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Total Joint Replacement

Our guest expert in October 2011 was Dr. Cory Borkhoff, a postdoctoral research fellow at the Women’s College Research Institute. Dr. Borkhoff is part of the Canadian Osteoarthritis Research Program (CORP) and is interested in developing effective ways to improve health care quality or reduce disparities in the care of disadvantaged populations with osteoarthritis.

Dr. Borkhoff answered questions about the total joint replacement procedure and recovery process, arthroscopic surgery, possible new knee joint replacement products and much more! Check out the latest answers to your questions. 

 

Q: What is the research on arthroscopic surgery and the evidence of success prior to full joint replacement? Is total joint replacement inevitable following arthroscopic surgery?

A: Arthroscopic surgery is an orthopedic procedure that is used to diagnose and treat problems in joints. The word ‘arthroscopy’ comes from two Greek words: 'arthro' meaning ‘joint’ and 'scope' meaning ‘look’. Thus, arthroscopic surgery is an orthopedic procedure that is used to look inside a joint to diagnose and hopefully treat the problem. While arthroscopic surgery can be performed on any joint, the knee is by far the most common joint to be arthroscoped, or ‘scoped,’ among the weight-bearing joints of the lower limb (hip, knee and ankle). Arthroscopic surgery can be done under general, regional or local anesthesia. Arthroscopic knee surgery involves inserting a small camera inside the knee joint through a small incision (about one centimetre) and inserting instruments to repair or remove damaged structures through one or more other small incisions.

Not all causes of knee pain can be effectively treated with an arthroscopic procedure. Some of the reasons for performing arthroscopic knee surgery include repairing or removing a portion of the meniscus cartilage from the knee joint to relieve the symptoms of a meniscus tear. The meniscus is a shock-absorbing wedge of cartilage that sits between the bone ends to provide cushioning and support. Both the covering of the bone within the joint and the meniscus are made of cartilage, and this makes the issue a little confusing. People often say ‘cartilage’ to mean the meniscus (the wedge of cartilage between the bone) or to mean the joint surface (the articular cartilage which caps the ends of the bone). The surgeon has two options: either to trim/remove the torn meniscus, or to repair the meniscus by rejoining the torn outer edges of the meniscal tissue to heal in their proper place, thereby restoring the normal anatomy of the knee.

Many meniscal tears, particularly chronic tears, can be treated non-operatively with physiotherapy, including exercises to strengthen the muscles around the knee, anti-inflammatory medications, and cortisone injections. Tears of the meniscus that cause so-called ‘mechanical symptoms’ are those that tend to respond best to surgical repair or removal. A mechanical symptom is caused by a piece of the torn meniscus physically impinging the normal movement of the knee. Common ‘mechanical symptoms’ include locking of the knee joint (unable to bend), inability to completely straighten the knee joint, a popping or clicking sound or sensation within the knee. The success rate of a meniscus repair is 60 to 80 per cent and is dependent on two factors:

  1. the meniscus repair is attempted on a meniscus tear near the outer edge of the meniscus in an area of good blood supply
  2. the patient must be compliant with the post-operative rehabilitation after surgery. 

Patients who have osteoarthritis of the knee joint do well with arthroscopic knee surgery when their symptoms are coming primarily from loose or torn cartilage and they are experiencing mechanical symptoms listed above. However, generalized discomfort due to osteoarthritis in the knee joint is unlikely to improve with arthroscopic knee surgery. Determining the source of discomfort is critically important to predicting the outcome of surgery for this problem. This will involve a careful history, physical examination and an MRI to help the surgeon to visualize the meniscus. 

Arthroscopic knee surgery came under public scrutiny after a paper published in the New England Journal of Medicine in 2002 suggested that arthroscopic knee surgery for treatment of osteoarthritis of the knee joint was no better than a ‘sham’ surgery. For this study, 180 patients at a hospital in Texas were separated into three groups. One group received arthroscopic knee surgery, where the knee was 'cleaned up,’ another group received a knee wash-out with a saline solution and the final group had no procedure at all, a ‘sham’ surgery. Interestingly, all of the patient groups were ‘better’ after their treatment, even the sham surgery group (this is known as a placebo effect). However, the results also showed that there was no difference in outcome between these groups. A number of orthopedic surgeons criticized this study because many of the patients in all three groups did not have ‘mechanical symptoms’ (typically described by patients as a ‘catching sensation,’ a giving way, or painful popping) and would therefore not have undergone arthroscopic knee surgery. This leads me to answer your second question by saying that no, total knee replacement is not inevitable following arthroscopic surgery. As long as arthroscopic surgery is done for the right reasons, it is usually effective.

Reference

Moseley JB, O'Malley K, Petersen N, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton C M, Wray NP.  A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81–8.

 

Q: I have been bone on bone in my left knee on the outside of the knee for over two years. The inner side of my left knee seems to be okay. My orthopedist said he doesn’t believe in partial replacement, therefore I am scheduled for a total replacement this January. He said that this surgery is harder to do and will result in a 10-inch scar and a half-moon scar on the right of the knee, and probably a bulge on the left side. These two results of surgery are a surprise to me and it all seems horribly disfiguring. He didn't say what the success rate is, so I am afraid. I have heard horror stories regarding pain, infections and physiotherapy that sound agonizing. What if the surgery isn't successful? I fear going through all this with little or no improvement. My knee is bad. I can't walk far or dance, and my balance is off, but I think my right hip is even worse. I have had unrelenting bursitis now for at least eight years, for which I have had physiotherapy for, so I’m wondering if I should have the total knee replacement. What is the success rate for this surgery? How do I overcome my fears of having plastic and metal jammed in my knee and the horrors of physiotherapy? Is there anything else I can do about my hip besides physiotherapy? My hip is more of a pain and a bother to me than my knee. Thank you very much for your answers.

A: Being ‘bone on bone’ in your left knee, not being able to walk far and your balance being off, suggests that your osteoarthritis is severe and that you are an appropriate candidate for total knee replacement. Total knee replacement surgery is the accepted treatment for those with moderate to severe osteoarthritis when medical therapy no longer adequately controls the pain and /or physical functioning reaches a level that is unacceptable to the patient. Approximately 60,000 Canadians per year have a total hip or knee replacement (that is, an artificial hip or knee made of plastic and metal parts). Most patients (90 per cent) who have a total knee replacement experience a substantial and long-term reduction in joint pain, and improvement in physical function and quality of life. In fact, total joint replacement surgery ranks near the top among medical and surgical interventions in improving the quality of life of individuals. About 89 out of 100 people find that almost all of their pain goes away after recovery from surgery. That means that 11 out of 100 people still have pain, though only about one out of 100 say that the pain remains severe. 

It would appear that what your surgeon has recommended is right for you and that you have already decided to have surgery, since you are scheduled for January. If you are having reservations about whether or not to have a total knee replacement, it is important that you have this discussion with your surgeon. Your decision about if and when to have a total knee replacement depends on how your knee pain affects your life, how much non-surgical treatment helps, and what you want to do to make things better. Having a total knee replacement sooner gives you a better chance at having the best function from the artificial knee. It is important to know that while total knee replacements do not last forever, the rate of revision surgery (needing a second knee replacement) is low. For 96 out of 100 people, the artificial knee lasted at least 15 years and 82 out of 100 people had artificial knees that lasted at least 23 years. The patients who are overweight, are more active and younger tend to wear out artificial knees more quickly. Having your knee replaced sooner may increase the chance that you will need a revision surgery sooner, and this is the reason why some surgeons advise people in their 50s to hold off as long as they can before having a total knee replacement. There is a less than one per cent risk of major complications, including blood clots and a deep infection in the joint. Every surgery carries the chance of death (one in 200 people over age 65) from problems with anesthesia, blood clots in the lungs or other causes. 

The time it takes to recover from total knee replacement surgery is different for every person. For the first six months you may continue to have some joint pain; however the pain will reduce with time. For most people, total knee replacement relieves pain and restores normal movement. It does take time and effort after surgery to get to this point, but an experienced physiotherapist will help you get there. You will likely receive physiotherapy from a physiotherapist dedicated to providing therapy to people post total joint replacement. In addition, you will receive appropriate pain management throughout your recovery. As for the length of the scar, this will depend on the surgical technique your surgeon uses and how big your leg is (i.e., the bigger your leg is, the bigger the scar). Rather than focus on the length of the scar, it might be better to focus on what your surgeon is doing underneath your skin to your muscles and tendons to try to reduce your pain and improve your function.    

My answer to you wouldn't be complete without a word about partial total knee replacement. The partial knee replacement surgical procedure has generated interest because it involves a smaller incision and faster recovery than total knee replacement surgery. However, partial knee replacement is only for those with osteoarthritis in the knee confined to a limited area. If the arthritis is widespread, then the partial knee replacement is NOT appropriate and should not be considered. Most patients who seek surgical management have osteoarthritis that is too advanced for the ‘minimally invasive’ partial knee replacement procedure. If partial knee replacement is done in a patient who is a poor candidate, failure rates can be high and patients may need additional surgery and possible conversion to a total knee replacement, which would then be more difficult. 

I'm terribly sorry to hear that you have been experiencing right hip pain on top of having to cope with osteoarthritis in your left knee. As you probably know, your right hip pain may have contributed to a worsening of your left knee osteoarthritis. Eight years of bursitis in your right hip is a long time and may have contributed to you not wanting to endure any more physiotherapy. Are you currently seeing a physiotherapist for your bursitis? Have you been seeing the same physiotherapist for your bursitis for the last eight years? If so, you may wish to consider treatment by a new physiotherapist. It is important that your physiotherapist is registered and has the proper credentials. A new physiotherapist may lead to a more positive experience of physiotherapy.  

Treatment for hip bursitis is aimed at controlling the inflammation caused by this condition. This involves: rest, anti-inflammatory medications, and icing the area of hip bursitis three times per day for 20 minutes to alleviate your symptoms. Especially after being active, ice can control inflammation and stimulate blood flow to the injured area. Most patients who are faithful about treatment to control the inflammation see improvement within about six weeks. Working with a physiotherapist is considered adjunct treatment for patients with hip bursitis. A qualified physiotherapist can provide a proper stretching and exercise program, and use modalities such as ultrasound which may be helpful as well. Most patients find relief with stretching of the muscles and tendons that are found over the outside of the hip, specifically the iliotibial band. 

Since you have had hip bursitis for eight years now, it may worth being re-examined by your doctor. The diagnosis of hip bursitis is made most reliably on physical examination. Your doctor may obtain an MRI if the diagnosis is unclear or because your problem has not resolved with treatment. Should you have a significant amount of fluid that has collected within the bursa, your doctor may place a needle into the bursa to remove the fluid. Or your doctor may consider giving you a cortisone injection into the bursa to see if it helps to alleviate your pain. If you visit your orthopedic surgeon to discuss having a total knee replacement, your surgeon could also help treat your hip bursitis.

 

Q: I'm hearing about new, better knee joint replacement products making a surgical solution available to younger patients, in their 50s. Can you comment? The surgeon said I am too young for a surgical option, and felt I am ‘dealing’ with it – he told me to try to stay active and lose weight. When I am walking, the pain is at a 10. Exercise is now problematic, but my weight is escalating. Hiking, camping and cross-country skiing are all things of the past. I have severe osteoarthritis in the right knee and significant arthritis in the left. There is mild evidence of arthritis in my left thumb and left ankle. I am 52, 5'2" and 210 pounds. Weight is an obvious issue.

A: Many orthopedic surgeons advise people in their 50s to hold off as long as they can before having total knee replacement surgery. This is to reduce their chances of needing to have the artificial knee replaced again later in life – this is called revision surgery. About four in 100 need to have second knee replacement within 15 years of having their first knee replacement. This number goes up for people who weigh more, are young and more active. When the knee is replaced a second or third time, the results may not be as good as the initial replacement. There may be a significant amount of bone loss and damage to the muscles and ligaments around the knee joint that makes it harder for a surgeon to make the new artificial implant fit well with each subsequent replacement surgery. That is, with each successive surgery, the surgeon has ‘less of you’ to work with.   

Putting off knee replacement surgery until later may make sense for people who can manage their knee pain, who can still do the things they want and need to do. But the level of pain you are describing can make people less active and weaken their muscles, ultimately making it harder to take part in rehabilitation post total joint replacement surgery. This could result in less improvement after surgery and a decline in overall health. So it's extremely important to remain active. Keep in mind that you also shouldn't wait too long, as we know that those who receive surgery at a more advanced stage of disease do not receive as much of a benefit from total knee replacement as someone with relatively lesser degree of disability. You may wish to consult your orthopedic surgeon on an annual basis to re-evaluate how your knee pain affects your life, how much non-surgical treatment helps, and what you want to do to make things better. 

In the meantime, resources exist to help you find other options for managing your knee osteoarthritis. The Multidisciplinary Osteoarthritis Program at Women's College Hospital provides patients with individualized, in-depth assessments to assist individuals to participate in all aspects of their osteoarthritis care. Patients learn about treatment options and strategies to help them manage the symptoms of osteoarthritis with access to a team of specially educated professionals. An individualized, comprehensive program is developed along with the individual in order to promote a healthy, active lifestyle. A referral from a physician is required. Please visit the website to learn more and to download the referral form.

The Arthritis Society (http://www.arthritis.ca/) is another valuable resource that offers treatment and education opportunities in your community. Most of the programs they offer are free or only charge a nominal fee. The Arthritis Society offers a program called the Arthritis Self-Management Program (ASMP) which is taught over a six-week period in weekly two-hour sessions. Each of these programs usually has from eight to 14 people and is led by a pair of volunteer leaders, who have arthritis themselves. The Arthritis Society also offers personalized programs as part of their Arthritis Rehabilitation and Education program that involves an individualized assessment by a physiotherapist, occupational therapist and/or social worker with advanced training in the management of arthritis. All of their programs will help you learn exercises to reduce stiffness and improve fitness, how to manage pain, how to feel less tired, learn about updates on medication and medical devices, and learn ways to cope with emotional impact of arthritis.

To be assessed by one of their therapists or to learn more about their Arthritis Self-Management Program, you can call their toll-free information line at 1-800-321-1433, or email info@on.arthritis.ca.

You mentioned that exercise is now problematic. After an individualized assessment, they will likely suggest you to try other forms of exercise that are non-weight-bearing and non-impact, such as cycling (indoor and out), water aerobics or exercises, swimming, stretching, tai chi and/or flexibility exercises.

But remember, as you embark on a new program, it is important not to strain yourself and to go at your own pace.

You mentioned hearing about new knee joint replacement products making a surgical solution available to younger patients. I'm not exactly sure what you may be referring to. One possibility is the use of robotics combined with computer-assisted surgery. These high-tech tools provide a surgeon with 3-D visualization. This allows for greater visibility to help guide the positioning of the prosthesis components and the potential to more precisely align an artificial knee implant according to the structure of the patient's body and achieve a more optimal position. Computer-assisted surgery is either ‘active,’ involving surgical robots, or ‘passive,’ whereby computer systems do not perform any of the surgery but assist only in the positioning of the surgical instruments. With a more exact placement of the implant, there is a decreased possibility of needing to have revision surgery. As mentioned previously, conventional total knee replacement usually lasts about 15 to 20 years. Some suggest that with computer-assisted surgery, the knee replacement may last up to 30 years. With an increased longevity of the initial implant, these new and high technologies may mean being able to offer knee replacement surgery to younger patients. However, these technologies are relatively new, only receiving approval by Health Canada in 2004. And there is a lack of evidence on important outcomes such as function, satisfaction and survival that will not be available for another five to 10 years. While there are some hospitals in Canada using this new technology, it tends to be used only in more complicated total knee replacement surgeries and for only very few procedures. Until more data are available, the Ontario Health Technology Assessment Committee has concluded that there is not enough evidence regarding the long-term outcomes and safety of computer-assisted joint replacement surgery to support its recommendation.

 

Q: I was told I needed a total knee replacement on my right knee in 2009. Later the same year, my L5 nerve was crushed by a massive herniated disc between vertebrae L4 and L5 resulting in immediate drop-foot in my right foot. The muscles controlled by this nerve are not functional, although I am independently mobile, use a foot brace, and exercise with aquafit and Pilates. However, my knee problem has worsened considerably since the spinal problem and I have taken my first cortisone shot which has eradicated the pain for now. I am seriously considering having a total knee replacement. My question is: what is your experience with patients with drop-foot and a total knee replacement? I am concerned not only about the recovery time, but perhaps the possibility that the outcome might be worse than it is now. Are there any other recommended therapies?

A: Since you were told that you need a total knee replacement on your right knee in 2009, that suggests your knee osteoarthritis is significant. Specifically strengthening the muscles around your knee prior to surgery is important for all surgical candidates to improve one’s chances of experiencing the full benefit of total knee replacement. This is even more important for someone with muscle weakness due to foot drop. Cortisone has helped to eradicate your pain for now, and this is a very good opportunity to work specifically at strengthening the muscles around your right knee, since you are pain-free. Timing your total knee replacement once you have made significant gains in increasing your strength could help you to achieve greater benefit from surgery. Given that you are managing quite well with your foot drop (you are independently mobile, use a foot brace and exercise), you will likely experience a satisfactory outcome, but you will have a slower recovery. Muscle weakness caused by your foot drop will slow the recovery of your balance and proprioception (the sense of the relative position of neighbouring parts of the body and strength of effort required to move your body parts). Thus, the strengthening exercises are key in helping you begin your recovery from "a better baseline" prior to surgery.

You mentioned that your knee problem has worsened since your herniated disc. Did you receive or consider surgery to alleviate the underlying problem causing your foot drop (surgical procedure involving disc removal to 'decompress' the nerve)? There is a chance that the increasing pain in your knee may be a result of residual pain associated with your back problem travelling down your leg. If this is the case, you may not get pain relief in your knee from having a total knee replacement. Instead, you may need to address this residual pain. A spine surgeon or neurosurgeon would be able to advise you. Surgery for removal of the disc at this stage would not be for correcting the foot drop, rather it is done to prevent pain radiating to the legs.

I would recommend finding a good physiotherapist to help you with exercises to strengthen the muscles around your knee, as well as to strengthen your lower back and stomach muscles. You will be encouraged to stretch and increase the flexibility of your spine and legs. Physiotherapists can also instruct you on proper posture, lifting and walking techniques. Please see my response to question three above and consider an individualized assessment at either the Multidisciplinary Osteoarthritis Program at Women's College Hospital or with a therapist at the Arthritis Society. 


Q: I am a 56-year-old female with osteoporosis and degenerative osteoarthritis in the right hip. My general physician doesn’t seem to take my complaints seriously, telling me I am too young for hip replacement and that the general mode of treatment is pain management. I have been active all my life and am finding it more and more difficult, but I push through the pain with some assistance of pain meds and force myself to continue my active lifestyle. Finally, through my urging, I have a referral to an orthopedic surgeon but must wait a year for an appointment. I am totally frustrated. My quality of life is suffering, along with my sex life. Are there other treatments that might help while I wait (such as massage therapy or acupuncture)? I have tried physiotherapy without much relief.

A: Good for you for urging your general physician for a referral to finally see an orthopedic surgeon.  However, you should not have to wait so long to see one. In 2004, Canada introduced a National Wait Times Strategy to better manage and reduce surgical wait times, including hip replacement surgery. The goal has been to reduce the wait time for surgery (the time from when your surgery is booked to the time you receive it). By the same token, this should help to reduce the time it takes for you to have your first appointment with an orthopedic surgeon. The Ontario Ministry of Health has a website where one can look up wait times for hip replacement by city or postal code. Follow the link at http://bit.ly/uoiVkb and enter the city in which you live to find out more information.

If you enter Toronto, for example, University Health Network is listed as having the shortest wait time at 90 days. Although this is referring to the wait time for the surgery itself, you should be able to see a surgeon in three months. Ask your physician to refer you to see another orthopedic surgeon who has a shorter wait list.  Another option is to ask your doctor to refer you to a rheumatologist, who can also refer you to an orthopedic surgeon with a shorter wait list and help you to better manage your osteoarthritis (along with your osteoporosis) in the meantime.

 Please also see my response to question three above and consider an individualized assessment at either the Multidisciplinary Osteoarthritis Program at Women's College Hospital or with a therapist at the Arthritis Society. Remember, to be assessed by an Arthritis Society therapist, you can call their information line toll-free at 1-800-321-1433 or email them at info@on.arthritis.ca, as it is a self-referral. Both programs have professionals who will assist you in developing an individualized, comprehensive program to help you manage your osteoarthritis.

 With respect to other treatment, there are many effective treatments. The only strategy that we know that works to slow the progression of osteoarthritis is weight loss and exercise. However, both are often under-prescribed. Conditioning exercises including strengthening exercises (joint specific circuit training (e.g. Nautilus) and aerobic exercises (walking, cycling, aquafit) decrease pain due to osteoarthritis. Many people who suffer from pain due to osteoarthritis are reluctant to take pain medication (for example, for fear of becoming addicted), and intentionally take their medication less often or at a lower dose than prescribed.  However, you cannot become addicted. Along with exercise and weight loss, treatment guidelines recommend the use of Tylenol, an analgesic for pain. One can use up to four grams of Tylenol per day for three to four weeks. After this, it should be reduced to a maintenance dose of up to 3.2 grams per day.  Tylenol Extra Strength is 500 milligrams per tablet, meaning that one can use up to two tablets four times daily. It sounds like you may benefit from more pain medication. I suggest you try using it before activity that may exacerbate the pain. There is conflicting evidence regarding the efficacy of traditional Chinese acupuncture in reducing osteoarthritis pain, largely because of the problem in blinding subjects from the treatment in clinical trials. And while massage will make you feel good as it promotes relaxation and reduces stress, there is no evidence to support that massage therapy reduces pain due to osteoarthritis. 

 

 

 

 

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