Hip and Knee Reconstruction
From the Show: UK HealthCast
Summary:
Air Date: 3/4/19
Duration: 10 Minutes
Dr. Patrick O'Donnell explains when hip and knee reconstruction might be the right option for patients.
Transcription:
Melanie Cole (Host): With people living longer than ever, arthritis of the hip and knee is becoming more common, but when that severe pain or joint damage limits your daily activities, that’s when it might be time to consider seeing a physician to assess your pain. My guest today is Dr. Patrick O'Donnell. He’s a hip and knee surgeon that does advanced reconstruction at UK Healthcare. Dr. O’Donnell, what are some of the most common causes of joint pain? What types of conditions cause the hip or the knee to breakdown?
Dr. Patrick O'Donnell (Guest): The most common cause, Melanie, is arthritis. Arthritis can come in a lot of different forms, but I would say that the most common type of arthritis that we see is just degenerative joint disease, somebody has worn through the cartilage in their knee, and if you think of the cartilage like the tread on the tires of your car, patients are walking around on old tires. That’s probably the most common thing that we see in our clinic.
Host: So how do you diagnose? When someone comes to you in pain, and maybe they’ve had pain for a while and they put off coming to you, how do you diagnose what the cause is?
Dr. O'Donnell: The first thing we do is we do a thorough history. We want to ask the patient about their pain, what causes their pain. Where the pain is located is a big thing and then the real diagnostic tool that we use are some of our x-ray technology. Arthritis is diagnosed on an x-ray. A lot of patients will think they need an MRI, but the MRI isn’t actually the standard of care. You can tell a lot just by a basic x-ray, so that’s where we typically start for hip and knee arthritis is a good history, a good physical exam, and then an x-ray.
Host: Let’s talk about first line of defense and conservative management, some nonsurgical treatments. Kind of go down in order, what might you try first, and what do you think about modalities that people try at home such as ice or heat or bracing, activity modification, tell us what you would recommend?
Dr. O'Donnell: Yeah, I think you’ve stolen a lot of my thunder Melanie. Arthritis – you can break arthritis down into three levels, mild, moderate, and severe. Mild arthritis is something that’s very well treated with over the counter pain medicines, sometimes bracing, definitely activity modification. Moderate arthritis, is more treated with injections. Injections come in two varieties, either cortisone injections or what’s called viscosupplementation that some people may know of as a rooster comb injection or a joint lube, and then it’s the severe arthritis that we start talking about surgical management. So we really try to push with our patients, activity modifications, physical therapy, and injections before we even start talking or offering surgical options.
Host: What does that discussion look like when you’re discussing surgery for replacement with your patients and what questions would you like patients to ask a potential surgeon before moving forward with having a joint replaced?
Dr. O'Donnell: Yeah, good question. So joint replacements are an elective surgical procedure. It’s not a heart attack, it’s not a stroke, it’s not a cancer, it’s not something that I ever go to a patient and say you have to have this done. A joint replacement is meant to improve the patient’s quality of life, and so when I meet a patient who’s thinking about a joint replacement, I tend to ask three quality of life questions. Does your pain bother you every day? Does your pain keep you from doing things that you want to do in life and often does your pain keep you from sleeping? If your arthritis pain is affecting those three areas of your life, it’s probably time to have a discussion about surgical management once the patient has exhausted all the conservative measures. We think of it like the patient’s painted into a corner. They’ve tried injections, they’ve tried physical therapy, they’ve tried braces, but they’re still having pain that keeps them from enjoying their life. It’s only then that we even begin to talk about surgical management.
Host: Tell us about some of the types of surgeries that you perform, Dr. O’Donnell. People hear partial replacement, total replacement, they’re not sure what any of that means.
Dr. O'Donnell: Yeah, so the partial versus total replacement is mostly trying to talk about varieties of knee replacement. So the knee has three compartments. A total knee replacement replaces all three compartments with a knee that’s made of metal and plastic. A partial knee replacement will replace one of those three compartments, and that’s typically only used for patients if they have arthritis in one compartment of the knee but the other two compartments of the knee have no arthritis. For hip replacements, we in today’s day and age, we typically offer total hip replacements for arthritis. There are a lot of different historic techniques for hip arthritis, but in today’s day and age, everybody sees the total replacement replacing both the ball and the socket as the standard of care.
Host: And are you doing hip replacement in the anterior approach? Tell us a little bit about what’s changed with hip replacement over the years.
Dr. O'Donnell: Yeah so hip replacement, there are a lot of ways to skin a cat in the hip replacement. Patients will come in and ask for an anterior hip replacement or a posterior hip replacement. Some people will do a direct lateral hip replacement. These are all different variations in the way that you cut into the hip, but the hip replacement is the same. We cut off the ball of the hip and give you a new ball, we then scrape out the cup and give you a new cup. The anterior hip replacement is something that we do offer in select indications. Patients have to be the right size, they have to have the right bone quality because it is definitely more of a risky procedure to do it – do the hip replacement anteriorly or through the front. The gold standard and I would say what we do the majority of our hip replacements today is what’s called a posterior hip replacement. That’s the way that hip replacements have been done since the 1950s and it is an awesome surgery. If a patient gets a posterior, that does not mean that their outcome is going to be any different than an anterior, it just changes their rehabilitation by about 2 to 3 weeks. So in the grand scheme of a 20 to 25 year hip replacement, 2 to 3 weeks probably doesn’t make that big of a deal.
Host: Tell us about the implants, Dr. O’Donnell, what’s new and exciting with them and what’s changed over the years?
Dr. O'Donnell: Yeah so in orthopedic replacement, there are I would say five main manufacturers of orthopedic implants. Personally I use Stryker implants. I think that the Stryker Triathlon is an excellent knee replacement that has a great track record. We have great customer service from our Stryker colleagues. We actually have a member of Stryker in the operating room in real time who during the surgery can answer questions regarding sizing the patient, regarding motion for the patient, that can help me while the patient’s asleep in real time troubleshoot the surgery. For hip replacements it’s the same. I use Stryker components for the hip replacement, and again the Stryker hip replacement has a great track record. Other hip replacements and knee replacements like Biomet, Zimmer, Smith and Nephew, DePuy, they’re all great implants, we just tend to get better results with our Stryker implants, and that’s why we’ve stuck with them for about 7 years now.
Host: How long do they last and tell us about what life is like after an implant? Can they go through metal detectors in airports? What realistic expectations would you like patients to have?
Dr. O'Donnell: Yeah so for a hip replacement, a realistic expectation is what we call a forgotten joint. Patients will come in, in excruciating pain that limits their quality of life and 3 to 6 months after their hip replacements, they forget they’ve even had a hip replacement. They walk normal, without pain, and they just kind of tend to forget that they’ve had it, and that’s in the joint replacement world is considered a slam dunk, having a forgotten joint that the patient doesn’t even know that they’ve had a surgery. Knee replacements I’d say that the forgotten joint isn’t the standard. Knee replacements tend to feel a little bit more clunky for patients. It feels like a metal and plastic knee, so for our patients who like to hunt, or fish, or hike, uneven surfaces can be difficult on a knee replacement. So the goal of the knee replacement is a painless joint. It still doesn’t feel like that knee that you had when you were 20 years old, but the hope would be it’s painless. Both hip and knee replacements, we’re getting somewhere between 20 to 25 years out of the implant. So when the implants start to wear, it’s not a catastrophic bomb that goes off in the hip or the knee, but what we see radiographically on the x-rays is the thinning of the plastic component, the polyethylene that suggests it may need to be changed over time. Again, just think of the tire analogy that the polyethylene or the plastic is starting to wear like the tires on the car and it just needs to be replaced. Sometimes the implants can wiggle lose if the bone hasn’t accepted them, and so the failure of hip and knee replacements, while it is pretty rare, is something that we typically either pick up with pain or on an x-ray seeing the plastic getting too thin.
Host: What’s the rehabilitation process like after joint replacement? I understand it would be different for knees and hips, but how soon do you tell people they can kind of get back to physical activity or driving? What is rehab like for them?
Dr. O'Donnell: Yeah, so the hip replacement is the easier one but probably the more risky one. When we do the hip replacement, we actually pop the ball out of the socket, do what’s called dislocate the hip, and so after the hip surgery, patients are at a slight risk for a re-dislocation event, which sometimes can mean more surgery. So while the recovery is easier for a hip replacement, it’s actually a little bit more risky and patients have to abide by the hip precautions that the therapist will show them both before and after the surgery. Hip replacements tend to take about an hour to do. You get up and walk right away. You’re typically in the hospital maybe a night, and then I counsel patients that it takes somewhere between 8 to 12 weeks depending on the individual until you’re really back doing everything that you want to do. Knee replacements are a lot harder. I don’t make a whole lot of friends in our patients for about the first 4 to 6 weeks after a knee replacement because the knee replacement, the hardest part of it, is the recovery. Again, the knee replacement surgery takes about an hour to do. You can get up and walk right away, typically again a short maybe one or two night hospital stay, but the pain after the knee replacement can be very difficult for patients and the key for the knee replacement is while the patient is in pain, you have to do all of your therapy, you have to get your motion back, and so it’s pretty difficult. Patients don’t feel like themselves. They tend to really need to focus on their physical therapy, so the recovery is again in the 8 to 12 week mark, but it’s much more intense early on. We have great pain medicine we give patients but it doesn’t take away all the pain. As far as driving, it depends on whether it’s a right or a left sided surgery. If you do a right sided knee replacement or hip replacement, you’re probably looking at somewhere between 6 and 8 weeks before you can get back to drive. We tend to tell people that when you’re getting close to that point, to go test yourself in a parking lot prior to actually driving, so that they can be safe and morally responsible on the road. For a left sided hip or knee replacement, patients can tend to drive as soon as they can get into and out of a car and they’re off of their narcotic pain medicine, so much sooner.
Host: Wow, Dr. O’Donnell, you have given us so much great information and so much to think about. Thank you for coming on and really sharing your expertise explaining everything so beautifully for us about hip and knee replacement. Give us your best advice now on keeping healthy joints as we wrap up.
Dr. O'Donnell: I’d say keeping healthy joints is staying out of the operating room personally. I’m a surgeon, I love to operate, but I think what nature gave patients is better than anything we have as far as a replacement. The best way for patients to stay out of the operating room for hip and knee arthritis is to stay mobile. Motion is lotion. The more your move your joints, they better they’ll do and so really having an active lifestyle, walking, exercise, biking, elliptical, doing things where you’re really getting some motion in those joints can really help get you a few more miles. When the knees do wear out or the hips do wear out, we’re happy to see you but the hope would be prevention honestly Melanie.
Host: That’s great advice Dr. O’Donnell, it really is. Thank you again for joining us. This is UK Healthcare with the University of Kentucky Healthcare. For more information, you can go to ukhealthcare.uky.edu, that’s ukhealthcare.uky.edu. I’m Melanie Cole, thanks for tuning in.
Melanie Cole (Host): With people living longer than ever, arthritis of the hip and knee is becoming more common, but when that severe pain or joint damage limits your daily activities, that’s when it might be time to consider seeing a physician to assess your pain. My guest today is Dr. Patrick O'Donnell. He’s a hip and knee surgeon that does advanced reconstruction at UK Healthcare. Dr. O’Donnell, what are some of the most common causes of joint pain? What types of conditions cause the hip or the knee to breakdown?
Dr. Patrick O'Donnell (Guest): The most common cause, Melanie, is arthritis. Arthritis can come in a lot of different forms, but I would say that the most common type of arthritis that we see is just degenerative joint disease, somebody has worn through the cartilage in their knee, and if you think of the cartilage like the tread on the tires of your car, patients are walking around on old tires. That’s probably the most common thing that we see in our clinic.
Host: So how do you diagnose? When someone comes to you in pain, and maybe they’ve had pain for a while and they put off coming to you, how do you diagnose what the cause is?
Dr. O'Donnell: The first thing we do is we do a thorough history. We want to ask the patient about their pain, what causes their pain. Where the pain is located is a big thing and then the real diagnostic tool that we use are some of our x-ray technology. Arthritis is diagnosed on an x-ray. A lot of patients will think they need an MRI, but the MRI isn’t actually the standard of care. You can tell a lot just by a basic x-ray, so that’s where we typically start for hip and knee arthritis is a good history, a good physical exam, and then an x-ray.
Host: Let’s talk about first line of defense and conservative management, some nonsurgical treatments. Kind of go down in order, what might you try first, and what do you think about modalities that people try at home such as ice or heat or bracing, activity modification, tell us what you would recommend?
Dr. O'Donnell: Yeah, I think you’ve stolen a lot of my thunder Melanie. Arthritis – you can break arthritis down into three levels, mild, moderate, and severe. Mild arthritis is something that’s very well treated with over the counter pain medicines, sometimes bracing, definitely activity modification. Moderate arthritis, is more treated with injections. Injections come in two varieties, either cortisone injections or what’s called viscosupplementation that some people may know of as a rooster comb injection or a joint lube, and then it’s the severe arthritis that we start talking about surgical management. So we really try to push with our patients, activity modifications, physical therapy, and injections before we even start talking or offering surgical options.
Host: What does that discussion look like when you’re discussing surgery for replacement with your patients and what questions would you like patients to ask a potential surgeon before moving forward with having a joint replaced?
Dr. O'Donnell: Yeah, good question. So joint replacements are an elective surgical procedure. It’s not a heart attack, it’s not a stroke, it’s not a cancer, it’s not something that I ever go to a patient and say you have to have this done. A joint replacement is meant to improve the patient’s quality of life, and so when I meet a patient who’s thinking about a joint replacement, I tend to ask three quality of life questions. Does your pain bother you every day? Does your pain keep you from doing things that you want to do in life and often does your pain keep you from sleeping? If your arthritis pain is affecting those three areas of your life, it’s probably time to have a discussion about surgical management once the patient has exhausted all the conservative measures. We think of it like the patient’s painted into a corner. They’ve tried injections, they’ve tried physical therapy, they’ve tried braces, but they’re still having pain that keeps them from enjoying their life. It’s only then that we even begin to talk about surgical management.
Host: Tell us about some of the types of surgeries that you perform, Dr. O’Donnell. People hear partial replacement, total replacement, they’re not sure what any of that means.
Dr. O'Donnell: Yeah, so the partial versus total replacement is mostly trying to talk about varieties of knee replacement. So the knee has three compartments. A total knee replacement replaces all three compartments with a knee that’s made of metal and plastic. A partial knee replacement will replace one of those three compartments, and that’s typically only used for patients if they have arthritis in one compartment of the knee but the other two compartments of the knee have no arthritis. For hip replacements, we in today’s day and age, we typically offer total hip replacements for arthritis. There are a lot of different historic techniques for hip arthritis, but in today’s day and age, everybody sees the total replacement replacing both the ball and the socket as the standard of care.
Host: And are you doing hip replacement in the anterior approach? Tell us a little bit about what’s changed with hip replacement over the years.
Dr. O'Donnell: Yeah so hip replacement, there are a lot of ways to skin a cat in the hip replacement. Patients will come in and ask for an anterior hip replacement or a posterior hip replacement. Some people will do a direct lateral hip replacement. These are all different variations in the way that you cut into the hip, but the hip replacement is the same. We cut off the ball of the hip and give you a new ball, we then scrape out the cup and give you a new cup. The anterior hip replacement is something that we do offer in select indications. Patients have to be the right size, they have to have the right bone quality because it is definitely more of a risky procedure to do it – do the hip replacement anteriorly or through the front. The gold standard and I would say what we do the majority of our hip replacements today is what’s called a posterior hip replacement. That’s the way that hip replacements have been done since the 1950s and it is an awesome surgery. If a patient gets a posterior, that does not mean that their outcome is going to be any different than an anterior, it just changes their rehabilitation by about 2 to 3 weeks. So in the grand scheme of a 20 to 25 year hip replacement, 2 to 3 weeks probably doesn’t make that big of a deal.
Host: Tell us about the implants, Dr. O’Donnell, what’s new and exciting with them and what’s changed over the years?
Dr. O'Donnell: Yeah so in orthopedic replacement, there are I would say five main manufacturers of orthopedic implants. Personally I use Stryker implants. I think that the Stryker Triathlon is an excellent knee replacement that has a great track record. We have great customer service from our Stryker colleagues. We actually have a member of Stryker in the operating room in real time who during the surgery can answer questions regarding sizing the patient, regarding motion for the patient, that can help me while the patient’s asleep in real time troubleshoot the surgery. For hip replacements it’s the same. I use Stryker components for the hip replacement, and again the Stryker hip replacement has a great track record. Other hip replacements and knee replacements like Biomet, Zimmer, Smith and Nephew, DePuy, they’re all great implants, we just tend to get better results with our Stryker implants, and that’s why we’ve stuck with them for about 7 years now.
Host: How long do they last and tell us about what life is like after an implant? Can they go through metal detectors in airports? What realistic expectations would you like patients to have?
Dr. O'Donnell: Yeah so for a hip replacement, a realistic expectation is what we call a forgotten joint. Patients will come in, in excruciating pain that limits their quality of life and 3 to 6 months after their hip replacements, they forget they’ve even had a hip replacement. They walk normal, without pain, and they just kind of tend to forget that they’ve had it, and that’s in the joint replacement world is considered a slam dunk, having a forgotten joint that the patient doesn’t even know that they’ve had a surgery. Knee replacements I’d say that the forgotten joint isn’t the standard. Knee replacements tend to feel a little bit more clunky for patients. It feels like a metal and plastic knee, so for our patients who like to hunt, or fish, or hike, uneven surfaces can be difficult on a knee replacement. So the goal of the knee replacement is a painless joint. It still doesn’t feel like that knee that you had when you were 20 years old, but the hope would be it’s painless. Both hip and knee replacements, we’re getting somewhere between 20 to 25 years out of the implant. So when the implants start to wear, it’s not a catastrophic bomb that goes off in the hip or the knee, but what we see radiographically on the x-rays is the thinning of the plastic component, the polyethylene that suggests it may need to be changed over time. Again, just think of the tire analogy that the polyethylene or the plastic is starting to wear like the tires on the car and it just needs to be replaced. Sometimes the implants can wiggle lose if the bone hasn’t accepted them, and so the failure of hip and knee replacements, while it is pretty rare, is something that we typically either pick up with pain or on an x-ray seeing the plastic getting too thin.
Host: What’s the rehabilitation process like after joint replacement? I understand it would be different for knees and hips, but how soon do you tell people they can kind of get back to physical activity or driving? What is rehab like for them?
Dr. O'Donnell: Yeah, so the hip replacement is the easier one but probably the more risky one. When we do the hip replacement, we actually pop the ball out of the socket, do what’s called dislocate the hip, and so after the hip surgery, patients are at a slight risk for a re-dislocation event, which sometimes can mean more surgery. So while the recovery is easier for a hip replacement, it’s actually a little bit more risky and patients have to abide by the hip precautions that the therapist will show them both before and after the surgery. Hip replacements tend to take about an hour to do. You get up and walk right away. You’re typically in the hospital maybe a night, and then I counsel patients that it takes somewhere between 8 to 12 weeks depending on the individual until you’re really back doing everything that you want to do. Knee replacements are a lot harder. I don’t make a whole lot of friends in our patients for about the first 4 to 6 weeks after a knee replacement because the knee replacement, the hardest part of it, is the recovery. Again, the knee replacement surgery takes about an hour to do. You can get up and walk right away, typically again a short maybe one or two night hospital stay, but the pain after the knee replacement can be very difficult for patients and the key for the knee replacement is while the patient is in pain, you have to do all of your therapy, you have to get your motion back, and so it’s pretty difficult. Patients don’t feel like themselves. They tend to really need to focus on their physical therapy, so the recovery is again in the 8 to 12 week mark, but it’s much more intense early on. We have great pain medicine we give patients but it doesn’t take away all the pain. As far as driving, it depends on whether it’s a right or a left sided surgery. If you do a right sided knee replacement or hip replacement, you’re probably looking at somewhere between 6 and 8 weeks before you can get back to drive. We tend to tell people that when you’re getting close to that point, to go test yourself in a parking lot prior to actually driving, so that they can be safe and morally responsible on the road. For a left sided hip or knee replacement, patients can tend to drive as soon as they can get into and out of a car and they’re off of their narcotic pain medicine, so much sooner.
Host: Wow, Dr. O’Donnell, you have given us so much great information and so much to think about. Thank you for coming on and really sharing your expertise explaining everything so beautifully for us about hip and knee replacement. Give us your best advice now on keeping healthy joints as we wrap up.
Dr. O'Donnell: I’d say keeping healthy joints is staying out of the operating room personally. I’m a surgeon, I love to operate, but I think what nature gave patients is better than anything we have as far as a replacement. The best way for patients to stay out of the operating room for hip and knee arthritis is to stay mobile. Motion is lotion. The more your move your joints, they better they’ll do and so really having an active lifestyle, walking, exercise, biking, elliptical, doing things where you’re really getting some motion in those joints can really help get you a few more miles. When the knees do wear out or the hips do wear out, we’re happy to see you but the hope would be prevention honestly Melanie.
Host: That’s great advice Dr. O’Donnell, it really is. Thank you again for joining us. This is UK Healthcare with the University of Kentucky Healthcare. For more information, you can go to ukhealthcare.uky.edu, that’s ukhealthcare.uky.edu. I’m Melanie Cole, thanks for tuning in.
