over time.   i will let you know what new things I learned after the course in my next Blog Post 🙂

Office Charges:

I am aware that “quality” specialty healthcare has become very expensive in our country.  In my present practice role, I have decided to NOT participate with traditional insurance plans, including Medicare.  I believe I can provide a better personalized service to slected patients in this way.  Please email Dr. Kozinn at SKozinnmd@gmail.com with your specific request, and he will email you back ( or call you if you leave a cell phone number) to discuss the office charges in effect, so all  patients will know in advance what to expect, if theydo  decide to come for an evaluation in the office.   If you are over 65 and on Medicare, you should know that Medicare does not re-imburse you for my medical services because  I have  “oped-out” of the Medicare program (non-participating provider).  You can still be seen and will be asked to sign a “Medicare Private Contract” form, which allows you to pay for your own healthcare outside of the Medicare program.

Tom Clark is an IronMan competitor and personal trainer. He went home on the same day as his anterior total hip surgery!

 

 

When am I ready for Total Hip Replacement ?

Patients often ask me, “When am I ready to have my total hip replacement ?” The answer to that question may be different for each patient. Years ago, before hip replacement was available, patient’s lived with their arthritic hips “forever”. I suspect there was much pain and limping going on in those days. Aspirin was the most common pain medicine used. The psychological aspects of pain tolerance are interesting to consider. If you know there is nothing else available to help you, then you tend to tolerate it better and “live with it”.  Now that we know total hips work quite well in the majority of patients, most patients want to get rid of their pain as soon as possible.  In fact, since the anterior hip replacements have become more popular, more patients are asking for the surgery at an earlier age.  This is because the recovery process appears to be faster and less painful for the anterior approach in most patients.  The posterior approach, was the “gold standard” in hip replacement for many years. Results were good in most cases, but the recovery process was longer, because more muscles are cut to get into the hip joint from behind. There are also more “precautions” necessary after the posterior approach, because it is easier to dislocate the joint posteriorly after the posterior capsule ligaments have been cut. The idea of sleeping on your back, with a wedge pillow between your legs for 3 months was not a “happy or easy period” for many posterior hip replacement patients to get through.  Also taking time off from work was difficult for many younger patients. While the final result from hip replacement is good from either approach, it does appear that the early recovery process is easier and faster for most patients after an anterior approach total hip. The anterior approach uses an anatomical plane to enter the hip joint that “spreads muscles apart”, but does not need to cut them.  This leads to less pain and a more stable joint, as those muscles act like big rubber bands to hold the hip in place. Complications can and do occur with both the anterior and posterior approaches. Your surgeon will explain these during the “informed consent” process. Some complications may even be higher with the anterior approach.., these may include bone fractures and implant position issues, related to the “tighter window” the surgeon has to work through to get the job done. I am also seeing a higher incidence of anterior soft-tissue tendonitis, and some cases of numbness or tingling in the anterior lateral skin.  This is related to some stretching of branches of the lateral femoral cutaneous nerve, which is very close to the anterior incision. Very large patients, or very muscular ones with large thighs, may be better treated with a posterior approach because of some increased difficulty getting to the joint from the front.  The skin edges on the anterior incision can also get irritated, and the wound often crosses the groin crease. This can lead to some mechanical rubbing of the fresh incision, which means more compulsive wound care is needed post op.  Even with some drawbacks, the average patient is usually a good candidate for the anterior approach. Net, net…the risks and benefits of each procedure usually weigh in favor of the anterior approach for the average sized individual. So the answer to the opening question is, if your pain is significant and unrelenting, you are ready for your hip replacement when you have learned all of the risks, potential benefits, and alternatives to the procedure you and your surgeon choose. There is no specific time for any given patient,…pain and disability varies greatly amongst individuals. Maybe there is no standard answer, but you should go see a qualified orthopedic surgeon to discuss your options before you decide.

Total Shoulder Replacement Update

Total Shoulder Replacement is becoming a much more common surgery than it was a few years ago. New implant designs, surgical techniques,  and biomaterials are leading to better results. The shoulder joint is a very complex joint, controlled by many muscles. It is inherently unstable, and that is what gives it such a remarkable range of motion. The shoulder  is very much more dependent on soft tissues than other joints like the knee and hip.  shoulder anatomy 4The shoulder joint is likened to be similar to a golf ball sitting sideways on a golf tee. The shoulder socket, also called the glenoid,  is analogous to the golf tee. The glenoid is dish shaped and very shallow, and this is the reason the shoulder is the most common joint in the body to dislocate. So it is very important to have a strong rotator cuff, the muscles that move, balance,  and support the shoulder. Unfortunately, it is very common to see degeneration and tears of the rotator cuff associated with severe shoulder arthritis. If there is a large or unrepairable cuff tear, then a Reverse Shoulder Replacement may be a better option for your shoulder. The reverse shoulder is a more difficult operation and has more activity restrictions.  The implants are more constrained, and therefore may be more prone to damage during heavy lifting or sports.

Reverse Total Shoulder Replacement performed by Dr. Kozinn at The Scottsdale Joint Center.

Reverse Total Shoulder Replacement performed by Dr. Kozinn at The Scottsdale Joint Center.

The best indication for shoulder replacement is for the relief of pain. We will do a “hemiarthroplasty” on younger patients who still want to do heavy lifting or sports. The hemiarthroplasty only replaces the metal “ball” of the humerus, and leaves the socket bone in place without a plastic glenoid component.  The thin plastic is the most vulnerable to wear and loosening in active younger patients.

Traditional shoulder replacement with a humerus and glenoid (socket) component

Traditional shoulder replacement with a humerus and glenoid (socket) component

If you have shoulder pain and stiffness from arthritis, avascular necrosis, or prior trauma,  you should see a qualified and well trained shoulder surgeon and see if shoulder replacement can help you become more functional.  Rehabilitation after shoulder replacement is a bit easier than hip and knee replacement surgery, as we let you use the arm immediately for simple tasks (like feeding yourself), and you do not need to walk on your hands after the surgery.

When should you have your total knee replacement?

When is the right time to have your knee replaced? Knee arthritis takes years to reach a true bone-on-bone end point.  Each individual patient makes the decision to have a total knee replacement based on a number of factors.  Generally, the younger you are, the longer you should wait to replace a joint. This is mostly because we know that knee replacements will not last forever. Recent papers suggest the average total knee replacement done with modern techniques and implants has a 90 percent chance of lasting 20 years. Of course this does not guaranty any particular knee will last this long.  Revision knees may not last as long because the bone quality is not as good the second or third time around. All patients should exhaust all non-operative options before having a total knee.  This includes physical therapy, steroid injections, anti-inflammatory medication, and sometimes arthroscopic debridement. When the knee pain makes it impossible to do the activities you want to do, such as tennis, golf, or hiking, then it is reasonable to proceed. If narcotics are needed to control the pain, that is also a sign that total knee replacement may be the best option. Your surgeon will take an Xray of the knee and if the joint is worn out, and the bones are touching, then you are likely close to your replacement. See an orthopedist who specializes in joint replacement, and who operates in a Total Joint Center if possible.

The Pre-Operative Medical Exam

Before a surgical procedure, in most patient cases, a pre-operative medical evaluation is ordered and accomplished.  This is done to minimize any potential medical complications that could develop related to the stress of surgery, anesthesia, and changes in medications. Commonly referred to as “the medical clearance” evaluation, it is an important step to insure patient safety and quality care. We try to use the patient’s regular primary care physician to provide this service whenever possible. Since many patient’s arrive from out of town, or are “in between” medical physician’s, we often get involved to help place the patient with a local medical provider.  In some cases, the patient will only be under the care of this physician for the “peri-operative period”. This means they will ultimately return for their routine general medical care to their primary care physician when they return to their home locale.

The pre-operative exam will often include a Chest X-ray and an EKG ( cardiac electrocardiogram) to screen for any acute or chronic respiratory or cardiac conditions. Routine blood-work is also ordered to check for anemia or electrolyte abnormalities. If any tests are abnormal, the patient will be sent for an additional evaluation with a cardiologist, pulmonologist, or medical sub-specialist as needed.  It is common for more elderly patients, or those with an active cardiac condition such as atherosclerosis or heart rythym abnormality to get “cardiac clearance”. Patients who are asymptomatic but have a strong family history of cardiac disease will also see the cardiologist pre-op. Often a cardiac “stress test” is ordered, which can involve walking fast on a treadmill to speed the heartbeat up, while checking the ongoing concurrent EKG. More often, cardiac “stress” is artificially induced by injecting a medication in the patient’s IV that speeds the heart up, simulating the same physiologic effect of exercise. The function of the heart in response to this stress, tells us whether it is safe to proceed with your surgical procedure.ve a d

We have a dedicated team of medical professionals to care for you in the hospital

We have a dedicated team of medical professionals to care for you in the hospital

A history of renal (kidney function), liver disease ( hepatitis), gastrointestinal disease ( bleeding ulcer or diverticulitis), may also trigger an medical specialty consultation. Some of the more common conditions known to increase surgical risk are diabetes, hypertension, and bleeding / clotting disorders of the blood. These problems will be controlled and the patient will be “medically maximized” in preparation for surgery. Smokers, and patients who are very overweight, tend to have increased medical risk and we do our best to follow these patients closely.  if you drink more than one glass of an alcoholic beverage a day, it can interfere with medications given in the hospital, or lead to a stressful “withdrawal” episode.  If indicated, we will often give patients “a drink” with dinner to keep any possible negative physiological responses stable. We are very serious about preventing complications, so bear with us during the “inconvenience” of completing the medical clearance process. After your surgery, if indicated, a medical “hospitalist” will often be part of your care to check and treat any medical issues that arise. This may be a different doctor than the one who did the pre-op clearance! Hospitalists specialize in the treatment of in-hospital patients only, and often they do not have an outside office to see you after discharge.

Many of our patient’s now leave the hospital so quickly, that we do ask them to “follow-up” with their regular physician if problems develop after they are discharged to home. This is rare, and I encourage my patient’s to call me with any medical or surgical questions that come up in the early post-operative period. We will often bring you back to our office quickly if there is any concerns about the operative site or wound care. Call the office or Dr. Kozinn if you have questions. If there is a medical emergency that appears life or limb threatening, then please call “911” and/or head over to the nearest emergency room for fast evaluation and treatment.

Thankfully, peri-operative medical problems are not common, mostly because of all of our “pre-operative” medical preparations!

The Chief of Surgery Position

I was honored to be named the new Chief of Surgery at the Scottsdale Health  – Osborn Hospital starting January 2015.  People have become more aware of the importance of this position through medical drama TV shows like “Grey’s Anatomy” and “New York Med”.   My biggest job is inspiring and supporting the provision of quality care for all surgery patients. It is a big responsibility, as complicated issues requiring resolution involving the care of surgery patients ends up on my desk.  I am excited and energized to do my best at resolving  many issues that now arise even more frequently in our modern medical society. New healthcare regulations and requirements have many sectors in healthcare jumping to re-invent policy and procedures.  It is my ethical duty and responsibility to represent the patient’s best interests and uphold the highest quality care in our hospital.  I believe at Scottsdale Osborn we will always strive to provide the highest quality care during the coming period of more and more administrative complexity.

Dr. Kozinn was recently featured on the cover of Camelback Corridor Magazine for his leadership in orthopedic surgery.

Dr. Kozinn  featured on the cover of Camelback Corridor Magazine for leadership in surgery.

Administrative pressures leading to less personalized care are being brought upon us by government and the insurance industry.  In the face of this, we must do our best to maintain the highest levels of compassionate care.  I thank my supporters for their trust in me.  I thank my teachers for teaching me to “always try to do the right thing”.  I thank my patients for their amazing efforts towards recovery after illness and adversity has challenged them. It is a hard and challenging world we live in, and it is sometimes difficult to keep our attitudes positive. Yet somehow with grit and determination, the human spirit  rises above and continues to move forward.  As Chief of Surgery, I hope to inspire others, and I will work harder to make care better for patients at our hospital.

Dr. Kozinn making rounds with medical students and nurses at The Scottsdale Total Joint Center.

Dr. Kozinn making rounds with medical students and nurses at The Scottsdale Total Joint Center.

Stuart C. Kozinn MD / Chief of Surgery

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