Traditionally, orthopedic surgeons universally recommended patients with joint replacements take a dose of antibiotics prior to dental work. This practice was generally supported by the American Academy of Orthopedic Surgeons. Recently, this recommendation has come into question with the American Dental Association stating that routine use of antibiotic prophylaxis following total joint replacement is not necessary.
Why the controversy?
Simple. We do not have sufficient data to make a strong recommendation backed up by science. The incidence (regardless of cause) of total joint infection is quite low at around 1-2%. When a problem occurs very infrequently, testing an intervention requires an enormous study to show an effect. Such a study simply has not been done.
Let's look as some more data. While the bacteria implicated in the majority of total joint infections are staphylococcus species, which are mainly found on the skin, infections can also occur due to streptococcus species. The predominant bacteria in the mouth are streptococcus species. We know that bacteremia (bacteria present in the bloodstream) occurs during and after dental work. Whenever bacteria are present in the bloodstream, there is concern that they can be deposited on "at risk" material such as artificial heart valves and total joint replacement prostheses. The tendency for bacteria to be deposited is likely higher in areas of increased and/or turbulent blood flow. Dental bacteria have been isolated from tissues deep within the body. And documented total joint infections due to dental bacteria have indeed been reported. Even native (non-replaced) joints can become infected as a result of oral bacteria following dental work.
Although based mainly on a few case reports, my conclusion is that oral bacteria routinely enter the blood stream during dental work, and it is possible that a deep prosthetic joint infection can result.
So why the controversy? There are different perspectives.
First, orthopedic surgeons know that an infected total joint replacement is a big deal. It usually requires more surgery, sometimes multiple operations and long-term IV antibiotics to cure. A cure is not guaranteed, and even when cured, return to pain-free function is not guaranteed.
Second, dentists. Since there is not overwhelming evidence linking dental work to total joint infections I believe the issue has been minimized a bit by the dental community. I feel the American Dental Association has overstepped the science when stating antibiotic prophylaxis is not indicated prior to dental work. This conclusion was essentially based on a single case-control study. To make such a conclusion, a properly conducted, prospective randomized study on a huge population is required. Dentists do not directly see or have to take care of a total joint infection and therefore may under-estimate the magnitude of such a problem. Perhaps also distancing the dental field from orthopedic infections could be felt to minimize liability in such cases. Interestingly, most local dentists actually encourage prophylactic antibiotics in spite of the ADA recommendations.
Third, population health. Antibiotic overuse is not without consequence. There are multi-drug resistant bacteria that have evolved in part due to the tremendous volume of antibiotic medication used worldwide. (Of course the vast majority of antibiotic use is in veterinary medicine and food production, which is clearly a topic for another blog posting.)
Fourth, the total joint replacement patient. Antibiotics can be associated with negative side effects, allergic reactions, and secondary infections. So we need to carefully balance the risks and benefits. As I have outlined above, this is challenging because the risks and benefits have not been clearly defined scientifically.
Here is my approach. I recommend all of my total joint patients take a single dose of prophylactic antibiotics prior to dental work for a minimum of 2 years following surgery. 2 years is significant because we know there is increased bone metabolic activity (increased and turbulent blood-flow) around the total joint prosthesis during this time. If a standard-risk patient wants to use antibiotic prophylaxis in this way indefinitely, I would not deny them the antibiotics after carefully discussing with them the risks and benefits. I recommend any high-risk patient (immunocompromised, diabetic, cancer, rheumatoid arthritis, etc) take a single dose of prophylactic antibiotics prior to dental work forever.
With this approach, I am clearly biased in favor of my patients over the general population. In other words I feel that the single antibiotic dose I prescribe to my patients every six months is unlikely to have a major negative effect and also very unlikely to make a major contribution to worldwide bacterial resistance. Antibiotics are used in far greater quantities in the veterinary medicine and food industries, and are also inappropriately used in viral illnesses where they will have no benefit. Although prosthetic joint infection is rare at the population level, sparing an individual patient such a negative experience is a tremendous benefit.
When I eventually undergo a joint replacement, based on my current understanding of the issues, I plan on using prophylactic antibiotics forever.
When can I drive?
This is a very common question patients ask following surgery. Some studies have suggested that reaction time and/or braking force is reduced for weeks or even months following total knee replacement surgery. This could lead us to recommend that patients do not drive for a prolonged period of time following total knee replacement surgery. Logistically, this can be challenging.
A recent study showed that patients with osteoarthritis of the knee (without having undergone knee replacement surgery) had reduced driving ability based on diminished reaction time, movement time, and they ultimately had reduced braking performance. In spite of these findings, is not reasonable to tell patients with osteoarthritis of the knee that they can never drive.
A brand new article in the Journal of Arthroplasty shows that 80% of patients have regained their pre-surgery braking performance by 2 weeks following total knee replacement. All patients in this study were back to baseline by 4 weeks.
This reinforces my standard recommendation, but still leaves out one key issue. Pain medication. Narcotic pain medication is commonly used for several weeks following total knee replacement. This can impair driving skill and reaction time independent of knee surgery.
My recommendation to patients after total knee replacement surgery is that they should not drive while they are using narcotic medications. Furthermore, they should not drive until they feel comfortable doing so. This time period is patient specific, and there is a wide range. Common sense should prevail. I believe patients generally know themselves, and certainly do not want to place anyone at risk by driving prematurely.
I recommend patients focus as much as possible on rehabilitating their new total knee replacement for the first few weeks, limiting their driving to the essentials: food shopping, physical therapy, and follow-up with their orthopedic surgeon. Soon, their pain level will be down, and their confidence to drive will return.
We can then add driving to the list of lifestyle improvements made possible by total knee replacement.
As always...please discuss specific recommendations with your surgeon.
Non-operative treatment for osteoarthritis includes activity modification (do less, reduce impact, reduce load, reduce distance, etc), topical medications, oral medications, bracing, and injections.
A common injection used in orthopedic clinics many times each day is generically referred to as "cortisone." It is a combination of a local anesthetic (like the dentist uses) and a steroid. There are a variety of local anesthetic agents used (lidocaine, bupivacaine, etc.), and a variety of concentrations available. Additionally, there are a variety of steroids that can be used. Each surgeon likely has a preferred combination.
Just a side-note: the steroids orthopedic surgeons inject for anti-inflammatory purposes are completely different from the anabolic steroids associated with body-building. They will not make you grow muscle.
Although not everybody responds the same, a cortisone injection often provides rapid and significant relief from arthritis pain. This relief can last for months. When the pain returns, we have a discussion regarding the amount and duration of relief experienced. I generally allow my patients to undergo up to 3 cortisone injections per joint, per year.
Some patients aggressively pursue these injections and would accept them much more frequently than I recommend. Others prefer to avoid them entirely. Reasons for this vary. Some patients are simply afraid of the needle. This is a shame, because most patients report only mild discomfort when I've performed a cortisone injection. Other patients are more concerned about the potential detrimental effects. They've heard that cortisone destroys cartilage and will hasten their joint deterioration.
Some in vitro (test tube) and animal studies have shown chondrocyte (cartilage cell) toxicity due to local anesthetics, steroids, and combinations of both. Cartilage cell damage in a test tube does not necessarily mean that an injection into a living human's joint will create similar damage. In fact, another study in which samples of living cartilage were taken after the knee was injected with local anesthetic showed no such effect. While I certainly understand that cells in culture may be negatively effected, I have seen no clinical evidence of joint destruction due to cortisone.
I think it is reasonable to assume, like with most medications, that while there is a benefit, there is also some potential for harm. The key is to use cortisone, like all medications, judiciously. That is, only when indicated, not too often, and at the lowest effective dose.
It is important to remember that we are using cortisone in joints that are already moderately to severely damaged due to arthritis. The joint is already irreversibly damaged due to the cumulative effects of gravity, activity, and time. A cortisone injection can provide a significant improvement in quality of life and can potentially delay surgery. A recent article in the Journal of the American Academy of Orthopedic Surgeons confirms the efficacy of cortisone injections to provide pain relief for osteoarthritis.
Remember, a total joint replacement involves removing ALL of the cartilage from the joint. I would argue that that is much more toxic to the cartilage than a few cortisone injections.
I am not suggesting people should not have their joints replaced when they wear out. The majority of my practice involves replacing destroyed knees, hips, and shoulders. These operations predictably alleviate pain and restore function. Total knee, total hip, and total shoulder replacements, help hundreds of thousands of patients every year in the U.S.
I am suggesting that appropriate use of cortisone can allow some patients to delay an operation, sometimes for years. And if there is a risk that microscopic cartilage damage occurs, the ability to reduce pain and delay surgery is worth it.
Although playing tennis can result in tennis elbow, most cases of tennis elbow, also known as lateral epicondylitis, are actually due to overuse when working with the hands. A tendon is the tissue that attaches muscle to bone. The suffix "itis" means inflammation, and while acute overuse injury can cause inflammation, the typical case of tennis elbow is more chronic, due to repeated overuse, and results in degeneration of the tissue. This situation is more appropriately called "tendinosis."
The pointy bone that sticks out on the outside of the elbow is called the lateral epicondyle. This is the common origin of the wrist extensor muscles which cross the elbow and then cross the wrist. It is this tendon that is injured with tennis elbow.
So, when attempting to grip something firmly, the wrist extensor muscles (that attach to the outside of the elbow called the lateral epicondyle) contract firmly. This is fine. Now when elbow range of motion is added simultaneously, the wrist extensor muscles experience shearing, or variation in the force they experience, while the elbow moves. Additional irritation like a short rapid wrist flexion force can sometimes occur. This combination of forces can create trauma to the extensor muscle group at its insertion point on the lateral elbow (lateral epicondyle).
A perfect example of the above scenario is when the tennis ball makes contact with the racket during a backhand swing, hence the name tennis elbow.
A more common situation in my practice would be swinging a hammer all day, scraping paint, or pulling weeds. Basically power grip with the hand superimposed on simultaneous wrist and elbow range of motion.
Acutely, micro-tears can occur in the muscle origin on the outside of the elbow (lateral epicondyle). This can create pain and inflammation. When allowed to rest and recover, the issue resolves. However when the overuse occurs repeatedly, and the micro-tears are not allowed to fully resolve prior to additional trauma, the condition can become chronic. The normal tendon tissue (a tendon is the tissue that attaches muscle to bone) breaks down, and the tissue becomes disorganized and weak (tendinosis).
Lets talk about treatment. It is important to know that proper non-operative treatment will cure 90% of people. Unfortunately, especially in chronic cases, it can take months to resolve.
Also known as patellofemoral syndrome, anterior knee pain can be extremely frustrating for patients and surgeons alike. Anterior knee pain is extremely common and can have a variety of causes. Patellofemoral arthritis (knee-cap arthritis), and knee-cap dislocation (patellofemoral instability) are two diagnoses that can cause anterior knee pain, but they each will require a separate blog posting of their own.
Patients experiencing patellofemoral syndrome complain of aching pain in the front of the knee which can range in severity from mild to intense. It is often made worse by sitting with the knee bent for a prolonged period (movie theater or back seat of car). In this situation the pain can be improved by extending the knee (straightening it). Climbing or descending stairs can also be quite irritating.
This condition affects people of all ages and of all fitness and activity levels. I have diagnosed and treated this condition in marathon runners, adolescents, and patients who previously underwent total knee replacement. Usually the problem gradually worsened and has been present for a fairly long time when it gets to me. The key to the diagnosis is to listen to the patient. The history given tends to be very consistent.
To better understand this condition, let's start with some background information.
The patella (knee-cap) is subjected to the greatest force of any cartilage in the body (3-5 times body weight during normal activity and up to 10 times body weight when jumping). It is embedded within the extensor mechanism of the knee so that it can provide leverage to the quadriceps muscle group. The front of the knee is richly innervated and is thus very sensitive to abnormal pressures. The position of the femur (thigh bone) during activity will change the amount and distribution of forces on the patella.
There is a very consistent examination finding associated with this diagnosis. Patients usually will have very weak hip flexors (muscles than bring the thigh forward relative to the torso) and hip abductors (muscles that bring the thigh away from the midline). Usually the hip external rotators will also be affected.
What does the hip have to do with the knee-cap?
The hip flexors and abductors are very important during the gait cycle (walking). The abductors must contract with great force to keep the pelvis level during single leg stance. The hip muscles together act as the "foundation" for your leg. If they are weak, your leg will be poorly controlled when walking. This can result in abnormal gait mechanics, abnormal rotation of the femur when weight bearing, and abnormal patellofemoral mechanics.
This combination of issues multiplied over thousands of steps each day can result in anterior knee pain.
Ok, so how do we fix it?
My recommendation is to focus on the hip. Strengthening the weak hip muscles will almost always result in a cure. Unfortunately, this can sometimes takes weeks or months. Remember, we are rebuilding muscles that have gotten deconditioned over a long period of time. This takes time. Knee pain gradually resolves as hip strength gradually improves. The exercises I recommend are very simple:
Keep your knee locked in extension. Raise your leg from your hip keeping your toes pointing toward ceiling. Up and down counts as one repetition. Aim for a set of 30 repetitions. Then add sets.
It is important to do these exercises on both sides, even if only one knee hurts. You want to keep things balanced.
Lateral raise. This exercise focuses on the hip abductor muscles. Lying on your side, slowly elevate the leg from your hip, keeping your knee straight and your toes pointing forward (not toward the ceiling). You should feel the burn on the side of your butt.
So, that's basically it. Remember, we are building hip muscles. It takes time. I recommend doing these exercises on both sides (even if only one knee is painful) so everything stays balanced. Each repetition should be done slowly when raising and lowering. You may be surprised by how challenging this set of hip exercises can be. You should work up to 3 sets of 30 repetitions for each muscle group. Repeat the workout twice per week. The total work-out should only take about 15 minutes. Resist the urge to do these exercises more frequently. The purpose of exercise is to stimulate the muscle to grow. It then needs to be allowed to grow, and this takes time. Stimulating the muscles with resistance exercise too frequently will be counter-productive.
When doing this exercise becomes easy, feel free to add some additional resistance. You can wear a boot, or use an ankle weight.
It is a common misconception that one should exercise the quadriceps using a leg extension machine. This is a mistake and I would strongly suggest avoiding any knee isolation exercises in general, but when dealing with patellofemoral syndrome in particular. The knee extension machine will worsen anterior knee pain.
Be patient, and consistent with these exercises. As your hip strength improves, your knee pain will improve as well.
Orthopedic Surgeon focused on the entire patient, not just a single joint.