In 2002, more than 760,000 hip and knee replacement operations (total or partial) were performed in the U.S. That number is certainly higher today. As people push the limits of their bodies, the medical community is pushing the boundaries of prosthetic joints – an increasingly commonplace solution to severe joint problems, and a very successful one.
Key issues are:
- Who is – and who isn't – a candidate for joint replacement surgery?
- What role do medications play in treatment today, and how safe are they?
- What implant options are currently available?
- Are so-called "alternative" treatments worth considering?
- What can be done to avoid, minimize or postpone severe joint problems?
Joint problems tend to affect older people, but all age groups are susceptible. These problems – acute pain, loss of mobility, weakness or instability – could result from bone deterioration (osteoarthritis), joint inflammation (rheumatoid arthritis), deformity, physical injury or other causes. Treatments are many and varied, with joint replacement commonly viewed as a last (yet highly effective) resort. Exercise, weight loss, physical therapy, medications, magnetic pulse therapy, acupuncture, injections, irrigation – any of these options might provide relief. They're worth exploring before any decision for joint replacement surgery is made.
- Joint replacement is not for everyone. It is a significant procedure that carries certain risks. It can consume a great deal of your energy and resources, put demands on family and friends, and require long convalescence. However, it often provides dramatic relief and is a viable option after other remedies have been tried.
- Usually, the basic symptoms that must exist for a doctor to recommend joint replacement surgery – known as arthroplasty – are disabling pain and x-ray evidence of joint damage, leading to a significant drop in ability to function and quality of life.
- Arthroplasty doesn't cure arthritis, but it can improve movement and ease localized pain.
- More than 500,000 total hip and knee replacement surgeries are performed each year in the U.S. Partial replacement procedures each year reach about half that number. There also are replacement procedures for other joints performed (shoulder, ankle, wrist).
- Generally, the age of a person receiving a total joint replacement is in the mid- to upper 60s. This may vary depending on a patient's diagnosis and individual circumstances.
- Overall, more women undergo joint replacement procedures than men, and a much higher percentage (as high as 75 percent) undergo partial joint replacement procedures.
- Among patients identified as having the best chance for success with arthroplasty, three out of four replacement joints are fully functional after 25 years. More than 90 percent of artificial hip and knee joints are successful for 15 years or more.
- Success rates for younger people tend to be lower due to greater "wear and tear" on the joint. About two out of three patients 40 years old or younger achieve a 25-year success rate.
- Post-procedure complications can include dislocation, deep infection, aseptic loosening and osteolysis (bone loss).
- Replacement joints utilizing metal-on-polyethylene components enjoy excellent success rates and are the most common choice today. New materials for hips include metal-on-metal and ceramics.
- NSAIDs – non-steroidal anti-inflammatory drugs – are often prescribed in connection with arthritis and severe joint problems, while narcotic-based drugs are not. There are a wide variety of NSAIDs, ranging from aspirin and Motrin to Vioxx and Celebrex.
- Cardiovascular side effects from certain Cox-2 Inhibitors (a category of NSAIDs) appear to be related to dose size. For patients still taking Celebrex and other Cox-2 Inhibitors, the FDA and Arthritis Foundation recommend the lowest possible dose that best controls their symptoms.
- Physical therapy after arthroplasty is a virtual necessity and should be planned for. It is a highly beneficial aspect of recovery.
- Arthroplasty patients who keep their weight under control and engage in a regular, low-impact exercise regimen have the best outcomes in terms of leading a normal life "post-implant."
*Quick Facts have been reviewed by Medical Advisors and are current as of October 2005.
Ask Your Doctor
Adapted from information available on the following web sites:
- American Association of Hip and Knee Surgeons
- American Academy of Orthopaedic Surgeons
- The Arthritis Foundation
- The Hip Society
- National Institute of Arthritis & Musculoskeletal and Skin Disease
This list of questions will provide a good starting point for a discussion with your doctor. However, it is not a comprehensive list.
General questions about joint replacement
- What are the most common causes of severe joint problems that can lead to the need for joint replacement?
- What conditions or symptoms must exist before a doctor will recommend such a procedure?
- Arthroplasty is a major invasive procedure. How disruptive is it to a person?
- What does joint replacement surgery involve? Describe the process.
- What is an artificial joint made of? How does it work?
- How does an artificial joint "interface" with a person's flesh and bone?
- How long do artificial joints last? Will I need another arthroplasty at some point?
- What are the success rates for arthroplasty?
- What are the possible complications, and how common are they?
- Are there reasonable, effective alternatives to arthroplasty?
- What about new research and findings? Are there any less invasive but equally effective remedies "right around the corner" that I might want to hold out for?
- What can a person do to put off severe joint problems or relieve their symptoms?
If joint replacement becomes a likely course of treatment for you
- Specifically, why is this procedure being recommended? What alternatives were considered and why were they rejected?
- What benefits should I anticipate in terms of pain relief, improvements in mobility, etc., and to what degree?
- What percentage of arthroplasty patients have seen these improvements, and for how long?
- What are the risks associated with arthroplasty? Do my circumstances suggest I face any particular issues or risks?
- Is there a long-term "down side" to this procedure? Will I lose certain abilities?
- What type of joint "hardware" is being recommended for me, and why?
- What can I expect immediately after surgery?
- How long will it take for me to recover, and what will I have to do?
- What role will medication play in my recovery, and what kinds will I have to take?
- What's your view of these anti-inflammatory medications that have been shown to cause cardiovascular problems?
- What kinds of exercise and physical therapy will I have to do "post-implant"?
- Should I make any changes around my home to accommodate my recovery?
- What specific roles do my personal doctor and my orthopaedist play?
- What should I expect if I decide not to have the surgery at this time?
- If I want a second opinion, who can I consult?
Key Point 1
Non-operative intervention of arthritic or injured joints can relieve pain and maintain or restore function.
There are many treatments to try before opting for joint replacement surgery, considered a last resort but also a highly successful one.
Health and behavior modification
Sometimes the simplest answer is the best. You can often gain relief from joint pain, inflammation and stiffness through these techniques:
- exercise / physical therapy
- avoiding activities that cause stress or strain
- weight loss
- wearing a supportive brace
Medications available to treat joint problems run the gamut, from plain aspirin to complex prescription-only drugs. Major drug categories include:
- acetaminophens, such as pain relievers like Anacin-3 and Tylenol for mild symptoms
- traditional NSAIDs (non-steroidal anti-inflammatory drugs) are for moderate to more severe pain come in prescription and over-the-counter strengths, with names like Advil, Nuprin and Aleve
- Cox-2 inhibitors, for moderate to more severe pain, ease symptoms without the stomach upset from traditional NSAIDs, but some (Vioxx, Bextra, Celebrex) can increase the risk of heart attack or other cardiovascular problems
- opiate and oxycodone drugs might be prescribed for pain that does not respond to other medications, but tend to mask the pain rather than address its underlying cause
- glucosamine and chondroitin sulfate pills slow the progression of osteoarthritis and tend to work best when taken before the disease progresses significantly
About Cox-2 Inhibitors
Recently the Cox-2 Inhibitors – Vioxx, Celebrex and Bextra – have come under close scrutiny. Research indicates an increased risk of heart attack, stroke and other cardiovascular events after 18 months of use. The research findings are being taken seriously by health officials and acted on accordingly. The FDA took Vioxx and Bextra off the market, and now requires strong warnings on Celebrex labels.
However, in the midst of these recent actions, medical experts are keeping in mind that the Cox-2 Inhibitors have been successful in treating severe joint problems. Officials at the Arthritis Foundation, for example, believe the ensuing discussion "has failed to take into account the potential benefits from these drugs and their contribution to improving the lives of millions of people with arthritis." The Foundation also acknowledges that there are other NSAIDs that make suitable substitutes for those taking Cox-2 Inhibitors. Research indicates the cardiovascular side effects are related to dosage size. As a result, some doctors are prescribing the smallest dose of Celebrex that's still effective for the patient. We're likely to see more research conducted, and additional findings appear in the news. In the meantime, experts say the best course of action is to speak with your doctor and conduct some research of your own before coming to a decision. Information is available from a variety of agencies and organizations.
Sometimes the answer is to replenish the fluids found in the troubled joint. Doctors inject anti-inflammatory drugs that imitate the natural body fluids normally found in a joint. These drugs lubricate arthritic joints to reduce pain, swelling, and inflammation. They tend to work best in less advanced cases. There are two types:
- corticosteroid (cortisone) injections imitate the fluid produced in the adrenal gland
- hyaluronic acid imitates a different bodily fluid and must be injected once a week for a total of 3 to 5 injections. The success rate is approximately 30 percent.
For people who cannot or will not engage in traditional therapies, certain alternative approaches have shown some promise while others have not.
- acupuncture, which involves the insertion of needles into specific exterior body locations, has been shown to reduce pain and improve function for people with arthritis
- magnetic pulse therapy subjects the joint to a low-frequency pulsed electromagnetic field (PEMF), but research to date hasn't identified any benefits
- topical (cream) NSAIDs and vitamins are two other treatments being studied, but the data so far is inconclusive
If it becomes necessary to operate on a problem joint, there are several options.
- arthroscopy uses a small fiberoptic telescope, called an arthroscope, inserted into a joint to view and irrigate structures in the joint, trim cartilage and remove bone chips
- osteotomy involves cutting or modifying the bone to improve alignment, weight bearing or other performance characteristics, with no reliance on artificial parts or implants
- arthroplasty, the total or partial replacement of a joint with artificial components, can be very disruptive to a person's life for several months, but results generally are very positive
Key Point 2
Joint replacement is serious surgery. You need to know about the surgeon's skill, the facility's success rate and also about the hardware that is being put in your body. All of these things greatly affect your outcome.
Joint replacement – called arthroplasty – is a surgical procedure in which diseased or damaged parts of a joint are removed and replaced with new artificial implants. Its goals are to relieve pain, increase mobility and improve or restore normal joint functions.
The most common reason that people have joint replacement surgery is the wearing down or disintegration of a joint caused by osteoarthritis. Other conditions that can lead to deterioration of a joint and require arthroplasty include rheumatoid arthritis (chronic or severe inflammation), avascular necrosis (loss of bone due to insufficient blood supply), physical injury and bone tumors.
People who undergo arthroplasty can expect dramatic pain relief and improved ability to function normally. But there is a cost. Joint replacement is a very invasive operation. It requires a lot of preparation, and a long and somewhat intense recuperation. There are a lot of things the patient can do before and after surgery to make everyday tasks easier and speed their recovery
- Research the most experienced surgeons and the best hospitals for joint replacement surgery in as wide a geographic area as is reasonable for you. You can evaluate a provider's competence by looking at:
- whether they participate in continuing medical education
- quality reports
- how they are viewed by former patients, peers and staff
- how they monitor and improve their quality of care
- Request and read information written for patients from the doctor and support agencies to make sure you understand the risks as well as the rewards
- If you have any factors that would increase your risk factors (such as being overweight or a smoker), work with your doctor to correct them.
- Ask your doctor for pre-surgical exercises.
- Enlist someone to help around the house for a couple of weeks after you get home from the hospital
- Set up a "recovery station" at home where you'll spend most of your time – complete with TV remote, radio, telephone, medicine, tissues, waste basket, water pitcher and glass
- Arrange your house so you can get around easily, and place everyday items at arm level so you don't have to bend or stretch
- Stock up on kitchen staples, fill the cupboard with easy-to-make foods like canned soup, and prepare and freeze meals in advance
- Arrange for transportation to and from the hospital, and for things like errands
- Take your medicines religiously and your physical therapy seriously – both will be integral parts of your recovery
- Follow all doctor instructions related to diet, movement and other critical matters
- Wear an apron with pockets to carry essentials around with you
- Use a long-handled "reacher" to turn on lights or grab things that are beyond your reach
- Be active when you're supposed to be active (during physical therapy) and rest when you're supposed to rest. Be committed to your rehabilitation program.
Complications are rare. The most common problems are dislocation for hip replacement patients, inflammation caused by tiny particles wearing off the artificial joint surfaces, blood clots, infection and excessive bone growth. Patient with knee replacements are more at risk for blood clots and usually take medication after surgery to prevent them.
Implants can wear out or become loose with time. Historically these types of problems might occure after 10 to 15 years. Newer hip implants may now last much longer, but the long term function of knew implants is less clear. Collectively, over 90 percent of replacement joints are fully functional after 25 years. But especially for younger patients, whose artificial joints tend to get more wear and tear, revision surgery might be needed.
Doctors usually consider revision surgery for three reasons: If accompanying medication and lifestyle changes do not relieve pain and dysfunction, if damage to or failure of the artificial joint must be corrected, or if there is ongoing bone loss. Subsequent surgeries tend to be more difficult and not as successful as the original surgery. So it's important to explore all available options before proceeding with additional surgery.
Once joint replacement is selected as the appropriate treatment, choices need to be made among the types and characteristics of implants available. A variety of factors influence this selection process.
Most artificial joints and implant components are made out of some combination of specialty metals and plastics. There are three main types of replacement parts used in joint replacement. An osteopaedic surgeon will suggest one type or another based on a patient's particular situation. Among them are age, weight, bone strength, activity level and the joint being replaced. The types are:
The surgeon uses a bone "cement" or glue to hold the artificial parts in place and connect them to healthy bone. This surgery is recommended for older or less active people, because results are consistently good and recovery is relatively quick.
Cementless (or non-cemented)
Parts that come in contact with healthy bone are produced from a material and feature a design that encourages the bone to grow into and around them. This type of implant generally lasts longer. However, it requires healthy bones that will grow into the replacement joint, as well as a longer recovery time. Most people who receive cementless joint implants are younger or more active. Some newer designs are used for all ages.
These replacement joints are made up of both cemented and cementless components. The surgeon selects the parts after a determination of what will work best, given the condition of the patient's joint and surrounding bone and tissue. The goal is to provide a solution that will best alleviate adverse symptoms and restore natural function and movement.
There are other pros and cons related to the various types of replacement joints. For example, cement particles can break off the joint through use and movement, which can cause irritation. Revision surgery is usually more difficult with a cemented joint. On the other side, uncemented joints take an extremely long time to heal and stabilize – three months or more. And the process of natural bone growth can cause pain for a number of months after surgery.
In the end, the doctor and patient together should weigh the advantages and disadvantages of each type. They also must factor in the unique aspects of the patient's condition and circumstances. The right replacement joint has the potential to relieve the patient's pain, restore normalcy to their movement and function – and greatly improve their quality of life.
Key Point 3
Rehabilitation after joint replacement is a life-long commitment. It will make the long term difference to living with restored function and little or no pain.
Treatment of a diseased joint doesn't end with surgical replacement. The ultimate goal is ensuring a pain-free function of the joint to improve the patient's quality of life.
The most important factor is to follow your doctor's prescribed rehabilitation program. Excessive activity can damage tissue and/or the implant.
The journey to recovery is not always an easy one. The rehabilitation from joint replacement surgery can be grueling, and can take about a year for full recovery so it takes dedication and determination. However, getting back to living life to the fullest is a powerful reward.
Early rehabilitation includes gentle, range of motion (stretching) exercises designed to restore movement and strength to the joint and to promote blood flow for healing. Preexisting conditions such as hip weakness, osteoporosis, and the condition of other joints determine what and how much a patient can do. A patient should only perform the exercises that are ordered by his or her surgeon.
Long term rehabilitation will include more, low-impact strengthening exercise. Walking and swimming are ideal but are not a substitute for continuing prescribed exercise. As time passes more vigorous activity can be undertaken – dancing, golfing (with spikeless shoes) and bicycling. To be avoided are jarring or repetitive activities which overload the joint, (jogging, jumping, horseback riding), exercise that could result in excessive joint flexion (racquet sports) or contact sports (football, baseball). There also may be weight bearing restrictions depending on the type of implant and other issues specific to an individual's situation.
It's especially important to prevent any bacterial infections from settling in a joint implant. Every joint replacement patient should get a medical alert card and take antibiotics whenever there is the possibility of a bacterial infection. Antibiotics are recommended during any invasive procedures, whether surgical, urological, gastroenterological, or dental. Infections elsewhere in the body should also be treated to prevent seeding of infection into the joint.
Joint replacement patients should continue to watch their weight to avoid putting more stress on the joint as well as moderate their consumption of alcohol to avoid potential falls.
Doctors follow patients with joint replacements according to a definite protocol. This includes at least a review at 1 year and every 2 to 3 years thereafter for life. This follow-up helps diagnose potential and actual problems which may arise. The patient may not be aware of a problem without this exam.
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