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JP Driver-Jowitt is an orthopaedic surgeon with wide experience across the entire field of orthopaedics. He spent much of his professional career in vertebral management, and now has a special interest in the foot and ankle.
He is registered in many countries, which include the United Kingdom, Ireland, Malta and Zimbabwe and has decades of experience acquired in five continents. These include the National Health Services of United Kingdom, Canada, New Zealand and others. He has been a Professor of orthopaedic surgery and has held posts as a teaching hospital consultant as well as with the armed forces, and a dedicated private practice. He has worked extensively in underdeveloped countries, with wide experience of battlefield and other trauma.
Comments or enquiries are welcomed: large volumes of requests are received which means that questions which have earlier been addressed will not necessarily receive a response.
My husband has had a recent scan of his left hip and pelvis. This is after a “resurfacing” with a Du Puy implants, which have subsequently been recalled (what does that mean?) The scan showed that the mechanics of the hip (re-surfacing) joint are OK. The orthopaedic surgeon he saw recently has requested that he have a sonar scan at the end of January, to assess whether he has some inflammation in and around the joint. My husband has pain in his hip joint, especially when he is lying down and sometimes when he is out walking. He can, however, do his regular exercises, jump on his mini trampoline etc., without any pain. What should he do?
As has been said often only an exceedingly small number of recipients have had problems after their resurfacings, and only incrementally more than the frequency of complications in other replacements. From what I know you do not seem to have the unpleasant events or reaction which have initiated the recalls. Some pain / discomfort is frequent after any hip replacement. The reality is that these are never replacements, and the term is inappropriate. They are hip substitutes. None will exactly duplicate the original, natural hip joint. For that reason the "substitutes" should not be regarded as, or used in the way that the natural joint could have been used. Remember, too, that some aberration of function destroyed the original hip joint, and those (unknown largely) factors will also apply to the new substitute. Therefore these substitutes should be coddled, and much restraint is wise. Do not challenge the joint. For example I would not advise using a trampoline, which inflicts considerable impact and rotational leverages on the joint. Having said that it would also be wise to remain in contact with your surgeon for many years ahead, and report any difficulties which might arise.
I want to publicly thank Dr. Driver-Jowitt for the information he provides. It is remarkable that a doctor of his stature presents expert information without selling products. I am grateful for his efforts and all the time he must spend doing this. Thank you, Doctor.
I looked up compartment syndrome on the internet. Would this be an easy detection for the doctor yesterday? or is this something that continues to progress? Example the more numbness and tingling he is experiencing in his toes? I'm very concerned. I saw where they can do blood, urine tests and pressure tests. What should we do? On the internet I saw where the problem was more in the leg not the foot. Jared's swelling is on the ankle of the foot.
His fractured fibula was five inches above the ankle, with likely much impact on the soft tissues. At that level it is possible to have a compartment syndrome. The tingling / numbness of a compartment syndrome are most likely in the first day or two, but can persist.
I hope your not tired of hearing from me! We decided to change doctors to one with much more experience and specialty of the foot and ankle. We feel better about our decision. Waiting the extra week gave us time to research. We meet with him on Monday and hopefully surgery next week. However, the last couple of days JP, my son, has had night sweats and a low grade fever. Is this normal? The first hospital visit in the emergency room put a support cast on his leg no cleaning of the leg. Then when we visited the doctor on the following Monday there was a small scrape that they cleaned and put something on it and re-supported his leg with a partial cast. He doesn't move much and keeps his leg elevated with ice. Not sure why he's not feeling well? He did stop taking the pain medication on regular 4 hour intervals. His pain was not that great - it aches. I told him the medicine was as needed, but he thought the doctor wanted him to take if every 4 hours. Now he's taking the pain medication once a day to help sleep. Could stopping the medication quickly have effects? I'll be so glad when we can move on with this! It has been a very stressful week!
A temperature after trauma does not necessarily imply infection. Collections of blood ("bruises") can raise body temperature, as can thromboses in the veins.
Thank you for your quick response! I wonder about the ligaments that were torn in his ankle. The doctor said they do not repair those anymore that letting them scar has the same outcome as repair of the ligaments have had in the past. Is this accurate? You also, mentioned delayed management, as one of your philosophies, but I'm having trouble finding information on what kind of delays? Such as when is it best to have a fracture surgery after the injury? One more question: My son is taking pain medicine every four hours. Should I be concerned about the type of pain medication and the length of time he is taking this? He is on Norco 325 mg. It has been 5 days since his football injury. I wished you would do my son's surgery! I would feel much better! It is not easy trying to find someone that has the same type of experience and who really cares enough to dig deeper into what is best practice based on the "uniqueness" of the patient. Thanks again!
"Repairing" ligaments was always a fatuous ritual. Ligaments cannot be repaired, they can only heal. Does operating help the healing? There is no evidence of that. What happens, instead, is that the surgery interferes with the regional blood supply by cutting (i.e. damaging) even more tissues, and so adding even more swelling and inflammatory response. The ligaments are usually shredded, and any form of secure mechanical reconstruction is impossible. Those surgeons who did operate could have seen, and should have known, this to be the case. Instead they performed a perfunctory idealization of what the patient wanted to believe - that they were being repaired, in a fantasy parody of a mechanical repair to machinery. Then the incised skin needed to be opposed, with more puncture wounds and (usually) tight sutures. As the swelling followed, these sutures became even tighter, with more tissue damage, more risk of infection and more pain. Even the idea that the tissues were being “put back into the right place” is wrong. The volume underneath the skin cannot do more than accommodate the tissues in their anatomical sites. Providing skin, bone and joint are intact, these tissues cannot move more than millimeters, which is inconsequential, and a very acceptable trade-off against open surgery. The ligament sutures, tied tightly around living tissues, strangled the blood supply within the ligament, causing more dead tissue, introducing foreign material, more to become rancidly infected, more pain and, and less living material to partake in the healing mechanisms. What would worry me more than the dose of analgesics your son is receiving is why he still has such sever, extended pain. [ligament "replacement", "substitution", "re-routing", "augmentation", "creation", are a different domain, usually elective surgery, but which also demand critical appraisal]
I asked my son about his pain. He said it aches a lot after the medicine wears off and he can't sleep. He can't sleep with the medicine until he becomes exhausted, which usually isn't until morning when he finally falls asleep. He doesn't move much right now. He only uses his crutches to the bathroom. He is tall and lean: 6'5, 215 lbs. He is waiting on surgery, but most likely not until next Thursday because of the blisters on his ankle. The doctor said there would only be a 20% chance of having to open the ligament area up; which would only happen if the ligaments were under the bone and he couldn't line the fibula properly. But, he wasn't comfortable operating until that area healed more just incase of infection and the cut site not healing well knowing the soft tissue is severely damaged in the ligament ankle area. However, after reading your response, that doesn't sound like that could happen? His skin, bone and joint are intact. Another concern I have is knowing in the past my son gets keloid scarring. Will this effect his healing and mobility? Thanks again for answering my questions!
An injury to a limb is usually described in terms of which bone is broken, "I had a fractured tibia" and similar. This is because the most graphic X-ray display is of the bones. However, it is never a broken tibia: it is always a broken LIMB. At times the soft tissue damages (seldom shown on X-ray) are the most important injuries. This is because the functional, dynamic, machinery of the limb is the soft tissue. The bone is a relatively inert, passive accomplice of the soft tissues. At times the most important long term complications are in the damaged soft tissue, such as fibrous shortening of soft tissue following a "compartment syndrome". If pain persists it is imperative to constantly re-visit and reconsider the reasons for this. Keloids exist primarily in particular parts of the skin : It is unlikely that this tendency will interfere with the recovery of the limb injuries.
My son recently had a football injury, blew his deltoid ligaments and broke the fibula about 5 inches from the ankle. We talked with his orthopedic surgeon about removing the screws connecting the fibula with the tibia. He said it wasn't necessary, but he could take them out in 12 weeks. I said I had been reading and thought 6 weeks would be better to avoid them breaking off in his leg. He said that would be too soon that the ligaments would not have had time to heal. I also asked about removing the plates and screws. He said he would not do that that it opens him up for infection and the nerve could get damaged which were unnecessary risks. He said if the plate was closer to the ankle that might be different because the plate is closer to the surface of the skin. I respect your experience as I have been reading on your site. What would your response be to this doctor? My son's surgery was postponed a week because of blood blisters from the injury in the ligament area.
All surgical decisions depend on variables of context which include (at least) the uniqueness of the patient, type of injury, parallel illnesses, surgical know-how, available medical resources, and finance. Because of this I cannot reconstruct any idealized approach from a distance. All I can usefully contribute is what I regard, in my context, as "basic principles" (which comes to mean science based learning) into which I try and meld empirical experience. Surgery can never be an arena of “absolutes" and (heaven forbid) a rigid algorithm of tick boxes. Much of my philosophy, such as delayed management of fractures, and the removal of metal implants if good reason exists, you will already know from other comments. Regard a surgeon of rigid dictums with caution.