Joint Replacement: When Medicine and Physical Therapy Aren’t Enough
Imagine that you can’t run, walk or even stand without experiencing pain in your knees. Maybe your hips hurt so bad it’s all you can do to get out of bed in the morning. Millions of Americans experience varying degrees of joint pain due to arthritis or injury, but if you’re one of them, it doesn’t mean you have to sit out life on the sidelines.
Physicians at Texas Health Resources work together every day to get North Texans back on their feet through a combination of therapy, medications and, in the most serious cases, surgery.
Donald Hohman, M.D., a joint replacement specialist on the medical staff at Texas Health Center for Diagnostics and Surgery, said he sees patients in four basic stages of joint pain, from those with occasional flare-ups to those needing total joint replacement surgery.
“Most commonly we see people in their 40s or 50s who are experiencing pain, usually due to strenuous exercise like CrossFit,” Hohman said. “They might have some pain and swelling, but can generally get back to normal by modifying their activities, taking over-the-counter pain relievers and resting.
“The next group are made up of those with more wear and tear on their X-rays, who experience pain on and off. Something might flare up or they might have a torn meniscus that just gets worse. Generally, we direct them to pain relievers and physical therapy, which helps keep the muscles strong around the knee.”
In addition to the weekend warrior types, Hohman said the third category of patients experiences more severe arthritis and significant pain, but a combination of therapy, braces and injections can usually get them through their discomfort.
“Sometimes the pain gets so bad it wakes them up at night and it may be unbearable when their knees touch together or they make any twisting motion,” he said. “These people have more impressive arthritis on their X-rays and are beyond just physical therapy, so we try injections, either steroid injections with numbing medication or lubricating-like injections that act like putting grease in the gears.”
The final category of patients that Hohman and his colleagues see includes those who need partial or total replacement surgery due to pain that has become unbearable.
“These are the people who have tried everything and say they just can’t live like this anymore,” Hohman said. “When joints start to wear out, there just aren’t a lot of good options. We see both young and older people with severe rheumatoid arthritis or psoriatic arthritis, which can cause horrific knee problems. The medications for these autoimmune diseases are improving, but surgery is still often necessary.”
According to the American Academy of Orthopaedic Surgeons, close to 1 million Americans received total joint replacements in 2011. And while hip and knee replacements are the most common, other joints such as the wrist, elbow, shoulder and ankle can be replaced as well.
Joint replacement surgery involves removing the damaged cartilage and bone before replacing them with metal, plastic or ceramic prosthetic components, which replicate the damaged joint. And while a large majority of patients who undergo joint replacement report a significant improvement, maintaining realistic expectations is important.
“It’s challenging to see a person in their 40s or 50s who is really active and the replacement doesn’t work the way they want it to because they aren’t designed for high performance,” Hohman explains. “I recently saw an avid weight lifter who had someone else do his knee replacement but he’s not happy because it’s not allowing him to do the things he did before.
“I try to be honest with people so they can make an informed decision with the right expectations. Knee replacement is a pain relieving operation, but it’s good for walking around the grocery store, not for climbing Mt. Everest.”
The most important thing for patients to understand before selecting joint replacement surgery is that while the surgery will relieve their pain, their bodies won’t feel or perform the same as before.
“These replacements are mechanical parts, so you’re not going to get the same feedback,” Hohman said. “You lose ligaments in surgery and since they’re no longer communicating to your brain, the joint isn’t going to work the same as it did when you were younger. If we can do a partial knee replacement and keep all of the ligaments inside the knee, it gives more stability and better maintains that ‘normal’ feeling because you have more of your own parts.”
Hohman said patients should be in the best physical and mental shape possible before heading into surgery to limit potential complications, such as blood clots and infections, and to limit extended recovery periods. Overweight patients should try to reach a body mass index of less than 40, and those with diabetes should aim to control their blood sugar levels for at least six months. Finally, patients should ask their doctors any questions about potential limitations and not expect more than the surgery can reasonably deliver.
“Sometimes we can help people get relief with braces, injections or physical therapy and that’s what we want,” he said. “I never want to perform surgery unless we have to, so we try to bridge the gaps in other ways if possible. When the pain gets too bad though, we’ll be ready to do surgery to improve their quality of life.”