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Many patients will ask me, "when do I need a joint replacement?" And my response is quite simple. "Nobody needs a joint replacement." It's really up to the patient and their activity and what they want out of their joint as far as what they need to do to improve their quality of life and activities of daily living. If the pain is so bad that they no longer are participating in the activities that they enjoy and limited by taking more and more pain medicines, certainly if they're on the verge of requiring narcotic medicines for their pain, then it may be a good idea to consider joint replacement surgery to improve their quality of life and decrease their pain.
Many patients will ask me, "when do I need a joint replacement?" And my response is quite simple. "Nobody needs a joint replacement." It's really up to the patient and their activity and what they want out of their joint as far as what they need to do to improve their quality of life and activities of daily living. If the pain is so bad that they no longer are participating in the activities that they enjoy and limited by taking more and more pain medicines, certainly if they're on the verge of requiring narcotic medicines for their pain, then it may be a good idea to consider joint replacement surgery to improve their quality of life and decrease their pain.
Some common diseases associated with degeneration of a joint that may require joint replacement include the most common, which is degenerative osteoarthritis or just normal wear and tear. In this process, the cartilage itself is denuded off of the cap of the joint. That causes this underlying subchondral bone to be exposed, which has many nerve endings in there. That leads to a process people commonly refer to as bone on bone arthritis. That subchondral bone is very sensitive and it becomes very painful. Another type of arthritis is called rheumatoid arthritis or really any other type of inflammatory condition that is actually more of a disease of the synovium or the lining of the joint itself rather than the cartilage surface. The lining is inflamed causing a degenerative process that takes away the cartilage in an inflammatory type of way. This condition, inflammatory arthritis is another common reason to undergo joint replacement surgery. Another common condition that can cause patients to require joint replacement surgery is a process called avascular necrosis. What happens in this condition is that the blood vessels that go to the bone itself become impeded for a variety of reasons. The most common are alcoholism and steroid use, either through the use of asthmatics or another different inflammatory condition. All of these processes lead to destruction of the joint that ultimately your body cannot respond or restore and may require joint replacement surgery. I typically do not tell patients that they need or require a joint replacement. That is that, those words don't usually come out of my mouth because most of the time it's a lifestyle decision. This is an elective surgery. Typically, we're not dealing with a tumor situation, requiring the replacement of a joint and therefore we're not saving this person's life necessarily. Instead, we're giving back their quality of life. And so it really becomes more to the patient's overall ability to respond to the anti-inflammatory medicines and different conservative treatments. And then how willing they are to continue with that path until they do want to proceed with hip replacement or knee replacement surgery.
For someone suffering from hip related condition such as degenerative osteoarthritis, typically the first signs that your hip is going bad is pain located predominantly in the groin that can radiate down the front of the thigh. Sometimes this pain can also be on the lateral side, on the outside part of the hip and associated with activities such as prolonged walking, as well as tying your shoes. A lot of people also discover that once the hip starts to go bad, they start to have less mobility in the joint itself, decreasing their range of motion and therefore limiting the types of activities they can do. Finally, once you start to have a degenerative joint, it can affect the other parts of your body in way that the way you walk and the way you carry yourself decreasing the longevity of your other joints as well as your low back. In the knees, typically the symptoms are you have pain either on the inside or outside parts of the knee, depending on where the localized arthritis is. A lot of patients will start to feel some instability and difficulty performing activities of daily living. They have difficulty walking longer distances as well as decreased range of motion itself.
Patients who are good candidates for this surgery have already failed the conservative measures including physical therapy, anti-inflammatory medicines, as well as injection treatments. Typically we use steroids or a type of viscosupplementation, which is a gel like substance that improves the viscosity of the fluid. Typically these are used in knees to delay knee replacement surgery. There are other forms of injection treatments available such as PRP and stem cell. Unfortunately, these have not yet been cleared by the FDA and do require substantial cost. Once many of these have already been completed and the pain persists, the patient is then a candidate for joint replacement surgery. There are particular subgroup of patients who are very high risk for joint replacement surgery. In our institution. We have cutoff values for different conditions such as diabetes with an A1C value of greater than 7.0%. another high risk population are patients who are obese. A BMI greater than 40 is a contraindication for joint replacement surgery due to the high risk of infection that these patients pursue. Typically patients with a higher than BMI of 40 require aquatic physical therapy, an appointment with a nutritionist to decrease and assist with their nutrition and BMI, as well as physical therapy. Typically in three to four months, we can get many of these patients much more reasonable down into a level which is much safer to proceed with joint replacement surgery. The last subgroup of patients who are very high risk are active smokers. We have multiple studies showing that smokers have a much higher risk of infection related and wound complications following their surgery, and we do require abstaining from smoking for at least three weeks prior to their joint replacement surgery and certainly during their recovery.
Many patients will come to me asking if they are appropriate candidate for partial knee replacement. In a partial knee replacement, we simply remove the arthritis from only one part of the knee leaving the remainder of the knee intact. This has multiple advantages, including a much improved recovery time, about half of what a total knee replacement takes. The procedure itself is an outpatient procedure where you go home the same day. In a partial knee replacement, all of the cruciates as well as collateral ligaments are completely intact and all we do is take away the damaged part of the knee. There's specific requirements for patients who may be a candidate for this specific procedure and may not have arthritis in the other parts of the knee. If on your MRI or x-rays suggest arthritis in more than one compartment in the knee, then you may not be a candidate for partial knee replacement, requiring full knee replacement surgery.
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