MedStar Health Blog

Increasingly younger patients are seeking partial or total hip or knee joint replacement—people in their 40s, 50s and 60s who are working and active and who can’t afford to slow down. As such, researchers expect a 77 percent growth in joint replacements over the next decade. These patients may have a surgical option previous generations never had before: outpatient joint replacement surgery. These advanced procedures allow patients to go home in as little as 24 hours after surgery.

Patients who are good candidates for outpatient joint replacement surgery are those who:

• Are healthy and active
• Are non-smokers
• Have a low body mass index (BMI)
• Have a good support system at home

It’s crucial that patients who go home the same day as their joint replacement surgeries have a robust support system at home—a friend or family member who can care for them so patients can enjoy all the benefits of outpatient techniques.

Many patients come to us who have been turned away from other centers. A lot of patients who come to us either have significant joint deformities or they’ve had several procedures that have been unsuccessful in the past. We evaluate them to provide a more stable functional prosthesis. We will frequently see those patients at our institutions because we use a personalized team approach that includes care at every step along the way—before, during and after their surgeries.

LISTEN: Orthopedic surgeon Savyasachi Thakkar discusses same-day joint replacements in the Medical Intel podcast.

What are the benefits of outpatient joint replacement?

One of the biggest benefits for patients is to recover in the comfort of their own home. We make this possible by collaborating with social workers called the post-acute care (PAC) coordinators. These experts address all of a patient’s needs before, during and after surgery. This includes home-based physical therapy for two weeks after surgery, which has several benefits for patients:

• Better pain levels without ongoing in-hospital vitals checks
• Cleaner, better-controlled environment
• Fewer falls after surgery
• No need to arrange transportation to physical therapy

For all of these reasons, outpatient joint replacement recovery often is healthier, quicker and much more effective than recovery after inpatient surgery.

We saw an energetic individual who clearly demonstrated a need and desire to get back to her active lifestyle. She needed a knee replacement surgery to do that. We brought her in for surgery and performed the operation without any complications. In fact, she was so ecstatic with her mobility and pain control that she was eager to leave the very same day.

How do outpatient and traditional joint replacements compare?

The actual surgical procedure is similar for both traditional and outpatient joint replacements. The main difference for patients who undergo traditional surgery is that rehabilitation occurs in the hospital, not at home. Inpatient rehab patients may experience:

• Higher pain scores because they’re not in their normal home environment
• Increased cost for the hospital stay
• Longer rehabilitation times

joint replacements make sense for some patients who are elderly and more fragile, who don’t have support systems at home and who are less active. But for more active, younger patients, we think that outpatient procedures are the way to go.

Frequently asked questions about outpatient joint replacement

How long is the recovery process?

For a younger, more active individual, recovery could be as quick as three or four weeks. For an elderly patient, it could be about seven to eight weeks. Many patients who have had these outpatient procedures are raring to go back to work after six weeks. We are starting to see a larger proportion of patients who want to get away from the distraction of having surgery and reduce their pain by going back to work sooner.

Is it possible to completely return to normal after surgery?

Absolutely! Joint deterioration happens over a long time, though it might cause noticeable symptoms only for a few months or a few years. Joint deterioration is associated with several other problems, such as loss of muscle mass and inability to perform or enjoy daily living activities. Those things take about three or four months to get back to normal. Our team of specialists work together to minimize pain as much as possible, and for the most part, when patients are pain-free after surgery, they experience such relief that they are able to tackle life at a much faster pace.

Related reading: Am I too young for knee or hip replacement?

What are the advantages of a team-based approach?

We have several specialists devoted to patients who need joint replacements. The team treats about 1,000 patients each year at MedStar Washington Hospital Center, from simple hip and knee replacements to complex surgical revisions:

• Dr. James Tozzi and Dr. Savyasachi Thakkar perform primary and revision hip and knee replacement surgeries
• Dr. Wiemi Douoguih and Dr. David Johnson perform primary knee replacement surgeries
• Physical therapists evaluate patients before surgery, immediately after surgery and then six to eight weeks after surgery on a continual basis
• Social workers exclusively care for patients having knee and hip replacement surgeries who also have complex medical needs and complex social situations
• Specialized nurses are devoted to patients on our orthopedic floors

We are a tertiary care facility, which means our patients also have streamlined access to other specialists, such as neurosurgeons, cardiac surgeons and other various doctors and specialists, so that any potential complications can be addressed easily. Also, if a patient we initially planned on leaving the same day ends up needing to stay in the hospital for a night or two, it’s easier to transition the patient. This is in contrast to numerous surgery centers that are popping up across our communities, where they do not have such facilities or expertise.

5 areas of upcoming research in total joint replacement

Joint replacements have come a long way, especially during the last decade, but there’s still room to grow. We are focusing on several areas of research for joint replacement patients:

• Improved patient outcomes through best practices and procedures that focus on safety and reduced readmissions.
• Pain management research so we can deliver different kinds of therapies at the same time.
• Pre- and postoperative nerve ablation, which is the blocking of pain signals from nerves using radiofrequency ablation to remove the skin nerves around the incision sites of the surgery, reducing pain.
• Robotics or computer-assisted navigation to help us reduce operative time, blood loss and the need for blood transfusion. We’re calling this “bloodless surgery” because we can avoid significant blood loss, reduce the risk of blood clots and perform the procedures safely without the risks involved with blood transfusion.
• Alternative bearing surfaces, in which we cap the bones with different materials that help form the new joint. Alternative bearing surfaces can give patients better pain control, better mobility and longer-lasting joint replacements.

We think most patients are shocked at first by the notion of having a joint replacement surgery and leaving the hospital the same day. They are often nervous about the idea, but when they look at our pain control strategies and how we have organized treatment for them, most patients wake up after the surgery remarkably happy and satisfied. They go home feeling comfortable that they can call us anytime and someone will be available to answer their questions, ease their fears and help them transition back to a more active lifestyle.

Triple-negative breast cancer is notoriously difficult to treat. It grows aggressively, and it lacks the three most common markers (estrogen and progesterone receptors and the HER2-neu protein) that we often target in our treatments. Some of our gold-standard treatments don’t work well enough against this type of cancer, and national survival rates are lower within five years of diagnosis compared to other forms of breast cancer.

As such, we are continually researching better ways to screen for and prevent this type of breast cancer. So when an August 2018 study published in the Journal of the National Cancer Institute found that several previously unknown genetic mutations were associated with a higher lifetime risk of triple-negative breast cancer, we were eager for good news. Some popular media outlets suggested that genetic testing could help identify more at-risk women and lead to better prevention strategies.

There’s no doubt that the discovery of these mutations is a potential breakthrough for triple-negative breast cancer prevention. But not every woman should rush to genetic testing to determine her risk. While there seems to be more benefits for women who previously have been diagnosed with triple-negative breast cancer, the results of genetic testing may not be as helpful for women who have never had the disease.

Benefits of genetic testing for triple-negative breast cancer survivors

The current guidelines from the National Comprehensive Cancer Network (NCCN) state that women should be referred for genetic counseling if they:

• Have been diagnosed with triple-negative breast cancer before age 60
• Were diagnosed with any type of breast cancer at or before age 50
• Have a close family member, such as a mother, grandmother, or sister, who has been diagnosed with breast cancer or ovarian cancer
• Have been diagnosed with two separate breast cancers

If a patient is referred for genetic counseling, the counselor will conduct a detailed review of her family history to determine whether she might benefit from genetic testing. We currently test for a number of known genetic mutations, including mutations to the BRCA1 and BRCA2 genes, which are known to greatly increase a woman’s risk for breast cancer. With the newly discovered mutations from the previously mentioned study, we potentially can add additional mutations to our routine screening and get a better idea of how likely a woman is to develop another triple-negative breast cancer. Patients who are found to be at high risk might benefit from more intensive screening with the addition of breast magnetic resonance imaging (breast MRI) tests to standard mammogram so we can find the disease earlier.

There’s an old expression that age doesn’t make you forgetful, it’s the amount of things you have to remember. But when it comes to dementia, which affects 5.7 million Americans, memory loss can be prevented or at least reduced as we grow older.

Dementia is an umbrella diagnosis that describes a group of diseases, including Alzheimer’s, that might cause the brain to fail. Dementia becomes increasingly higher after age 60. While 7 percent of adults 60 and older have dementia, nearly 30 percent of those 85 and older do. All types of dementia lead to a continued loss of brain tissue, which can affect:

• Behavior
• Emotions
• Memory
• Perceptions
• Thinking

Some forgetfulness is to be expected as we age, but these six tips can help slow down memory loss as we age—or stop it in its tracks.

Poor sleep is a risk factor for cognitive decline and Alzheimer’s disease. As a medical school professor, I’ve witnessed the short-term memory effects in my students. Those who don’t sleep well for a few days tend to forget more facts and do poorly on tests. Imagine the effect this can have on people over a long period of time! Sleep apnea can also contribute to memory problems.

2. Eat a healthy diet

A healthy diet benefits your brain as much as your waistline. You’ll see people in their 90s who have a good memory, and oftentimes their diets are healthy—full of fruits and vegetables, and hardly any processed foods. A poor diet can lead to nutritional disorders, which is another reason people experience memory loss. Having a healthy diet can help people avoid vitamin B1 and B12 deficiency, as well as thyroid conditions.

3. Exercise regularly

Exercise can help preserve brain health as we age. However, the National Academies of Sciences reports that, despite advances in understanding dementia risk factors, the idea that exercise might delay or slow age-related memory loss has not yet been proven.

Unfortunately, some adults shun exercise and many children watch TV and play video games more than they play sports or spend time outside. Taking the time to exercise at least 30 minutes per day can go a long way in preserving brain health.

4. Stimulate your mind

Evidence suggests that doing activities that require high levels of mental stimulation and education helps reduce cognitive decline. This can help people who are beginning to develop dementia function normally for longer.

I encourage people to spend their days doing what they enjoy. If working with computers makes you happy, then try to have a job that includes tinkering with computers or do so in your free time. If you like cars, make time for driving and working on them.

5. Prioritize your social life

Make time to have fun with friends and family—it’s good for the soul and the brain. In fact, one study found that being highly social later in life can decrease dementia risk by 70 percent. Regularly socializing with family and friends doesn’t mean you have to go to parties. Talk with friends and loved ones on the phone and consider volunteering. Helping others benefits you cognitively because you’re creatively using your brain by conversing and problem solving for others.

6. Manage your stress and anxiety

Chronic depression and anxiety might lead to an increased risk for developing dementia, studies suggest. We all deal with some level of stress and anxiety, but it’s important we always try to keep it under control. My best advice is to ask your primary care doctor for help managing your depression and anxiety, especially if it is chronic.

A majority of dementia cases are caused by lifestyle factors, not genetics. It’s up to us to take the necessary steps to reduce our risk and protect our memories for years to come.

Most of the time, people don’t notice their salivary glands. They are located in the mouth and throat, and they produce saliva. We start to notice these glands if a stone or tumor develops and blocks the flow of saliva. When that happens, they can become swollen and painful and can interfere with hydration, digestion and dental hygiene.

Salivary stones and tumors can range in size from smaller than a marble to larger than a golf ball! While the vast majority of salivary gland tumors are not cancerous, some continue to enlarge and can develop into cancer if left untreated. We treat a range of salivary gland conditions, including:

• Chronic inflammation or infection, called sialadenitis
• Parotid gland and submandibular gland tumors, either cancerous or benign
• Salivary gland stones, called sialolithiasis
• Salivary tumors

Let’s take a look at the risk factors and symptoms of salivary gland diseases and how we treat them.

LISTEN: Dr. Pierce discusses salivary gland diseases in the Medical Intel podcast.

Risk factors and behavior of salivary gland disorders

We don’t know why some people develop salivary stones or tumors. However, we know some behaviors are associated with them:

• Not drinking enough fluid
• High calcium levels
• Smoking
• Previous radiation or radioactive iodine treatment for thyroid cancer

Salivary gland tumors can occur in young people, but they are found most commonly in patients in their 40s and older. Often, the condition is discovered when the patient is getting imaging such as an X-ray for an unrelated reason. If the tumors are not treated early, they can continue to enlarge over time and can potentially lead to cancer.

Salivary gland conditions behave differently from patient to patient. A stone or tumor:

• May appear and get better—even go away—then come back
• May cause no noticeable symptoms
• May be quite painful

Because we don't know exactly why stones develop in salivary glands, our best recommendation to prevent them is to stay well-hydrated. We can provide mouthwashes and medications to patients who have dry mouth to help improve saliva production before or after treatment for a salivary gland disease.

Treatment for salivary gland diseases

Patients used to undergo invasive surgeries to remove salivary stones, or even the glands themselves. Today, we have a minimally invasive procedure called sialendoscopy, in which we use scopes with miniaturized instruments that can fit into the larger salivary glands. We use these tools to look for narrowing (stricture) of the ducts, as well as stones and other abnormalities. Then we use the tools to remove small stones from inside the salivary glands.

Sialendoscopy is a relatively straightforward and low-risk procedure, typically done with the patient asleep for comfort but sometimes can be done with the patient awake. Patients who have the procedure for a stricture or stone usually can go home the same day, whereas a hospital stay is usually required if the gland is removed for a tumor or other reason via an open procedure. However, sometimes a patient may be able to go home sooner than expected. For example, I had a patient who had a tumor of his parotid gland, and he elected to undergo surgery to remove the gland. He was able to go home the first day after surgery, and he is extremely happy with his result.

While we use minimally invasive techniques whenever possible, removal of some larger salivary gland stones usually is performed with open surgery under general anesthesia, which requires a small, discrete incision in the neck or right in front of the ear. Patients who have salivary gland cancers sometimes require further treatments in addition to surgery, including radiation and/or chemotherapy.

Salivary gland disease treatment has come a long way. Advanced treatments allow us to care for a wide range of patients with more minimally invasive options than ever before. The key, as in many conditions, is early diagnosis and treatment. The earlier we can intervene, the faster a patient can experience a better quality of life.

It’s summertime—everyone is out and about and having fun. But with the extra time outside comes increased susceptibility to ticks. Tick bites are known for spreading Lyme disease, a bacterial infection that affects about 300,000 Americans each year. Maryland and Virginia are among 14 states that account for about 95 percent of all cases, so it’s important that we understand ways to avoid ticks and identify and prevent the Lyme disease.

Lyme disease usually results in symptoms within the first 30 days of a tick bite. Symptoms can include:

• Bullseye rashes
• Chills
• Fatigue
• Fever
• Muscle aches

Severe cases can result in long-term conditions, including:

• Bell’s palsy
• Diffuse joint pain
• Heart palpitations
• Meningitis
• Nerve pain

Fortunately, in most cases ticks must be attached to humans for more than 24 hours to spread Lyme disease. Let’s discuss five ways to avoid tick bites and Lyme disease, and what to do if you’re bitten.

Avoid tick bites with these 5 tips

Preventing Lyme disease starts with being mindful when you’re out and about. If you’re going camping or hiking in grassy or wooded areas, follow these five tips:

1. Wear long clothing: Even in the summer, choose long-sleeved shirts and pants to prevent ticks from latching on to your skin.
2. Check your body for ticks: Ticks prefer warm, moist areas of the body, such as the armpits, groin, and hair. Remember to check your children, too!
3. Heat your clothes in the dryer: As soon as you come inside, put your clothes in the dryer for at least 10 minutes to kill ticks on your clothes.
4. Use insect repellents that contain DEET: This strong bug repellent is a common active ingredient in the most popular spray products.
5. Treat clothes with pyrethrin: This synthetic insecticide helps keep ticks and other bugs away.

Related reading: 2017’s growing tick problem: How to protect yourself

What to do if you’re bitten

Most tick bites will not result in Lyme disease. If you see a tick on your skin, remove it as quickly and as completely as possible with fine-tipped tweezers. Clean the area with soap and water or rubbing alcohol.

If a red rash or other symptoms mentioned start to arise, call your doctor. Be sure to indicate when you might have been exposed to ticks and when you first noticed the symptoms. The doctor will give you a physical exam and possibly a blood test to check you for Lyme disease. If the test is positive, the typical treatment is a course of antibiotics.

Avoiding Lyme disease starts with awareness and taking simple steps to avoid tick bites. Be sure to protect your family this summer and fall when you’re enjoying the great outdoors.

Does this sound like a typical day? Maybe you take an antacid with your morning coffee, a Zantac with lunch or a Nexium with dinner—perhaps a combination of tactics to keep heartburn at bay. If this sounds familiar, you’ve got a lot of company. It’s estimated that about 20 percent of American adults have heartburn symptoms at least once a week.

Over the long term, heartburn can increase your risk for serious health conditions, including cancer. That’s why it’s important to see a gastroenterologist and get frequent heartburn under control.

LISTEN: Dr. Patel discusses frequent heartburn in the Medical Intel podcast.

What is heartburn?

Heartburn happens in the esophagus, which is the tube food passes through as it goes from the mouth to the stomach. The esophagus has a sensitive lining that works much like the skin. As food reaches the stomach, it’s broken down into smaller particles by stomach acid so the body can absorb the nutrients. If some stomach acid splashes back into the esophagus, it can burn the lining there.

This splash-back process is called acid reflux. It can happen because the esophagus opens and closes with a ring of muscle that we can’t control called the lower esophageal sphincter, or LES. As you eat and swallow, you naturally swallow some air, and the LES relaxes five or six times an hour. People who have acid reflux on a daily basis may have many more of these relaxations—up to 20 in an hour. The more the LES is relaxed, the easier it is for stomach acid to get into the esophagus and cause the burning sensation of heartburn.

Dietary Do's and Don'ts - Click to enlarge.

Heartburn often can be triggered by a specific type of food, such as:

• Caffeine
• Chocolate
• Citrus fruits, such as grapefruits and oranges, which contain citric acid
• Spicy meals
• Tomatoes, including tomato juice and sauces

But for some patients, everything they eat causes heartburn. Being overweight or obese, especially if you carry extra weight in the upper torso, also can increase the risk of having heartburn. Chronic dry mouth—a common complaint of smokers—also contributes to the frequency and severity of heartburn, because saliva produced in the mouth naturally can shield the esophagus from some of the effects of stomach acid.

Why long-term self-treatment–or no treatment–is risky

There are many over-the-counter treatments available for heartburn. However, when patients tell me they’ve been treating heartburn on their own with antacids for many years, that’s a big red flag that something more serious might be going on.

Acid reflux and gastroesophageal reflux disease, or GERD (a chronic heartburn disease) do more than just cause heartburn, even though that’s all you may feel. The lining in your esophagus is delicate, and with repeated injury from acid reflux, the cells in that lining can transform into cells that are more like those in your stomach or intestines. This change is known as Barrett’s esophagus, and it can increase the risk for developing a dangerous form of esophageal cancer called esophageal adenocarcinoma.