An interview with Lee M. Zuckerman, MD
An article in the January 2009 issue of the Journal of the AAOS reviews the evaluation and treatment of orthopaedic conditions in patients with Parkinson’s disease (PD). In an interview with AAOS Now, author Lee M. Zuckerman, MD, chief orthopaedic resident at SUNY Downstate Medical Center in Brooklyn, N.Y., focused on issues relating to total joint arthroplasty (TJA) in Parkinson’s patients.
AAOS Now: Is it true that the tremors experienced by a patient with Parkinson’s will loosen an implanted prosthesis?
Dr. Zuckerman: No real data exists on this issue, or on whether a cemented or press-fit implant is better for patients with PD. Because patients with PD have tremors and rigidity, one theory was that the constant motion and muscular imbalance would prevent proper incorporation and increase the wear of the implant, leading to failure. In initial studies, patients were immobilized in an attempt to counteract this, but this resulted in worsening of the rigidity and tremor. Patients who are mobilized early actually do better and have similar short-term outcomes to patients without PD.
Parkinson’s disease doesn’t seem to be a real contraindication for TJA; it’s more an issue of getting the patient mobilized to prevent the symptoms from worsening and proper patient selection.
AAOS Now: Is there any reason not to perform TJA on a patient with PD?
Dr. Zuckerman: The indications for TJA are pretty much the same for patients with PD as for other patients. The goal of the surgery may differ, however, because Parkinson’s disease affects a patient’s gait and function. Although a TJA that enables the patient to walk better and reduces pain will be beneficial in the long run, it won’t necessarily improve function. As the disease progresses, patients with PD may become bed-bound, with increased tremors and difficulty in walking. A TJA may not help them move better, but does result in pain relief.
Patients with PD need a lot of preoperative counseling and patient selection is extremely important. They must be told that TJA is not a cure-all for them to walk better, especially if their disease is advanced or not well-controlled. It should help with the pain, but as the disease progresses, they will have problems walking—not from pain of arthritis but from the PD. They also need to understand that the surgery and the rehab will be much more difficult for them than for other patients.
AAOS Now: Is one treatment better than another for hip fractures in patients with Parkinson’s disease?
Dr. Zuckerman: Many surgeons will treat a nondisplaced femoral neck fracture with percutaneous cannulated screws. There are currently no studies that examine this treatment, and only a dynamic hip screw type of implant has been shown to work for patients with PD.
Whether a patient has PD or not, the treatment for a displaced femoral neck fracture in older patients should be the same—hemiarthroplasty. More studies are needed to determine whether a primary total hip arthroplasty is beneficial for patients with preexisting degenerative changes.
The effectiveness of intramedullary nailing for intertrochanteric fractures is not known, but a dynamic hip screw construct has been shown to work. In my opinion, fixing the hip so that the patient can start walking and bearing weight right away is the most important factor. A procedure that gives the patient some sort of rigid fixation and enables him or her to walk early is better than one that immobilizes the patient or requires a long period of nonweightbearing. Patients with PD frequently have difficulty with both upper and lower extremity function; they may not be able to use a walker or cane as well as other patients and they are more likely to need prolonged rehabilitation.
AAOS Now: More patients are receiving total joint implants at younger ages. If these patients are later diagnosed with PD, what impact might the disease have and how can orthopaedic surgeons help patients cope?
Dr. Zuckerman: That’s a tough question and difficult situation. A person who is diagnosed with PD has a higher risk for fracture. Patients who already have a TJA will be at increased risk of a periprosthetic fracture, and the complication rate for total hip revisions in patients with PD is high—about 50 percent.
Orthopaedic surgeons should recommend physical therapy and bone-strengthening treatments to help prevent these problems. Optimizing treatment of the PD, improving mobilization, increasing bone mass, and developing strategies to prevent falls is extremely important. Counseling the patient and involving the family or caregivers can have a huge impact.
Early diagnosis is also important. Patients who are post-op who develop the classic symptoms of tremor, rigidity, or bradykinesia should be referred to a neurologist immediately. Although dystonic deformities usually develop in the later stages of PD, they may be present earlier in a small percentage of patients. In the hands, these fixed contractures or rigid posturing can resemble rheumatoid arthritis. If, in fact, the patient does have early PD and not rheumatoid arthritis, the orthopaedic surgeon can have a huge impact on how early this person gets treatment.
AAOS Now: What mental or physical impact might Parkinson’s have on a patient’s ability to deal with a musculoskeletal condition or treatment? How can an orthopaedic surgeon help?
Dr. Zuckerman: We know that patients with PD may also be affected with other conditions, such as diabetes or dementia, and may be on several medications. So treatment must take a multidisciplinary approach.
If diabetes develops, for example, the orthopaedic surgeon must make sure that the patient has the proper foot care to avoid the development of complications. Orthostatic hypotension is a side effect of certain PD medications, and when the patient gets up, he or she might feel dizzy and fall. In this situation, the orthopaedist can prescribe pressure stockings to improve with venous return.
Physical therapy to address gait dysfunction and strengthen muscles is a way to improve mobility and reduce bone loss. Dystonia can occur naturally, but it may also develop if the patient is immobilized for period of time as the result of a fracture. Getting the patient moving early can have a positive impact.
Educating the patient, family members, and caregivers on what to expect is important. Dementia, depression, and the musculoskeletal manifestations of PD can all result in a prolonged and difficult recovery period. Patients with PD can also have a lot of falls; caring for them is a very physical ordeal. Taking a multidisciplinary approach—including a neurologist, physiatrist, podiatrist, and family or caregivers—will result in optimal outcomes for patients with Parkinson’s disease.
“Parkinson’s Disease and the Orthopaedic Patient” by Lee M. Zuckerman, MD, appears in the January 2009 issue of the Journal of the AAOS, available online at www.jaaos.org Dr. Zuckerman reports no conflicts of interest.