Knee pain may be linked to the hip
Q: I read your recent column about a person who had knee pain after a knee replacement. I am a retired orthopedic surgeon who performed on over 10,000 total joints of the hip, knee and shoulder in my 47 years of active surgical practice. A well-done total knee replacement does not give the patient much pain postoperatively. I saw many patients who had this story in my career, and the first thing that comes to mind is that the patient was having referred pain to the knee from an arthritic hip joint.
Oftentimes, the surgeon who performed a painful knee replacement never X-rayed the hip or did a complete exam to look for a limited range of motion in the hip. The patient who has knee pain after a total knee replacement needs to have an examination and X-ray of the hip.
I saw more than a few patients who had surgery on their knee when it was their arthritic hip causing referred knee pain that was the real diagnosis. In this case, performing a total hip replacement may eliminate the pain completely. Qualified orthopedic surgeons will agree with me in this case. My advice to inexperienced surgeons is: “Always check the hip before jumping into a total knee replacement!”
Gary Wolfgang, M.D., retired orthopedic surgeon A: I thank Dr. Wolfgang for writing and for the important reminder of the close connection between the knee and hip. It isn’t that the knee doesn’t have any problems; it’s that there may be more than one cause for knee pain, and I have certainly seen, as Dr. Wolfgang has, many patients with knee pain whose pain was actually due to a hip problem. So, replacing the knee won’t help the hip, which is the underlying cause of the pain.
Q: I have just had my prostate gland surgically removed three weeks ago, and I am experiencing incontinence because of the surgery. I am worried that if I drink my usual amount of eight glasses of water a day, like I did in the past, I will be inside the bathroom more than I am outside of it.
What is your opinion on this issue of not drinking enough water because of my fear of bathroom trips? Do you think I should just keep drinking water and not care about the trips to the bathrooms?
A: Some degree of incontinence is extremely common after surgery for prostate cancer. But you will be glad to hear that over time, most men regain much better control over their bladder function. The rates of complete continence are much higher one month after surgery compared to one week, and the rates continue to improve months or even years after surgery. The use of pelvic floor muscle training also speeds up the recovery of bladder control.
In the short-term, you absolutely need to stay well-hydrated, especially after surgery, but this doesn’t mean you need to force down fluids. Most people don’t need eight glasses a day; four is enough. Thirst remains an excellent guide of whether you need fluids or not.
Q: I am a 79-year-old woman who weighs 123 pounds and exercises with Zumba, yoga and cardio drumming. I feel well and have plenty of energy, friends, support and family. I have been on a low-salt eating program to treat Meniere’s disease for 25 years. My blood pressure is 115/69 mm Hg.
My doctor recently retired, so my new doctor took blood tests and discovered that I had an estimated glomerular filtration rate (eGFR) of less than 59. They sent me to a nephrologist, and the nephrologist said to cut down my total liquid intake to 7-8 cups a day and up my protein to 80-100 grams a day.
This seem contrary to everything I have ever heard. Eating more protein is not hard, but I’m feeling tired, deprived and constipated from such little liquid. Can you explain why I would be directed to drink so little liquid? Can I find a dietary plan to help with this variety of ailments?
A: This advice is contrary to what I was taught and what is published in the literature — so much so that I wonder if there wasn’t a miscommunication.
Protein restriction has been part of the standard of care for decades, and its benefit in preventing progression to dialysis or a transplant has been shown in many studies. For a 56-kilogram woman like yourself, your goal would be 35-45 grams of protein per day. Some studies have also shown that plant-based protein may have benefits over animal protein.
People with chronic kidney disease are at risk for fluid overload and low sodium levels, which can be dangerous. However, restricting you to 2 liters is not usually necessary, and given your current symptoms, it isn’t the best idea, unless the nephrologist knows something that I don’t. (For example, if you already had a low sodium level, modest fluid restriction would be appropriate.)
Q: I take 20 mg of famotidine and have for years. Is this safe to take daily? I’ve tried looking up the answer online and get a lot of conflicting results.
A: In an ideal world, it would be great if you didn’t have to take any medications. However, reflux disease is very common; about 20% of the North American population has this symptomatic disease, with an even higher prevalence in older ages.
Lifestyle changes are the first line of treatment. Avoidance of food triggers, weight loss if appropriate, elevation of the head of your bed, and avoiding eating at least two hours before bed are among the most effective. Smoking and excess alcohol use should be stopped.
When lifestyle changes aren’t enough, a histamine-2 blocker like famotidine is a reasonable option, especially for someone with intermittent symptoms. Side effects are rare, and if you haven’t had them yet, you aren’t likely to get them. Proton pump inhibitors like omeprazole have more clearly defined risks with long-term use, so these should be reserved for when they are truly necessary. Famotidine starts working quickly, while omeprazole and similar drugs take days to work.