hip resurfacing?

Instead of having a total hip arthoplasty how about resurfacing the hip?  We offer this at RHYNEER CLINIC but everyone needs to know this is not a operation for everyone.  This is not because one is being denied some new technology but there are instances where a resurfaced hip joint may lead to a femoral neck fracture or other complication.

There are many difference surfaces that can rub together to make your artificial hip joint work!  A metal ball on a plastic liner works extremely well and is used probably the most in the world and America.  Science is always looking for something better though.  We would like to say our artificial hips will last for ever but there is nothing out there….yet, that will.   What wears out in an artificial hip is the plastic.  It is slowly ground away by the smooth ball… kind of like a microscopic mortar and pestal.  Your body tries to eat up the plastic debrie but is unsuccessful.  Cells around the plastic debrie release so many chemicals in trying to eat up the pieces that the bone cells around the rest of your artificial hip start to “turn on” and reabsorb bone around the hip and it becomes “loose”.  Micro motion of the loose hip HURTS.   So, get rid of the plastic or make a super smooth ball or make a plastic that doesn’t wear.  Science has given us all of these.  We have ceramic balls…super smooth.  Ceramic balls on ceramic cups (the acetabulum), or metal balls on metal cups.  They all have their place and advocates.   The thing is none of these new joints we can say will last 30 plus years and not have to be “revised”.  A new hip put in after the old one wears out.  These second time hips don’t usually work as well as the first.  Ever had a rebuilt transmission?  That second one usually just isn’t like the original and usually doesn’t last as long! 

So,  with resurfacing, very little of the bone on the femur is lost.  The ball is just shaved off a bit and capped with metal.  It really is for people that are not going to change their lifestyle and want to have NO LIMITS.  They are going to use that hip for every darn adventure they want to.  These are the folks who get a resurfacing in may practice today.  If the resurfaced joint fails for what ever reason.  Its very easy to remove that metal head and replace the ball and stem with a traditional one…it’s not a true revision surgery like the old ones were.

I hope this makes sense.  I think the most important thing is your surgeon shouldn’t be dogmatic about what is the “best hip” made in the world and that’s the one “they use”.  It’s hubris.  One should be open and discuss a variety of choices for you, and help you find what may give your joint the longest longevity and pain free lifestyle.  Sincerely Dr. Rhyneer

double bundle ACL surgery

Recently the “double bundle” ACL reconstruction has surfaced as the new way or, more “anatomic” method of recreating ones torn ACL.  We have done them here at the RhyneerClinic and I have a few things to say about them.  First of all in the labratory they do seem to show better rotation stability.  However, the biologic body is not a dead cadaver part on an engineering bench and the human studies really don’t appear to show any difference as presented at the most recent American Academy  of Orthopedic Surgeons.   No one has yet shown that the outcome years later is better than the single bundle technique.  We also have to drive 4 holes in the bone instead of two and this may compromise or even fracture the tibia in doing this. Four hole sites have to have perfect fixation instead of two.  The graft fixation is also soft tissue to bone and at times has to be “backed up” by other staples and screws.  I really don’t like surgical procedures that “need backing up”  The last issue is that most surgeons I speak with including the originators of the procedure use mostly donated tissue for their graft material.  I personally am not a great fan of this.  Tissue donation for ACL grafts are mostly irradiated today to kill off HIV.  It does denature and change the collagen in the graft and when ones graft stretches out or “fails” one always wonders if the graft was of poor quality.  

By all means there are different opinions in the world regarding ACL reconstruction, the tissues used for the tendon, and the methods.  I believe if you polled the world orthopedic community and had a vote, the majority would still say the bone-patellar tendon-bone autograft is the gold standard.  No wonder this is what most Olympians use when they need one.  Need I say more?  This is my preferential  method of reconstruction.

Cartilage

“I heard you can grow my cartilage back,” a 54 year old runner said to me the other day. She was talking about her sore knee.

“Well let me tell you about that.”  I said.  

There are really four (4) main ways we deal with cartilage injuries these days.  Since our cartilage cells do not regrow once we are skeletally mature we need a method of replacing them once we’ve killed them off from injury and/or abuse.  

One method is to stimulate the bone marrow behind or underneath the cartilage by making small holes in the bone, “micro-fracture”.  This is a method that’s been around for dozens of years now and the bone marrow stem cells come to the surface and form a fibrin clot that then forms into “hyalin-like” cartilage. This is fibrous cartilage.  This is NOT real cartilage and though there are studies to show is makes some people feel better we have more advanced things available these days.  Sometimes however, it is the best thing it offer for small lesions or when a person is not a candidate for something more complicated.

A second method is to borrow small plugs of cartilage from one less used part of the joint and plug it into the bad spot.  Robbing Peter to pay Paul does work for small lesions, say less then a nickel size. You can use if for larger lesions but I personally have found other methods to work better.  This is REAL cartilage and it is your own good stuff!  This method is called OATS. (osteochondral autograft transfer system)

The third method is to borrow some little rice bodies of your own cartilage and stimulate them to grow in a dish with nutrients in it.  Then in a second surgery we inject them below a drumskin of tissue on joint surface and let them grow. They take many months to grow and mature. This is REAL cartilage also, but frequently soft.  Unfortunately if a little blood gets into that space you’ve made (those stem cells again), you get fibrous cartilage again.  There are alot of studies supporting this method called ACI (autologous cartilage implantation), but a lot of rightful critics also.  It seems to work better in younger people with more growth potential.   Once we’re able to grow the cells in some type of impermeable matrix this technology is going to take off.

The last method is large or massive allograft transplantation.  This method uses a piece of fresh cartilage from someone else and implants it into you.  This is also REAL cartilage, and it works well too! Your own body doesn’t reject the new cartilage because the cells are “hidden” in the cartilage matrix.  The nice thing about this method is you’re not robbing peter to pay paul and it only takes one surgery and has a very high chance of a good outcome.

I think probably what is most important is to find a surgeon that does all three or four methods and knows the pros and cons of each.  Someone who universally uses one thing for all types of cartilage lesions and thinks that “their” method is the only way I would worry about.   I like to say “the emperor has no clothes”. We have a lot to learn still!  Sincerely Dr. Rhyneer

shoulder dislocations—the scoop

A 25 year old gentleman in my clinic came in because he was recently in the emergency room with his 3rd dislocation in the past 7 years.  He was placed in a sling by the emergency room and was alarmed when I told him this would probably all happen again. 

You see, I told him,”The shoulder is rather like a golf ball on a tee.  What holds it in is primarily the muscles around it, the shape of the bones, and some small fibrous chalk-block type ligaments around the very shallow cup (the tee). These ligaments are called the labrum.  The military did some very nice studies years ago showing that 100% of men under the age of 20 tear off those ligaments with their first time dislocation, and it leads to a very high redislocation rate, basically 100%.  You can almost always see this on a contrast MRI or when you have arthroscopy of the shoulder.

That rate of repedative dislocation goes down as we get older and less active.  Physiotherapy CAN help but if you’re super ACTIVE (no age discrimination here!) the chance of having a dislocation again is… very high”

“In general, I tell pt’s that if you’re a first time dislocator, I would wear the sling until your initial swelling goes down and you’re regaining your range of motion.  Then I’d get a MRI of the shoulder with contrast injected into it.  If the MRI shows a nicely defined tear of those anterior ligaments I’d get it repaired when it’s easy to do, in other words now.  If the MRI shows ill defined stretching or indeterminant findings.  Do your physical therapy and see how it goes.  If you have a repeat dislocation, fix it!  

Every time your shoulder comes out you ding up the anterior cartilage in your shoulder and make things worse,  finally shaping the small cup ( the tee) into an inclined plane where the shoulder wants to slide out almost no matter what you do. Frequently also,  the pain one has with the shoulder 10-15yrs down the road with chronic dislocations is now due to the loss of cartilage along the anterior rim of the cup.  A stability procedure and this point may not cure the pain.  Make you more stable, but not cure the pain.

This is only a brief summary of this type of problem.  Certainly one can also injure the rotator cuff tendons with dislocations.  In general, don’t hesitate to seek advice and information about your body.  Information is power.  Sincerely Dr. Rhyneer

Any new movement begins at a starting point…

Welcome to the starting point of our leap into social media. We will be using this area to give orthopedic advice and help answer questions (so if you have one, leave it in the ‘comments’ area and we’ll get back to you as soon as we can!)

At Rhyneer Clinic, we truly believe your experience with us is about you and your comfort.

The Rhyneer Clinic has two objectives. Both are about patient comfort.

1. The first objective is to provide the best orthopedic diagnosis along with a range of options to reduce joint pain and increase mobility.
2. The second objective is to enable you to do comfortably the things in life that bring you pleasure.

The Rhyneer Clinic engages patients completely in their own health and recovery. After thorough research and analysis, we discuss your options candidly. Are there alternatives that could forestall or avoid surgery? You are central to that conversation. You make that decision with Dr. Rhyneer’s assistance.

Dr. Rhyneer opened this clinic in 2007 because he wanted a small practice known for personal attention, outstanding orthopedic care, good advice, the most modern technology, and staff members who exude warmth, professionalism and compassion.

When you need a partner to help you restore orthopedic health, please give Dr. Rhyneer a call at: 907.563.2663