What is Total Joint Replacement?
Any joint in our bodies can “wear out”. Wearing out means the surfaces that rub together no longer do so smoothly. The cartilage cushion is gone and often the body has formed bone spurs. When non-surgical treatments no longer provide acceptable pain relief, we can resurface the ends of the two bones and considerably improve the way the joint feels. Typically, the joint replacement “parts” consist of a piece of metal, then plastic then another piece of metal. The components are made of very special materials. Sometimes they are fixed to the bone with “bone cement”, screws, or the bone may be able to “grow into the prosthesis” if the patient is young and healthy enough.
Who is a potential candidate for knee or hip replacement?
Whether you are a candidate for a joint replacement is really a question that is better answered by your doctor after he/she has had a chance to examine you and review your history. The basic answer is “most people”. What we look for is a patient with a joint that is not functioning properly, non-surgical treatments have failed, the resulting pain is not acceptable to the patient and interferes with “activities of daily living”. The patient will also need to be in good enough health to undergo the surgical procedure. With newer metals / alternate bearing surfaces we can now offer joint replacement to patients that were formally felt to be “too young” for the procedure.
Are there alternatives to joint replacement?
Yes. No one should jump into a joint replacement without first exhausting all conservative measures available. Allergies always need to be considered, but here are a few of the options you might want to talk over with your doctor: Activity Modification, NSAIDS (anti-inflammatory medications), Physical Therapy, Joint Fluid Therapy (Synvisc, Supartz, etc.), Losing Weight, Cold/Heat Therapy, Cortisone Injections.
Are there risks to surgery?
Yes. Any surgery bears some risks, but a joint replacement is one of the larger surgeries we do and carries some very serious risks that you need to be aware of. Those risks may include but are not necessarily limited to: Blood clots (DVT), infection, the need for a blood transfusion, breakage of implants, loosening of the implants, the need for a revision of the replaced joint or one of its components, pain after surgery, injury to a nerve, artery or vein, the formation of a hematoma (collection of blood at the surgery site that may need to be surgically drained), pulmonary embolism or thrombosis, fat embolism, stroke, even death. The truth is that any of these things can happen. But,…surgeons follow/have very specific ways of taking care of you while you’re in the hospital as well as afterward that are meant to eliminate or help minimize the potential for any of these complications.
As an example: Ancef (a 1st generation cephalosporin antibiotic) is commonly given as a single dose one hour before surgery and then given again after surgery but discontinued within 24 hours. These are the guidelines offered by the CDC (Center for Disease Control) as optimal for preventing infection.
Another example: Lovenox is anticoagulant used to help prevent blood clots. It is started after surgery and either continued for 2 weeks or it is used as a bridging agent to Coumadin if a longer therapy treatment period (typically 1 month) is felt to be more appropriate for a particular patient.
How long will a traditional knee or hip replacement last?
The typical range quoted for a traditional knee replacement (cobalt chrome metal) is between 15 and 25 years. The life of the replacement is affected primarily by the size/weight of the patient and their activity level. Non-traditional materials (ceramic, etc.) offer some longer life possibilities that may be appropriate for some of the younger patients to consider. More accurate soft tissue balancing, boney cuts, and placement of these components is also key to an optimal outcome and lifespan of the prosthesis. This can be more easily and accurately achieved through the use of a computer-assisted surgical approach. X-rays are taken at 3-month intervals for the 1st year after surgery. After that, we take one x-ray per year, which allows us to monitor the status of the joint replacement.
How does the use of the computer help?
The computer “learns your anatomy” and then designs the knee and guides the surgeon through the bony cuts and prosthetic placement. It can aid in the evaluation of the soft tissue balancing (which makes the knee work and feel better), and allows all of this to happen through a smaller approach without compromising the surgeon’s ability to “see” the anatomy necessary to perform the surgery. The use of a computer in total joint replacement is rare. Most hospitals will not spend the money to purchase such a computer (often as much as $500,000+), and most surgeons will not take the time to learn how to use it.
What happens when and if a total joint replacement wears out?
You may need to replace it. Sometimes just the plastic will wear out, and sometimes the metal will become loose because of the plastic wearing out (periprosthetic osteolysis). In either case, you and your doctor need to discuss what is right for you. A revision total joint replacement is a big surgery for both the patient and the doctor. Newer types of bearing surface (the parts that rub together) are helping to minimize the need for revision surgery, especially in young people.
Do you do the new, minimally invasive procedure?
Yes. Our hip scars (incision) are typically between 4-5 inches in length (a traditional hip incision is usually between 10 and 14 inches), and our knee incisions are typically between 4-6 inches in length (traditional knee incision is usually 10 to 12 inches). Sometimes we do have to make the incision longer depending on what we find or run into when we are “in there”, but this is rare. The type of material we use does not affect whether we use the smaller incision or not. We essentially plan on doing all of our procedures with the smaller incision technique. There is a faster recovery for the patient, less pain, better postoperative strength, less potential for complications. Why all surgeons wouldn’t at least try to use the smaller incision is a question we can’t answer either.
How long can patients expect to be in the hospital for a joint replacement?
Typically, 3-5 days with the vast majority leaving the hospital after just 3 days (or 3 midnights as the insurance companies like to call it).
Who is involved with my care?
The surgeon that you speak to in the office about your procedure is the person who does your surgery. On occasion, another surgeon/ physician may be asked to assist in your procedure, but they do not perform the procedure. We currently have 4 PA’s (physician assistants – essentially equal to a master’s degree in medicine) that assist in the office by seeing patients, and in the hospital by doing rounds on those patients who are admitted. They all work under the supervision of the attending physicians.
Will I need physical therapy after surgery?
Yes, in most cases. Typically, you will need to be able to get out of bed on your own, get dressed on your own, walk 200 feet under your own power (walker OK but no one holding you up), and go up and down 2 stairs on your own. If you can do these things you are probably safe to go home and then follow-up with home physical therapy followed by a transition to outpatient physical therapy. If you still need help to do any of the above after 3 days in the hospital, you will be strongly encouraged to go to an in-patient physical therapy (means you stay there) for about 5-7 days (or until you can do those things we mentioned earlier) so that we know you are safe to go home. Overall therapy is usually a minimum of 6 weeks and may be as long as 3 months after surgery. Therapy can help you achieve the most motion and least amount of pain as quickly as possible.
How many joint replacements have you done?
Currently, we do about 150-200 joint replacements a year. The majority of those are Total Knee Replacements performed by Dr. Hartman. To keep things in perspective, a typical general orthopedic surgeon does about 10-30 total joints a year.
Is a Total Joint Replacement covered by my health insurance?
Yes. All that is required is the proper documentation of the patient’s pathology along with the need for a Total Joint Replacement, and the insurance will approve it.