Joint Replacement: Weighing Individual Goals, Risks and Benefits Key to Success

As an orthopedic surgeon, I spend a fair amount of time working with an experienced team performing various types of hip and knee replacement surgery on appropriate patients.

Joint replacement is a surgical procedure where parts of an arthritic or damaged joint are removed and replaced with a metal, plastic or ceramic device called a “prosthesis.” The prosthesis is designed to replicate the movement of a normal, healthy joint.

When to consider surgery

You might be considering joint replacement surgery if a hip or knee has been painful and is restricting movement. Although immediate benefits of surgery include less pain and enhanced mobility, you should first exhaust non-surgical options for management.

I remind all my patients that joint replacement surgery is elective and should come down to a quality-of-life decision. My advice almost always includes recommending that they try non-surgical treatments first – whether that be ice, heat, anti-inflammatory medication, swimming or physical therapy.

However, if nothing works, people should ask themselves if pain and disability are destroying their quality of life. If the answer is yes, I advise them that it’s the appropriate time to discuss surgical options.

Risks

Like every type of surgery, joint replacement is not without risks, which include:

• Infection

• Damage to a blood vessel

or nerve

• Loosening or dislocation of

the new joint over time

• Medical complications, such as heart attacks or blood clots, due to the physical stress of undergoing surgery

Fortunately, these risks can be significantly reduced with good management before and after surgery, which most orthopedic surgery centers are very experienced at providing.

Benefits

Studies have consistently shown that hip and knee replacement are some of the most successful procedures in all of medicine when it comes to patient satisfaction and quality-of-life improvement. Most patients are able to resume activities that arthritis had made difficult, whether that be golfing, biking, caring for family members, or missing fewer work days due to pain.

Types of joint replacement

Thanks to advancements in surgical techniques, prostheses, imaging, post-operative care and rehabilitation, many orthopedic surgeons are able to offer patients in need of joint replacement a variety of surgical options – depending on their individual situation and other factors like overall health, chronic disease and anatomy.

Options often include:

• Posterior total hip replacement – This proven hip replacement method has a long-term track record of success. During this one- to two-hour surgery, a three- to six-inch incision is made over the damaged hip to expose deeper tissue. The damaged “ball” or head of the thigh bone (femur) is dislocated and removed. Damaged bone and cartilage in the “socket” are removed and the socket is smoothed and enlarged to receive the metal implant. A highly polished socket liner, which is usually made of polyethylene plastic, is secured inside the socket. The surgeon then creates a narrow, five-inch channel on top of the thigh bone to receive the new implant’s stem and ball. Materials in the new ball-and-socket joint press against one another easily to help restore hip motion.

• Anterior total hip replacement – This procedure is very similar to a posterior total hip replacement, except the surgeon accesses the hip joint from the front, as opposed to the back side (posterior) of the hip. This method has gained a lot of interest over the past decade and patients can generally expect an excellent outcome, as they can from the posterior approach.

• Revision hip replacement – After a period of normal wear and tear on an artificial hip joint, parts of the prosthesis may wear out or become loose. In these cases, hip revision surgery may be recommended. It is done to repair a prosthesis that has been damaged over time due to infection or normal wear and tear. Revision surgery helps correct the problem so the hip can function normally.

• Partial knee replacement – Also known as “unicompartmental knee arthroplasty,” this procedure is appropriate for people who are in good health and have exhausted conservative measures for managing knee pain. These patients may have had a torn meniscus (cartilage) or avascular necrosis (dead bone tissue) in the past that later led to arthritis in one part of the knee. For younger adults, a partial knee implant may be considered a bridge to surgically amend what can currently be repaired before further degeneration in the joint leads to the need for total knee replacement. Older adults may also be candidates, which is then expected to last the remainder of their lives.

• Total knee replacement – The implant usually consists of two parts made of chrome cobalt, titanium alloy and polyethylene plastic. The cobalt-chrome part is attached to the end of the thigh bone (femur) and a titanium alloy base plate is attached to the end of the leg bone (tibia). A polyethylene plastic “articulating” surface is then positioned between them. A polyethylene plastic “button” is attached to the undersurface of the knee cap (patella).

• Revision knee replacement – A knee replacement may fail over time for various reasons. If this occurs, a knee can become painful, swollen, stiff or unstable, making it difficult to perform everyday activities. If a knee replacement fails, your doctor may recommend a second surgery, called a revision total knee replacement. In this procedure, an orthopedic surgeon removes some or all of the original prosthesis and replaces it with a new one.

Improving your odds of success

No matter which joint replacement surgery may be most appropriate for any one patient, there are things people can do to help improve their odds of benefitting from a successful surgery, including:

• Losing weight, if necessary

• Quitting smoking

• Limiting alcohol use

• Muscle-strengthening

exercises

• Making sure other medical conditions, such as diabetes, are under optimal control

Making a personal decision

Although an orthopedic surgeon can help you understand risks and benefits of joint replacement, only you can decide at what point pain and limitation of arthritis is affecting your quality of life enough to consider surgery. Understandably, the threshold where benefits outweigh risks is different for every patient.

Final recommendation

Deciding whether to have joint replacement is a very personal choice. Work with your doctor to fully understand the plan for managing your individual risk factors before and after joint replacement.

Kevin MacDonald, M.D.

Kevin MacDonald, MD, is a board-certified orthopedic surgeon who specializes in orthopedic oncology, adult reconstructive surgery and anterior hip replacement. He has a special interest in benign and malignant bone and soft tissue tumors, surgical treatment of sarcoma, limb reconstruction, total hip replacement, total knee replacement, revision hip and knee replacement, and partial knee replacement. Dr. MacDonald practices at Virginia Mason.

For more information, visit:

• OrthoInfo.AAOS.org

• AAHKS.org

• Arthritis.org

• AJRR.net

• VirginiaMason.org/Orthopedics