Out of Joint: Hip and Knee Replacement

Out of Joint: Hip and Knee Replacement

Joint stiffness and pain, particularly in the hip and knee, can have a serious impact on a sufferer’s quality of life, limiting both athletic pursuits and everyday physical activities. When the pain and loss of function are severe, the culprit is often osteoarthritis, which is caused by the breakdown of joint cartilage. Though such a diagnosis sounds dire, patients can usually get their quality of life back with hip and knee replacement surgeries.

In terms of patient satisfaction, hip and knee replacements rank at the top. In fact, more than 95 percent of patients said they are satisfied with the outcome of their total knee replacement one year after surgery, according to a study presented at the 2010 annual meeting of the American Association of Orthopaedic Surgeons.

Joint replacements now last longer and perform better than replacements conducted 10 or 20 years ago, says Dr. Henry Finn, chief of orthopedic surgery at Louis A. Weiss Memorial Hospital, medical director of the Chicago Center for Orthopedics at Weiss and professor of surgery at the University of Chicago.

“Now, we’re trying to put in joints that last many, many years, if a patient has appropriate expectations,” says Dr. Finn, who specializes in complicated cases such as trauma cases, deformity and revisional surgery.

But with many physicians pushing new techniques, Dr. Finn cautions that the newest innovations are not always the best.

For instance, many patients now ask about minimally invasive surgery, which strives to make the smallest incision possible, without cutting muscles, ligaments and tendons. “’Minimally invasive’ is a misnomer,” Dr. Finn says. “No matter how you do surgery, you still have to cut and shape the bones with power tools that are strong enough to do construction. It would be more appropriate to call it ‘less invasive’ surgery.”

Dr. Finn likens minimally invasive surgery to trying to build a ship in a bottle. Struggling through small incisions can cause more tissue damage and can put more stress on muscles, tendons and tissues, he says.

“An incision should be as big as we need to do a job, without taking unnecessary risks and without compromising long-term durability,” he says. “Patients should be more concerned about what the joint is going to be like 20 years after the surgery, rather than 20 days after the surgery.”

Rapid recovery relies heavily on education, support and appropriate expectations. Dr. Finn’s patients take a two-hour class that prepares them prior to their surgery, and he has found that a coach—whether it’s a spouse, partner or friend—improves the recovery experience. He also stresses preemptive pain and nausea control. When “a cocktail of drugs” is injected into the tissue prior to closing the incision, it eliminates most of the pain that patients feel within the first two days, he says.

And the edict of “appropriate expectations” is key. “Joint replacement is not made for high-impact, repetitive athletic activities,” he says. “It is to restore the function of the joint and alleviate pain from everyday activities and some recreational activities like golfing or bike riding. It’s not for jogging or downhill skiing.”

Today, improvements in the types of implants and bearings used in surgery have led to better outcomes. For example, cement previously had been used to bond surfaces. But now, a porous material allows the bone to grow in through the pores of the metal implant, securing the bone to the implant. And bearings, which have historically been metal on plastic, are now ceramic on ceramic, metal on metal or advanced medical-grade plastic that wears better.

Also encouraging are partial joint replacements, which are good for younger patients who have osteoarthritis in only one part of the knee. Partial replacements involve smaller incisions, less bleeding, quicker recovery and less bone loss than a total knee replacement.

While hip and knee replacements are largely safe and reliable, that doesn’t mean patients should rush into surgery, says Dr. S. David Stulberg, professor of clinical orthopaedic surgery at Northwestern University Feinberg School of Medicine and director of the Joint Reconstruction and Implantation Service at Northwestern Memorial Hospital. Patients should first be placed on a nonsurgical program. When such a regimen is no longer providing adequate pain relief or satisfactory function—and the patient’s X-ray is fully consistent with his or her symptoms and shows advanced arthritis—surgery may be appropriate. Still, Dr. Stulberg cautions against jumping at the latest heavily marketed medical technology.

“Technique trumps technology,” he says. “We tend to equate the newest development with the best development, but that’s not necessarily so. With joint replacement surgery, the technology has been around long enough that current devices are likely to function extremely well for a very long period of time.”

However, computer-aided surgery—particularly patient-specific or patient-matched devices—does show promise, says Dr. Stulberg, a pioneer in computer-assisted surgical techniques. Patient-matched instrumentation utilizes a patient’s MRI and X-ray results to create customized surgical instruments based on the person’s unique anatomy. These instruments can then be used to precisely align the implant.

“In surgery, there’s a certain amount of judgment that has an effect on the outcome,” he says. Computer-assisted surgery and patient-matched devices are more likely to produce more consistent results. “The goal of computer-assisted surgical techniques, such as patient-matched devices, is to assure that surgeons with a wide range of experience can perform reproducible, highly accurate operations,” he says.

Dr. Stulberg also stresses the importance of good communication between patients and physicians. “It’s important for patients to have clear expectations about their upcoming surgery. They should tell their physicians what they plan to do after their joint replacement—walking, tennis, golf—and explain it honestly.”

The doctor-patient relationship was especially important to Ronald Allen, a patient of Dr. Stulberg’s, who had both of his hips replaced by the age of 45. (The two worked so well together, in fact, that they co-authored, along with Physiatrist Dr. Victoria Anne Brander, a book titled Arthritis of the Hip and Knee: The Active Person’s Guide to Taking Charge.) Allen notes many improvements since his first surgery in 1988.

“There’s an increasing recognition that, following these surgeries, you can have a better quality of life than the orthopedic community previously thought,” says Allen, the John Henry Wigmore Professor of Law at Northwestern University. He thinks that rehabilitation is key. “You must undergo a long-term rehabilitation regimen, which can be time consuming, difficult and painful. You have to be willing to make the effort, get good therapeutic advice after the operation and be willing to
follow it.”

Of course, choosing the right physician is crucial. “Patients should insist on a doctor who recognizes the importance of long-term physical therapy—not just for a few weeks, but a real commitment to physical therapy, where the objective is full functionality, or as close to it as you can get,” says Allen, who now plays tennis with two artificial hips.

Allen is a clear example of just how successful hip and knee replacements can be. Unfortunately, many people who would benefit from such operations never get them, living instead with the pain and reduced functioning, says Dr. Richard Berger, assistant professor of orthopedics at Rush University Medical Center and a physician practicing with Midwest Orthopaedics at Rush.

“Joint replacement is a wonderful option that restores mobility and alleviates pain,” Dr. Berger says. “But studies show that only three out of 10 people who would benefit from joint replacement surgery get it. Some people don’t know about it, or they’re worried that it’s not covered by insurance, or they are afraid they’d be out of work for too long.”

However, “with minimally invasive joint replacement, many patients have less pain the day of surgery or the day after surgery than they did before the surgery,” he concludes.

Dr. Berger specializes in minimally invasive hip and knee replacement. His specialized procedure typically entails a 3 ½-inch incision and does not cut muscles, ligaments and tendons. The joint is cut out in small pieces without disrupting soft tissues. This results in less swelling, less blood loss and, of course, less pain.

“Since we haven’t cut the ligaments and tendons, patients are able to get up and walk shortly after the surgery,” he says. Most of his patients go home the same day of the surgery and are walking unassisted or with a cane on that same day. They’re back driving in a week or so, back to work in one or two weeks and back at activities like golf in two or three weeks, he says.

Indeed, given today’s innovations, no one should have to live with debilitating hip and knee pain. “All of these things make it easier to get a joint replacement,” Dr. Berger says. “Most people say, ‘Why did I wait so long?’”


Originally published in Chicago Health Spring 2010