Dr. Loddengaard Answers Key Orthopedic Questions

Torrance Orthopaedic & Sports Medicine Group
Orthopedic Doctors
Physical, Hand & Aquatic Therapy

Two locations:

23456 Hawthorne Blvd.,
Suite 300
Torrance, CA 90505-4716

El Segundo

Phone: 310-316-6190
Fax: 310-540-7362

James M. Loddengaard, M.D. has been an orthopedic surgeon since 1983. He specializes in spine surgery, joint replacement, and knee and shoulder arthroscopy. He is board certified.

Below Dr. Loddengaard discusses the spinal fusion surgery and hip replacement surgery of Marlene, one of his patients. Click here to read Marlene's interview. He also talks about what patients can expect from their doctor if they're considering treatment for back pain, whether it's related to a herniated disc or other cause, or treatment for any knee, hip, or shoulder joint issues.

Why are you passionate about being an orthopedic surgeon?
It's wonderful to be able to fix things and make people better. It's extremely gratifying and because people are so different, it's interesting. I went to Cal Tech for my undergraduate degree. There wasn't a single multiple-choice test. The whole education was based on problem solving. Because of that my patients benefit from my ability to investigate their problems with a fresh perspective. Real life isn't a multiple-choice test.

What helps you relate better to your patients?
I've had my share of shoulder and knee injuries and surgeries. I had to recover from those, so I understand what the process is. When someone comes to me in pain, I know what I would feel like in that situation. Everybody is very different, though. I can't look at myself and assume everybody else is going to be the same. Some of my patients are fearful and cautious, while some are just eager to return to normal life as quickly as possible. People have a wide range of responses to pain and injury. I look at each patient and try to understand who they are and what their limitations and strengths are.

What did you think when you first met Marlene and heard about her problems?
Marlene had been in a terrible bicycling accident about a year before and had sustained several injuries. By the time she saw me, her spine and hip problems were big and disabling. She had spondylolisthesis, a condition where a spinal disc is not lined up properly. This was pinching a nerve and causing a lot of pain, which was radiating down her leg. Marlene's hip had also been injured in her accident. She had a dead femoral head, the "ball" of the hip's ball and socket. Bone is full of blood and her hip bone hadn't gotten enough of it, so it died. She had already pursued physical therapy, chiropractic care, medication, and just about everything else she could think of prior to seeing me. It was clear that those smaller measures were not helping her anymore and that she needed surgery.

How was her recovery?
Marlene was and still is a get-up-and-go kind of person. She had no post-op pain, did her physical therapy, and was fine in a month. She's had no complications, and that's not uncommon in active, healthy people, even those much older than she is. She was 51 years old when she came to see me, and it's been three years.

Why do you think Marlene is such a success story?
She is motivated and energetic. She is a strong person and optimistic, not fearful. She is athletic and not overweight. As her surgeon I gave her a chance, and she took the ball and ran with it.

Is Marlene's type of success common?
There is a range of results, but success is high among those who have similar procedures as Marlene. About 90% of people who have degenerative spondylolisthesis and stenosis repaired surgically recover very well. About 90% of people who have a total hip replacement also recover very well. That's a high number of patients who are happy with their outcomes. Marlene has no symptoms at all, so obviously she has done extremely well, but she is certainly not the only one who has done quite well.

When a patient comes to you with pain, where do you start?
First I see what sort of treatment they've had, how disabled they are, and look at their MRI and x-ray findings. Some of my patients are not ready to sign up for surgery, some will do anything they can to avoid it, while others don't want to fool around with ineffective treatments or hopeful ones that are not that likely to help them. I'm not an autocrat—I work with people and see how they want to proceed.

Do a lot of people live with their pain longer than necessary?
Most people I see have a reasonable tolerance for pain and come to see me when they can't manage it themselves anymore. There are some patients that do wait until their problem is more difficult to treat.

It seems difficult to determine when to seek an orthopedic surgeon for back pain. There are so many other practitioners and options out there. How do people know whether you're the best doctor to see?
Anyone with severe pain down their leg, weakness, or numbness and whose MRI and x-rays show a pinched nerve is often a good candidate for surgery. The longer a damaged nerve is left untreated, the smaller the chance that it will get better. For example, one of my patients had bad leg pain and weakness in her ankle. There was a one-month delay before she could have surgery, due to some of her other medical issues, and during just that one month, the weakness turned into a full foot drop. She couldn't lift her ankle at all. That's how quickly nerve damage can progress. She's actually doing well now and the nerve seems to be coming back, but I've seen patients that weren't so lucky getting function back because they waited too long. You don't want to let nerves get too squished and damaged because they may not wake up.

Some patients are not good candidates for surgery. I treated one man who had back pain for five years. He had a couple of degenerated discs, no leg pain or pinched nerves, but he is tired of his back pain. His best option was a better living program: exercise, stretching, cardio, and core strength. Not everyone likes the idea of changing their lifestyle, though. Those patients may find a spine surgeon who will perform a fusion or a disc replacement, but the success rate on those patients is not as good as it is for pinched nerves. I've seen patients that had fusions from very aggressive spine surgeons and their back still hurts. Now they have a stiff back and they aren't happy. You can't fix it at that point. So I personally am not a fan of doing fusions for back pain except under very specific circumstances, like in Marlene's.

You see a lot of patients every year. Approximately what percentage of them do you operate on?
I send lots of people to therapy and talk about exercise with them. I perform surgery on somewhere between 5% and 10% of my patients.

What kind of pain should people not ignore?
Pain that gets steadily worse should be evaluated by a doctor.

Should people see an orthopedic surgeon before seeing a physical therapist?
Generally speaking, yes. The issue is how well a physical therapist can diagnose something in comparison to an orthopedic doctor. Therapists have wonderful skills, but they don't take x-rays or MRI's, and without that critical step they may give the wrong diagnosis and treatment.

What do you say to people who are scared of surgery?
I discuss possible complications and the frequency at which they statistically occur. Those numbers give a great perspective to patients. It helps them realize that having surgery gives them a good chance at getting better, even though there are still risks. Then they can make their decision in an educated way, hopefully with less fear.

What treatments do you recommend to patients who are not surgery candidates?
Medication, exercise, therapy, braces…there are a lot of options.

Do you find that those measures just delay surgery, but don't help patients avoid it?
No, there are a lot of conditions that just don't need surgery. They just need time or they need a specific treatment. One of my patients had back pain for years. She was only 20 years old. I sent her to a physical therapist because she had a little scoliosis and a couple of little structural quirks. Two months later she was so happy. Her back felt so much better and she didn't need surgery. There is nothing for me to do for her and that is true of most back problems.

Another condition like that may not need surgery is a torn meniscus in the knee. If playing tennis is a patient's life and they can't do it because their torn meniscus won't let them, I'll fix it. A patient who just wants to walk from here to there, who doesn't want surgery, and has a stable knee can elect not to have surgery.

Some patients follow their rehabilitation instructions very well and some don't. What is the difference in outcomes?
Most conditions won't improve unless the patient follows their rehabilitation. I remember a patient who had a fracture in his leg. After surgery to repair it, he didn't really do his exercises. One year later his thigh was an inch and a half smaller on the operated side. The muscle doesn't just come back automatically.

Exactly how fast does muscle atrophy (weakness and shrinking) happen?
It can start within a week. We can use a CT scan to measure muscle volume on the first day of someone who has become bedridden and by the eighth day the volume is smaller. It's kind of scary-fast. That old cliché, "If you don't use it, you lose it," is very true.

Every recovery is different. Talk about different "normals" you have seen.
Marlene, for instance, is on the fast end of recovery. She bounced back really fast, which is great. There is a certain class of people that seems to be like that.

Another patient, a 75-year-old man, was in his mid-70's and worked out all the time. He had spinal stenosis with leg pains and weakness and wasn't able to walk much. I performed a six-hour, three-level fusion and cleaned out his spine. It was a complicated situation, but he is back to exercising regularly. He has virtually no pain and can walk as far as he wants again. He bounced back amazingly fast because he is a motivated athlete.

An overweight patient in their 50's who hasn't exercised since P.E. in high school is more likely to have a slower recovery. They might take several months before they get to the point where they can walk as much as they want.

It seems like age isn't the primary factor when considering surgery. Is that true?
The issues are what medical conditions a patient has and how does that affect whether they are a good surgery candidate. Someone whose heart condition requires blood thinning medication can't be operated on. It doesn't matter if they are 50 or 75. I've performed about a half dozen spine surgeries on patients over 90, who couldn't get out of bed and had severe pain in their leg. I have done a lot of back surgeries on patients in their 80's. A recent 86-year-old patient who had a partial knee replacement is six weeks post-op and feels great. He's walking around with his cane and his knee is hardly swollen at all.

The oldest joint replacement patient I've treated was 94. She wasn't complaining of pain that much, but her leg was unstable. It was so crooked that it was giving out. After I replaced her knee joint, she recovered slower than average, but she was stable and did wonderfully.

Can smokers have surgery?
I just saw one of my patients who is about 50 years old. He smoked, was overweight, and had back pain for a few years. I gave him the data on smoking: it increases spine degeneration, and smokers have poor outcomes with surgery or physical therapy. They don't bounce back. Smoking interferes with function and recovery because it constricts blood vessels, limiting blood supply. Blood brings all the good healing components to our body parts. I was really excited when he quit smoking and lost weight, and now his back feels better.

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