As a total joint surgeon for the past 20 years, I have spent a great deal of time counseling patients with hip and knee arthritis who are considering their alternatives.
The two most common questions patients ask me are:
1. “Will I need a joint replacement?”
2. “When should I have a joint replacement?”
The first question is fairly easily answered. A good medical history, examination and simple x-rays can usually establish a diagnosis of arthritis. Given the progressive nature of arthritic diseases, these patients are potential candidates for joint replacement surgery. Of course, other treatment options for arthritis short of joint replacement must be considered first. These include:
• weight control
• activity modification
• corticosteroid injection
• arthroscopic debridement
The second question, as to when to proceed with the surgery, is sometimes more difficult to answer. Most importantly, the decision when or when not to proceed with surgery must be individualized for each patient based on many factors. I remind patients that joint replacement is an elective procedure so it can be planned for. Patients should be in optimal medical condition and not proceed with surgery if there are other acute medical problems or illnesses. Rather, these types of issues should be addressed prior to surgery as much as possible so as to not complicate recovery.
Second, pain is the primary reason for the surgery. Not mild or intermittent pain but daily or even nightly pain requiring regular strong medications or significant reduction of normal activities such as walking or standing. It is also reasonable to consider pain that limits enjoyable activities such as golf, tennis or other hobbies as a relative indication for surgery.
Third, I’ve learned over the years that pain is often perceived differently by different patients. A deteriorated arthritic knee joint on x-ray may bother a patient very little and should not necessarily be replaced. On the other hand, a mild arthritic change on x-ray may translate to excruciating pain in another patient. If all else fails, joint replacement for this patient can be considered. In other words, as the old medical axiom goes, “don’t treat the x-ray, treat the patient.” I agree with that philosophy.
Next, I remind patients that modern joint replacement techniques and materials allow us to offer these procedures to younger and more active patients (in their 50’s, 60’s or even younger) since good studies now show that implants can function well for 20 years or more. No longer must we insist that patients suffer in pain for decades to get “old enough” to have a new knee or hip. However, patients having joint replacement must be made aware that implants won’t last forever. In younger patients, an implant revision might be necessary in the future which may be a more complicated surgery.
Additionally, the last five years have shown a dramatic decrease in hospital stays (now two or three days) for joint replacement patients. This reduced “down time’ allows patients with busy lives to plan a joint replacement surgery without a major interruption in their life and a quick return to normal function.
Often, patients arrive in our office with a wealth of information from various sources and with well intentioned advice from family and friends. Much of this relates to surgical techniques, type of implants and length of recovery. A key role I play as the total joint surgeon is to help sort fact from fiction so my patients can make an informed and correct decision. Most times, when I’ve gone through this process with a patient who has arthritis, I’ll end by telling them “You will know when it is time to go forward with the surgery”. I make it a point not to make the decision for them but help guide them through the process. When we work together, I can usually count on an excellent surgical outcome and a very satisfied patient.
Mark Hartley, MD, specializes in total joint replacement. He practices in our Reston office.