General Questions
Will this surgery get rid of all of my pain?
This question goes to the very heart of expectations and disappointments after surgery. If you have pain that is coming from elsewhere, i.e., another source besides the replaced joint, that pain will continue after surgery. Such pain may be caused by osteoarthritis, rheumatoid arthritis, fibromyalgia, back disease, poor circulation or damaged nerves. Such pre-existing conditions continue after surgery and may compromise the result of joint replacement surgery.
An artificial joint made of metal and plastic is no match for the real thing. It takes time and re-education of muscle, ligaments, tendons, nerves and the brain to get accustomed to an artificial joint. In some instances, a low-grade, mild pain may persist for several years despite an otherwise successful result.
Artificial joint replacement of the hip and knee should therefore be considered if, and only if:
- All other methods of treatment have failed to help you.
- You have debilitating and severe pain with loss of function.
- You are emotionally and psychologically prepared for surgery.
- You have a thorough and comprehensive understanding of the operation and the potential outcomes.
Experience shows that motivated patients who satisfy these criteria and keep a positive outlook typically have the best results.
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Do knee replacements hurt more than hip replacements?
People perceive pain in highly individual ways. Generally, knee replacements tend to be more painful. Why? Heavy muscles cover and support the hip joint, whereas the knee joint is close to the skin. The nerves that carry pain sensations from the hip and knee joints differ. After knee replacement, the physical therapist pushes you to move the knee and regain mobility, whereas with a hip replacement, the therapist has less of a role, other than teaching you how to walk with assistive devices.
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If my hip is arthritic, why does my knee hurt?
Pain refers from the arthritic hip to the knee. This happens in other places in the body. For example, a heart attack can manifest as shoulder and arm pain that goes up the neck. The nerves that supply the hip joint also supply the knee joint. Even though you may feel pain in your knee, it might actually come from your hip joint. Addressing the hip problem will lead to pain relief in the knee in such situations.
With one major arthritic joint, it is not uncommon for people to limp, compensate or alter their gait. Even subtle compensation can cause pain developing in adjacent joints. People with a diseased hip may develop back and knee pain, or pain in the opposite hip and knee. People with major arthritis in one joint sometimes have arthritis in other joints. When you protect a diseased and worn-out joint during load bearing, other joints bear the weight and that can lead cause them to hurt. Taking care of the worn-out joint usually relieves some, or all, of the pain radiating to other locations.
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How much pain can I expect with a hip or knee
replacement?
These days, not very much at all. Most patients are pleasantly surprised at how little pain is present early on. Later, as sore muscles start moving, and muscles weakened by long standing arthritis start to gain strength, some aches and pains are inevitable.
Many reasons explain the decreased after first-time hip or knee joint replacement surgery. One, the anesthesia techniques have advanced. We were using femoral nerve blocks and spinal anesthesia which greatly reduce or eliminate pain after surgery. Since the femoral nerve blocks also make it difficult for the patient to move the leg during therapy, we recently switched to a continuously infusing “pain buster” pump that drips an anesthetic drug directly into the joint via a thin catheter for 24-48 hours after surgery; with this modality, we have been able to eliminate the need for any nerve block since patients do not hurt. (Find more information at http://.askyoursurgeon.com/howitworks.php and http://www.iflo.com) The anesthetic infusion serves to block the pain fibers right at the surgical site.
In addition to the above, we also inject a mixture of anesthetic and anti-inflammatory drugs directly into the knee tissues during total knee replacement. This helps with post-surgical pain relief considerably.
Finally, we begin anti-inflammatory, anti-nausea, anti-constipation, and narcotic pain medications before the surgery, right when you are in the pre-surgical area getting prepared for surgery. By pre-empting nausea, pain, constipation, and the other unpleasant side-effects of surgery, the overall experience is improved considerably, compared to what we did just a few years ago.
None of this changes the fact that ANY surgery is still a serious undertaking, and is associated with certain risks and side-effects that you need to know about, no matter how rare their occurrence. For a description of things that can go wrong in surgery, please click here.
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How much physical therapy will I need after surgery
on my hip or knee?
With the two-incision hip replacement, physical therapy
is needed only to help you learn to use a walker or crutches, and
instruct you on partial weight bearing. For a month after
surgery, usually home health will help you with therapy and exercises
at home. Few, if any total hip patients now need extensive
therapy because the muscles are not cut as they used to be with
our latest surgical methods. An occasional patient may need
therapy after the one month interval, and this can be addressed
on an individual basis.
With the new minimally invasive knee techniques, about half of
our patients do not need any physical therapy beyond one month. During
the first month, the therapy is at home anyway. The rest
of the patients need outpatient physical therapy that we can arrange
on an individual basis.
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How long do artificial hip and knee joints last?
For most patients who undergo an expertly-executed hip or knee replacement procedure, the implants should last the rest of the life of the patient.The 15-20 year data on the longevity of total hips and total knees is very encouraging. More than 90 percent of the implants still function well in many studies. This is not a guarantee or assurance. Many things can go wrong, such as fractures, implant failure, late infections and deterioration in your overall health.
Joint replacement longevity depends on:
- How well you take care of yourself and your health.
- Understanding and respecting the limitations of a prosthetic lifestyle.
- Activity level.
- Understanding that things like running, racquetball, tennis, jogging, jumping and high-impact aerobics or sports compromise the longevity of your prosthetic joint.
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My knee is degenerative and I am not ready for a replacement. Will arthroscopic surgery help?
It depends on the extent of arthritis. If the pain suddenly turns worse, or the knee catches or locks, then arthroscopy often helps relieve acute symptoms. In almost all cases of knee arthritis, the arthroscopic procedure allows us to make a couple of small holes, look inside the knee, get an idea of the extent of the degenerative change, shave off and remove any loose pieces, and trim away any sharp, torn cartilage edges. Almost everyone feels better after such a procedure.
Whether such a procedure will help in your specific case is an individual
decision. Arthroscopy can be very useful at temporizing the situation
and might be preferable to a complete knee replacement. Arthroscopy
does not prevent the eventual need for further surgery. In most cases,
arthritis progressively destroys joints and makes further surgery inevitable.
For information on arthroscopic hip surgery, follow this
link.
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Will I gain or lose any leg length as a result of my surgery?
It is not possible to gain or lose leg lengths to any significant degree with a knee replacement, because your ligaments guide how thick the polyethylene insert can be. Whatever is taken out of the knee joint must be replaced with artificial parts in order to balance the knee for optimal performance. During hip replacement, because the ball at the top of the femur is removed entirely, the surgeon has more control of your leg lengths. In most, if not all cases it is possible to nearly equalize leg lengths after hip replacement, keeping in mind that normally, our two legs are not quite equal to begin with. We aim to reproduce the pre-existing leg lengths, but slight lengthening is sometimes necessary to achieve optimal stability in a hip replacement and avoid the complication of dislocation of the artificial parts.
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How may joints can one have replaced?
It is possible to have multiple joints replaced safely. It is wisest and safest to get these done one at a time, starting with the worst one first. Some of our patients have had more than a single hip or knee replacement. In certain instances, it is possible to have both hips and both knees replaced with artificial implants.
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How big will my scar be?
The routine hip replacement can be done through two incisions. One is about an inch long. The other is anywhere from two to four inches, depending on the size of the patient, the degree to which the tissues are contracted from long-standing degenerative disease, and the degree to which the hip is deformed. Most knee replacements require a four-inch incision, with variability necessary to accommodate each patient's individual anatomy and needs.
The size of the incision does not affect healing, although who would not prefer a smaller incision? The key is what the surgeon does once the incision is made. With the MIS-2-incision total hip procedure, the muscles are simply pushed apart, and the recovery is dramatically better than with any standard hip approach, regardless of the size of the incision. Patients who have had this procedure on one side, and the standard, traditional approach on the other side for a prior hip replacement cannot stop telling us how much easier and faster the recovery with the MIS-2-incision hip replacement is. Likewise, in knee replacement, independent of the size of the skin cut, the key is not to invade the quadriceps muscle. Traditional knee replacement surgery required that the quadriceps muscle be cut for exposure, and then re-stitched. By using custom instruments that we have designed in our operating rooms over the past several years, and by sharing our experiences with colleagues elsewhere around the country, we can spare the quadriceps muscle, resulting in a much easier and quicker recovery.
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I have arthritis of the hip or knee joint. The
joint surfaces are rough instead of being smooth; so won’t therapy
and exercise before surgery hurt the joint?
No, the human joints are living tissues and they respond very
well to a regular program of light, aerobic exercise when osteoarthritis
develops. Proper nutrition, regular exercise, weight loss, and
over-the-counter anti-inflammatory medications help relieve the pain
of osteoarthritis. These non-surgical methods should always be
considered before embarking upon any surgery.
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With the new, minimally invasive surgery methods, should
I not go ahead and have my joint replaced, or should I wait longer?
New technology, easier surgical methods, and better implants
should never enter your decision making process to embark upon any surgical
intervention. It is imperative that you try non-surgical methods
described elsewhere on this web site first. Surgery is always the
last option; and it is best avoided if possible. Joint replacement
surgery is always a salvage procedure for your own joint that is worn
out. So, it is best to wait until you have uncontrolled pain, or
if the symptoms otherwise interfere with living your life. No matter
how advanced our surgical methods get, the fact remains that the joints
you were born with are the best that nature offers. Keep them as
long as you possibly can.
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Another orthopaedic surgeon looked at my knee or hip
x-rays and said that the arthritis is really bad. I was advised
to have surgery done quickly, because waiting will only make things
worse. Can I safely wait in such a situation?
Yes. Waiting till symptoms dictate the need for surgery
is always wise. Do not let any doctor, no matter how well-intentioned,
talk you into surgery. You can safely wait; the deformity of arthritis
can always be easily corrected by surgery. About the only downside
to waiting is that as muscles get weaker, the recovery from surgery may
take a little longer. You can of course avoid this by maintaining
reasonable body weight, and a program of light exercise to keep your
muscles in shape. We have performed surgery on even severely deformed
knees and hips that have been misshapen since birth or since an accident
during childhood. Experience shows that even those patients who
have waited for many years with an arthritic joint do very well after
joint replacement surgery. There is never any hurry to rush into
elective, first-time joint replacement surgery.
One exception applies to revision, or re-do surgery. If your joint
was replaced many years ago, and the wear particles are starting to dissolve
bone, we may advise you to have surgery sooner rather than later. This
is to avoid further compromise of bone. Another exception applies
to joints that have a suspected infection of the prosthetic device. In
those cases, corrective surgery is recommended early, so that the infection
does not penetrate the bone.
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How much do the implants weigh? What are they
made of?
The usual hip and knee parts are made of metal alloys, commonly
cobalt-chrome and titanium. Both are extremely durable, and inert,
i.e., they do not react with the body. For the bearing parts, i.e.,
that parts that do the actual moving, ultra-high molecular weight polyethylene
is the most common bearing, followed by polished metal, and ceramic.
In a primary, i.e., first-time hip or knee replacement, the parts weight
around 5 pounds or so, which is more than the weight of the bone we remove. But,
given the strength of human muscles, you will not feel any change in weight. The
knee or hip may feel tired easily early on in your recovery, but as you
gain strength, this will disappear. So, in summary, the artificial
parts weigh more than what we take out, but this fact is of little, if
any, clinical consequence. |
