Joint Replacement Blog

Recovering from hip and/or knee replacement surgery

Dr. William Barrett — Mon, 30 Apr 2012 20:10:37 +0000

You have done all you can to improve your health and maximize your outcome and the day has finally arrived. You check into the hospital, meet the anesthesiologist, discuss the different options for anesthetic, and away you go to the operating room. The operation generally takes an hour or two, depending on your particular circumstances. After surgery, you will be in the recovery room for 45 minutes to 2 hours, depending on how quickly you recover from the anesthetic. In most circumstances, you will be getting up and moving around the day of surgery. It is important not to lie around in bed because you want to decrease your risk of getting blood clots in your legs. Under the supervision of a therapist and your nursing team, you will get up and begin walking. Each day you will follow a prescribed therapy regimen until you are ready to go home. This can vary from 1 to 3 days in most circumstances. The more you do, moving around, taking charge of your recovery, the better off you will be in the long run. With hip replacements, there are sometimes precautions that need to be followed. With knee replacement, patients often find this is more challenging due to the fact not only are you getting up and walking around, you are having to work on range of motion to re-establish the function of your knee joint. But this is not a time when you can sit back passively and expect others to make you better. You are in charge of your recovery, and following your team’s orders, you will make the most of the opportunity presented to you. Multimodal pain management makes it possible for you to be up moving around with only a minor degree of discomfort. There will be pain, and that is to be expected after any type of surgery. No matter how small are the incisions, there is still discomfort to be expected, but it is usually well controlled by pain medication and/or anti-inflammatory medication. It is important you do as much as you can to improve your outcome over the first few months after surgery. You have to be patient, as the total recovery after hip or knee replacement often takes a year, though the majority of your recognizable improvement will be in the first few months. Your surgeon will do their best to give you a joint that functions well, but it is up to the patient to be an active participant in the recovery.

Having done this for many years, I am continually impressed with the diligence of most of our patients in getting up and getting going after surgery. So, get out there, get exercising, get rehabbing, and make the most of your joint replacement procedure.�
— William P. Barrett, MD

Avoiding surgery for osteoarthritic hips and knees

Dr. William Barrett — Fri, 06 Apr 2012 19:46:28 +0000

As I have stated in previous blogs, osteoarthritis is a spectrum of disorders that range from mild symptoms, such as aching and swelling after activity to disabling pain which significantly impacts your ability to carry out many daily activities. The treatment for osteoarthritis clearly varies depending on where you are in the spectrum of the disease. Patients with mild-to-moderate osteoarthritis can often be managed nonoperatively for quite some time. The nonoperative treatment includes things that the patient can take responsibility for, such as weight loss, increasing low-impact exercise to improve strength and tone, modification of activity, and use of over-the-counter anti-inflammatory and analgesic medications such as acetaminophen and ibuprofen. Treatments that your physician can arrange include physical therapy to improve the strength and function of arthritic joints, use of prescription anti-inflammatory medications, and injection of either cortisone to decrease inflammation in the joint or viscosupplementation drugs which improve the lubrication and function of the joint. All of these modalities will decrease the symptoms from osteoarthritis. They will not alter the progression or “cure” osteoarthritis. The goal in the early-to-moderate stages of osteoarthritis is to decrease pain and improve function. Many patients state they cannot lose weight when they have arthritis because they cannot exercise as much. While an arthritic joint will impair your ability to exercise in certain areas, there are still many low-impact exercises that can be accomplished. More importantly, modification of diet, eating healthier, and eating less will lead to weight loss in the overwhelming majority of people. The less weight on an arthritic joint, the better that joint will feel and the fewer symptoms the patient will experience.

Once arthritis advances to a more severe state where there is loss of cartilage and bone-on-bone rubbing between the surfaces, these symptomatic treatments will often not suffice and surgical intervention will ultimately be an option. In subsequent blogs, I will outline how to go about finding a surgeon and preparing yourself for surgery and recovering from the operation.
William P. Barrett, MD

Continued success of anterior approach total hip

Dr. William Barrett — Tue, 06 Mar 2012 18:34:51 +0000

Recently (February 24 and 25 of 2012), I moderated a course in Las Vegas, Nevada regarding anterior approach total hip replacement. The faculty, including Dr. Joel Matta, an early adapter of the anterior approach THA, discussed techniques and results using this approach. It has been widely acknowledged that the anterior approach hip disrupts less soft tissue and, therefore, has the potential to speed recovery and improve function early on.

As previously noted, I presented a paper at the American Academy of Orthopedic Surgeons annual meeting in San Francisco, California, in February 2012 outlining our results with a prospective randomized study comparing direct anterior approach to a posterior approach for total hip replacement. There were significant benefits with regard to pain relief and function early on after an anterior approach total hip. These benefits continued for the first 3 months after surgery. Individual patient stories support this clinical finding in the patients who have had a previous posterior approach and subsequently underwent an anterior approach and were surprised at the speed of recovery and ease of returning to work. This approach is not for every patient, and learning the technique can be time consuming. The results continue to be quite gratifying, and as indicated by the number of participants in this recent course, there is increased interest nationwide in adopting the anterior approach for total hip replacement.�
—William P. Barrett, MD

The need for national joint registries

Dr. William Barrett — Fri, 24 Feb 2012 16:25:53 +0000

In a supplement on December 21, 2011 Journal of Bone and Joint Surgery, a gathering of joint registries from around the world concluded that the importance of joint registries in finding early differences between various implants is extremely helpful. Concerns over the last year regarding metal-on-metal total hip replacements and hip resurfacings arose mainly from results of joint registries in Australia and England. These registries were able to differentiate differences in outcome much sooner than individual authors, case reports, or studies would have been able to accomplish. Unfortunately, in the United States, we do not have a joint registry which tracks the outcomes of various implants. There are a variety of reasons why this has not happened, a lot of which have to do with the medicolegal environment of our society. Efforts are under way to establish a joint registry here in the United States so that individual hospitals and surgeons could track their outcomes and compare them to other hospitals and other surgeons. This will be a great step forward for patients, surgeons, device manufacturers, among others.

We at Valley Medical Center have maintained a joint registry of our hip and knee patients, assessing outcomes, comparing these to national standards and reporting on these on a yearly basis. So, individuals in the market for a joint replacement can shop and compare outcomes and get a better handle on what is important to consider when contemplating joint replacement surgery.

If you have any questions, do not hesitate to contact the joint center at Valley Medical Center for more information.

—William P. Barrett, MD

The Joint Center at Valley Medical Center 2012

Dr. William Barrett — Fri, 24 Feb 2012 16:24:19 +0000

As we start a new year, we look forward to new opportunities to better serve our patients at the Joint Center. Making our patient/customer satisfaction our highest priority, we continue to refine the model that we have established. Trying to make the entire experience a very positive one, we look at all aspects of your care, starting with the moment you walk through the door at Valley Medical Center or dropping off your car at the valet parking outside the admitting area. The check-in, preop registration, and preop process are constantly being evaluated to better serve our patients. The coordination between surgeon, anesthesia, and nursing in the operating room is a highly interactive process, again with continual tweaking to the process. Those of you who have had surgery at the Joint Center know the nursing and therapy care after surgery is outstanding, and we continue to learn from each other how to improve our outcomes.

We look forward to beginning a study evaluating the results of our revision total knee replacements using metaphyseal sleeves and will report on that in 2013 after we have gathered the data with a group of surgeons from around the country. We continue to track our hip and knee replacement outcomes and look forward to introducing a new line of knee replacement options that will be available in 2012. Overall, there is a lot to be excited about, and we continue to look forward to improving the experience of those entrusting their care to us.

— William P. Barrett, MD

Metal-on-Metal Bearings in Total Hip Replacement—Update 2012

Dr. William Barrett — Fri, 20 Jan 2012 16:57:32 +0000

At the beginning of the 21st century, metal-on-highly cross-linked polyethelene bearings were introduced, along with metal-on-metal bearings and ceramic-on-ceramic bearings. All of these “newer” bearings were introduced to try and combat wear associated with metal-on-conventional polyethylene, which in some patients would lead to significant bone loss around total hip replacement implants. Several mid-term studies revealed promising results utilizing metal-on-metal bearings in both hip replacement and hip resurfacing in younger, more active, individuals. However, over the last 3 to 4 years, studies have been published that revealed failures of metal-on-metal hips associated with an adverse tissue reaction felt to be associated with elevated levels of metal ion around the implants. These “adverse tissue reactions” can manifest as a small fluid collection, a cystic mass, or a solid mass referred to as a pseudotumor. This is a mass which is neither malignant nor infectious, can be small or large, and occurs in the soft tissue around hip replacement components. These adverse tissue reactions appear to be related to metal-on-metal bearing wear and may be an allergic reaction to low levels of wear debris or a toxic reaction to elevated levels of wear debris. Most likely, a combination of factors may be involved in these reactions. At present, there is no consensus as to what is the cause and why they occur.

Why does this happen?
All bearings utilized in hip replacements lead to wear between moving parts. This wear leads to particles in the surrounding soft tissue of the joint. The body reacts to different particles in a variety of ways. We know from experience in the 1980s and 1990s that polyethylene particles can lead to bone destruction by activation of cells that try to vacuum up the polyethylene particles. These cells release chemicals that lead to destruction of bone around the hip implants. Metal-on-metal particles, which are quite a bit smaller and in some cases dissolve in the fluid, are absorbed by cells and in some cases lead to a toxic reaction killing the cells. Therefore, the reaction of the cell to the particle is variable and varies from one patient to the next. The amount of wear of bearings used in total hip replacements is influenced by implant design and component placement. We know that smaller cup sizes may lead to greater wear or vertical cups may also lead to increased wear due to an edge-loading phenomenon where the edge of the socket articulates against the ball of the hip decreasing the contact area, decreasing the amount of coverage of the ball by the socket, all of which leads to less lubrication between the bearing surfaces and increased wear of the parts.

A central question in metal on metal bearings is why do some patients develop an adverse tissue reaction while others do not. It would appear that the level of wear and, therefore, wear debris influences this reaction. The patient’s response to wear debris is highly variable. Some patients with very low wear can develop a significant soft tissue reaction, while in other patients significant amounts of wear can lead to no reaction whatsoever. It, therefore, appears this is a combination of inflammatory and possibly allergic-type reaction to the debris.

What are the risks of different bearings?
It is important to realize that the overwhelming majority of hip replacements are highly successful. To date, metal-on-metal hip replacements still have greater than 90% success rate at followup available in 2012. Because of concerns about soft tissue reactions to metal debris, the number of metal-on-metal bearings implanted in the U.S. has dropped significantly. There has also been quite a bit of hyperbole in the press regarding patients who have had an adverse tissue reaction. While the complication in any one patient can be devastating, it is important to realize that the majority of patients continue to function quite well. Each bearing surface has its own set of potential complications and time will tell which bearing proves to be the most successful.

What should I do going forward?
If you have a hip replacement, you should follow up with your surgeon on a routine basis, usually at the first and second year at a minimum, then per the surgeon’s protocol thereafter. If you have a metal-on-metal hip, you should follow up with your surgeon on a yearly basis to check in to see if there is any change in the status of your hip. If you have symptoms, the most common of which are pain in and around the hip, a thorough history, physical exam, x-ray, and if appropriate, blood studies, will be ordered. If there is concern about an adverse tissue reaction to a metal-on-metal bearing, your surgeon may decide to measure your blood cobalt and chromium levels and/or check a specialized imaging study, such as an MRI or ultrasound, looking for soft tissue reaction around the implant. Like with any drug or implant, careful monitoring over time will help us better determine what is the appropriate use for specific devices.

William P. Barrett, MD

Preoperative risk factors, their effect on total hip and knee replacement

Dr. William Barrett — Thu, 05 Jan 2012 22:40:10 +0000

At the 21st annual meeting of the American Association of Hip and Knee Surgeons in Dallas, Texas in November of 2011, a survey of joint replacement surgeons was presented. Within the past year, 82% of respondents stated they had discouraged patients from having a hip or knee replacement because of obesity. The cutoff value was a BMI greater than or equal to 44. Many of these surgeons referred their patients to a bariatric program for weight loss. Diabetic patients with an A1c greater than 7.5 were referred to their internists for better management of their diabetes prior to scheduling surgery.

The results of this survey are consistent with a growing trend among joint replacement surgeons to encourage patients to decrease their preoperative risk factors, particularly obesity and control of their diabetes and to have good control of their medical conditions prior to undergoing elective hip and knee replacement surgery.

The influence of these comorbidities or preop medical issues will be greater in the coming years when payments for care are bundled together to include many postop complications and readmissions.�
William P. Barrett, MD

Uncemented total hip replacement in patients less than 50

Dr. William Barrett — Thu, 05 Jan 2012 16:48:51 +0000

There were several papers presented at the 21st Annual meeting of the American Association of Hip and Knee Surgeons in Dallas, Texas in November of 2011. These papers demonstrated excellent long-term fixation both at 10 and 20 years using cementless femoral and acetabular components. Failures did occur due to wear at the bearing surface between the metal ball and polyethylene socket. Changes to the polyethylene, which were introduced over a decade ago, have improved the longevity of polyethylene inserts used for total hip replacements.

With the current concerns over metal-on-metal and ceramic-on-ceramic bearings, the most common bearing used today in the United States for younger and older individuals undergoing hip replacement is a metal ball mated with a crosslink polyethylene liner.

These studies confirm the durability of cementless fixation even in younger, more active individuals.

William P. Barrett, M.D.

Chronic narcotic use prior to total knee replacement

Dr. William Barrett — Tue, 29 Nov 2011 00:35:51 +0000

In a study reported in the American Journal of Bone and Joint Surgery in November of 2011, Dr. Zywiel and co-authors reviewed the results of patients who are using chronic narcotics prior to knee replacement and compared them to a group of patients not using narcotics prior to the knee replacement surgery. They noted that the patients in the preop narcotic use group had poorer outcomes, had longer length of stays in the hospital after surgery, had a higher rate of re-operation for manipulation of stiff knees, and a higher revision rate for pain.

With the increased use by primary care physicians of narcotics to treat the pain of osteoarthritis, this trend should be dampened somewhat by the poorer outcomes in patients who are taking narcotics prior to their knee replacement surgery. For this reason, if the patients fail to obtain pain relief with over-the-counter analgesics and oral anti-inflammatory medications, perhaps earlier referral to an orthopedic surgeon for evaluation of a painful, weightbearing joint would make sense prior to starting a patient on chronic narcotic use which may ultimately jeopardize the outcome of their subsequent joint replacement procedure. �
William P. Barrett, MD

Quad sparing total knee replacement versus conventional total knee arthroplasty, is there a difference?

Dr. William Barrett — Fri, 11 Nov 2011 00:34:33 +0000

Two studies presented at the 21st Annual American Association of Hip and Knee Surgeons in Dallas, Texas in November of 2011 reviewed the effect of surgical exposure, in particular use of quad sparing versus conventional total knee arthroplasty. They checked multiple variables including postoperative pain, quality of life, quadriceps strength postoperatively, gait, and function. One of the studies by Dr. Pagnano at the Mayo Clinic, was a prospective, randomized study dividing patients equally into a quad sparing and conventional total knee group. Patients and the evaluators were blind to which technique was used in the patients. Using objective measures postoperatively, they found no difference in the two groups, specifically no difference in pain control, quadriceps strength, gait, or function. In a second study presented at the same meeting, similar results were found. The bulk of data available in the orthopedic literature would support the fact that the surgical approach by itself has no significant impact on the outcome of knee replacement. Rather improved outcomes over the last several years would be attributed to multimodal pain management, preoperative education, and aggressive physical therapy. All of these components, when utilized together, lead to more rapid rehabilitation and earlier return to activity.

Groups of surgeons have traveled around the west toting more precise joint replacement and better outcomes as a result of “less invasive techniques”. The orthopedic literature does not support those claims, and while many claims are made, the objective data does not back up what some of the surgeons advertise.

As a patient, you want to look for a program that has a comprehensive approach to joint replacement surgery, evaluates and documents it’s outcomes in objective forms, and can back up it’s claims made with objective data.

William P. Barrett, MD