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What Your Doctor May Not Tell You About Joint Replacement


by Ronald P. Grelsamer, M.D.

How do I know when I need a joint replacement?
When your pain becomes intractable despite all reasonable nonoperative approaches. You don’t need a joint replacement just because the X-ray “looks bad.”

Where do I find a surgeon who can put in a hip replacement through a mini-incision?
You are asking the wrong question. You want a surgeon who can give you a painfree hip for a long time to come.

How long should my joint replacement last?
Ten years. At least that’s the party line. Many implants will last over twenty years. After that either the implant loosens or the bearing wears out, especially if you are still young or active at that point.

Where is the hip joint?
Not where you think it is! The hip joint is closer to the front of your thigh than to your butt. A hip problem will, therefore, tend to cause pain in the groin area, at the crease between your upper thigh and belly. Pain in the area of your butt is much more likely to come from a pinched nerve in your back than from a hip problem.

Is arthritis always painful?
No! This is true of arthritis anywhere in the body. You can have arthritis for years without even knowing it. Don’t let yourself get talked into a joint replacement on the basis of a “bad looking” X-ray. (“Mrs. Jones, this X-ray looks terrible. Why don’t we replace your knee at the beginning of next month?”)

Are some implants glued in?
No. There is no glue in joint replacement surgery. Many implants are cemented in place, but the cement isn’t sticky. No more so than the cement between two bricks.
Is the whole knee removed in a total knee replacement?
No. Only slivers at the ends of the bone are removed.

What is a hip dislocation?
The hip joint consists of a ball and a socket. When the ball slips out of the socket, the hip is said to have dislocated. This is a painful situation. The process of putting it back in is called the reduction, and once the process is complete, the hip is said to be reduced.
Are there warning signs before a hip dislocates?
Alas, no. Heed the precautions taught to you by your surgeon, nurse, and therapist, and don’t count on any warning signs. If your hip pops out, it will do so in a fraction of a second.

Is a hip dislocation a lifelong risk? Do I have to watch what I do the rest of my life?
Yes. After a while the precautions become second nature.

What’s the big deal about a “revision” (redo) joint replacement?
Redoing a hip replacement is much more difficult and much riskier than a first-time replacement. This is true anywhere in the body, and it is the result of the tissues being much less soft and pliable. Also, dense scar will have wrapped itself around everything, and this will have to be slowly and methodically peeled away by the surgeon before he can do anything to your hip or knee.

Why the reluctance on the surgeon’s part to place a joint replacement in a young person?
The implant will loosen or wear out in the person’s lifetime, thus subjecting them to a revision.

I am eighty-two years old. Am I too old for a joint replacement?
It’s a question of health and motivation, not age. In fact, there’s no advantage to waiting. The implant will last your lifetime. If you meet all the criteria for a joint replacement, have the procedure while your doctor still allows it.

Why won’t my doctor let me play tennis after a joint replacement?
He might let you play some easy doubles, but he’ll discourage you from any vigorous running and twisting. Unless, of course, he doesn’t plan on being around when you’ve worn out the bearing of your joint replacement and it needs to be replaced.

Can I get an MRI if I’ve had a joint replacement?
Yes. Your implant is metallic but nonmagnetic. The pictures produced by an MRI will be blurry in the immediate vicinity of the implant, but it is not dangerous to undergo an MRI. Pictures taken of areas away from the joint replacement will be perfectly clear.

Why do I need to see my surgeon on a regular basis even if I’m feeling well?
You won’t feel the plastic wearing out in your joint replacement. If this should happen to any significant degree, the microscopic debris may cause the surrounding bone to gradually disappear. And you won’t feel that either until a massive amount of bone is gone! Better to discover this early.

It’s been three months and I’m still having pain after my joint replacement. Is this normal?
Not if the pain is severe. Some achiness is normal, but no more than that—especially in the hip. The knee can be sore from the bending and straightening exercises. In the first three months, pain can be attributed to the surgery itself, but after three months, the surgeon will start to look for other sources of pain.

I need a joint replacement and I’ve just read about a new type of implant. I should make sure my surgeon uses this model. Right or wrong?
Wrong. Your implant should last you ten, twenty, or thirty years, if not longer. If it hasn’t been around that long, how do you know it will? Because of the manufacturer’s assurances? Note that no manufacturer will ever make that assurance on a new implant. And most implants introduced since the inception of joint replacement surgery have not stood the test of time.

Joint replacement is big-time surgery and the surgeon is making big-time bucks. Right or Wrong?
Wrong. Although a surgeon may occasionally be well reimbursed, the average hip or knee replacement earns a surgeon between $1,600 and $1,800—and that includes three months of follow-up care no matter how stormy your postoperative course is. An orthopedic surgeon pays upwards of $75,000 a year in malpractice insurance. You do the math.

Will my implant set off the alarms at the airport?
It used to be unlikely, but since 9/11, the possibility of setting off an alarm has increased.

A special joint replacement ID card will allow me to breeze through airport security, no?
No. Anybody in the terror business can make an ID purporting to show that the bearer has had a joint replacement. No halfway competent airport security guard is going to wave you on just because you have an ID card.

In performing a hip replacement, is it not harmful to remove the marrow from the thighbone?
No. The marrow found in the upper femur (thighbone) doesn’t produce blood cells in any significant quantity.

What is a “press-fit” implant?
An implant needs to be fixed to the underlying bone. If it is pressed/jammed/impacted into the bone rather than being cemented, it is said to be press-fit.

Should I have both hips/knees replaced on the same day?
Maybe. It’s a lot of surgery. You have to be physically and mentally up to it. I usually recommend operating on one hip or knee at a time unless the other one is so bad that rehabilitation will be impossible. Your family doctor will have a say in this.

What’s the difference between the true and apparent length of my leg, and why does it matter?
The apparent leg length is what you feel. The true leg length is the actual measurement of your legs as measured, for example, on an X-ray. The two don’t always match. For example, one leg might be short, but if your pelvis and back have adapted, you might not notice because your apparent leg lengths might be the same.

Who is going to be unhappier with a difference in leg length after surgery: Sally, who’s had a hip fracture, or Gordon, who’s been suffering from arthritis?
In fact, Sally in general is going to be less happy. Sally had absolutely no pain before her fracture. She wants to be good as new after the surgery. Anything less will leave her unhappy. Gordon has suffered for years. Any significant improvement should please him. So given the same result, Gordon will be more grateful.

The day before surgery why can’t I eat or drink anything after midnight?
Because anesthesia relaxes the muscles around your stomach and esophagus, stomach contents can go back up toward your throat and back down into your lungs. This leads to a very serious type of pneumonia because stomach contents are very acidic and can burn through lung tissue.

If the doctor thinks I have an infection, why does he not simply prescribe antibiotics?
Antibiotics alone are often ineffective because scar tissue prevents them from reaching the infection.
What can I do to prevent an infection?
Alert the doctor to the presence of drainage (liquid coming from the wound) even if the liquid appears to be no more than water. Eat well. You want a healthy mix of foods. If your appetite isn’t great, consider milk shake–like products that your doctor or pharmacist can point you to.

How long should my hip or knee hurt after joint replacement surgery?
There is no specific answer to that question, because patients exhibit very different levels of pain tolerance. By and large, most of the hip pain should have resolved within a month and knee pain should be very tolerable by the end of the third month. This is a rough guideline. Patients with noncemented (“cementless”) implants may take a little longer.

Why did Sally need crutches for six weeks while Harry needed them for only four?
The two variables here are the magnitude of the surgery and the surgeon’s preference. Bone is a living tissue that adapts to its surroundings. A joint replacement radically alters the forces around a hip or knee, and it will take time for the bones in those areas to adjust to this new set of forces. Excessive pressure applied to bones that are remodeling may or may not cause pain. The surgeon will combine his experience and understanding of the orthopedic literature with his knowledge of your particular operation to judge how long you should use crutches.

My hip still hurts, and my surgeon is blaming it on my back. Is he full of malarkey?
Not necessarily. It is true that hip pain can be coming from the back, even in the absence of back pain. One should be particularly suspicious of this when the hip X-rays don’t suggest much pathology.

Do I need anti-rejection medications after a joint replacement?

Excerpted from What Your Doctor May Not Tell You About Hip and Knee Replacement Surgery by Ronald P. Grelsamer, M.D. Copyright © 2004 Ronald Grelsamer, M.D. Excerpted by arrangement with Warner Books, Inc., New York, NY. All rights reserved. $14.95. Available in local bookstores or click here.

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