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How To Get The Most Out Of Your Joint Replacement Surgery

Dr. Adam Rothenberg explains the process of a joint replacement procedure, what you should expect and how to prepare.
How To Get The Most Out Of Your Joint Replacement Surgery
Featuring:
Adam Rothenberg, MD
Dr. Adam Rothenberg is a fellowship-trained orthopedic surgeon specializing in total hip, total knee and partial knee replacement surgery. With extensive training in robotic-assisted techniques, he focuses on using minimally invasive approaches and patient specific instrumentation to achieve the best results for his patients. Dr. Rothenberg also has advanced training in performing complex hip and knee arthroplasty revisions. 

Learn more about Adam Rothenberg, MD
Transcription:

Melanie Cole: Welcome to Checkup Chat with Evergreen Health. I'm Melanie Cole, and I invite you to listen in, as we discuss joint replacement surgery, how to get the most out of your joint replacement surgery. Joining me is Dr. Adam Rothenberg. He's an Orthopedic Surgeon and Orthopedic and Sports Medicine Physician at Evergreen Health Orthopedic and Sports Care. Dr. Rothenberg, it's a pleasure to have you join us today before we get into joint replacement surgery. What types of conditions cause our joints to break down? And what's generally the first conservative line of management for that type of pain?

Dr. Rothenberg: Hi Melanie. Thanks for having me. The conditions that break down our joints are usually osteoarthritis and rheumatoid arthritis. In addition, if patients have had trauma in the past, they may develop a process called avascular necrosis, otherwise known as osteonecrosis, where the joint surfaces are damaged and due to poor blood supply. So there's a number of conditions that lead to joint destruction. In addition, gout or pseudo gout, or a couple of inflammatory conditions that are more rare in terms of causing damage, but can lead to arthritic conditions. And then the first conservative option is usually multi-factorial or multi pointed approach, including weight loss is an important component of taking stress off of our joints, eating a healthy, balanced diets, just overall preventative measures. And in terms of interventions, we tend to use a lot of nonsteroidal anti-inflammatories. Those have been shown to be effective in osteoarthritis care. And they're one of the first line options for treating pain and keeping people mobile before considering surgery.

Host: And let's talk about when that discussion about surgery becomes that discussion. When does that happen? What really is it like for the patient and what are the different types of replacements that you perform?

Dr. Rothenberg: Good questions. So the transition for every patient from a conservative pathway to a surgical pathway is a bit unique and it depends on each patient and their unique desires for postoperative recovery, like quality of life, how much pain they can tolerate, how much dysfunction they can tolerate within their daily life. And so those interviewing questions with patients are really standardized, but the answers are often very unique to each patient. Typically patients that cross over from a conservative to a surgical pathway are really having pain with activities of daily living. And so that's a kind of a buzzword or a jargony term, but really what that means is pain walking on level surfaces. You just don't want to go out to the grocery store. You don't want to leave your house. You don't want to go around the block pain going up and downstairs.

You got to take the escalator or the elevator, even like with hip replacements pain, where you can't even put your shoes or socks on, because you can't rotate or bend your hip. So we know from outcome scores, patients who have those types of symptoms, that's a Verity of symptoms actually do the best from joint replacement because they've really gotten to a functional deficit that replacement's going to make them really improve their quality of life. There are patients that it's more of a nuance thing. They have pain with certain activities such as biking or not quite the level of severity that I was previously describing that are still joint replacement candidates because arthritis can manifest for everyone in a different way. And if you're a biker or you're trying to stay active and you have arthritis and it just keeps you from doing the things that you enjoy in your life. Sometimes we pull a trigger at a little different place for that patient, even at a younger age because it just it's a quality of life and surgery.

And then I think your second question was, what type of replacements do I perform? I do total hip replacements, total knee replacements and partial knee replacements. I do partial hip replacements, but usually for surgical trauma. And so that's not typically an elective type procedure where patients come through the office and the partial knee replacements, conversely, are usually targeted towards replacing just one of the three parts of the knee that can go wrong, a preservation of the other two parts. And so we try to minimize the invasiveness of the procedure and target just the area that's damaged when we can.

Host: Interesting field that you are in Dr. Rothenberg, what are some of the risks or complications that you tell patients that can present themselves after a joint replacement and how can a patient prepare for recovery? What do you like them to do before a joint replacement? And whether it's weight loss, which you mentioned a little, should they be exercising, strengthening their quads and hamstrings? What should they be doing before a joint replacement that will give them better outcomes?

Dr. Rothenberg: Great question. I'll tackle those in the order that you, you mentioned them. So complications are a little bit specific and a little bit general and both cases for hip and knee replacements in terms of both a common risk is a blood clot in the leg. And sometimes blood clots that can go to the heart or lung area called a pulmonary embolism. Fortunately, the pulmonary embolisms are low risk, extremely uncommon, but blood clots in the leg, which can be painful and require blood thinning medications after they're sustained can happen in as many as one to 2% of patients. Infection is a devastating complication that can occur after joint replacement or the infections through bacteria within the joint replacement requires at least one surgical intervention where we go back in, clean the infection. And then the patient receives antibiotics for some time after that procedure. In addition to that, we do have procedural risks that are specific to hip or knee replacement.

As I mentioned, hip replacement has a risk of fracture or placing an implant within the bone that then the bone breaks. And we have to repair that the time of surgery. Also the hip coming out of the socket, which is called dislocation is a unique to hip replacement. Both of those fortunately are lower and lower risk these days with newer technology and techniques, but they do occur in patients between one and 250 to one in a few thousand, depending on the technique and the patient type. For the knee replacements, there's a slightly higher risk of blood vessel and nerve damage just because of the proximity of those to the knee. And there's a slightly higher risk of the implants coming loose over time, just based on the mechanics. But again, those are extremely rare risks. So we're really focusing when I'm talking to patients, how do we prevent wound complications so the poor healing of the wound?

And how do we prevent deep infections? The devastating complication that I mentioned earlier. And so prevention is totally the most important thing we it's undervalued in our country and our society. We really want to prevent problems before they happen because they're easier to tackle and it's a longer term solution and it's way easier to prevent a problem than it is to take care of one. And so how do we just decrease our risk of wound, complications and infections? What we want to do is we want to be at our healthiest weight. So every patient's going to be unique. Some people have carry a little bit more weight than they'd like to. I think most of us do that, but we do ask our patients to have their BMI below certain thresholds. And that's a calculation of your height and your weight together. And we definitely want to be have patients below a BMI of 40 and ideally even below 35 or 30. And the reason why that is that complication rates, including wound infections, all of the rates of complications of everything I just discussed earlier go up when we are heavier.

Additionally, the other two things that are commonly the most important is if you have diabetes or pre-diabetes, we really want our blood sugars to be well controlled. If the diabetes is not properly controlled, the immune system is inhibited and then wound healing is slowed. Infection levels peak, and people just don't do well. For smoking, that's another risk factor where if people have any nicotine use of all, whether that's smoking cigarettes, chewing tobacco, etcetera, that nicotine can decrease blood flow to the body. Cause poor wound healing increase the risk of blood clots and increase the risk of infections. So we do ask our patients to stop smoking and to remove all nicotine products before surgery. The prevention part of it also is about like what you said, optimization of how well they're going to do after the procedure.

And so, we, in addition to kind of making sure we're at our healthiest best before surgery, as much as we can. We also do want people to strengthen the muscles around the joints so that they are able to take advantage of the pain relief that they get from the procedure. We want them to do at least, I have my patients all go to at least one therapy session before surgery to really focus not only on the exercises that they're going to do, but also how to adapt their home environment and their day to day, and their recovery period so that they are prepared for the surgery and to optimize how well they do postoperatively.

Host: So, let's talk about postoperative care. Do they need to have set up certain things at home? Tell us when they can get back home, how long they're in the hospital, when can they begin some normal activities? Does someone have to stay with them? What's it like for a patient Dr.. Rothenberg, after the surgery?

Dr. Rothenberg: These are all very common questions. I think there's a lot of buildup to the decision to make the choice to proceed with surgery. And then there's a little bit of confusion about how the after care will go. And so I do spend a lot of time with the patients and we do a preoperative visit with usually with one of my physician assistants to really go through all this and kind of uniquely drive this home with patients so that they're prepared for the recovery process in advance. In general, the patients stay in the hospital now less and less, but most patients on average stay one night in the hospital and leave the subsequent day. If you're a knee or hip replay splint patient, the vast majority of patients can weight bear as tolerated, meaning they can put his full weight on the joint replacement immediately after the surgery, as much as is comfortable for them, considering that they do have some pain after the procedure.

In terms of recovery in the hospital period, and then immediately at home, we do have them walk usually with a Walker to give them some support because there is going to be some pain with the surgery. And that may last for two to three weeks though. It depends on each surgeon's protocols. I do have patients fitted with waterproof dressing. So patients do get to shower right away, which is a new improvement, I think, for the patient experience so that they don't feel like they can't get in the shower and get that relief until their wound completely heals. A little further out driving is a common question. And it does take usually between two to four to six weeks, depending on whether it's the right leg that we've operated on, here in the US or the type of procedure, but it can be a big obstacle for some patients. So you definitely want to set up that you have someone that can transport you to and fro for your postoperative visits and for your outpatient physical therapy.

There's also, you asked about preparing your home. There are some adaptive equipment that help with certain procedures. Some patients require, might require an elevated toilet seat. They might have something that helps them grab stuff low on the floor. They definitely want to remove rugs or tripping hazards around their house. We do have all of our patients get a front wheel Walker to provide support for them. So we go through that in advance with the physical therapy and occupational therapists. And we go through that with our patients and make sure that those are all set up prior to the procedure and really, you know, a 40 year old patient who has early onset arthritis is going to have a different set of needs than an 80 year old patient with osteoarthritis. So we try to individualize that care for each patient.

Host: Dr. Rothenberg, how is pain managed after joint surgery? I imagine many people ask this question as we've seen this opioid crisis going on in the country, tell us how you manage pain?

Dr. Rothenberg: It's a very hot topic, Melanie, because we know the opioid crisis is a big deal and we're all trying to minimize those risks for our patients. So what we've gone to is what's called a multimodal protocol. What we do is we provide patients with small doses of medications and multiple families of types of medications. So we minimize the risk of patients and we attack pain in a different way through each medication. So my patients are on Tylenol and they don't, they may underestimate the effect of the Tylenol, but when we add it together with a anti-inflammatory such as celecoxib or ibuprofen in certain patients, and then we add that together with the opioid and a medication called pregabalin, the combination of all four at lower doses than what would be needed for individual medications, really help the patient tackle the pain effectively and lower the risk profile. In addition for knee and hip replacements, there are the options to leave indwelling catheters or tubes that deliver medications, such as numbing medication that most people might know in terms of going to the dentist or procedures, and that can infuse and bathe the nerves postoperatively for up to four days and really help with the hardest recovery period, which is in the first 24 to 48 hours, in terms of getting people mobile and getting them through the tough few days, right after surgery.

Host: Well, thank you for that answer. So as we wrap up, please give us your best advice for prevention in the first place. So that maybe a patient doesn't need a joint replacement. You mentioned prevention earlier. So give us your best advice, Dr. Rothenberg.

Dr. Rothenberg: Yeah. The best thing for us all is to move more and to eat healthy. It sounds really fundamental, and it sounds like the doctor recommending an Apple and go on for a walk, but that's really what we need to do every day is I, my patients ask if they even have some arthritis, can I damage it further if I use it? And my answer always is not going to do something that I can't fix, but I want you to keep stay active. I want you to use your muscles, use your joints. Our bodies are meant to move. We're meant to be active. That's our physiology. And if we are active, we lose weight and we stay healthy and our mood improves and we're able to handle pain better. So just stay active, stay healthy, and that's the best advice I can give.

Host: Well, it certainly is great advice. And thank you so much, Dr. Rothenberg for joining us today. To learn more or to make an appointment, please visit evergreenhealth.com/orthosportsmedicine. That concludes this episode of Checkup Chat with Evergreen Health. Please remember to subscribe, rate, and review this podcast and all the other Evergreen Health podcasts. For more health tips and updates, follow us on your social channels. I'm Melanie Cole.