Ask the Doctors September 2010 Issue

Ask The Doctors: September 2010

Bilateral Knee Replacement . . . NSAID Protection. . .Carpal Tunnel Remedies

I suffer from severe arthritis in both my knees, and my doctor has recommended knee replacement. Should I get both knees replaced at the same time, or individually? If they are replaced individually, how long should I wait until replacing the other?

Simultaneous bilateral total knee replacement and staged bilateral replacement produce equally good relief of knee pain and equally good return of knee function.

The decision is based on the health status of the patient. The ideal candidate is in good physical health, with no cardiac, pulmonary, or vascular disease. When both knee replacements are done at the same time, you have only one surgical "event" with a single anesthesia. Hospital stays have been found to be shorter and rehabilitation faster in patients who have both knees replaced at the same time.

One disadvantage of simultaneous knee replacement is that the early rehabilitation can be more difficult as patients do not have a "good leg" to work with. Studies have also shown that patients undergoing simultaneous knee replacement have a slightly higher risk of cardiac events.

Overall, the risk of complications, such as infection, blood clots, pulmonary embolism, or death is about the same for both simultaneous and staged bilateral procedures.

My doctor says Iím not a good candidate for celecoxib (Celebrex), but Iím concerned about the risk of NSAID-induced ulcers. Is there anything I can take to protect my stomach when taking an NSAID?

Celecoxib at high dosages (400mg per day) has been shown to increase the risk of adverse cardiovascular events. Most physicians try to limit celecoxib use to 200mg per day, a dose that is believed not to produce adverse cardiac effects.

Using an acid blocker, especially a proton pump inhibitor (PPI), has been shown to reduce the risk of adverse gastrointestinal events when using a nonsteroidal anti-inflammatory (NSAID) medication.

A new medication combining naproxen and esomeprazole (brand name Vimovo) couples an NSAID with a PPI. Another medication that reduces the risk of adverse gastrointestinalevents when taking an NSAID is misoprostol (Cytotec). There is also a combination pill available which combines the NSAID diclofenac and misoprostol (brand name Arthrotec).

Iíve been diagnosed with carpal tunnel syndrome. Besides surgery, what can be done for carpal tunnel pain? For those with chronic symptoms of carpal tunnel syndrome, surgery offers the best chance for long-lasting relief. However, there are other measures that can help in the short to medium term.If youíre experiencing relatively mild symptoms associated with a particular activity, behavior modification may be the only treatment that is necessary. If you find that you experience carpal tunnel pain after riding a bicycle, for example, choosing another form of exercise may be helpful. If you experience more persistent symptoms, wearing a night splint and taking a nonsteroidal anti-inflammatory drug (NSAID) may help your situation over a prolonged period of time.

If symptoms are more severe, an injection of dexamethasone, a water-based steroid, can shrink the tissue within the carpal tunnel, providing relief. If you find that you benefit from injections, you are likely to be a good candidate for carpal tunnel surgery.