Anthony M. DiGioia III, MD

RESTLESS LEG SYNDROME (RLS)

What is "restless leg syndrome?"

Restless leg is a neurological disorder in which people feel the urge to move the legs when at rest.  People often describe the sensation as burning, creeping, or pain in the legs, which can range from uncomfortable to extremely painful.  This sensation usually occurs deep inside the leg, between the leg and ankle, and less commonly in the feet, arms, thighs and hands. Because of this sensation to constantly move the legs that does relieve the pain, it is often difficult to sleep and stay asleep, causing extreme daytime fatigue and exhaustion.  The lack of sleep can then cause impaired memory, difficulty concentrating and inability to perform activities of daily living. 

Restless leg syndrome is slightly more common in women and usually occurs in patients middle aged and older.   Events which can trigger restless leg are long car trips, sitting in a movie or any other periods of prolonged inactivity.  In most cases the cause of restless leg syndrome is unknown, but it can be caused by certain medications, chronic medical conditions, pregnancy, and even caffeine, alcohol and tobacco.  Temporary restless leg syndrome can be caused by total joint replacement. 

RESTLESS LEG SYNDROME AFTER TOTAL JOINT REPLACEMENT

After a total joint replacement, patients can often experience a "restless leg-like syndrome."  That is not a true restless leg, but rather a temporary condition resulting from muscle and joint healing as well as the swelling from surgery.  It is more likely to occur after knee replacements, and it can involve a feeling of diffuse pain, calf pain, cramping or the sensation to move leg around.  It is mostly experienced at night and resolves as the muscles and joints heal - approximately 6-10 weeks after the surgery.

TREATMENT OF RESTLESS LEGS SYNDROME

AFTER TOTAL JOINT REPLACEMENT

Treatment of restless leg after total joint replacement involves just moving the leg.  When awakened at night by the sensation, the best thing to do is stretch and walk around.  Also, for most patients the symptoms are less noticeable in the early morning, allowing time to rest.  Decreasing caffeine intake and tobacco and alcohol use can also lessen RLS.  Moderate exercise, regular sleep patterns, ice and massage can help eliminate the urge to move the leg.

·      Walking

·      Exercising or moving your joint, especially at night

·      Stretching

·      Ice and massage

·      Regular sleep patterns

·      Anti-inflammatories or other medications on a case-by case basis

Please keep in mind that restless leg syndrome caused by total joint replacement is a temporary condition and usually will resolve 6-10 weeks after the surgery.

WHAT IS A CONTINUOUS PASSIVE MOTION (CPM) MACHINE?

A motion machine will be used post-operatively to improve your range of motion more quickly and to make you feel more comfortable following the knee replacement surgery.  Even with the less invasive procedure, the healing of your incision can cause scar tissue to form, which causes your tissues to be stiffer than normal tissue.  The use of the CPM machine after your total knee replacement guides tissue growth, increases motion and helps reduce stiffness.  Your new joint also likes to be moved so this motion machine can make you feel more comfortable too!

You can use the CPM machine based on your comfort level, and it can be used as much or as little as you would like to use it.  We recommend that you use the CPM machine at least two times daily for one to three hours at a time.

WHAT TO EXPECT...

• The Day of Surgery

A CPM machine will be set up on your bed.  The motion will be set to full straightening with an initial bending of up to 90 degrees.  Even when you are resting, the CPM machine will work your knee!

• Post-op Days One to Three

Your bending will be increased based on how much bending you achieve in physical therapy.  In general, the bending will be increased by 10 degrees more than achieved during your last exercise session.  The goal will be for you to achieve 110 degrees or more of bending.  A portable CPM machine also will follow you to home.

·               Bruising may last for up to 6-8 weeks.  This is part of the normal healing process.

·               Being on the blood thinner after surgery can contribute to this bruising too.  However, this medication is very important so please continue to use it as you are directed.

·               Swelling of the leg, and down into the foot, can sometimes last for two or three months.

THINGS YOU CAN DO TO MINIMIZE THE

SWELLING AND BRUISING:

·               Elevate the leg when you are not doing your exercises or when you are resting.

·               For the first two to three weeks after your surgery, ice your knee or hip for 20 minutes every hour and also after exercising.  This will help to minimize both the swelling and the bruising.  After a total knee replacement, using your CPM (Continuous Passive Motion) will improve your range of motion, make your knee feel better and reduce swelling.

• What restrictions do I have after total joint replacement?
• There are very few restrictions for patients after surgery.  The only activity we do not recommend for patients is jogging for exercise as it accelerates the wear on your new joint.  Patients with hip replacements are told not to cross the operative leg over the other leg at the knees as this can put you in a position where you could potentially dislocate. You can cross at the ankle and bend all the way down as long as the legs are apart at the knees. You can resume all other activities based on your comfort and confidence level.
• Do I need to take an anticoagulant after surgery?
• All of Dr. DiGioia's surgical patients are to have Lovenox injections for 2 weeks postoperatively and then ASA (aspirin) for 2 weeks. Some patients have a higher risk for blood clots and have to take the blood thinners for a longer time. 
• How soon after my total joint replacement can I return to work?
• You may return to work as soon as you feel comfortable. Following a normal TKR/THR a patient should be out of work no longer than 4-8 weeks, but many patients can return to work in as little as 3 weeks.
• Will I be able to go to a rehab facility after surgery?
• 99% of our patients are able to return home after surgery without any problems. You are full weight bearing the night of your surgery and are able to climb stairs right away as well.  For 2-5 days following discharge, a physical therapist will come to your home to work with you, and you will attend outpatient therapy for 2 to 4 weeks at a physical therapy location close to your home.  On occasion, however, if there are medical or surgical issues, patients will be sent to a skilled nursing facility, but we always prefer for our patients to go home.  For the most part insurance companies are no longer covering stays in rehabilitation facilities after joint replacement.

• How do I know when I am ready for surgery?
• When you have endstage or "bone on bone" arthritis, injections are helping the pain less than three months and your pain is affecting your quality of life then you will be a surgical candidate.  Until you reach this point Dr. DiGioia will continue to advise conservative treatment.
• Why have I been asked to lose weight prior to my surgery?
• Knee and hip replacements wear out just like your regular knees and hips.  For every pound of extra weight that is six pounds of pressure on both your knees and hips!  If you are 10 pounds overweight, that is 60 pounds on your knees and hips! If you would wear out your new knee or hip, it would require a revision or redo surgery which can have more complications and higher risks. We know it is hard to lose weight because of pain, but the role of the injections is to relieve pain and allow you to be more active.  Dr. DiGioia wants you to be in the best shape possible before your surgery so that you can have the best results afterwards.
• What is arthritis?
• Cartilage acts as a cushion for the weight bearing surfaces of the joint.  When arthritis sets in, the cartilage between your joints begins to wear over time, and eventually the bone wears down too.   This causes the inflammation and pain which prevents you from maintaining your active lifestyle. 
• What is minimally invasive total joint replacement?
• This surgery is not truly "minimally" invasive, but, more accurately, "less" invasive.  There is a smaller incision and less muscle work involved, but the implants are still the same.
• What medications do I stop prior to surgery?
• All medications with ASA base (aspirin), blood thinners, NSAIDs (such as Aleve and ibuprofen), all arthritis medications (except for Celebrex) and vitamin E.  Please ask about any herbal supplements you may be taking.
• Can I take Tylenol?
• Yes.
• Can I take Celebrex?
• Yes.  Unlike other arthritis medications, you can take Celebrex right up to the day of your surgery. We also use Celebrex as a pain medicine after surgery.
• How long can I expect my total joint replacement to last?
• 75% of people are still with their original implants in place and doing well at 15 years. This is not to say that once it is year 15 that you will start having problems. TJR can wear out just like your normal knee, and the longer you have the joint replacement the greater the risk wear.  Also, the modern implants are modular systems so we can often catch wear early enough and replace ONLY the part that is worn. This is why we recommend that you get new x-rays every three years!  

BACKGROUND INFORMATION:

In the last decade, there has been increasing evidence that a significant number of Pennsylvania physicians are choosing to practice in other states, are retiring early, or are no longer performing high-risk procedures.  This is especially true for specialists, such as orthopaedic surgeons, obstetricians, gynecologists, neurosurgeons, cardiologists and cardiothoracic surgeons.  The reason for this decline in Pennsylvania physicians is due to the surging malpractice insurance costs coupled with low private insurer reimbursement.  Not only are Pennsylvania physicians choosing to leave the state, but graduating residents are choosing not to practice in this state at all. 

Data from a study conducted by the U.S. Bureau of Health Professions and the American Medical Association revealed that between 1985 and 2002 Pennsylvania lost 143 orthopaedic surgeons, a reduction from 892 to 749, or 16%.  Furthermore, the number of orthopaedic surgeons per 100,000 population dropped from 7.42 in 1997 to 5.83 in 2002, the lowest in the 18 years studied.  This decline in specialists paired with the increased demand as baby boomers age, is putting patient access to medical care in jeopardy.  In addition, the high turnover rate of specialists is extremely disruptive to the care of patients, especially those with chronic illnesses.

Physicians are not only leaving the state but those who stay are restricting their practice to lower risk procedures.  For example, according to the American Association of Orthopaedic Surgeons, rising liability premiums have caused 55% of orthopaedic surgeons to avoid certain high-risk procedures, with 6% eliminating all surgery.  Some physicians are choosing to not "take call" for hospital emergency room departments to minimize their risk of lawsuits.  In extreme cases, emergency and trauma centers are even shutting down completely.

SO WHAT IS FACT FROM FICTION?

Doctors are no longer performing complex or high-risk medical procedures due to medical liability.  The unrestrained escalation of jury awards is driving up doctors' liability insurance premiums and even forcing some insurance companies out of business.  According to the Physicians Insurance Association of America (PIAA) the median jury award doubled from $157,000 to $300,000 from 1997 to 2003.  This in turn has caused insurers to stop selling medical liability insurance altogether. The June 2003 GOA report found that in 2002 nearly 40% of orthopaedic surgeons in Pennsylvania were not able to renew their coverage with the same carrier and 31% did not find new coverage.  In 1999 jury awards in Philadelphia alone exceeded the total amount of jury awards for the entire state of California.

Doctors are not only avoiding high-risk patients, but also even practicing defensive medicine, which involves ordering a battery of tests to reduce their exposure to malpractice liability.

Demand spike is also promoting the increased MD shortage.

The baby boomer generation is one of the main factors adding to this increased demand.  Between 2001 and 2030, the demographics of the baby boomer phenomena will quadruple, leaving the elderly with the greatest shortages.  It is predicted that there will be a shortage of between 27-43% physicians by 2020, with the shortage in orthopaedic surgery in the range of 40-50%. 

WHAT ARE SOME SOLUTIONS TO THE MD SHORTAGE AND MEDICAL LIABILITY CRISIS? 

            We need to minimize insurance premium increases and provide damage caps so that physicians not only want to stay in this state, but so we can attract physicians from other states.  By stopping the medical liability crisis, we will enable more physicians to be here to handle the increasing demand that is inevitably going to come as the baby boomer generation ages.  In order to provide appropriate and fair compensation to those who are truly injured, but also protect physicians from excessive damage payouts, the Pennsylvania Orthopaedic Society has developed several goals, including:

•  Amending the Pennsylvania Constitution to adopt caps on awards for non-economic damages of $250,000.
• Ensuring a stable liability insurance market and reducing costs to high-risk specialty doctors, such as orthopaedic surgeons.
• Lowering mandatory malpractice insurance coverage levels to $250,000 per occurrence and $750,000 per annual aggregate.
• Establishing a no fault medical liability proposal, which would limit lawsuits to those cases involving death, serious impairment of bodily function, or permanent disfigurement. 
• Permanent MCARE abatement, the state run insurance program, which provides catastrophic medical liability insurance.  By providing high-risk specialists like orthopaedic surgeons with 100% abatement through a cigarette tax to pay the doctors' premiums, orthopaedic surgeons have saved $109,000 in the past few years.

Both physicians and patients need to work together to change state policies concerning medical liability.  If we do not change liability policies soon, we will face a future with limited access to healthcare.  Once the physician shortage occurs, there could be pressure to decrease demand by increasing co-pays, denying care to certain groups, physicians not accepting new patients and increasing the use of physician assistants and nurse practitioners.  Patients would be forced to wait longer to see doctors, have shorter physician visits and possibly be denied care altogether.  Patients might even have to travel out of state to seek specialty care.  This would then force patients to use the already overcrowded emergency rooms for routine primary care.  

For more information, please visit the American Academy of Orthopaedic Surgeons (AAOS) www.aaos.org or the Pennsylvania Orthopaedic Society www.pasociety.org.  

Patients can get involved by contacting the Patients And Physicians Alliance (PAPA) at 215-271-9590.

The following is a patient's own account of her activity level since having two total knee replacement surgeries.

When friends ask me how I am doing since my total knee replacements, I proudly tell them about the 14 hour flight for my long-delayed dream trip to China where I climbed The Great Wall, or about my new bicycle and the joy of riding again, or how I am able to walk the long platforms at train stations up and down the East coast.  

Before my second knee replacement only a year before going to China, and my first knee replacement five months before that, I couldn't even walk across the street and up a hilly driveway to visit my elderly neighbor.  But one recent morning I had an epiphany!  After finishing breakfast and climbing up the stairs to my bedroom on the second floor, I suddenly realized I had left some important mail from the previous night on the kitchen counter.  Without thinking, I whirled around, trekked back down the stairs and got the mail. When I got up the second time, my eyes filled with tears of gratitude. I realized the true miracle of my knee replacements was in what physical therapists call ADL-- "activities of daily living."

After not being able to cook a simple lunch without sitting on a stool, I was once again able to stand all day preparing our family's favorite dishes for Thanksgiving and Christmas dinners.  When I wanted a particular ingredient that was available at only one store, I parked in the only spot I could find, in the last row of the parking lot, and trudged into the big store and walked to the last shelf in the last row of the store to get the item I needed.  In addition, not only have I resumed going to the basement to do laundry, I do several loads in the same day.  I can even run the vacuum cleaner without having any pain.  I never imagined that I would be so excited about vacuuming! 

Ironically, the artificial joints that Dr. DiGioia put in my knees have made me feel like my real self again!  

I love being able to ride my bicycle once again.










I was able to climb The Great Wall of China because I had knee replacement surgery.