Prevention of Wound Infection in a Total Joint

joint infection 

Patients can have an active role in the prevention of post-operative wound infections. These include management of glucose levels, cessation of smoking, proper hygiene, not removing hair to the area, and the use of antiseptic agents.

Prior to your surgery, we require the use of chlorhexidine wipes the night before your total joint surgery. This helps to decrease the normal bacteria on your skin. We also require that post-operatively, you avoid hot tubs or bathing. Depending on your surgeon, you may or may not shower with the aquacel dressing intact. On your way back to the OR, you are given IV antibiotics to prevent post-operative infection.

Smoking and nicotine use (including smokeless tobacco) can increased platelet adhesion (resulting in blood clot). Nicotine is a vasoconstrictor (narrowing of the blood vessels) that can decrease nutritional blood flow to the skin.   This can delay the healing process and even lead to tissue ischemia (lack of oxygen and tissue cell death).

Controlling Diabetes plays a major role in prevention of wound infection and would healing. Diabetics have a slower healing time, poor circulation, nerve damage, and weakened immune systems. Our surgeons prefer not to proceed with surgery with a HbA1c higher than 7.5; as this can increase complications.

For further information, please don’t hesitate to contact our office and speak with Sarah Yost PA-C.

Knee Pain and Arthritis in Women, Part 2

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Here are 5 more frequently asked questions in regards to knee pain and arthritis in women.

  1. What if my knees are already making grinding noises when I climb or descend stairs or get out a chair?

Answer: While knee grinding noises can be present in up to 40% of women’s knees without pain, this is not the same as saying it is normal for knees to make grinding sounds.  The grinding is called crepitation (which is a sound like walking on snow). Many doctors tend to ignore its importance.  This in unfortunate, since in my experience, knees which grind often have significant joint wear on the undersurface of the kneecap.  Chondromalacia (chondro=cartilage; malacia=softening) of the patella (kneecap) is the term for this situation.  The condition is nearly synonymous with kneecap arthritis.  Excessive knee bending exercise or impact in these patients can lead to the rapid onset of crippling arthritis.  Many of these patients are younger than 40 years of age and have to give up what they would normally do daily and are told to live with their pain.

  1. Can I be born with reasons for my knee pain or arthritis?

Answer: Yes, there are significant congenital reasons for women’s knee pain and problems.  Most commonly, the kneecaps are not properly aligned.  This “maltracking” of the kneecap leads to lifelong symptoms often staring with a history of kneecap pain and dislocation in childhood and leading to premature arthritis in midlife.  Another congenital reason for pain in the female is patellofemoral dysplasia (meaning that the kneecap and its groove are not the proper shape.  Such factors lead to surface wear just like the tire on your car with improper alignment.

  1. If I have knee pain that interferes with my daily activity, work, or exercise, what should I expect my doctor to say, do or not do for me?

Answer: Knee pain that interferes with and/or prevents normal activities and exercising must be taken seriously.  You should expect a thorough history and exam by your doctor, with special attention to your overall leg alignment and knee cap movement.  X-rays should be taken of your knee and knee cap to check for wear and malalignment.  In some cases, MRI and bone scans are useful, especially when there is fluid or swelling.  Most patients have muscle weakness and leg alignment issues that can respond to physical therapy.  A proper exam should educate you and teach you how to live and remain as comfortably active as possible.

  1. What about the Internet? Why can’t I just look up knee pain and go from there?

Today, looking up the answers to medical questions on the Internet is a common practice, but be careful.  First, make sure what you are reading relates to the diagnosis you have.  The point is everyone is at least a little bit different.  As much as the Internet can provide information, you can have a hard time knowing whether the information is both accurate and really applies to your situation.  Also, remember that today, the Internet is filled with commercial motives and advertisements that either will not help you or almost always will cost you money.  Knee pain and arthritis treatment is a multi-billion dollar business.

  1. If I do decide to look for information on the Internet, are there any sites that are better than others?

Here are some of the better peer reviewed (physician approved) sites: This is the official site of the American Academy of Orthopedic Surgeons : Good discussions of medical topics and knee problems in general : Find under the search term “chondromalacia patella”. Good illustrations.

Remember: While these sites may provide initial information, your exact diagnosis and treatment will not be determined solely by what you can read. These sites offer a good starting point for discussion with your physician or therapist.

Information Provided by Wayne B Leadbetter,MD. Dr. Leadbetter is a Board Certified Orthopedic Surgeon recognized for his interest and publications on the female knee and women’s knee complaints especially relating to the kneecap. He may be reached at the Center for Joint Surgery and Sports Medicine, Hagerstown ,Maryland. Appointments: 301-665-4575

Knee Pain and Arthritis in Women, Part 1

women knee pain

If you are a female with a history of knee pain, knee injury, or arthritis, you are not alone!

Knee complaints have overtaken low back pain as the #1 complaint in the average Orthopedic Clinic and most of those complaining are women!

Add to this that slightly greater than half of all joint replacements of the knee are done on women in the United States and you have plenty of reasons to learn more about your knees and how to make them last.

Here are the answers to 5 questions about the female knee that will help you to understand how to improve your chances of avoiding pain and eventual surgery.

  1. What factors have contributed to the current pattern of painful knees in women?

Answer: Knee problems are likely getting worse in women, as they now participate in many of the same activities, sports, and occupations as men.  This is a good thing, as being fit and in shape is important.  However, female anatomy is different, in that the pelvis is a little wider, and this ultimately puts more stress on the knees.  There is more on this below.

  1. What differences between men and women may contribute to the observed greater injury occurrences in women?

Answer: Females are more often likely to have more inward rotation of the thigh bone.  When this happens, the rest of the leg has to compensate for this.  The knee joint and kneecap end up taking extra stress.  Women’s knees accumulate loads of up to 6-8 times body weight during running and jumping activities.  Another factor thought to contribute to arthritis is the lack of estrogen that occurs in women after menopause. Family predisposition (genetics) may play a role, too.

  1. Is it true that if I exercise improperly I can actually cause more harm than good to my knees?

Answer: Absolutely.  Proper exercise and fitness requires a balance of frequency, intensity and duration. Some years ago , I conceived the “Rule of Too’s”, which says your chances of having an injury go way up if you exercise too hard, too often, too little recovery or rest, too much of the same activity, too quick or fast an exercise, etc.  We talk about “using it or losing it”, but as we age, especially over the age of 50, your knees cannot recover or adapt to stress as fast.

  1. Are there popular fitness exercises that can be particularly tough on the knee?

Answer: Yes. We have programs that claim to train your knee in less than 10 minutes a day!  Women are a consumer target for enrollment in these fast fix schemes which tend to offer cheaper cost, availability, and shorter time commitment.  Beware of such programs as Curves and Crossfit if you have had prior injury, swelling, knee pain, or have been told you have kneecap problems.  Women over 50 years old have reached the decade when many knee problems and arthritis start to become symptomatic.  You can easily aggravate any prior or existing problem.  Bent knee exercises such a step aerobics, steppers, squat lifts, and lunges are particularly likely to be bad for you, especially if your knees already make crunchy or grinding noises on stairs and with knee bending.

  1. If I have started an exercise program, what do I look for to know if my knees are OK?

Answer: There are several key things about your knee to keep track of to know if you are doing more harm than good. First, how does the exercise make you feel—during, the day after, and week to week?  While everyone may experience some aches and small pains when starting to exercise, what counts is the intensity of the pain, how long it lasts, and whether you feel better as time goes along.  Any pain that increases or comes back every day is a red flag.  Additional red flags include limping, swelling (stiffness), warmth (feel your knee with the back of your hand and compare to your non-painful knee), loss of motion (can you knee fully straighten and can you do a deep knee bend), and giving way or catching.  Do not train through pain.  Do not do exercises that cause your knees to make grinding noises.  If any of these symptoms occur, you should seek orthopedic advice.

Stay tuned for Part 2 of Knee Pain and Arthritis in Women.  To be posted next week!

Information Provided by Wayne B Leadbetter,MD. Dr. Leadbetter is a Board Certified Orthopedic Surgeon recognized for his interest and publications on the female knee and women’s knee complaints especially relating to the kneecap. He may be reached at the Center for Joint Surgery and Sports Medicine, Hagerstown ,Maryland. Appointments: 301-665-4575

Frequently Asked Questions after having a Total Joint Replacement


Why did you use staples to close my incision?

Stitching with sutures or staples are cosmetically equivalent, and the choice of   staples tends to allow for rapid skin closure with minimal wound inflammation, and are easier to remove than stitches.

Why don’t you use skin glue to close my incision

While surgical &super glue& can be used to close surgical incisions, Staples provide a stronger closure for more mobile surgical sites required for post operative rehabilitation.

Will I set off the metal detector at the airport?

More than likely, and TSA won’t accept a card or Surgeon’s letter, so be prepared for a secondary inspection.

Why Is The Outside Of My Knee Numb After Knee Replacement Surgery?

The lateral side of the knee is numb initially after surgery because the skin nerves travel from the inner (medial) side of the knee to the outer (lateral) side. They are cut when we make the incision and the sensation may return in first year or may remain numb.

How Much Does The Prosthesis Weigh?

The prosthesis generally weighs less than a pound and we also remove some bone so it comes out pretty even.

After My Hip Replacement, My Foot On That Side Is Swollen. Why?

The body’s mechanism for pumping fluid out of the legs, is the the leg muscles. Once you are putting full weight on your operative leg, your swelling should resolve

Is it normal for my knee to feel warm?

Yes,for up to about 9-12 months. The warmth comes from your body’s healing, increased blood flow and to the surgery itself. One of the best gauges you’ll have for knowing when the warmth should go away is when the scar completely fades to the color of your skin.

Can I kneel?

The reason we don’t want you to kneel on your kneecap is because during surgery, we thin the kneecap. Therefore, theoretically, the thinned kneecap is weaker than the original. Also, when kneeling a great deal of stress is put on the polyethylene cap that we’ve placed inside your knee. If you must kneel, such as to pray or perform a particular aspect of your job, we ask that you kneel on the upper part of the shinbone. You can find the area for safe kneeling by feeling your kneecap and moving your hand towards your ankle. You’ll feel a knot on your leg where the tendon attaches. That’s where we want you to put the pressure when you kneel.

Is popping/clicking in the knee normal?

We prefer that the knee be completely quiet, but popping is not uncommon. The popping is caused by scarring in the knee joint as a result of the surgery. Most of the time popping will resolve at about the same time the warmth resolves. However don’t be alarmed if you have some occasional pops for the remainder of the knee’s life. 

How long will the scar be red?

Some people lose the redness by 3 months and other people take 15 months. As long as the scar is red, remember that you’re still healing. 

-Ron Spruill, PA-C

When he’s not assisting Dr. Salvagno in the OR or taking out staples at CJS, you can find Ron working at Urgent Care.  In his spare time, you might be lucky enough to catch him moonlighting as Ronnie Ray, a very talented blues musician.

Joint Pain and Obesity


Our joints carry the weight of our body. The heavier we are the more difficult it is for our joints to work effectively. More than 40 percent of American adults are classified as obese. Even a few pounds of extra weight make a difference in our joints. The joint force in the hips and knees increases at least three fold with everyday walking. For instance that means if you carry even five pounds of extra body weight your hips and knees feel that as an extra 15 pounds.


The chance of developing arthritis increases with obesity. Although there are exceptions, those with a high body mass index are more likely to develop arthritis at a younger age. The need for a joint replacement at a younger age sets up the patient for a possible revision arthroplasty as they age. Joint replacement and subsequent recovery may take longer in obese patients.


Losing weight will not reverse the amount of osteoarthritis that has already occurred. The goal after the diagnosis of osteoarthritis would be to lose weight in order to decrease joint pain and abort future rapid cartilage loss. Weight loss is possible even if the joints are arthritic. Low impact activities such as walking on a treadmill, biking and swimming are examples of exercise. Weight loss is not an easy task to take on, but the benefits of maintaining a healthy lifestyle will be well worth the work.

– Lynne Kline, CRNP

Getting Started on an Exercise Program

winter workout

Most individuals are more inactive during the cold winter months, but before we know it, spring will be right around the corner. When warmer weather is upon us, we will have more options to get outside and get moving. Until that time, in order to maintain overall health and wellness, and avoid the risk of injury when the weather does improve, it is important to participate in an exercise program. Only exercise to your level of health and make sure you are cleared for physical activity by your physician prior to starting any new exercise regimen.

Begin by exercising three times a week for 30 minutes of moderate cardiovascular and light strength training. Allow time for both warm-up and cool-down with exercise, approximately 5-10 minutes. Light impact activities (i.e. walking, biking) are a good way to exercise without placing additional stress on your joints. Strengthening of your legs is also important for function and protection from injury. By increasing muscle strength, you can give support to the joints and allow energy conservation with daily activity. Winter is often a time when muscle tightness increases due to decreased activity. Make sure that you are taking time to stretch your muscles to maintain flexibility. Stretches can be done daily and should be held for 15-20seconds and repeated 2-3x for each muscle group.

It is not uncommon to have muscle soreness after starting an exercise program.  A day of rest between exercising will help to decrease the onset of muscle soreness. If soreness does occur, ice can be used for 10-15 minutes. If you suffer a minor injury to a muscle or joint, make sure to rest. To avoid further injury or inflammation, you should elevate and ice the area 10-15 minutes, several times per day.

-The Center for Joint Surgery Physical Therapy Team.

If you have further questions or concerns, please do not hesitate to contact us at the Center for Joint Surgery and Sports Medicine (240-452-3205).

The Anterior Hip Replacement

the anterior hip replacement

A recent trend in hip replacement surgery has been to perform the surgical procedure through smaller and less invasive approaches.  The idea of this method of surgery is to perform the same procedure with less disruption to the surrounding muscles and soft-tissues. By performing surgery through smaller incisions, with less soft-tissue dissection, it is hoped that patients will have less pain and a faster recovery.

Surgeons have used an anterior approach to perform surgeries for people needing hip repairs for decades. Anterior hip replacements have been described in America since the 1980s and have gradually gained popularity.

The anterior approach hip replacement is a muscle-splitting approach, meaning that the surgeon gets to the hip between two muscles, rather than by removing and then reattaching a muscle. Surgeons promoting this procedure note that because the operation spares muscles, patients don’t need to limit their movement during the recovery period. The advantage is thought to be that rehabilitation can proceed more quickly by not having to allow the reattached muscle to heal.

Despite optimism and support for this new technique, not all orthopaedic surgeons are convinced the anterior hip replacement offers significant advantage over traditional approaches. The operation has a steep learning curve and is not common in training during orthopaedic residency programs.

In conclusion, surgeon skill and experience is by far the most important factor.  Doctors who perform many hip replacements in a year have lower complication rates, no matter what approach they favor. It is important to have a discussion with your doctor as to benefits and risk of a hip replacement surgery and what would be best for you.

Dr. Cabezas brings his experience from one of New Jersey’s busiest referral institutions, where he was trained in the latest techniques and advancements in orthopaedic sugery.  He is a graduate of the University of Medicine and Dentistry of New Jersey, where he also recently completed his residency.  He is a veteran of the U.S. Army, serving under Operation Enduring Freedom while stationed in Fort Gordon, Georgia.  His time as a combat medic and laboratory technician in the military has helped him refine his ability to work with a variety of individuals.  Being fluent in English and Spanish, he brings comprehensive care to a wide population of patients.  Dr. Cabezas is a Board-Eligible Orthopaedic Surgeon, as well as a member of the American Academy of Orthopedic Surgeons.

Washington County Welcomes Athletic Trainers

It’s a great year to be an athlete in the Washington County Public School system.  For the first time in this county, there are athletic trainers on staff at every high school within the public school realm.  Having athletic trainers as part of the team approach to treating our student athletes has been something that the staff at the Center for Joint Surgery and Sports Medicine have been advocating for for many years.  We have seen surrounding counties successfully integrate athletic trainers into their schools, and now this year, we are very excited to have them join our team as providers of care in Washington County!!! The National Athletic Trainers’ Association defines athletic trainers as, “health care professionals who collaborate with physicians to provide preventative services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions. Students who want to become certified athletic trainers must earn a degree from an accredited athletic training curriculum. Accredited programs include formal instruction in areas such as injury/illness prevention, first aid and emergency care, assessment of injury/illness, human anatomy and physiology, therapeutic modalities, and nutrition. Classroom learning is enhanced through clinical education experiences.”  Once obtaining at least a Bachelor’s degree, and many go on to obtain a Master’s degree, an athletic trainer must pass a certification exam in order to become licensed to practice.  To maintain their license, they must adhere to their state practice act, take continuing education courses, and have a physician sign off on their certification. As part of a team of healthcare professionals, athletic trainers play a vital role in the treatment of an injured athlete.  Their expertise and skill set in the assessment of injuries that occur on the field or court during games and at practices is the first step in getting an injured athlete safely back on his or her feet and into the game.  They have an important role in both rehabilitating the injured athlete if the case requires only conservative interventions, as well as recognizing the need for further diagnostic testing or interventions by a physician.  If an injury requires surgery and/or long-term rehabilitation to restore motor control and proper functional mobility, they may also work directly with physical therapists to return an athlete to their sport.  This team approach to caring for our student athletes will effectively and efficiently return athletes to their sports with the least risk of further injury. The Center for Joint Surgery and Sports Medicine is very excited about the addition of athletic trainers in Washington County.  We are looking forward to developing professional working relationships to best serve our community and our student athletes.  If your son or daughter does incur an injury, please know that our office is available to assist your needs.  We will do our very best to have any injured athlete examined by a healthcare provider within 24 hours of their injury.  We wish the student athletes and the athletic trainers in the Washington County and the Tri-State area the best of luck this 2014-2015 school year! athletic training pic

Jolee Ashley, DPT, CCRP is a physical therapist at the Center for Joint Surgery and Sports Medicine.  She has been in practice for 7 years and has a love for orthopedics and sports medicine.  She enjoys partnering with her patients to achieve their goals and to help rehabilitate them so that they, too, can get back to doing the things that they love.

The Challenges Facing Female Athletes

soccer pic blog

Female athletes have challenges to face with their sports that males often do not. Here are some tips to help females stay healthy and allow them to remain in their sports.
Females have higher incidences of knee injuries for a variety of reasons. They are much more at risk of tearing the ACL (anterior cruciate ligament – in the front of the knee). We feel this is related to several factors. Females tend to have more weakness in their hamstrings (muscles in the back of the leg). It is important to make sure the hamstrings are strong to help protect the ACL. Sports like volleyball and basketball, which require constant jumping, require good hamstring strength to assist the athlete in landing from her jumps. In addition, females have a wider pelvis than males, also putting extra stress on the knees. While we can’t change the pelvis, good strength and flexibility of the hip muscles can help protect the knees.
Another challenge facing female athletes is called the female athlete triad. This is a combination of eating disorders, amenorrhea (lack of a period), and osteoporosis. These issues are found in females with frequent and intense athletic participation. Eating disorders can be either anorexia (lack of eating) or bulimia (binge eating). Athletes will do this to control their weight and often end up underweight and undernourished.
Amenorrhea can either be defined as late onset of puberty or no menstrual cycles for greater than 6 months. Rest from an intense athletic schedule often helps restore a normal cycle.
Osteoporosis is characterized as loss of bone mineral and often comes from amenorrhea. Bone loss can be stopped with return of menstruation, however, the bone that is already lost cannot be replaced. This can cause future risk of fractures to hips or spine.
If you are or know an athlete with any of the triad symptoms, you should consult your family MD. Any questions about female athlete knee injuries can be answered at Center for Joint Surgery and Sports Medicine at (301)665-4575.
Laura Blair is a physical therapist at Center for Joint Surgery and Sports Medicine.

Five Simple Things to Improve Your Whole Body Health

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Balance is a very important factor in our everyday lives, however, one that we don’t often think about until after a fall or injury. So try taking a proactive approach and challenge your balance system every day. One way to do this would be to try standing on one leg for ten seconds every day. Choose a certain activity that you do daily (i.e. brushing your teeth) and try standing on one leg while you do this.


Muscles provide our ability to move from point A to point B, therefore it is essential to keep them strong. Good muscle strength helps support joints and can prevent injury. A simple exercise that you can add to your daily routine is trying to get out of a firm chair without the use of your arms (or as little help as possible).   The ability to achieve this task indicates good leg strength, which you need to achieve task essential to everyday life (i.e. toileting, getting in and out of a chair, car, etc.)


Don’t you know you should always listen to your mother? That’s right, when you mother told you to “Stand up straight”, she actually knew what she was talking about. Your posture impacts every aspect of your body, therefore when it is out of line (rounded, slouched) you are creating abnormal stress on joints, muscles, tendons and ligaments. Here is a simple way to know if you are in proper posture: When you stand up your ear should be directly over your shoulder, which should be directly over your hip, which should be directly over your ankle.


Strive to walk somewhere every day! For those of you that are active, kudos to you, however, try to do more. Make a goal each day to try moving more and sitting less!


Your muscles and organs depend on water to work properly. When you do not drink enough water your muscle tissue is more likely to cramp and your organs are under more stress. Make a goal each day to drink more water! Try setting a cup of water by you whether you are at work or at home. Having it beside you is a visual reminder to drink more often.


– Julie Martin, PTA