Some of the most common questions that our patients have prior to surgery are in regard to the possible need for a blood transfusion during the operation.  At the Leone Center for Orthopedic Care, we welcome such questions as part of our patient-care philosoply. We want you to fully understand all aspects of your surgery and be completely prepared before the procedure takes place.

According to the National Heart, Lung and Blood Institute, U.S. Department of Health & Human Services, almost five million people in the U.S. require blood transfusions annually. The procedure is used for people of all ages, typically for severe injuries from accidents, critical illnesses and blood loss during surgery.

One of the major changes that I’ve seen over the past few years is a highened insight or sensitivity that a transfusion is really a transplant of multiple living cells that we hope will function to deliver oxygen to the body’s tissues. We regard it as any other transplant.

Below are three questions we often are asked about blood transfusions:

• Is a blood transfusion always necessary during surgery?
  • The answer is no.  Actually, a much smaller percentage of our patients are transfused now as compared with several years ago.
  • Modern surgical procedures, techniques and the medical community’s knowledge about the body’s need for replacing blood loss during surgery have changed. This current thinking has greatly reduced the need for transfusion.
  • Previously it was thought that a transfusion was necessary if hemoglobin levels dropped below 10 g / dL (grams of hemoglobin in a deciliter of a blood sample). We now have the confidence to allow hemoglobin levels to drop as low as 7 or 8 g / dL before we consider a transfusion, as long as our patient clinically is tolerating the lower level and doesn’t have any other conditions which might raise the threshold, such as coronary artery disease.
  • We now concentrate on increasing intravascular fluid or volume to maintain a feeling of vitality and blood pressure, and allow the body to naturally regenerate the lost red cells.
  • Because our techniques are much more refined and most patients have their surgeries with regional (spinal) anesthesia, blood loss during surgery usually is minimal and much less than has been in the past.
  • Instead, surgial patients are encouraged to increase their hemoglobin levels pre-operatively with iron supplements and a healthy diet.
  • Occassionally, patients are directed to increase their pre-operative hemoglobin levels with Erythropoitin, a prescribed hormone that regulates red blood cell production.

• Is blood from a donor bank safe?
  • The risk of AIDS or other viruses from a blood transfusion are very low. Because of the stringent screening and testing processes in place today, your chance of being transfused with blood that carries HIV is about one in two million, lower than your chance of being struck and killed by lightning.
  • In spite of this low risk, it still is better to avoid a transfusion whenever possible from either a blood bank or from your own donated (autologous) blood.

• Are there benefits to donating your own blood for use prior to surgery?

Previous thinking by the medical community was that your body would respond better to being transfused with its own blood, with the crucial benefit being no risk of reaction to foreign antigens, which are substances that cause your immune system to produce antibodies to fight them.  However, it has been recognized that a person’s own blood doesn’t necessarily benefit the system any more than blood from an outside donor source. In fact, there can be drawbacks to using your own blood for transfusion:

• Historically it was thought that if you donated your own blood, then the cells within our bone marrow that make blood cells would be reveved up quickly to replace it. Now we realize that this is not the case as it takes six to eight weeks for your body to replenish one unit or pint of blood that you donate.
• Also, the general concensus used to be that being transfused with your own blood would be safer and more advantageous than blood from a blood bank. We now know that this is not necessarly true. The longer the cells that you donate are out of your body, the less well they will function in terms of delivering oxygen to your tissues. There also is a risk of infection, either from contamination during processing or delivery. Or, if you have any undetected bacteria during the donation, that potentially could cause an infection later during the transfusion.
• There still are certain indications or benefits in donating your own blood, but self-donatinon is much more selective  than it was a few years ago.

Donating your own blood can be costly, at approximately $700 per unit. Insurance does not always cover the expense. It’s also time consuming and there are far fewer places to donate now that it is done less frequently.

• What I see now clinically is that because so few patients donate their own blood, they are going into the operating room with much higher hemoglobin levels, further decreasing the need to transfuse.

As you approach any surgery, it is most important that you feel confident in your surgeon and that all of your questions have been answered, so that you are fully prepared for the procedure.

The human body’s “shared wiring” can intermingle and cause unusual effects, especially with regard to pain. At the Leone Center for Orthopedic Care, we sometimes see patients who are experiencing what commonly is known as “referred pain” or persistent pain in one area of the body that actually is caused by injury, weakness or arthritis in a completely different location.

Referred pain most typically occurs in the joints and can be common for people who suffer from osteoarthritis.  For example, people with osteoarthitis in the hip often complain of intense knee pain, totally unaware that it’s not the knee at all that is the culprit, but rather the hip, which may not even hurt at all.

Not surprisingly, certain types of back injuries including disk compression and arthritis in the spine also can cause referred pain to the hip, the knee or both.

If you are experiencing persistent pain in the hip or knee, the only way to diagnose exactly where the problem lies is to have a thorough history and examination, which often includes an X-ray, to determine the source and cause of the pain.

What you can do is keep track of your pain and its characteristics. For example, is your pain constant or intermittent, worse in cold or damp weather or after having been still for a long period of time?  Is your pain related to activity like walking or getting up from a seated position? Does the pain wake you from your sleep? Take notes and then discuss all of your symptoms with your doctor.

Depending on your diagnosis, treatment options can include a combination of physical therapy and anti-inflammatory medications, or in advanced cases, joint replacement surgery.

Persistent joint pain should not be ignored, because if left untreated you could be causing further, irreparable damage to your joints.  More importantly, there are treatments to help you regain your quality of life, in some cases totally pain free.

Recently the FDA released a statement of concern about hip replacements performed with a metal-on-metal bearing. The metals used in these prostheses include chromium and cobalt. There had been a recent surge in usage by many orthopedic surgeons because preliminary information suggested that metal-on-metal was more durable and therefore potentially more long-lasting then other bearing surfaces. Unfortunately, this is proving not to be the case.

In the past I have used metal-on-metal bearings only in select patients on whom I performed hip resurfacing, as this was the only bearing available for that procedure.  However, I have all but stopped doing hip resurfacing because of my concerns with metal-on-metal as well as other problems associated with this procedure. I don’t think the potential benefits of using a metal-on-metal articulation outweigh the known and significant risks.

I have avoided metal-on-metal hip replacements because it may increase the potential risk of soft tissue destruction around the hip and throughout the body. In my opinion, the potential for a longer lasting hip — which has not been proven — is not justification for the possible damage and long-term consequences of having increased levels of cobalt and chromium released in the body.

Problems associated with use of metal-on-metal hip replacements include tissue and bone damage and in some cases infection.  All artificial joints shed tiny pieces of debris and researchers believe that particles released by all-metal hips cause the body’s protective tracking cells to convert the debris into metallic ions, which ultimately can cause a chain reaction and destroy tissue and muscle. The metal ions potentially can trigger a hypersensitivity reaction and cause problems associated with the kidneys and worse.

Some 500,000 people in the U.S. have received all-metal hips over the past decade.  Now there are reports that patients with metal-on-metal artificial hips intended to last 15 years or more are experiencing early prosthesis failure in as little as two years.  Studies also predict that these numbers will rise.

According to the New York Times, the FDA received more than 5,000 reports about all-metal hip problems during the first six months of 2011.

I prefer to use a metal or ceramic femoral head against highly crossed-linked polyethylene. Highly crossed-linked polyethylene has become the gold standard for implants as evidenced by the fact that all the major implant companies now produce it and tout its benefits. The wear characteristics are much, much better than conventional or non-highly crossed-linked polyethylene. Plastic wear debris still is produced, but the amount is much smaller and the consequences of this debris are much better understood.

We encourage anyone who has had an all-metal hip replacement to have a check-up as sometimes tissue destruction occurs although the patient has no obvious symptoms such as pain.

At the Leone Center we are prepared to treat people suffering from problems associated with all-metal hip replacements and provide solutions with safer, more durable outcomes.

At the Leone Center for Orthopedic Care, we define our Concierge Medicine practice as a personal, in-depth relationship with our patients where they feel the concern and experience the care of good old-fashioned medicine, while benefiting from our entire team’s experience and my expertise and use of the latest and most proven techniques for solving complex hip and knee problems, including hip and knee replacement surgery. I have specialized in orthopedic surgery and practiced at top-ranked Holy Cross Hospital in Fort Lauderdale, Fla. for more than 20 years.  During the past 10 years, I have performed 500 to 600 joint replacements a year.

The concept of Concierge Medicine, also known as Direct Care, dates back to 1966, when several physicians in Seattle created a patient/physician relationship in which the patient would pay an annual fee or retainer for care.  Their idea was to provide highly attentive care, modeled after the family doctors of the past who made house calls and were able to see patients and treat them without delay. Depending on the contract, a Concierge agreement retainer may or may not be in addition to other medical charges.

The benefits of the Leone Center Concierge Medicine approach begin with the initial consultation and are carried through to post-operative care.  Our patients are guaranteed increased availability with me and my entire staff.  Patients are able to make an appointment within two weeks and are assigned a designated patient liaison.

When you arrive for your appointment, you receive immediate personal attention at the Leone Center’s beautiful new office at the Holy Cross HealthPlex, beginning with the offer of a cup of herbal tea.  We then honor your appointment time as we know and respect that your time is valuable. Our goal is to achieve superb clinical outcomes for patients while respecting their dignity and time, and by making the entire experience as pleasant, comfortable and hassle-free as possible.

The Society for Innovative Medical Practice Design estimates that today there are about 5,000 physicians nationwide using various models of Concierge Medicine for their practices and the trend is growing.  More people are taking control of their own healthcare today than ever before, having grown tired of long wait times to get an appointment and long hours waiting to be seen on the day of an appointment. Patients also want more availability with the physicians on whom they depend.

At the Leone Center, we work together as a team to assure that our patients receive personalized, attentive care and help them return to normal, active lifestyles. Our commitment is to meet and exceed patient expectations and provide the best environment for a positive experience.

The science and technology of joint replacement continue to evolve, so it is no surprise that patients have many questions and concerns as they navigate the process of finding the right orthopedic surgeon and determining the best approach to achieving the outcomes they desire. To begin the process, here are five important questions you should ask to find the right surgeon for you.

1. How many surgeries of this type have you performed?

An orthopedic surgeon who is highly experienced in the type of surgery you require brings valuable expertise and typically has built an experienced team to assist with all aspects of patient care, from the new patient interview through post-operative care. Working with a skilled, well-coordinated team of healthcare professionals goes a long way in addressing unexpected situations and assuring a calm, reassuring and successful experience.

2. What is your infection rate?

Ask the orthopedic surgeon if he or she has a recent complication rating from a reputable company that compares healthcare data. Preventing infection is a priority after joint replacement, as with all surgeries. Infection can impact the new joint, even necessitating additional surgery and removal of the prosthetic joint.

3. What is your incidence of short- and long-term complications?

Talk with the orthopedic surgeon about the surgical and operating techniques that will be used. Low infection rates, minimal complications, and successful outcomes are more assured when the operating theater is equipped with ventilation that reduces the number of infective organisms in the air and the entire surgical team wears body exhaust suits to reduce the risk of infection.  The orthopedic surgeon should have a rating to share with you.

4. How long have you used your current prosthesis, and what are your reasons for having selected it?

An orthopedic surgeon should know from personal experience with and repeated use of any prosthesis, which are optimal, safe, long lasting and provide the best results.

5. What level of attentive care can I expect throughout my surgical experience?

Most importantly, you need to feel comfortable not only with the orthopedic surgeon but with the entire staff as well. Don’t be afraid to ask questions such as:

• Will I be able to make an appointment within a reasonable amount of  time?
• How will I be able to ask questions and will they be answered in a timely manner?
• How will the surgeon and staff make the entire experience as comfortable and easy as possible?

The candid discussion you have with an orthopedic surgeon to familiarize yourself with the benefits and risks of your surgery may be the most pivotal part of your care.

The art and science of joint replacement surgery are constantly evolving and our goal at the Leone Center for Orthopedics is to help our patients regain the highest possible quality of life.

In 2009, the American Academy of Orthopedic Surgeons estimated that there are about 270,000 knee replacement surgeries performed each year in the United States. At that time, nearly 70 percent of these operations were performed on people over the age of 65.  However, a growing number of knee replacement surgeries now are being performed on younger patients due to wear and tear on knee joints from sports and other activities as well as conditions such as osteoarthritis.

Knee replacement or partial knee replacement surgery is major surgery and should be considered only after a diagnosis is made by your orthopedic surgeon, all non surgical treatments are no longer effective and finally after a thorough discussion with your orthopedic surgeon.  At the Leone Center for Orthopedic Care, a diagnosis is made for every patient based on a personal history, a comprehensive physical examination and state-of-the-art imaging.

The Journal of Bone & Joint Surgery, December 2007, projected that total knee replacements would increase from 450,400 to nearly 3.48 million by the year 2030. What are the signs that you may be a candidate for knee replacement surgery and how do you know when the procedure is right for you?

The following signs might help you to know if the time is right to have that conversation with your doctor:

• Knee pain habitually keeps you awake at night or you wake up during the middle of the night with pain.

• Knee pain limits your ability to perform typical daily activities such as walking, climbing stairs, or getting up and down from a sitting position and in and out of your car. Another sign is apprehension that your knee might give way when you pivot or step up or down from a curb.

• Knee pain limits leisure activities such as walking, exercising, dancing, golf, tennis, traveling or even shopping.

• You have tried other less-invasive treatments for a suggested period of time, such as exercise, physical therapy, a brace, anti-inflammatory medicines, or injections and still have no relief from pain, or you simply “can’t trust” your knee

• If you are experiencing total frustration that you are losing your quality of life due to impaired mobility.

• You are developing progressive “knock knee” or “bowleg” or become aware of progressive loss of motion.

At the Leone Center for Orthopedic Care, we see patients with complex knee problems of all types due to joint and bone destruction including trauma, angular deformity, bad outcomes from prior surgery, infection, rheumatoid or inflammatory arthritis, or childhood diseases.
For patients who do require full or partial knee replacement, I will choose the implant that is best suited to each person’s medical and lifestyle needs. Implants are individualized for each patient’s unique anatomy and precisely implanted using computer navigation and robotic techniques. For some patients, alternatives to joint replacement are offered, such as specialized injections or arthroscopy which can delay or sometimes permanently eliminate the need for an artificial joint.

All patients receive as minimally invasive surgery as possible, emphasizing precise component positioning, meticulous soft tissue handling and closure. This approach results in less soft tissue trauma and as rapid a recovery as possible.

By Dr. Leone

If you have ever cancelled a tennis match or golf game because of knee pain, you are not alone. Knee problems are very common.  They occur in people of all ages and are caused by a variety of issues –ranging from injury to arthritis.

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By Dr. Leone

In my last post, I listed the advantages and disadvantages of the anterior approach to hip replacement surgery.  Now, let’s discuss the mini-posterior approach.

The mini-posterior approach to hip replacement surgery involves dividing the muscle by separating – not cutting – muscle fibers at the side or the back of the hip.  This method insures that muscle function is preserved.

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By Dr. Leone

There are many well-established surgical approaches to the hip.  Two surgical approaches for total hip that have gained recent notoriety are the direct anterior approach and the minimally invasive or mini-posterior approach.

The direct anterior approach involves splitting the fibers between the two main muscles located at the front of the hip and working through the natural interval between the muscles.

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By Dr. Leone

More than 400,000 total hip replacement surgeries are preformed in the United States each year.  Because of advances in surgical instruments and techniques, total hip replacement is one of the most successful surgeries performed in modern medicine.

 As with any surgery, there are risks.  Two common complications continue to occur during hip replacement surgery include:

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