good evening and welcome to doctors on call I'm Dr Peter Nan professor and head of the Department of Family Medicine and biobehavioral health at the University of Minnesota medical school duth campus I'm your host for our program tonight on lower extremity knee foot and hip problems the success of this program is very dependent on you the viewer so please call in your questions tonight or send them in ahead of time to our email address ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Taylor PUK an orthopedic surgeon with Orthopedic Associates of duth Dr Sandy sto a family medicine physician and faculty member at the medical school duth and Dr Philip Thomas an orthopedic surgeon with asentia health our medical students answering the phones tonight are Sydney clawen from Stewartville Minnesota Jessica crosson from Hugo Minnesota and Wyatt windhorse from Alexandria Minnesota and now on to tonight's program lower extremity knee foot and hip problems and the first question is for Dr Stover Dr Stover would you tell us how you advise your patients with bunions on the feet oh well bunions are one of those things that uh it's really not anything you do that creates a bunion it's it's basically sort of what is going to happen because of genetics uh there are um changes in the foot that start to to change the angle of the the big toe and the best thing to do is to give it room in your shoes So Soft shoes leather shoes that can be stretched uh things that help reduce some of the wear and tear and the rubbing on the on the side of the toe there are um a variety of things that that uh padding different kinds of padding that can be used the the kind of change that happens with a bunion we can be corrected by surg can have the toes straightened but it will recur so you want to wait as long as possible before addressing any kind of surgical correction for it thank you Dr Thomas do all Achilles tendon repairs go to surgery yeah that's a great question I think it's one of those things where um Achilles tendons were were something that debated in the literature quite a bit and that we used to sort of fix all of them because the tendon would separate and that would make complete sense and with the rise of pickle ball we're seeing an actually incredible rise in Achilles tendon ruptures uh and I think oftentimes those do kind of get pushed towards the surgery or the feel the need for surgery and uh there's really good literature out that actually says the vast majority of Achilles tendons don't need to go to surgery and can be treated very well non-operatively uh so I think at the very least it's worth a discussion with your surger or your doctor whoever you're working with for it uh from the idea of is this the right thing for you and there's certainly risks that come with surgery and there's risks that come from that surgery in particular so I think they certainly do not all need to be fixed and some of them it makes sense and some of them it's appropriate thank you Dr PUK this question is for you how soon do hip replacement patients begin walking yeah that's a great question I think it's one of the more common questions we get asked about with almost any surgical intervention specifically regarding the lower extremities and for the hip knee uh back anything really try and get people up moving as fast as possible so the same day for hip and knee Replacements most of them are done under spinal anesthesia now so as soon as that kind of wears off and the appropriate exception and strength is back we have them walking usually that's in with uh within a couple hours of surgery um we have really really good evidence suggests that early mobilization uh is not only good for the first you know one to 10 days after surgery but long term as well prolonged immobilization leads to you know inflammation all over the body and it can really delay someone's progress from rehabilitation standpoint thank you Dr Stover how do major lower extremity joints become infected that's a good question um you bacteria generally don't easily get into the joint because there's a lot of protective things the skin and the joint capsule itself but it can happen through the blood system sometimes if there's traveling bacteria that aren't caught by the immune system it can happen if there's an injury somewhere near the knee that it locally gets infected and there's things like Lyme disease that can create a a vector that infects the body that that likes to go to joints U but it's joint infections without a direct injury are are less common than ones that are have an injury related near The Joint thank you Dr Thomas this uh caller from uh Chago city in Minnesota um needs a knee replacement but I'm in my 60s and I'm worried I will need it replaced should I wait to get it yeah that's a very common question we also get as well I think it's one of those great things that uh we've reached the point now with sort of advances in technology and how we're doing this the biggest thing being I with the joint replacement is it's just a resurfacing everyone's like Oh I thought you were going to cut off the end of one leg and cut off the end of the other and then put it all back together uh but really we just take off the arthritis which is the pain-causing problem of of the need for a joint replacement and then ultimately what really mattered uh in the history of where people used to say oh you get a joint replacement last 10 12 15 years and then you need another one was the piece of plastic we actually put in between those two pieces of metal that allowed to move and articulate uh we've come a very long way in a very short period of time where those that piece of plastic has become very very stable and very long lasting so the the most recent literature we have is is showing that these joints likely last 25 to 30 years or longer with the answer really being that we don't know how long they last because they've gotten as good as they've gotten so I think 60 is is a more than a reasonable age frame to talk about a joint replacement the big thing I always tell patients is that you tell us when you're ready to have a joint replacement it's not us telling you so it's when you can't do the things that you want to be doing because of that pain in your joint if you're starting to lose motion if you're having issues sleeping those types of things but we do total joints in 40y olds and say yes there's a higher chance at 70 80 you may need what we call a revision and an additional joint after that but in your 60s and 70s there's a very high likelihood that lasts the vast majority of your life if not the entire thing and for some of those younger patients we have alternative bearing surfaces ceramic un ceramic that even last longer um than the metal and polyethylene wear so if that's a real issue for someone that's just a conversation you have with your surgeon you guys make a a decision together there's no right or wrong answer to that kind of stuff thank you Dr Stover um why do hip fractures increase mortality rates in Elders so much the caller from South Dakota that's a really good question because it's one of the reasons that we really work hard to develop strength for of our some of our older patients and reduce things that could make a fall happen in a home like throw rugs like um having shoes that are don't fit well but the issue is that once a hip fracture occurs there is a longer healing time so it is a little different than if you have a hip replac for arthritis and it's a controlled setting but if you have trauma there's more swelling and more fracture elements there and so people are often bed bound longer and in Elders the that's hard on skin and on uh the the longer you're in bed the lighter your bones get the weaker your muscles get and that sort of feeds itself and so it uh ideally people maintain their bone strength as as much as they can by walking uh and reduce the things that are more likely to to lead in to a fall yep Dr puka caller wants to know does being overweight cause a lot of knee and foot problems um it undoubtedly plays a role anytime you're talking about putting stress through a joint um it it it it um kind of predisposes you uh to developing something early on in life but we have really really good evidence um now in the literature that suggests that even if you're you know a high performance athlete or morbidly obese that doesn't mean you're going to develop arthritis it just means that you may have an increased risk for it I think more so than anything else is that uh there's a genetic predisposition to developing hip or knee arthritis shoulder arthritis uh back issues things like that and so um while you know maintaining a healthy weight is is good for your overall health uh and your joint health it isn't the end all Beall and it's it's something that is very patient specific and is not necessarily A one-sized fitall scenario and I do think there's reason you know there's plenty of folks that come in with bad knee pain and you say well you know BMI is this level we got to get a little lower before we talk about joint Replacements and a lot of those folks come in and they've lost 10 15 20 pounds I tell everyone you do four times your body weight across your knee joint depending on your alignment but most commonly and so folks that lose 10 pounds end up losing 40 pounds across their knee joint and often times they come in and say I don't need a knee replacement anymore because my knee feels so much better now that I'm not carrying that weight across my joint so that can be the kind of the one plus side of that is saying hey let's get a little lighter from the stand what we're carrying on our lower extremities thank you Dr Stover a caller Luke from Alexandria wants to know does glucosamine help that's a good question so there's been some back and forth in the literature over the last 30 years and I think it's pretty clear it does not cause harm and I think it's also clear that for some people there is benefit uh they feel better with it but the there is not it's it's hard to pin down literature unless you guys have seen more recent literature uh that that there's a specific thing that it does and I think a good nutrition definitely helps joints so uh you know and and regular activity keeping the the tone of the muscles pretty even around the joint so it doesn't have you know too much stress across there physical therapist can be really super helpful um for for that and for trainers um yoga is one of the things that helps reduce issues because that evens out some of the pressures across all the joints and no I don't do it I should do it but I don't do any yoga thank you Dr Thomas uh this caller wants to know is ankle replacement too new of a procedure or has it had a lot of research supporting it yeah I think that's a challenging thing too because like many things and and unfortunately this is just the nature of healthcare is that it's it's very patient specific so it's one of those things where if you're the right patient and the right candidate for a total ankle I think people do extremely well with those and just like total knees and total hips 30 40 years ago you know we're certainly in the relatively early stages of some of that but uh We've Come an extremely long way in a very short period of time in terms of the quality of those implants again how long those implants last big thing with the ankle is how well those implants are fixed it's much harder than in the an than in the knee or the hip uh but certainly in the right indication the right patient it's just not quite as with most of the ankle Replacements we have now you don't get the kind of activity level with total knees and total hips that you typically get with a total ankle but it's still a very viable option versus really the only other alternative for the most part is a fusion so that's where the bone gets stuck together and you can't really move it anymore to kind of fix that arthritis so it can be a certainly better alternative than that uh depending on the situation and depending on sort of expectations and outcomes thank you Dr PUK for you from Mark in Marine on St Croy Minnesota uh why does one's knees crack every time they Bend uh cracking snapping popping in any joint and or around any joint is very very non-specific but it can be secondary to if you have Baseline arthritis you have some osteophytes or which are just bony projections from your arthritis sticking off catching different ligaments in this guy things of that nature but it's very very non-specific and very very patient specific um but the snapping of itself that audible sound generally speaking is not a a a major issue it's the the underlying cause of that snapping that's the the major issue thank you Dr Stover Tom from Superior wants to know what therapies other than compression socks can be used to treat lymphadema specifically of the lower legs that's a good question and it depends a little bit on on the cause so lymphadema of itself is different than just swelling in the legs and lymphadema does respond to um some of the physical therapy techniques to do some massage to get the fluid moving out of the tissue um the the reason that it forms doesn't get fixed by that so you have to be careful but and that's why compression socks are so commonly used um there are better ones out there than there were even 10 years ago and so that's something that for people to consider is looking at other options besides the classic teds there are some many others out there now that can be more comfortable to wear Dr Thomas a caller from uh Finland Minnesota uh asks about bulges on the Achilles could they be from fluoroquinolones could there be treatment for this yes I think it depends on where the bulges are located typically for folks they're usually where the Achilles inserts into the calcaneous bone if that's the case that's something called a Haggins deformity that's a very different type of Bulge there's thickening of the tendon itself typically with fluoroquinolones it's actually a weakening of the tendon not a thickening of the tendon so it'd be unlikely that' be the cause for it to sort of have that sort of bald up uh formation to it but there could be partial te tearing that's healed and has led to some of that uh bald up as well but typically it's right on the heel where we feel that that's often actually a bony formation on the back side of the tendon and it can be quite painful and then that's you know that can lead to a surgery where we actually take the tendon off cut that bone off that small kind of extra bone and then reattach the tendon and essentially do it an Achilles tendon repair thank you Dr POS a uh caller from Hibbing Minnesota 76-year-old male with a laboral tear in the right hip shots have been tried they haven't worked is there anything other than a complete hip replacement that could help um so I think that's a a really really good question the idea of laboral repairs in the hip uh become pretty Vogue in the literature over the past you know 10 20 30 years as we get older the underlying cause of laboral Tears in the hip more often is a degenerative process so again kind of the chicken or the egg more often than not the arthritis led to the labal tear and so fixing the labal tear um in the setting of arthritis is kind of a predisposition to failure um in that setting I think the alternatives are are strengthening the muscle girdle around the hip Physical Therapy things of that nature occasionally injections in the hip that's again debated but um outside of um a hip replacement from a surgical standpoint I wouldn't recommend getting your labal repair laum repaired at that age um again if you have underlying arthritis but again everyone is very different and I I know this is a a question on a piece of paper rather than looking at images and stuff like that so thank you Dr Stover Robin in Wisconsin asks for fibro fibromatosis pardon me on the feet and hands once removed from the foot already came back bigger what's the treatment and how long should one wait it's a good question and um that's another one that's I think it's we kind of fall back on you should talk to your doctor about that they know you best how big it is uh how long it's been there what other other options are there for you but those kinds of things are are often level there's some inflammation going on and addressing what that is may be most helpful for keeping it from coming back sometimes stad shots are helpful but in the foot they have to be really care careful about that because it can impact the the gristle of the bottom of the foot um so I I would I would bounce that one back to the individual's physici to kind of look at that and and make some plans okay thank you Dr Thomas from uh Sam in Virginia Minnesota uh if a knee replacement is needed but the patient is allergic to metal how will the surgeon pardon me how will the patient be able to have this surgery yeah so typically it's it's a specific metal itself and if that's the case then it's just a matter of figuring out what that metal is there are some Alternatives uh most commonly is the nickel allergy there truly is a fair amount of debate in the literature as to whether or not that nickel allergies truly exists from the standpoint of implants in the bone or at least it's extremely rare uh to have that true nickel allergy versus something like oh I wear nickel earrings then I get a skin reaction that's very different than putting something in your body um but if that's the case it's certainly something where you know allergy tests those types of things can be sorted out to say is there a specific metal that would be tolerated versus not and there are there are alternatives excuse me to the standard What's called the cobalt chrome alloy which has nickel as its component that's typically the most allergic metal of the metals in the joint replacement itself they're very very very often or other options it'd be extremely rare that there would be something available thank you Dr PUK this question from Mark a caller are there any newer knee replacement surgeries that are more amenable to running after word um so I think it it it depends I mean there are Hemi Replacements so either you're replacing the pelop feral joint or one cond or the other meaning the outside or the inside of the knee I think you know it depends on how active you are uh again harping back to what um Dr Thomas said the the polyethylene that we're using now which is that plastic spacer between the metal on metal is really come a long long way and while you know if you're jumping off 10ft cliffs every day you're you're more likely to to wear that out I think running is a very organic motion and we put these polyethylene liners through these trials of millions and millions and millions of Cycles um and they they are not wearing out and so I I would say that the knee replacement however you have it done um in today's world the the components itself are not super amendable to wearing out because you're running marathons um I think if you're going to do that I think that's a a perfectly reasonable thing to do and it's just a conversation with your physician regarding um the limitations of the the longevity of your implants but I don't think that would uh prevent you from having anything or you should seek out something different than a standard new replacement I think the other thing with that too that people often don't understand is that if you based on what's called alignment so your hips to your ankles align often folks are a little what we call bowlegged or knock kned or the medical term is Varys or valgus if you have isolated arthritis to one component of your knee there are certainly surgeries as well outside of knee Replacements depending on your age that can be very reason able options that very high level athletes have had done and very high level performers in terms of impact on their joints they can buy you 10 12 15 more years if it's a hey I really want to run a lot and this is where the arthritis is there's certain images and things we can get to look at that as well to say oh no based on this I think we' actually this surgery save you a total need for another 10 12 15 years to where your degree of how you hope to run is likely much less in a decade than it is now so there are potentially alternatives to that as well that often times aren't always looked into so abolutely thank you Dr Stover a caller wants to know for numbness on the bottom of both feet what could the cause or causes be so the numbness on the foot is usually due to something related to one of the nerves and so it can be a nerve from the back or it can be a what we call a peripheral nerve so the little ones that kind of come out and fan out like branches from a tree and the most common from a a national perspective is diabetes and so if there's numbness on the foot it's good to just make sure your regular doc has checked that out at some point time um and there are tests we can do to kind of help tease that out test looking at the nerves and test looking at some of the other metabolic things that can impact the ability of the nerve to do its job so numbness on the foot is worth checking out because to the other question that we talked about with Falls when you don't fill your feet in the same good way it's it's easier to have a fall happen thank you Dr PUK if uh a caller from Esco has very painful diabetic neuropathy and side effects with Gabapentin how about a t unit to address that pain or other therapies yeah that's a painful diabetic neuropathy I think is a a probably a very challenging thing to treat and again very patient specific I think there are a host of medications Gaba Penton being one of them LCA various different trade names um that can go about addressing it every patient is very individualized based on how sensitive those nerves are um because of the microvascular changes that occur in the setting of diabetes um but I I I don't think there's a one siiz fits-all in this category I think I would talk to your physician try a host of different things um and try and get some relief I think I would stay away from some of the stronger pain medications of course um but I I think exercise and triing various different medications and or a t unit or ice or heat some variation of that um with the advice of your physician is probably what I would do I don't I don't think there's a one-size fit all for that answer for that question thank you Dr Thomas um Bobby from uh evth yeah um how do doctors determine what size hip replacement to use and when to replace it yeah so kind of bouncing back from the previous question I think from the standpoint of when to replace it that's again the conversation of you tell me when your life's reached the point that your quality of life is suffering in a way that says I just can't live the life I want to live and do what I want to be doing therefore I'd like to talk about a hip replacement and then that's supported by a clinical exam where we move your leg around and see what bothers you and what doesn't challenge with the hip I think that's an important thing I always tell patients is it can get very uh blended with the back as well so you want to be certain that you're not misdiagnosing something and saying this is coming from your hip when it's actually a different cause cuz the last thing you want is a total hip then you get done and your back was the cause so the same pain is still there it's still just as painful or maybe not quite as painful but still very bothersome but uh so once you reach that point you say hey x-rays all these things look like it's amendable to hip replacement then essentially what we do is we get a just an x-ray of your AP pelvis and it we call it a low AP pelvis so we see a good chunk of your femur as well your thigh bone uh and then we just do what's called templating and we have software that we use based on the implants that we're using uh and all that software is is we basically put that up on the screen and we size it in our our office and we set all that up ahead of time essentially and then based on that when we're in surgery we have a rough idea of what those implants are going to be and then we just do I mean there's it gets kind of complex from there but we basically size Things based on the size of your femoral head so the head on that femur that goes into the the cup and ball basically the ball part of that we measure that size and we get close to about that size for the cup and then for the stem we just uh use a series of what are called broaching where we start a very small stem and we get bigger and bigger bigger till it essentially fills up your femur more or less uh and that's usually within one size of whatever that templated size is thank you Dr Stover uh this caller from duth wants to know how to tell the difference between sciatica and arthritis it's a good question um so sciatica is a term we use for when there's a nerve irritation or inflammation that causes pain to go to shoot down the leg and so it tends to be kind of a zinging pain arthritis tends to be more in a joint but if it's in the back uh it's in theint the many joints that are in the back it can also cause some compression on a nerve so you can have arthritis and sciatica or just sciatica or just arthritis so that the teasing that out there's a number of different kinds of physical exam Maneuvers but also some tests like emgs electromyograms and things that can help tease out which thing is it that's causing the pain yeah they're not binary they could very much be um you know in conjunction with one another especially when it comes to the back when you start to get arthritis in your back it's in close proc proximity to the nerves that make up the sciatic nerve we in general refer to as sciatica but that's a conglomeration of nerves from your entire low back um and so it can be compressed at any one uh of five levels and uh cause that pain going down the leg true pain in the lower extremity of the hip or the knee is generally speaking pretty focal to that area um Can radiate in some capacity but not necessarily shooting all the way down the leg thank you Dr Stover uh this is perhaps a brief question is there a role for magnesium to help with conditions of the lower extremity um mixed thoughts about that when there's not a lot in the literature that that specifically supports magnesium unless you guys have read anything um but so there are other reasons magnesium is helpful but specifically for pain in the legs or issues in the legs I haven't seen anything in the literature on that restless leg is the only thing I I talk to some patients about and then I always tell them just be careful which magnesium you're getting because magnesium citrate is for your GI and you will not like the results of that loose DS yes exactly versus magnesium glycinate is the typical one and that can help us sleep as well so that's pretty much the only thing from a lower extremity standpoint this question for a short answer Dr PUK and with time available an 84 yearold caller from Two Harbors both knees were replaced no pain but one leg is angulated now should the patient be worried or be seen uh if she if the main issue is cosmetic and not pain related I would say no um as long as it's not causing a functional debilitation um with that being said uh you know it would very much take uh an examination to delineate exactly how angulated that knee was if in fact that happened you know before after or during surgery or you know I think that's very much a conversation between the patient and their physician especially in the setting of no pain and a clinically um kind of irrelevant exam well thank you very much and I want to thank our panelists Dr Taylor PUK Dr Sandy Stover and Dr Philip Thomas and our medical student volunteers Sydney clawen Jessica cren and Wyatt windhorse please join Mary Morehouse next week for a program on mental health and couples thank you for watching good night e