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Advanced Knee Care

Knee Surgeon and Specialist Stefan D. Tarlow, M.D.

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The Obesity Epidemic: A Doctor’s Perspective

March 20, 2017 By Stefan D. Tarlow MD Leave a Comment

Personal Health Risks Obesity Linked to Cancer/Death

The identification of new obesity-related cancer sites will add to the number of deaths worldwide attributable to obesity.

In 2013, there were an estimated 4.5 million deaths worldwide attributable to overweight and obesity.  Longevity and wellness is linked to body weight.  The absence of excess body fatness reduces the risk of cancers.

A summary was published online August 25 in the New England Journal of Medicine.
These 13 cancers are linked to obesity ― colorectal, esophageal (adenocarcinoma), renal cell carcinoma, breast cancer in postmenopausal women, uterine endometrial cancer, stomach (gastric cardia), liver, gall bladder, pancreas, ovarian, thyroid, meningioma, and multiple myeloma.
Several mechanisms linking excess body fat with carcinogenesis were identified, including chronic inflammation and dysregulation of the metabolism of sex hormones, the IARC notes.
Worldwide Obesity Epidemic
Worldwide, an estimated 640 million adults were obese in 2014, which is a sixfold increase since 1975. There were 110 million obese children and adolescents in 2013 (a twofold increase since 1975).
What to Do?  Prevention is the Answer:
Obviously, the best way forward would be to prevent people from becoming overweight (defined as having a body mass index [BMI] ≥ 25 kg/m2) and obese (BMI ≥ 30 kg/m2) in the first place. There was an increased rate of repeat knee surgery (including revision total knee replacement surgery) as well a striking increase of knee joint infection, a serious complications in the morbidly obese group (BMI 35-40).
But once people have excess body fat, does reducing it also reduce the increased risk for cancer? Here, there is evidence from animal studies, but not yet from studies in humans.
From Medscape August 2016

Extra Weight Piles on Knee Arthritis Risk

Doctors have few weapons to treat obesity. There are detrimental physical and mental consequences of obesity. Medications and surgery infrequently help. Self prevention of obesity is very important for improving the health of our country AND decreasing expenditures for health care. It is time people take ownership of their well being. Eliminating obesity is a mission of top priority.

Reuters Health summarized the findings.

Researchers calculate that as many as half of all cases of knee osteoarthritis could be prevented if obesity was eliminated. Being overweight (BMI 26-30) doubles a person’s risk for osteoarthritis of the knees and being obese (BMI > 30) quadruples it, according to a new review of past studies that was designed to calculate how many knee arthritis cases would be avoided in a normal-weight world.

The researchers calculated that as many as half of all cases of knee osteoarthritis could be prevented if obesity was eliminated.

One in ten people over age 55 have severe knee arthritis, and many more suffer from chronic knee pain, researchers report.

Zhang and his colleagues reviewed 47 studies that compared the chance of developing knee osteoarthritis in normal weight, overweight, and obese people, including a total of almost 450,000 participants.

What is clear is that extra weight and arthritis are closely linked.

Extra weight can also increase a person’s chance of getting arthritis in the hip, but the knee “is the joint where osteoarthritis causes the most trouble, (and) it’s the one where obesity has its strongest effects.”

Lots to Lose: How America’s Health and Obesity Crisis Threatens our Economic Future

A report released by the nonprofit Bipartisan Policy Center offers recommendations for public and private sector promotion of healthy nutrition and exercise to reduce obesity. “Lots to Lose: How America’s Health and Obesity Crisis Threatens our Economic Future” states that escalating healthcare costs are the primary driver of an increasing national debt, and obesity-related illness is an increasing portion of healthcare costs. Among other things, the report argues that nutrition and physical activity training should be incorporated in all phases of medical education, and that large, private-sector institutions should procure and serve healthier foods, using their significant market power to shift food supply chains and make healthier options more available and cost-competitive.

We Can Do Better – Americans Not Much Healthier Now Compared to 15 Years Ago

                                                                                                                                             From nbcnews.com : Maggie Fox, Senior WriterNBC News

 Our biggest enemies are our own bad habits – poor diet, smoking and obesity. They’re far more dangerous to our health than pollution or risks from radiation. And although women used to be far healthier than men, men are closing the gap fast, the survey by Dr. Christopher Murray of the University of Washington and colleagues finds.

“We need to really try to get at the social and environmental causes of these issues and really focus on true prevention, which is not managing in a clinical setting but creating the conditions where this doesn’t happen in the first place.”

Americans may be living longer and even exercising a little more, but we really are not much healthier than we were 10 years ago and we are still far behind other rich countries when it comes to our health, researchers said Wednesday.

Americans lost ground compared to people living in other countries in the Organization for Economic Cooperation and Development.

“There are places with the best life expectancy in the world in the U..S., and there are places in Mississippi, for example, or West Virginia where life expectancies are in the mid-60s for men and low 70s for women. That’s about the same as a number of poor developing countries,” Murray says.

The biggest killers: clogged arteries (known medically as ischemic heart disease), lung cancer, stroke, chronic obstructive pulmonary disease and road accidents.

But the diseases that caused the most misery, known in the lingo as disability-adjusted life years, are low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders.

 In other words, individuals in the US are living longer, but not necessarily in good health,” they concluded.

“For the first time we’re saying that the composition of diet, which is made up 14 different components, things like fruits, grains, nuts, seeds (and) other aspects of diet being analyzed is the biggest determinant of health in the US, followed by smoking, followed by obesity, and then followed by high blood sugar and physical inactivity,” Murray told NBC news.

“So if you put all of those together there’s huge potential to improve health in the U.S. and in fact get ahead of other high income countries if we were to address these modifiable risks.”

“It’s unsophisticated to say it’s because we are not eating right,” Woolf said in a telephone interview.

“There is a large contingent of Americans who react by saying this is a matter of personal responsibility. To some extent that’s true but there is much more about the way our lives are structured in the U.S.”.

“Those distinctions are really about income and education level,” Levi told NBC News.
“OECD countries are spending more on education and income support than we do and that is what is helping to create this healthier environment.”

Physician’s Weight May Influence Obesity Diagnosis and Care

Released: 1/26/2012 10:10 AM EST
Source: Johns Hopkins Bloomberg School of Public Health
Newswise — A patient’s body mass index (BMI) may not be the only factor at play when a physician diagnoses a patient as obese. According to researchers at the Johns Hopkins Bloomberg School of Public Health, the diagnosis could also depend on the weight of your physician. Researchers examined the impact of physician BMI on obesity care and found that physicians with a normal BMI, as compared to overweight and obese physicians, were more likely to diagnose a patient as obese if they perceived the patient’s BMI met or exceed their own (93 percent vs. 7 percent). The results are featured in the January issue of Obesity.
According to the Centers for Disease Control and Prevention (CDC) obesity affects more than one-third of the U.S. adult population and is estimated to cost $147 billion annually in related health care costs. Obesity increases the risk of many adverse health conditions including osteoarthritis of the knee, type 2 diabetes, coronary heart disease, stroke and high blood pressure. Despite guidelines for physicians to counsel and treat obese patients, previous studies have found only one-third of these patients report receiving an obesity diagnosis or weight-related counseling from their physicians.

Filed Under: obesity

Improving Total Knee Replacement Surgery Results: Optimize Risk Factors PreOp

March 20, 2017 By Stefan D. Tarlow MD Leave a Comment

Knee surgery risks photo

One way of improving the results of Total Knee Replacement Surgery is to optimize the risk factors. The common patient risk factors include the following: uncontrolled diabetes (Blood Sugar >150, HbA1C>8), Smoking, Obesity (BMI > 40), Opioid use, and Kidney disease. All these risk factors should be corrected prior to having the surgery.

There are treatments available to reverse these risk factors. Uncorrected, the above listed factors increase the chance a patient will suffer an prosthetic joint infection, a return to the operating room for another knee procedure, wound healing problems, revision knee surgery or an unsatisfactory surgical result.

Knee Replacement Surgery Risks

Like any other surgery, total knee replacement carries some risks. However, the occurrence of these risks is quite low: infection, nerve damage, stroke or blood clot. The aforementioned risks are those that might occur during or after the surgery. What we are going to focus on are the factors that might affect the outcome of the surgery. Such factors or risks must be corrected before the surgery is conducted. They include the following: uncontrolled diabetes, smoking, obesity, opioid use and kidney disease.

Uncontrolled Diabetes

  • The Risks

According to a number of studies, people with diabetes face a higher risk of postsurgical complications. The possible complications that a patient may experience if he/she undergoes a surgery such as total knee replacement with uncontrolled diabetes are the following: joint loosening, fracture around the implant, blood clot, stroke and wound infection.

  • The Treatment

Diabetes is an important consideration before a patient undergoes a surgical procedure. The research suggests that patients need to control their diabetes before undergoing a major surgery such as total knee replacement. While your blood sugar will be tightly monitored right before and after surgery, it’s up to you to make the long-term lifestyle changes necessary to ensure you get the best outcome. This is an important conversation to have with both your surgeon and the physician or provider who helps you manage your diabetes. Eating well and exercising (if appropriate and with approval from your providers) can help you get your body ready for surgery.

Smoking

  • The Risks

Research shows that there is a correlation between smoking and the success of knee surgery. Some studies put the chance of redoing the surgery at a rate ten times higher in smokers than in non-smokers. Smokers also show higher rate of surgical complications which include blood clots, kidney problems, urinary tract infections, and abnormal or irregular heartbeats. This is because nicotine constricts the blood vessels, which interfere with and affect the healing process.

  • The Treatment

The best way to get rid of the risks is to quit smoking. You may have tried to do so in the past and not found success, but if you’re going to have total knee replacement surgery, let this be the big push you need to finally quit. In addition to the possibility of increased post-surgical complications, just imagine trying to find a place to smoke while you’re recuperating. Talk with your primary care provider about available techniques and support.

Obesity

  • The Risks

Obesity is the root of various health conditions and diseases like type 2 diabetes, obstructive sleep apnea, cardiovascular diseases, hypertension and metabolic syndrome.  All these conditions increase the risk of knee replacement surgery. Aside from these, patients with obesity are also more at risk to experience the following postsurgical risks: blood clots, difficulty breathing, poor and slow wound healing, infection and pulmonary embolism.

  • The Treatment

To lower the risks and to promote a better result, patients with obesity are advised to lose some weight. It is important that the patient is in good health and weight prior the surgery. Try hard to lose some weight and eat healthy before the scheduled surgery. Your immediate post-surgical health will improve—and along with your new knee, being in better shape will give you a new lease on life.

Opioid Use

  • The Risks

One of the total knee replacement precautions a patient must know concerns opioid use.  One study showed chronic opioid use before a total knee arthroplasty led to worse outcomes for patients, including “longer hospital stays, more postoperative pain, and higher complication rates… [patients] were also more likely to need additional procedures, require referrals for pain management, suffer from unexplained pain or stiffness, and have lower function and less motion in the replaced knee.”

  • The Treatment

The FDA suggests that patients undergoing knee replacement surgery should decrease the duration and amount of opioid use. There are many other pain management treatments available besides opioids, and you should explore them with your pain management physician—not just because of your surgery, but because chronic opioid use itself brings a whole host of problems you don’t want.

Kidney Disease

  • The Risks

Patients with kidney disease, particularly chronic renal disease, have increased risk for readmission after the surgery. The success of knee replacement surgery is also low and the occurrence of common complications is high among patients with kidney problems.

  • The Treatment

If you have kidney disease and need to have surgery—any kind of surgery—you and the doctor managing your disease, as well as the surgeon, need to work closely together to assess your risk and make sure surgery is the right course for you. If you and your providers move ahead, techniques like post-operative dialysis, substituting or changing the normal dose of medications like antibiotics given before and during surgery and avoiding pain medications that are known to cause problems are all good strategies to keep you healthy.

Reducing Total Knee Replacement Complications

We, the patient and the doctor, both want something in common. That is, the best outcome possible of the surgery. Knowing how to reduce the complications is powerful information. It is very important that you follow the tips mentioned in this article and control the risks mentioned to improve the results of your total knee replacement surgery.

If you’re contemplating knee replacement, schedule an appointment to see me and the rest of the team here at Advanced Knee Care. Assessing your needs and the appropriate treatment for you is our top priority.

Filed Under: knee replacement, knee surgeon, knee surgery, knee surgery complications, obesity Tagged With: Improved Knee Replacement Results, Improved Patient Outcomes, kidney disease, Obesity, risk factors, smoking

Knee Surgery for Obese Patients: Problems and Solutions

March 5, 2017 By Stefan D. Tarlow MD Leave a Comment

Why Obesity Poses Greater Risks for Surgical Complications

A literature review published in the May issue of the Journal of Arthroplasty attempts to define and identify areas of concern for obese patients undergoing total joint arthroplasty (TJA). “Obesity risk assessment is compounded by the fact that obesity is rarely an isolated diagnosis,” the authors write, “and tends to cluster with other co-morbidities that may independently lead to increased risk such as diabetes mellitus, coronary artery disease, hyperlipidemia, hypertension, and sleep apnea.” Among the authors’ findings:
    • Despite improvements in patient-related outcome measures, all obese patients undergoing total joint arthroplasty are at increased risk for perioperative complications.
    • Patients with a body mass index greater than or equal to 40 who undergo total knee arthroplasty are at risk for the majority of perioperative complications.
  • Published data on perioperative complications among obese patients undergoing total hip arthroplasty appear to be less clear.

New Procedure Offers Treatment Option for Obese Patients With Knee Pain

Subchondrplasty Joint Preservation Treatment Less Invasive Than Joint Replacement Surgery.
 
Photo of MRI of BME-Xray normal From Zimmer Institute
MRI of BME-Xray normal
From Zimmer Institute

Subchondroplasty® Procedure is the innovative new joint preservation procedure developed by Zimmer Knee Creations to treat the microfractures that develop just under the joint surface in painful knees.  These lesions are similar to stress fractures and develop due to overload of the bones that make up the knee joint.

 
Rather than replacing the entire knee, this treatment aims to stimulate nature to heal the bone lesion which can lead to reduced knee pain and better knee function.   Subchondroplasty is an arthroscopic knee surgical procedure done as an outpatient.  This is a safer and less invasive procedure than Total or Partial knee replacement and as such may be carried out in higher risk surgical patients, such as the obese patient,  with less fear of an adverse outcome such as infection or blood clot.
 
BML-MRI image
BML-MRI image
From Zimmer Institute
Bone Marrow Edema (BME), or Bone Marrow Lesions (BML) are thought to cause pain in knees with early or late osteoarthritis.  These lesions can only be diagnosed with high resolution 3 T MRI scans.  In 2001 Felson identified BME/BML as the strongest predictor of the presence of pain associated with knee OA.  They also determined that arthroscopy alone will not predictably relieve knee pain associated with arthritis.
 
 
This observation has been confirmed by other investigators.   However, the novel Subchondroplasty® Procedure is a percutaneous outpatient intervention that addresses the painful defects associated with subchondral bone marrow lesions (BME/BML). BMLs are related to stress fractures or micro-fractures, that can only be visualized using MRI scans. Left untreated, these defects have been shown to lead to cartilage degeneration, limited function, pain and greater risk for joint deterioration.
Theoretically, mechanical enhancement and/or biologic stimulation of chronically damaged and structurally compromised SubChondral bone, juxtaposed to a region of the joint with deficient cartilage, will relieve Knee pain emanating from the SubChondral bone and slow progression both bone and cartilage deterioration.
 
SCP Surgical Procedure Photo
From Zimmer Institute
 
 
In this minimally invasive, arthroscopically-assisted procedure, navigation instruments are used to inject specialized Ceramic Calcium Phosphate bone filler (Etex), without violating the joint. As the bone filler is resorbed, the pain due to BML subsides as the lesion is replaced with new, healthy bone.  The substitution of abnormal bone with healthy bone is the reason patients experience pain relief.    The Subchondroplasty Procedure is the first procedure to treat bone-based changes within a painful joint, and addresses an unmet clinical need between early interventions, such as NSAIDs and joint arthroscopy, and total joint replacement. Subchondroplasty was introduced in November 2010.  This procedure is now available in the Greater Phoenix area from Makoplasty Surgeon Stefan D. Tarlow, M.D. of Advanced Knee Care, PC.

Filed Under: knee surgery, knee pain, obesity Tagged With: Bone Marrow Lesions, Fractures, Joint Preservation Treatment, Surgical Complications

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The Patient’s Guide to Medicare and Robotic Knee Replacement

Why Out-of-Network Doctors are a Preferred Choice for Robotic Knee Replacement

A Comprehensive Guide to Understanding Patello-Femoral Replacement Surgery

ACL Reconstruction: What to Expect Before, During, and After Surgery

PRP Knee Injections: A Natural Approach to Relieve Joint Pain and Promote Healing

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