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John F. Irving, M.D.
As I approach 30 years of Orthopedic Surgery practice, dedicated to hip and knee replacement in arthritic patients, it is interesting to reflect on some headline news articles offering the latest and greatest improvements in orthopedic and arthritis care. In this short space available, I will touch on a few issues that deserve special attention and a reality check about what works and what is hype. These items receive a lot of press, patients spend a lot of money on them and most are unproven treatments. Please refer to my website for a more thorough review and don’t hesitate to ask questions on any of these subjects with any physician you see.
Anterior approach for total hip was developed and used by Dr. Kris Keggi 35 years ago. I have used it and variations (2-Incision) for almost 20 years. Patients were being discharged home the day after surgery 15 years ago! What is new and has changed is the pain medication protocol and anesthesia for the operation to make the procedure less painful and allow you to function independently and safely right away. Outpatient total hip is available to those patients wanting to go home the same day and is generally offered to younger, healthy and motivated patients. I have been offering this option since January 2015. Successful outpatient total hip experience relies on comprehensive post-operative pain control and home physical therapy arrangements. The most important advancement here is the realization and acceptance by patients and their families that you can go home the same day, walking with crutches and with minimal discomfort.
I had my left hip replaced in 2009 through an anterior approach and left the hospital the next day! It is not a new procedure!
The biggest factor in recovery from knee replacement is, as in all operations, is the patient’s post-operative biologic response to the surgery and NOT THE IMPLANT CHOICE.
This is called INFLAMMATION: swelling, stiffness, achiness and warmth. The second most important factor is the skill and the experience of the surgeon. There are NO MEDICAL STUDIES to show that the results (better motion, faster recovery, less pain) of so-called custom knee implants are better than the reliable implants, that have a proven track record, we have used for decades! It can take a year to get over the inflammation after a total knee replacement. To me, the most significant improvement in total knee implants for young and very active patients may be a newer design that preserves the Anterior Cruciate Ligament (ACL), that I use selectively: the Biomet XP® and Smith and Nephew XR. These implants preserve all the ligaments in the knee and therefore, should be more stable during activity and feel more like your natural knee! These knees implants have been used for 2 years and early results are very positive.
I have had total knee replacements of both knees. One was done 10 years ago, the other 5 years ago. I continue to maintain an active lifestyle! The key for me was working hard to build up the muscles in my legs, especially my quadriceps thigh muscles. Are the knees perfect? No, they can ache after rigorous exercise or after a day standing up and operating, but they are so much better than the arthritic knees I had before the operations, and there is no activity I can’t do... and these are NOT CUSTOM KNEES!
These products offer no scientific results to substantiate the claims that they prevent or improve the course of arthritis. Therefore, as required by the FDA, they must say in commercials and on the bottle that “These products are not intended to diagnose, treat or cure any disease.” Many people want to “try” all options before considering surgery which is okay if you don’t mind spending the money, which can be a significant amount. Glucosamine and Chondroitin sulfate are in this category. They may not help you, but they won’t hurt you, except in the pocketbook!
Arthritis is a condition that develops over time and is related to genetics, childhood development, injuries and age. Carrying extra body weight will add extra stress to your joints. A patient with arthritis loses the cartilage cap on the bones at a joint. It is similar to a car tire going bald! The best way to minimize the risk and effects of arthritis are to stay active and fit, and keep your weight under control. It is especially important to maintain the strength of your legs as you grow older.
This can be accomplished in the gym or with physical therapy. Keeping yourself in good physical health will help you maintain your independence, reduce the impairment of arthritis and minimize the risks of injurious falls later in life.
If you need a total hip or knee replacement, it is a great operation with tens of thousands of surgeries being performed in the US annually. The results are terrific. Complications are few. But remember, being artificial joints, they are good joints and not normal joints.
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John F. Irving, M.D.
Total knee replacement has been proven to be one of the best reconstructive procedures offered to patients suffering with debilitating arthritis over the past 30 years. It is expected that close to 750,000 total knees will implanted in the United States in 2014 with millions having been implanted in the last decade. The operation is primarily performed for pain relief. Secondary benefits include improvement in ability to perform activities of daily living such as dressing oneself, return to physical activities, ability to socialize, and maintain one’s independent living. Surgery will increase mobility, stability, and safety.
Total knee replacement is a very different operation than a total hip. The knee joint is very superficial, covered only by skin and ligaments whereas the hip is deep in the groin and protected and covered by large muscle groups. We demand more from the knee than the hip. The knee must move through a greater arc or range of motion than the hip during some activities such as stair climbing. The expectations of a rapid recovery from a total hip and total knee are different. The post-operative course from a total knee can be long, frustrating and requires consistent rehab.
Though the ultimate excellent result for a knee replacement is achieved in most patients, the speed and duration of the recovery process is quite individualized. Most of the time, the FUNCTIONAL recovery is quite rapid. Patients will progress from a walker and/or crutches to a cane in about 2 weeks’ time. Many patients, depending on their age and severity of the arthritis and disability before surgery, will not need any ambulatory assistance by a month or so after surgery. However, the biggest impediment to recovery and patient satisfaction is the biological healing process called INFLAMMATION. This is persistent SWELLING, ACHINESS, STIFFNESS and WARMTH. Patients may not feel the operation to be a success and worthwhile, feel like the knee is their own, for even 1-3 years after surgery even though they are FUNCTIONING AT A HIGH LEVEL.
Often, patients considering a total knee replacement may know someone who had this operation and is walking around and active without pain 3 weeks after surgery. Of course, this is the exception and not the rule. The majority of individuals take 1-3 months to recover enough from surgery to get back to many of the their former living, work and recreational activities.
The INFLAMMATORY response takes a long time to recede. This process may be frustrating to the patient, therapist and surgeon…..but you can’t rush Mother Nature! In general the swelling-stiffness-achiness –warmth is only 50%(1/2) resolved by 6 weeks after surgery, 75%(3/4) resolved by 3 months, with complete resolution taking a year and sometimes even longer. ( Please see link to New York Times article by Jane Brody from 6/5/08 on our web site, www.togct.com)
Despite the sometimes prolonged course to recovery for a Total Knee, it is a great life changing operation. You, as the patient have to be an active participant in the recovery and rehabilitation program! The final result is about 33% surgeon, 33% physical therapist and 33% patient effort.
If you are planning on having a total knee, please expect to work hard after the surgery to maximize your result and please be a patient PATIENT!
By John Irving, M.D.
Dr. Irving currently uses a direct anterior (or frontal) approach for most total hip replacements. He has been using this approach or a variation of it since 1995, starting with cemented hip stems. The anterior approach uses a 3 -5 inch incision near the groin, almost in the seam or pleat line of slacks. This way to do a total hip has been said to be the least invasive way to do the operation. Both parts of the hip replacement, the stem and the cup, can be precisely placed through this one incision. Most of the time no muscle is cut or released during the operation which minimizes post-operative discomfort while allowing a very fast return to normal lifestyle, work and recreational activities. Pain is low level after this hip replacement with patients requiring minimal narcotic use for 2-3 weeks afterward. The risk of the hip coming out of joint or dislocating in the early post-operative period is certainly reduced with this approach. When used with contemporary uncemented hip stems, patients can be up walking the same day as surgery. While some younger healthier patients can go home the day after surgery, the usual hospital stay is 2 days. Patients, who for safety and social reasons, elect to go a rehab center will stay in the hospital 3 days.
Patients initially use a walker or crutches. They are instructed on the use of a cane while hospitalized to be safe, comfortable and confident getting in and out of bed, on and off a toilet and up and down stairs. Because the femoral stem of implant is uncemented, and because a patient has just had major hip surgery, the leg must be protected for a short period of time. Dr. Irving asks patients to use the walker or crutches for a week post-operatively then progress to a cane. Patients usually can wean themselves off of the cane by 3 to 4 weeks after the operation. Still, some discomfort can persist as the healing process matures. Golf and other recreational activities can be attempted after 4 weeks.
Dr. Irving pioneered a 2-incision total hip approach which was used extensively between 2000 and 2008. He lectured on, demonstrated and taught this surgery to hundreds of surgeons from around the world. This operation incorporated a small portion of the anterior approach to place the socket and a small part of the standard posterior approach to place the hip stem. The introduction into the US of newer more compact uncemented hip stems allowed the hip replacement to be done again via one anterior incision. But, this is an operation Dr. Irving still uses for certain complex hip cases, especially revisions.
Less than 10% of patients undergoing a hip replacement need a blood transfusion, or have any kind of blood clot and the infection rate is well below 1%.
Total hip replacement is one of the best orthopedic reconstructive operations done today. Patients can return to most activities and live a normal life. The direct anterior approach is one option to help with an accelerated recovery.
By John Irving, M.D.
Why should a total hip or total knee need to be redone? This is a common question and is understandable given the history of joint replacement failures a generation ago. Yet, greater than 75% of total hips and knees done 25 years ago have not had to be re-operated on! Amazing when you consider these used radical surgical techniques and early implant designs, made of poor plastic and metal materials; a far cry from today’s standards! The current generation of implants and bearing surfaces should give excellent results in most patients for 20 years or more, before any maintenance needs to be done on them. The common perception that total joints have to be re-done every 10 years is totally wrong!
Two important changes have improved the lifespan of modern total joints:
Total joints are mechanical devices placed in an unforgiving biologic environment. In 30 years of use, the average active person will take more than 45 million steps, and each step puts stress on the implant. We do not have immortal total joint materials and with time the plastic surface of the joint (the bearing surface) will begin to wear down. As this occurs microscopic plastic particles are released into the joint. If a large amount of particles are released, the body may respond to them by causing a reaction that can loosen the metal pieces that are fixed to bone. That’s the undesirable consequence we all want to avoid!
Patients usually will not notice any symptoms of the plastic wearing out until there is a major problem with the joint, such as the metal implant becoming loose from bone. However, a regular examination of your total joint by your Orthopedic team with x-rays will reveal signs of early wear. Even if a plastic bearing surface wears out after 15 or more years this is NOT a failure of the operation but the expectation of a successful operation that permitted the patient to function at a normal high level for years! The plastic can be replaced, and this can be considered normal joint maintenance. Replacing the plastic is not the same major operation as the original surgery and can be likened to changing the brake linings to keep your car going versus buying a new vehicle. Yes it’s an operation, but minor compared with having to replace the whole total joint! Therefore, regularly scheduled follow-up evaluations are very important to identify a minor problem and correct it to keep it from becoming a major issue!
Having a total joint is a chronic condition that needs regular follow-up like any other medical condition, be it high blood pressure, diabetes or a heart valve. A typical post-operative course involves an examination and x-rays at 6 weeks, 3 months and 1 year from surgery. After that, a follow-up appointment interval of about every 2 years is reasonable. Please help us help you maintain your total hip or knee by coming back for your long term follow-up appointments, and with that you can expect a lifetime of great function from your total joint!