Making Connections: Joint Replacement Surgery

A new hip or knee can mean a new lease on life.

Three decades after a motorcycle accident left him with numerous fractured bones and almost took his life, Wade Norton began to experience knee pain that made it difficult to climb stars or enjoy a game of golf. He learned to manage by avoiding stairs and modifying his golf game, he says.

But when his left hip started bothering him a few years later, there was nothing he could avoid or modify that helped. He was in pain when he walked. He was in pain when he sat. He was in pain at night when he tried to sleep. “When my hip went bad, it went quickly,” says Norton. Within a year of feeling the first twinges, the pain had become relentless. He knew something had to give. “It was like ‘Someone, help me, please,’” he recalls.

That someone turned out to be Randall J. Ruark, M.D., medical director of GHS Orthopaedic Associates in Augusta and assistant professor at the Medical College of Georgia at Georgia Regents University. In June 2011, Dr. Ruark performed a total hip replacement, a procedure that involves surgically removing the painful, damaged hip and replacing it with a prosthesis made of metal or ceramic and plastics. Norton was so pleased with the result that he decided to have his painful knee replaced, too.

Improving Lives

Norton, 61, is one of the estimated 100,000 Americans who undergo hip or knee replacement each year. First performed widely in the 1970s, such replacements are lauded by many doctors, including Dr. Ruark, as two of the best medical treatments available today.

Unlike those of many other surgeries and treatments, the results of joint replacement are almost immediate – particularly for the hip, says Dr. Ruark. “Very quickly people are better than they were before,” he says. “The knee takes a little while to work through, but the hip is very dramatic.”

Norton was up and walking with the help of a walker the day after surgery; just a few days later, he was recovering at home with the help of a physical therapist and a sturdy recliner he purchased specially for his recovery. Although joint replacements don’t directly save lives, they improve quality of life. They make it possible for people to live without pain, to enjoy activities that were once off limits and to engage in the physical activity they need to reduce their risk of other health problems.

Although Norton’s knee and hip problems were precipitated and worsened by the injuries he suffered as a teenager, the eventual cause of his joint pain was osteoarthritis (OA). The most common form of arthritis, OA occurs when joint cartilage – the tough, slippery connective tissue that covers the ends of the bones where they meet to form joints – breaks down, causing pain and stiffness with movement. OA is increasingly common with age and often occurs in people, like Norton, who have suffered joint injuries.

OA is by far the most common reason for joint replacement surgery, says Stephen W. Smith, M.D., a surgeon with Peachtree Orthopaedic Clinic who personally performs as many as 700 of the 2,000 hip and knee replacements done at Atlanta’s Piedmont Hospital each year. “Probably 90 percent of the joints I do are due to osteoarthritis,” says Dr. Smith. One of the next most common reasons for joint replacement is rheumatoid arthritis (RA), a less prevalent form of arthritis that occurs when the immune system mistakenly attacks the lining of the joint, leading to pain and inflammation and eventually joint deformity. Together, RA, OA and other forms of arthritis affect an estimated 1.6 million Georgia adults, according to the Centers for Disease Control and Prevention. For 734,000 of these, arthritis is severe enough to limit daily activities.

Less common problems that may necessitate joint replacement include tumors in the joint and osteonecrosis, a disease caused by reduced blood flow to bones in the joints, says Dr. Smith.

The most commonly replaced joints are the hip and knee, but many centers around the state, including Piedmont, also perform shoulder replacement. Less commonly replaced joints includes the elbows, ankles and joints of the fingers and toes.

Who Needs It?

If a damaged joint causes constant pain or if joint pain or stiffness interferes with your daily life, you may be a candidate for a joint replacement, particularly if you have exhausted other forms of pain relief.

The procedure itself typically lasts a few hours and is performed under general or regional anesthesia, such as a spinal or epidural anesthesia. During the procedure, the surgeon removes the damaged joint and replaces it with a two-part prosthesis. The parts may be attached to the bone with a special cement or be made with a porous surface into which the person’s own bone grows to hold them secure. For people with damage to cartilage in only one part of the knee, a procedure called partial knee replacement – in which only the damaged portion is replaced – may be appropriate. Regardless of which joint is replaced, physical therapy is started during the hospital stay, which is typically three to five days.

The first step in joint replacement is an evaluation by an orthopaedic surgeon. Almost everyone who needs a joint replacement can have one, says Dr. Smith. “The only people I turn down are [obese] people with a BMI [body mass index] of over 50 and people with major medical problems that just can’t have surgery.”

Doctors also may advise delaying joint replacement in younger people who are more likely to outlive their prostheses and require a more difficult revision surgery later on.

To improve the chances of surgical success, Dr. Smith advises taking any steps you can to get in better shape before surgery, even if exercise is painful. “A lot of people think that because they have arthritis, they are going to make it worse by exercising, where the exact opposite is true,” he says. “The more exercise you can get before joint replacement, the better. If you can increase or maintain strength before the operation, I think that always helps you recover from the operation. Low-impact exercise is a good thing for people with arthritis.”

Other recommended lifestyle changes include weight loss, if necessary; quitting smoking can also be beneficial. Smoking can prolong recovery and healing, and excess body weight can stress the joints – both natural ones and prosthetic ones – and perhaps harm joints in unexpected ways.

“There are numerous studies [indicating] that obesity has been linked to osteoarthritis, but studies show the connection is more than just the wear and tear because they [patients] weigh more,” says Dr. Ruark, who performs around 200 hip and knee replacements at Georgia Regents Medical Center each year. Research suggests that fat cells produce inflammatory substances that can harm the joints and that weight loss can help all of the joints, not just those like the hip and knee that bear the body’s weight, he says.

“Some studies show it can also de-crease complications if they lose weight,” says Dr. Ruark.

Prospective patients can also prepare by learning about the replacement procedure, what to expect and how to prepare for recovery. That preparation, for most people, involves getting their homes ready for the rehabilitation period and having someone stay with them for several days after surgery. Most hospitals that perform joint replacements have a preparation class, such as “A Joint Journey,” offered by the Southeast Georgia Health System Joint Replacement Center in Bruns-wick, which replaces some 600 joints annually.

“Our ‘A Joint Journey’ program is a result of hundreds of hours of collaboration among doctors, nurses, therapists, ancillary staff and administrators to streamline the patient’s experience from start to finish,” says the center’s medical director, J. Kevin Brooks, M.D. 

Based on the system’s geographic location, it chose to incorporate a coastal theme throughout the “journey,” which includes an educational booklet and a pre-operative education class conducted by the center’s coordinating orthopaedic nurses. “The class exposes the patients and their families to the entire surgical and rehab processes,” says Dr. Brooks. After surgery, the coastal theme is continued in rehab, when patients regain their ability to perform daily activities during an imaginary trip down the coast, with activities such as picking up sand dollars from the beach.

Dr. Brooks recommends speaking to other patients who have successfully undergone joint replacement surgery, ensuring that any other chronic diseases are well managed, preparing your home environment to accommodate a walker and removing falling hazards and having a good support group postoperatively.

While complications of joint replacement are fairly uncommon, they can occur and include blood clots, dislocation and infection. Your doctor may prescribe medications – blood thinners and antibiotics – to reduce the risk. It’s important to speak to your doctor about signs of complications you should watch for and contact your doctor immediately if you experience any of them.

The Future

As the baby boom population ages and osteoarthritis becomes more common, experts predict that joint replacement will become more common, too. “In the next 25 years, knee replacement is supposed to climb around 600 percent, and hip re-placement is supposed to climb around 150 percent,” says Dr. Smith. “It is really mind blowing – the growth numbers we are going to see. It’s to the point that people are kind of wondering who is going to be doing all this surgery, because everyone I know is kind of tapped out; but I guess that will all play out in the future.”

Dr. Smith suspects another reason for the increase will be the refusal of baby boomers to be sidelined by joint pain or stiffness. “People are just less willing to accept a sedentary lifestyle,” he says. “They want to be active into the elderly years, and joint replacement is one way to allow them to do that.”

Since joint replacement became widely available in the 1970s, improvements in techniques and materials have made the procedure an easier, long-lasting one, says Dr. Ruark. “In the ‘70s, people were in the hospital for 14 days or so when they had joint replacement surgery,” he says. “Now they are up and walking in a day or two – maybe even the day of surgery.”

Research continues to make advances in the procedure both to improve the surgery itself and the prostheses that are implanted.

“Down the road, we are looking at trying to improve the longevity of implants through wear-resistant plastics,” says Dr. Ruark. “We are constantly looking at pain management techniques to eliminate the pain in the surgical period.” At some point, he says, robotics will likely play a role in many joint replacement surgeries.

Life After Surgery

Once healed, a new joint will perform much like a natural healthy joint; however, doctors often advise against high-impact exercises and movement such as crossing the legs or bending the hip at an angle greater than 90 degrees to reduce the risk of loosening, damage or dislocation.

“I allow joint replacement patients to do just about everything they want to do, but I am not a big fan of running,” says Dr. Smith. “I let people do any type of low-impact exercise they want to – playing tennis, snow skiing, playing golf, going to the gym, walking, riding a bike and swimming. Running and waterskiing are the only two I discourage.”

Yet he acknowledges that not all patients follow his advice, including one who sent him a picture of himself just the other day. “He had just finished the Ironman Triathlon [a grueling athletic event consisting of a 2.4-mile swim, 112-mile bicycle ride and 26.2-mile marathon foot race] in Hawaii about a year after his hip replacement,” says Dr. Smith. “He had done five Ironmans in his life, but when we replaced his hip he ran the quickest time that he had ever run.”

Wade Norton is not interested in accomplishing major athletic feats. He is happy just to retrieve his golf ball from the cup, climb stairs and accomplish other daily activities with little or no pain.

Norton, who jokes that he used to rate his pain as a 20 on a scale of one to 10, says he is now down to a one or two on most days. “For me, I had a motorcycle wreck that I almost died in so I am still going to have abnormalities, but the sharp pain I was having in my hip and the sharp pain I was having in my knee are gone.”

Norton’s only regret about his surgery is that he didn’t have it sooner – particularly on his knee. “I wish I had known then what I know today,” he says. “I would have gone ahead and done it sooner, because they did a great job and got me going. I realize that when you have [joint replacement surgery], you pay a little bit of time to your recovery in terms of weeks, but you don’t suffer for years like I did.”