Ask the Expert: Aches, pains, arthritis and joint replacements – Mr Niall Hogan

Joining Pat Kenny was Dr Niall Hogan, Consultant Orthopedic Surgeon at UPMC Sports Surgery Clinic, to answer all your orthopaedic questions.

Listen to the interview here:

Now, orthopaedic advancements, injuries, operations and recovery are on the operating table of discussion today. If you’ve got queries about your aches and pains and what might be done about them, text them to us at 53106 or WhatsApp at 087 1400 106. Our expert this week is Dr Niall Hogan, consultant orthopaedic surgeon at UPMC Sports Surgery Clinic.

Robotic knee surgery is something that is fascinating; you program the machine, and you stand back; can you explain?

Not quite, but it’s evolution. It’s a technology being brought into medicine. It’s already widely available in medicine, but in orthopaedic surgery, it’s relatively new. Certainly, in Ireland. It was introduced by an Australian surgeon, Stephen Brennan, in Cork, and then I was the first to use it in the Blackrock Clinic in Dublin in 2021. What can you use it on? What joints? You can use it on a number of joints, but predominantly I think knee surgery is the most relevant. I use it exclusively for knee replacement operations, and what we do is, say, a patient who has arthritis in their knee gets x-rays, they get a diagnosis confirmed, but then we get a CT scan, and we send that scan off to America at the moment to upload the software and make it compatible with the computer software. Then, on the day of surgery, we open up the knee and put in a special erase that will talk to the computer in the operating room, and we can fine-tune the position of the implant. It’s very accurate, very reproducible and reliable. Then, we bring the robot in to do all the cuts that we have asked it to do. Okay, so it will make the incisions at the beginning? Or does the surgeon make the incisions first? The surgeon will do that and put in the relevant probes or erase them, and then once we have worked out where we want to put the knee replacement on the computer screen, we can bring the robot in to do the accurate cutting. Okay, so it goes through bone and that.

What stuff gets replaced?

An artificial patella, or what is it? Well, a knee is made up of a number of bones, predominantly the femur or the thigh bone the tibia or the sin bone and also the patella is the knee cap at the front of the knee. Now, some surgeons will replace the kneecap all the time, and some surgeons will not. It’s not essential. What we will do is remove the artificial surface or just the cartilage layer that has been destroyed with a wafer of bone at the end of the thigh bone and the top of the shin bone, and then we will replace that with metal on both sides. Then there is an insert in between, which is a polyethene or plastic insert which is the bearing surface. Is that the synovial lining of the knee? It’s similar to plastic replacing the cartilage or the meniscus in the knee.

Okay, I presume it’s successful, or you wouldn’t be doing it. I mean how many have you done? How does it compare to the results from the classic way of doing it?

Well, I’ve done 50 now over the past year, and I feel my patients are doing an awful lot better. I think they are recovering quicker, and it’s slightly less invasive. There is less soft tissue trauma for the patient, and I believe it is more accurate; therefore, the patients will recover quicker and do better in the long term.

Now, I think the last time we were talking, I mentioned a thing called the bikini hip. Where they avoid cutting into the muscles like the classic hip operation, and therefore, recovery is much quicker.

Yes, and as I said before, there are various approaches to the hip. Anterior, lateral and posterior. The key thing is to get the surgeon to do your operation to be comfortable with whichever approach he or she feels is the most appropriate. Okay, now, many of the things you are talking about there are the product of age, like wear and tear, but there are other operations you are involved in involving sports injuries, like the ACL type treatments. How complicated are they and how successful are they because the athletes seem to get the very best, and they can make a recovery to the point where they can resume vigorous sport. Very much so, typically an anterior cruciate ligament tear is very traumatic for an athlete because they can’t play contact sports or pivoting sports, so it’s important that it gets fixed. Unfortunately, there is a nine-month recovery period for that post-operatively, but they can get back to full activity and full exercise gradually over a period, but usually, nine months is the period out of the sport. Yeah, it’s a long time in the short-ish career of a professional sportsperson. Yes, very much so; people now are very familiar with ACL, and people have access to MRI scans, and they get surgery quicker. Whereas, in the past, it would be a career-ending injury 25-30 years ago. People would not get back from this injury, whereas nowadays they do get back, but unfortunately, it’s the guts of one season that they have to spend on the rehab.

What about ankle injuries? People often feel that when you have an ankle injury, there is always a weakness there, even after the treatment, and you’ve got it fixed. I mean, there is no such thing as a replacement ankle, I presume?

I mean, it’s a very complicated area, I would suspect. There are replacement ankles, and there are two real operations when people get arthritis of the ankle one is an ankle replacement, and one is an ankle fusion. The fusion is probably more durable and longer lasting. Whereas ankle replacements have a lifespan, and it’s a small joint that takes a lot of weight going through it when we walk, so they can be quite tricky the injuries themselves, people often twist their ankles and sprain ligaments which often recover but often if they break an ankle they do damage, and then they will get post-traumatic arthritis in the future.

Now, when you do an ankle fusion, does it limit the movement of the ankle? Could you go back to your rugby or your squash or your tennis? No, I would say because there is quite a restriction. Now, having said that, people who have ankle replacements are not playing sports or ankle fusions are not playing sports up to that point; they are already retired from that level of exercise. They have pain in their ankle, and a fusion stiffens their ankle, so the movement is reduced. Although, you do compensate through other joints around your foot and beneath your ankle as well. What your aiming for is to give someone a pain-free ankle and make sure they are able to walk on. Could they cycle, for example? Yes absolutely. And swim? Yeah. The age profile for people with ankle fusions is well over 50 or 60, and therefore, their level of exercise is usually tailored to their age profile.

 What stage is surgery performed on bulging spinal discs?

Had an injection, no improvement, great pain. Low back pain is very common in the whole population, and everybody at a certain age will have a bulging disc. Some discs are bigger, and some are smaller. Is this what they call a prolapsed disc? 

Yes, a prolapsed disc or a herniated disc. Yeah, because I have one, and I was told to get walking, get yourself upright, and it might even put itself back. Well, again, initially talking to the GP or the physio, most of the treatment for this is non-operative; it’s the education of the patient, it’s low-intensity exercise, weight loss and time as well the disc will look after itself. If the disc is particularly big, it will put pressure on a nerve route, and that’s when people get sciatica and pain down their legs or electric shocks down their legs going into their foot and ankle, when that is very debilitating it doesn’t respond to treatment then you may need to see an orthopaedic or a neurosurgeon to decompress that nerve route.

I have one here about shoulder impingement. Can a shoulder impingement be dealt with in anything other than surgery? That’s from Dolores, and I don’t really understand what impingement means. I’ve heard of hip impingement, but what are these impingements?

Shoulder impingement is a restriction in the movement of a shoulder, and during the arc of movement, one will experience pain. That’s usually due to irritation or tendonitis of a combination of muscles called the rotator cuff muscles. They are a group of four small muscles around the top of the humerus bone, which stabilise that ball in the socket of the shoulder and allow the bigger muscles to work. When we get older, that rotator cuff gets degenerative, and it can become very irritable; therefore, when we move the shoulder, it can impinge. Usually, physiotherapy, non-steroid anti-inflammatory or steroid injections will help. If it doesn’t, then you are looking to see a shoulder surgeon who performs arthroscopic shoulder surgery and rotator cuff repair.

Yeah, I’m due to have minor surgery on a frozen shoulder which has lasted ten months now. Is it wise to have surgery for that?

Frozen shoulder is a very difficult condition for everybody, particularly the patient, but also for the doctor because we don’t know a huge amount about it. The capsule of the joint becomes very inflamed and sticky, and it causes pain initially. Intense pain for the first six months, and along with that, it causes stiffness. Whereby you have very little movement in your shoulder joint again is very debilitating for day-to-day activities, and then if you leave it for long enough, over the course of 18 months, it tends to resolve itself. Now, sometimes the pain and the stiffness are so severe that a surgeon will either opt for an injection. A steroid injection, hydrodistension of the joint, or they will do arthroscopic surgery to debride the capsule and try to release the adhesions.

Another one, I’m 64, and I’m told I should have a hip replacement, but afterwards, I have to give up running and football. Is there an alternative other than painkillers to allow me to continue sports for a few more years?

It’s debatable whether he would have to give up football or other activities that they want, like running. There are plenty of people who still run and play football after hip replacements, whether or not their doctor advises that or not. I suppose if you get it fixed now, you might have a career after your rehab. Whereas, if you leave it. Correct, I think the main thing is to get a hip replacement if you have pain and dehabilitation that affects your day-to-day life and then if it goes very well and you are able to play football, and you are able to run afterwards well, then that’s the patient’s decision and certainly, I wouldn’t object strongly to that.

I have a problem with my toes, the middle right toe is overlapping and squeezing the next outside toe, and it’s getting worse. I’ve tried toe dividers, too, but that doesn’t help. What can I do to stop it?

Again, surgery often is the answer to that problem. It often is associated with bunions of the big toe. The big toe cuts across and then compresses all the lesser toes, and they rise upwards. In that case, I think make a visit to a foot and ankle surgeon who can then assess the toes. They can realign the first toe and hopefully straighten all the other toes as well.

Someone else is asking about heel pain. What is it, what causes it and how to fix it?

Heel pain can happen in children and in adults. In children, it’s called severe disease, and it’s just a growth phenomenon. It’s traction on the growing point on the back of the heel. In adults, people talk about calcaneal spurs or plantar fasciitis. Again, a very difficult problem to deal with. Certainly, orthopaedic surgeons don’t operate on it; sometimes, they are injected, but the main treatment is physiotherapy and stretching. Unfortunately, it takes months and months for it to settle.

My husband is getting terrible pain in both the muscles in his arms and his wrist. None of the painkillers he has been prescribed are working for him. It started in one arm about three months ago, and now it has started in the second arm. Okay, that person certainly needs to see his GP. Does that sound like arthritis?

It could be arthritis; it could be bilateral shoulder rotator cuff problems or frozen shoulders. Sometimes when multiple joints cause trouble at the same time, then it might be a rheumatologist that this patient needs to see in case they have any evidence of inflammatory arthritis, which affects a number of joints at the same time.

Advice, please, on treating arthritis in feet, particularly on toes on the inside of the foot. Very painful. The GP mentioned metal plates.

Correct, the two major problems with the big toe we mentioned already, bunions or this one sounds like it is hallux rigidus so arthritis in that first metatarsal phalangeal joint, and if that is arthritic and sore, then that joint probably needs to be fused and a surgeon will either do that with screws or a combination of screws and maybe a metal plate.

Final general question, what is an injection of steroids useful for, and how long do they last?

Corticosteroids are very helpful for the treatment of arthritis, usually in a degenerative joint. It’s reasonable to perform a steroid injection every six months or so. After about 2 or 3 injections, its effectiveness wears off, and the patient then wants to move to the next step of treatment. Yeah, but it is a useful interim. Yeah, very much so. If it can buy time and kick the problem down the road, then it’s useful.

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