Joint Replacement: A Chat with my Surgeon
While certainly not inevitable, joint replacement is a viable treatment option for many people with RA when the effects of joint damage is no longer being adequately managed by other means. I consider myself a veteran having had three (hip, shoulder, and knee – in that order). Pain and decreased range of motion or mobility that interfered with my ability to take care of everyday tasks were the driving factors in my decisions to have joint replacement. I suspect the same is true with other patients. But what, I wondered, is the surgeon’s perspective on the subject?
Dr. William F. Tucker, Jr., MD, is a noted orthopaedic surgeon. His areas of special interest and expertise are hip and knee replacement and revision surgery and arthroscopic surgery of the knee and shoulder. He was the first orthopaedic surgeon in Dallas to perform minimally invasive total knee replacement and performs minimally invasive hip replacement where appropriate as well. He instructs practicing Orthopaedic Surgeons in the performance of minimally invasive joint replacement and is a Clinical Professor of Orthopaedic Surgery at the University of Texas Southwestern Medical School. I have been privileged that he and his wonderful staff have been taking excellent care of me for a number of years. We’ve been through a lot together. Not only did he perform both my hip and knee surgeries, he’s done multiple soft-tissue surgeries and more joint injections than I care to remember. He referred me to the highly talented and qualified surgeons who performed my shoulder replacement and back surgeries and, importantly, he’s the physician who referred me to a rheumatologist that led to my diagnosis and treatment for RA. (You can learn more about him on his website, www.williamtuckermd.com.)
The following is a recent conversation Dr. Tucker and I had about joint replacement. Note that this should not be considered medical advice. You should always discuss any medical issues and treatment with your personal health care team.
Carla: From a surgeon’s perspective, when is a patient a good candidate for joint replacement and at what point do you make the recommendation for replacement surgery?
Dr. Tucker: A good candidate for hip or knee replacement is an individual who has symptoms from their hip or knee that have persisted despite utilizing all of the nonsurgical options. Nonsurgical options include:
1) modifying activities such as low impact exercise (swimming, water walking, biking and, sometimes, using an elliptical exercise machine),
2) weight loss,
3) medications for pain/inflammation in accordance with their physician/rheumatologist’s recommendations,
4) physical therapy to strengthen the muscles around the joint and help protect it, and
5) as appropriate, joint injections (primarily for knee arthritis).
I recommend proceeding with surgery when symptoms have persisted despite the above measures and the symptoms are significant enough that they are beginning to cause other issues such as weight gain, loss of cardiovascular fitness, loss of overall muscle tone, and the inability to participate in the activities which make life meaningful.
Carla: I’ve had excellent results from my joint replacements and they’ve certainly improved not only my overall health but my life in general. However, joint replacements are a major decision that will affect the rest of a patient’s life. What are the long-term considerations of having a joint replaced?
Dr. Tucker: Joint replacement certainly offers the potential for a significant improvement in the overall quality of life. Some of those potential benefits must be exercised (pun intended) to achieve the maximum gain.
Care of the replaced joint is important. Maintaining a healthy form of lower-impact exercise, such as those I listed above, is good for the joint. "Motion is the lotion" to keep the joints moving.
Maintaining a healthy body weight is important both before and after surgery. A good rule of thumb is that hips and knees see approximately five pounds of stress for every pound of bodyweight. That means that losing 10 pounds translates to approximately 50 pounds less stress on the joint.
I recommend that patients who have had a joint replaced take antibiotics before dental procedures to minimize the risk of infection in their replaced joint. This is one dose of antibiotics one hour before the dental work is performed. It is also important to treat other infections, such as sinus or bladder infections appropriately. The most important thing is to see your physician if you are sick.
Periodic X-rays after surgery are appropriate to screen for issues. Following the initial after-surgery visits, I recommend a follow-up visit with X-rays every two years.
Carla: It seems that there have been advancements in every aspect of our lives. Have there also been advancements in joint replacement?
Dr. Tucker: There have been significant advances in both implants for joint replacement and the techniques utilized in surgery. Newer materials used in both hip and knee replacement offer the potential for longer-lasting joint replacements which is particularly important as younger people have hips and knees replaced. Previously, patients were advised to “wait until they were miserable” before having a joint replaced. It is preferable to proceed with surgery before the arthritis in the joint causes other, secondary issues that are often more difficult to treat/correct than the arthritis (for instance loss of muscle strength/tone, loss of cardiovascular fitness, weight gain, diabetes, and similar conditions).
Surgical techniques, such as the anterior approach for total hip arthroplasty and lesser invasive procedures for total knee arthroplasty allow shorter hospital stays (typically one to two nights) and quicker recovery/return to work. Minimizing the time in the hospital results provides major benefits such as a lower incidence of infections as well as cost savings for patients and a quicker return to normal activities.
I use medications in the joint at the time of surgery to minimize bleeding and pain following the procedure which helps minimize the need for transfusions and reduce the need for narcotics after surgery. Most of my patients describe their pain following the surgery as "soreness" rather than pain.
Carla: What other comments, concerns, or considerations do you have, particularly from a surgeon's perspective?
Dr. Tucker: As with anything else in medicine, all of the issues involved in an individual patient's care must be considered. Prevention/maintenance of other medical issues is of paramount importance with any surgical intervention. Controlling other medical conditions such as diabetes, hypertension, or obesity lowers the potential for problems during and after surgery.
For patients with rheumatoid arthritis who are often on medications that suppress the immune system, it is important to hold these medications before and after surgery to minimize the risk of infection or wound-healing problems. I recommend withholding methotrexate and any of the biologics (such as Remicade/Enbrel) as well as any medicines which could increase bleeding, such as aspirin and most anti-inflammatories (with the exception of Celebrex and Mobic), for two weeks prior to and two weeks following surgery.
It is imperative that patients who undergo surgery follow through with their physical therapy and all follow-up visits after surgery to maximize the benefits from the procedure.
For patients on Medicare it is important to note that Medicare's requirements for nonsurgical management must be met before Medicare will cover any aspect of the surgical procedure. At present, this requires at least three months of prescription medication for the arthritis. This is typically not an issue for patients with rheumatoid arthritis but is often an issue for patients with osteoarthritis. Medicare also requires a course of physical therapy prior to surgery. For patients with knee arthritis at least one steroid or viscosupplementation/"lubricating" injection is also a Medicare requirement. Common prescription names for some of the viscosupplementation drugs include Euflexxa, Halgan, and Orthovisc.
I recommend a course of physical therapy before surgery to minimize downtime and speed the recovery after surgery, even in patients who are not on Medicare.
When was your last flare?