Category: Surgeries

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Treating appendicitis with antibiotics as an alternative to surgical removal of the inflamed organ was found to be more costly in the long term and result in higher rates of hospital readmissions, according to a study by researchers at the Stanford University School of Medicine.

“People treated with antibiotics alone have a higher chance of coming back needing further treatment for appendicitis-related problems, such as abdominal abscesses,” said Lindsay Sceats, MD, a surgical resident and lead author of the study. “They also have a higher risk of having a reoccurrence, and the cost is no lower.”

The study will be published Nov. 14 in JAMA Surgery. Kristan Staudenmayer, MD, associate professor of surgery, is the senior author.

Appendicitis is an inflammation of the appendix, a finger-shaped pouch that projects from the colon on the lower right side of the abdomen. Acute appendicitis, if left untreated, can result in a ruptured appendix that can spread infection throughout the abdomen and be life-threatening. It occurs in about 5 percent of the United States population, according to the National Institutes of Health, and is most common before the age of 30.

While appendectomy, the surgery to remove the appendix, has long been the standard treatment, some physicians have begun offering drug therapy as an alternative, primarily to patients who are poor candidates for surgery, following the publication of several European studies showing positive outcomes.

“More and more patients in the Stanford emergency room have been asking about whether they can just take antibiotics when they come in with appendicitis instead of having surgery,” Sceats said. This study was designed, in part, to help answer those questions.

Analyzing claims data

To conduct the study, researchers used claims data from a private insurance database to compare patients admitted with appendicitis from 2008 through 2014. Of the 58,329 patients with appendicitis, 55,790, or 95.5 percent, underwent appendectomy. The remaining 4.5 percent were treated with drug therapy alone.

Results showed that, surprisingly, overall costs were 5.5 percent higher for patients who didn’t have the surgery. The average cost of care was $14,932 for these patients. For patients who underwent the surgery, the average cost of care was $14,186.

“Even if the initial hospitalization is cheaper, when you look at long-term cost, which our study did, it ends up being more expensive,” Sceats said. The study collected medical care data for patients after treatment for up to an average of three years.

“People treated with antibiotics are more likely to come back and be hospitalized for any sort of belly pain,” Sceats said. “Doctors may also be more cautious when the appendix isn’t removed. This extra caution can be expensive.”

The study also found slightly higher rates of abdominal abscess post-treatment for those who didn’t have surgery.

Low reoccurrence rate

The study did show that the reoccurrence of appendicitis is only 3.9 percent among those treated with antibiotics alone and pointed out that surgery comes with its own risks of postoperative complications, but the authors concluded that overall results suggest appendectomy should remain the first-line treatment for most people with appendicitis

“These results tell us that, in most cases, surgery is still the best strategy,” Sceats said. “For your average, healthy 30-year-old, the alternative treatment is no cheaper, and it’s easier to have the surgery. You also no longer have an appendix, so you’re no longer at risk of having appendicitis again.”

Journal reference:
JAMA Surgery

Provided by:
Stanford University Medical Center

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Knee replacement surgery is one of the most traumatic orthopedic surgeries that can be performed. It involves the removal of the entire kneecap and surrounding bone and the insertion of a prosthetic replacement. Although the surgery is a shock to the body, the outcome is almost always worth the risk and initial discomfort.

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Post-Op and the First 2 Weeks

• When you awaken from the surgery, you will be in a lot of discomfort and will likely be on a constant motion machine to keep the knee joint from stiffening. Pain medication will be provided, and constant monitoring, as well as nursing will occur. Despite the pain and the size of the incision, patients will be up and weight bearing within the first 24 hours, under the guidance of professional staff. Home therapy will be needed, and physical therapy is a must from day one. The patient usually goes home from the hospital within three to five days, and the remainder of the recovery will be on an outpatient basis. Physical therapy will start at twice a week, either at home or in-office, and move up to three times a week by the end of the first month. This first stage in PT will mainly focus on re-engaging your quadriceps muscles and learning how your replaced joint feels and functions. Pain medication will be necessary throughout this stage, as PT sessions are very likely to be extremely painful. Working through the pain and focusing on the goals is a critical step in this time frame. PT will mainly focus on regaining range of motion at this stage.

First 6 Months

• Physical therapy is hugely important to recover from total knee replacement surgery. A skilled PT can do more for your recovery than any medication or any doctor’s consult. The process involves the rehabilitation of the knee muscles, as well as the surrounding leg muscles and the core strength of the body. Balance, movement, motion and stability are all concentrated on at various stages of rehab, and by the end of physical therapy, which is usually around six months for a total knee replacement, the knee should be better than new, and the patient ready to resume a far more active and pain free lifestyle. Once the initial two weeks of general PT are done, the focus will shift to strength-building exercises such as legs lifts, resistance exercises, moderate weight training and continued range-of-motion exercises. Every week will see new goals set, and again, your focus on achieving these goals will make all the difference in the overall speed and totality of your recovery. There will be times when you dread going to physical therapy and think the pain is not worth the effort, but keep in mind the goal of an active, healthy lifestyle, and you can work through the challenges set in front of you. Pain medication will gradually be decreased and finally stopped, and reliance shifted to over-the-counter drugs such as Ibuprofen and Tylenol.

On-going treatment

• Although you may be released from a doctor’s care and from regular physical therapy after six months, there will be bi-annual follow ups to make sure that your knee is functioning as it should. In addition, it is critical to make sure that you continue some of the rehab techniques you learned while in physical therapy. Daily exercises should include: leg lifts, quad sets, stretching, and walking. These exercises are meant to be continued, and will help you maintain the strength and ease the wear on your new knee. Once you have a total knee replacement, it is important to remember that recovery is actually a lifelong process. The better you take care of the replaced knee, the longer it will last, and the better your life will be. If at anytime after your knee surgery, you should experience swelling or pain in the joint that does not clear up with icing, rest, elevation and compression, it is important that you see your doctor for a checkup. Remember, knee replacements can only be done twice in a lifetime, so taking care of your new knee is vital to its longevity.

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According to the Mayo Clinic, knee replacement surgery is one of the most successful orthopedic operations. Knee replacements are also becoming increasingly more common. More than 580,000 knee replacements are performed in the United States each year and the number is growing, according to the American Medical Association. There are two types of knee replacements: a total replacement (TKR) during which the entire joint is replaced and a partial replacement that is performed when only one part of the knee is damaged. TKR is the more common surgery, and this article provides information on TKR and its success rate.

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Success Rate

• The success rate of TKR is over 90 percent, and most patients who have the operation “experience a dramatic reduction of knee pain and a significant improvement in the ability to perform common activities of daily living,” according to the American Academy of Orthopedic Surgeons (AAOS). While the success rate is high, normal use and activity will cause the joint to wear and most replacements last 15 to 20 years. The number of years your new joint will last varies based on a variety of factors including your weight, activity and overall health.

Complications

• The rate of serious complications like heart attack, stroke or joint infection following TKR is less than 2 percent. However, as with all surgeries, there are risks. For TKR, these risks include infection, reaction to the anesthesia and damage to nearby blood vessels, bones or nerves. You also must be vigilant to ensure that minor infections don’t become major problems after surgery. Even minor sinus, urinary tract, respiratory tract or dental infections can spread through your bloodstream to your new joint, so treat them immediately.

Recovery

• After leaving the hospital, you will go to outpatient physical therapy two to three times a week for two to six months. In addition, you will have daily exercises to do at home to help with the bending (flexing) and straightening (extension) of your new knee.

Post Surgery Limitations

• After surgery, you will be able to resume most of your normal activities, but there will be some limitations. After a TKR, you must avoid high-impact exercises like running, jogging or contact sports.

Considerations

• When to have knee surgery is a decision you should make in conjunction with your healthcare provider. Usually more conservative methods like physical therapy and knee injections are tried before a TKR is considered. The impact your knee pain is having on your life should also be weighed. TKR is often considered if a patient has one or more of the following: constant pain; inability to sleep because of knee pain; inability to work; or the inability to walk more than three blocks because of pain.

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Most of us take kneeling for granted. But for anyone who has had one knee—or both knees—replaced for various health reasons, the act of kneeling can be painful, frightening or completely impossible. However, most doctors do not prohibit it, and there may be times when a patient feels it is necessary, especially if he or she lives alone. Before attempting to kneel, you will need to think through the process to ensure success, and avoid injury to the new knees.

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Things You’ll Need

• Cushion, pillow or towel to kneel on

• Furniture or walker to provide support when pulling up

• Wait until at least two months after surgery before attempting to kneel, as recommended by orthopaedic surgeons.

• Provide support for the kneeling process. Do not kneel down before first making sure there is something nearby to support your weight as you lower and lift yourself back into a standing position, especially if you live alone. Have a walker, chair or table nearby that can provide support for your weight when you pull yourself back up.

• Protect the knees with something soft. Kneeling is already uncomfortable, and placing the replaced knee on a hard surface, such as an uncovered floor, can be more difficult. Use a cushion, pillow or towel to give the knees a soft support during the kneeling process.

• Kneel slowly, especially the first few times you attempt this after recovery. Grip the support you have already chosen, and maneuver your body down slowly, using one knee first, and then the other. If there is excessive pain, stop immediately and pull yourself upright. This exercise may take several attempts before it can be done without pain; in fact, some orthopaedic surgeons believe it will get easier the more you do it.

• Pull yourself up slowly, as well, to make sure you do not strain the ligaments holding the new knee in place.

Tips & Warnings

• Check with your doctor before attempting to kneel, as some surgeons do not recommend kneeling if it can be avoided.

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Filing for disability is a necessary but often unwelcome step following many surgical operations, including knee surgery. When knee surgery leaves you subsequently unable to perform your job as required during the recovery period, you will have the option to collect benefits from the Social Security office. There are different routes that can be used to file for disability, so choose the one that fits your particular needs the best.

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• Call the Social Security office to provide them with your application information and schedule a disability interview to be conducted either over the phone or in person. Understand that Social Security disability will only pay out benefits to individuals who are expected to remain disabled for a period of a year or more. Be prepared to present medical documentation that this is the case by the time of your scheduled interview.

• Apply online for disability when you are unable or unwilling to complete the process over the phone. Go to the Social Security page at www.ssa.gov and click oh the link that says "Apply for Disability Benefits" to fill out your application. Following your completion of the process, you might want to call or e-mail the office to ensure that all of your materials were received.

• Complete your interview, demonstrating that you are likely to be disabled for a year or more, along with providing documentation of your work history to prove you meet both the "recent work" and "duration of work" tests, two tests that determine whether you qualify for benefits. The recent work test will judge whether you have worked enough in the period leading up to your disability, while the duration of work test will determine whether you have been employed a sufficient aggregate amount of time throughout your life to qualify for benefits.

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A torn meniscus is a painful but treatable knee injury that occurs when the knee is turned with force while also bearing significant weight. Often seen in sports and other physical activities, the injury is a tear of the cartilage in the knee rather than the ligaments themselves. Severe meniscus tears could require some form of surgery on the knee and if so will need specialized rehab before exercise can begin. More minor tears however will take some strengthening, stretching and exercise regimens to return the knee to full form.

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The thing to keep in mind when exercising to heal a torn meniscus is that it’s not necessarily the knee itself you want to work but rather the muscles in the entire leg. Strengthening and working the quadriceps, the hamstring and so forth will help increase mobility and flexibility in the knee as the torn cartilage repairs.

Begin the workout with some light exercises and stretches that incorporate the knee somewhat and get it ready for some movement and flexing. Light riding on a stationary bike is recommended as long as the tear isn’t so severe that riding causes significant pain. Finish the riding with some slow semi-extensions of the leg. Take care to not completely extend the leg, which could overwork the knee joint and worsen the injury.

For exercises, focus on muscles around the thigh and calf. Leg lifts are an excellent rehabilitation exercise for the knee, as they’ll stretch and strengthen the surrounding muscles while still putting minimal impact on the knee itself. Lie on either your stomach or back, and with your leg extended almost completely, lift it straight in the air, holding at the top before lowering it again and repeating. Take care not to completely extend the knee, but go almost that far to get maximum effect from the exercise.

You can also do heel raises to work the calf muscles. Stand with your feet at shoulder width and your hands supporting yourself on a chair or counter in front of you. Gently raise your heels off the floor as if you were standing on your toes, being sure to keep your knees straight. Hold at the top before gently lowering yourself back down.

Finally, if you have access to a pool, you can perform some excellent exercises that will work well for rehabilitating an injured meniscus. Doing aerobic exercise while submerged in water is virtually non-impact on the knees and also provides much greater resistance than traditional running or stretching exercises would. Standing in no less than waist-deep water, slowly run in place with exaggerated movements. Instead of typically short and quick running motions, slow your movements and draw them out. Bring your knee to a 90-degree angle as if you’re trying to touch the knee to the chest. Alternatively, you can hold onto the side of the pool and perform short, quick flutter kicks to achieve the same results. This will work the knee joint as well as the muscles around it, but because it’s so low-impact, you don’t run the risk of meniscus re-injury that you would by running on land.

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