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Joint Replacement (transcript)
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SPEAKER:          This week on Second Opinion orthopedic surgeons Dr. Alan Boyd -

DR. ALAN BOYD:        More people who are older are going to have wear and tear of a joint.

SPEAKER:        And Dr. McAlister Evarts along with rheumatologist Dr. John Baum and special guest Leslie Visser-

LESLIE VISSER:        I was at the point I said I can no longer do my job.

SPEAKER:        Join panel regulars Dr. Lisa Harris, Elissa Orlando and host, Dr. Peter Salgo, for a revealing look at joint pain.

ADVERTISEMENT:        Major funding for Second Opinion is provided by the Blue Cross and Blue Shield Association.  An association of independent Blue plans committed to better knowledge leading to better, more affordable healthcare for consumers. 

DR. PETER SALGO:    Welcome to Second Opinion where each week we solve a real medical mystery.  When we close this case file in half an hour from now you'll not only know the outcome of this week's case, you'll be better able to take charge of your own healthcare.  I'm your host, Dr. Peter Salgo, and our case file contains a story of Roger.  Now, you've already met the healthcare team assembled to tackle this case.  Some are doctors, some are not.  No one on the panel knows the case except for our resident civilian,

Elissa Orlando.  Welcome back.  Nice to see you again.

ELISSA ORLANDO:        Thank you, Peter.

DR. PETER SALGO:    Why don't we get right down to business.  I want to tell you a little bit about Roger.  Would you like to know about Roger?

ALL:            Absolutely.

DR. PETER SALGO:    Oh good.  Roger is a sixty-three year old man who is in good shape and the only problem is that he has pain in both hips.  Now, he was in a car accident thirty years ago.  He's had pain in one hip since that time, but now he has pain in both.  The pain in the other hip is more recent and he was diagnosed with "arthritis."  No other diagnosis here in the chart - that's by his history - about then years ago.  Now, we always hear about people with arthritis.  They're generally older.  Is it fair to say that arthritis is simply the territory of getting older and if so why? 

DR. LISA HARRIS:    I have a wide mix of arthritis patients from very young to very old and it's not age dependent.

DR. PETER SALGO:    What is arthritis?  How do we define this thing before we go on because we're going to be spending I suspect a lot of time talking about arthritis.

DR. JOHN BAUM:        The simplest definition is that it's pain, swelling, tenderness, loss of motion in a joint.

ELISSA ORLANDO:        Even though you can get arthritis at any age don't people as you get older do you tend to develop it? 

DR. LISA HARRIS:    Laypeople like to use terms that are not necessarily medically relevant, so if you have a pain anywhere - sometimes people tell me I have pain in the middle of my arm, I'm having arthritis, and by definition it has to involve a joint.  And then there's a wide variety of different types of arthritis, so for the medical profession our job is to figure out is there really inflammation, swelling, pain, tenderness, loss of motion within the joint and then what is it due to?

DR. PETER SALGO:    I think it's really key, though.  You hit on the key.  Part of the definition - it's got to be in a joint.

DR. ALAN BOYD:        I would say Peter that if you want to simplify it to the greatest extent, even though there are many, many different types of arthritis you can divide them into two general categories.  One is just a wear and tear that as we do age more people who are older are going to have wear and tear of a joint, any joint, and that's one very large group.  And then the other group is what's due to inflammation and that can be a whole host of diseases and other problems that can cause inflammation of a joint, not necessarily wear and tear.

DR. LISA HARRIS:    But wear and tear also involves people who are involved in sports, who have stressful lives that are doing things that cause wear and tear or trauma to the joints.

DR. MAC EVARTS:        You can overuse it by athletics as she's mentioned.  You're going to bang it up in construction work.  You could do it by falls.  There's something called post-traumatic arthritis that happens to many people and that ends up in earlier degeneration or wear of your joints.

DR. PETER SALGO:    Leslie, now you cover sports for CBS I might point out.  You also run, or did run, don't you?

LESLIE VISSER:        Yes, I was an avid athlete and a very serious runner and I had a very traumatic accident.  I used to do the six mile loop in Central Park.  Many people do it and I was coming around on the Tavern on the Green side and I tripped and my knee hit the pavement and drove my hip out the back.  It was described to me by Sid Nicholas, a great surgeon - he said it's like the back of your hip shattered like a teacup when you dislocated your hip.  And he did tell me you will experience tremendous arthritis and will have to get a hip replacement eventually.

DR. PETER SALGO:    That's what I wanted to ask you about because they repaired what they could at the time.  Then they said that magic word - you were going to have arthritis.  What was the pain like over the next few years?

LESLIE VISSER:        Of course my doctors advised me never run again, which I ignored, and continued to run and the pain continued to get pretty severe and of course all the guys I work with, everyone from Mike Ditka to Mike Sachefky have all had hip replacements and hip surgeries.  He said when your groin becomes incredibly painful and that for me was the telling point.

DR. LISA HARRIS:    The reason why they told you not to run again is you have to understand you had a trauma to that bone.  You shattered all of that bone and in the body's process of healing, inflammation or swelling occurs and as you begin to run and do more things you're continuing that inflammation type of process.

DR. MAC EVARTS:        I've had this happen.  The pain started out mildly.  You could try to ignore it.  It didn't work so well to ignore it and then the pain became in the groin, down the leg and it started to influence your daily activities.  It would hurt so much that tears come to your eyes.

DR. PETER SALGO:    Roger will tell you I think at this point - in fact, I know because I know what he told his doctor at this time - that he's having pain most of the time but he thinks he can deal with it.  He's worried, though.  He has pain in both sides now.  He's taking over the counter pain relief, which is working less well and he's worried enough to have come to see you.

DR. LISA HARRIS:    I would start him on a nonsteroidal, anti-inflammatory agent and of course physical therapy and exercise if he wasn't already involved in exercise.

DR. PETER SALGO:    Nonsteroidal.  Are we talking one of those famous COX-2 inhibitors such as Vioxx?

DR. LISA HARRIS:    That's in the class of agents that we would consider.  Not Vioxx because it's not available, but COX-2s that are in the -

DR. PETER SALGO:    There's a number of COX-2s.


ELISSA ORLANDO:        What are they?  What do they do?  They bring down inflammation is all - that all I know.

DR. JOHN BAUM:        Well, supposedly they reduce inflammation without causing the gastric upset.  As far as function goes they're really no better than the original agents that we have.

DR. PETER SALGO:    His doctor put him on a nonsteroidal and it does not say which one.  It might have been Vioxx, it might not have been.  But then Roger, although the pain was better, started looking on the Internet.  Don't all our patients do that from time to time - and came back and said I'm a little worried about this nonsteroidal pain reliever because I have hypertension, I have high cholesterol - I don't want to be on nonsteroidals because I don't want to be at a higher risk for heart attack.

ELISSA ORLANDO:        Yeah, I heard they were dangerous anyway.  I mean Vioxx is gone now because apparently it was dangerous.

DR. LISA HARRIS:    I can't tell you how many times I have this conversation in any given week.  It happens all of the time and, again, you're trying to manage the risk versus the benefit of any given medication.  Just because you're taking nonsteroidal does not mean you will develop hypertension.

DR. PETER SALGO:    He wants off.  He wants off the drug.

DR. LISA HARRIS:    And we have people that want off and when you stop off then the option is you're going to hurt.

DR. PETER SALGO:    Roger's heard of bone grease.  You got some of that bone grease?

DR. JOHN BAUM:        You can go in with someone who's got osteoarthritis and you can feel that grating of the knee and if you put this material in it will relieve it.

DR. PETER SALGO:    You inject it.

DR. JOHN BAUM:        You inject it.

LESLIE VISSER:        When you say bone grease, what is it?

DR. ALAN BOYD:        Well, bone grease is just -

LESLIE VISSER:        What are we putting in us?

DR. ALAN BOYD:        There are roughly two kinds.  One used to be from an animal product but now there's one that's purely synthetic.  So it's generated in a lab.

DR. JOHN BAUM:        The trouble with these bone greases are they don't stay.  The body doesn't like foreign material and it empties it out of the joint.  You do buy time.  I don't inject bone grease.  That patient I send right to the orthopedic.

DR. PETER SALGO:    What about steroids?  He's also read that you can inject steroids.  He's watched Leslie on television and all these guys are getting a little injection of steroids.

DR. JOHN BAUM:        But different kinds of steroids.  We use a special kind of steroid for joints and that's got nothing to do with the -  No.  No.  But that works temporarily as well because it does decrease inflammation but it does not arrest the process.

DR. MAC EVARTS:        I'm reluctant to inject the hip joint unless you really have to because it has many muscles over it.  It is a deep joint in your body and you can introduce infection by injections, so that I would not go that way very often.

DR. PETER SALGO:    Roger actually got some steroid injections into his hip.

DR. LISA HARRIS:    In his hip.

DR. PETER SALGO:    Yes and he got physical therapy.  Are we buying him time?  Are we curing him, we making him better?  What are you telling Roger?

DR. ALAN BOYD:        Usually your decision about what you're going to do with the medication or an injection is going to have something to do with what you find when you first evaluate him.  If he comes to see you and you examine him and he's got an impressive exam in terms of his hip doesn't move very well and you take an x-ray and he has what we often describe as bone against bone, that means all the cartilage has worn away, then nothing that you do symptomatically whether it's medicine, an injection or therapy is going to help him.  So then you can just jump to the next step.

DR. JOHN BAUM:        Well, that's why we have to know more about Roger.  I have to sit down with this man and say what kind of work do you do?  Do you want to keep working?  What do you do in your spare time?  Do you want to keep doing that?  That will influence my decision as to when I say look, if you want to continue with this you need a hip replacement as far as I'm concerned.  I'm sending you to - he might not operate on you, but he's got to evaluate him.

DR. PETER SALGO:    Nobody at this point, I can tell you, was talking to Roger about surgery, but there's a lot of other alternative medicine out there. 

ELISSA ORLANDO:        What about magnets, copper bracelets?  If I was in pain like -

DR. JOHN BAUM:        You know what they do?  They turn your wrist green.

DR. LISA HARRIS:    There's no data that shows that magnets do much of anything.  People want to believe - granted the earth is in a magnetic field.  We do have polarized particles within our body and they want to believe that if you put something externally that you are somehow repolarizing things and somehow that's magically creating healing within the joint.  If you believe that there's always a thing called a placebo effect.

ELISSA ORLANDO:        I mean no disrespect to doctors, but you guys also gave us the Vioxx and the Bextra to begin with and if I'm in a lot of pain I'm going to try anything.  I guess that's what I'm saying, but if you're in a lot of pain you're going to try anything.

DR. LISA HARRIS:    We have to educate and you have to look at the studies and since you brought up Vioxx we need to talk about it since the media has not brought out - the problem with Vioxx is that that study was done in cancer patients who are already at risk for heart attack and stroke.  That's all I'm going to say about it, but acupuncture, acupressure, physical therapy, Reiki, meditation, aquatic therapy.  If people want to try it it's out there but it needs to be supervised to make sure that they're not causing more damage.

DR. PETER SALGO:    Let's pause for just a moment here because I want to sum up where we are at this point.  Exercise, physical therapy, medications, other therapies for arthritic or injured joints can relieve pain.  They can maintain, even restore function, but they're not cures.  They're buying you time.  Now, Roger - let me tell you a little bit more about what's going on with Roger because he's still in pain.  He's seen his primary care.  He's gone to his rheumatologist.  Nothing is working at this point for Roger.  Things have gotten worse.  You wanted some more information.  I've got it.  He can't mow his lawn.  Now many of us would consider this a treat, but Roger likes to mow his lawn and now he can't do it.  It simply hurts him too much.  He sees himself now in a new light.  He's no longer Roger mobile, Roger the competent adult.  He's becoming Roger the cripple in his own mind and he doesn't like it.  One day he tells his doctor he was driving to work and after passing the same billboard that he passes every day to work he finally looked at it and it suddenly struck a chord.  It said that he could have a joint replacement at a joint replacement center in his city and he said maybe this billboard is talking to me.  So now he's back in your office - can I have joint replacement surgery?  What's the deal?

DR. JOHN BAUM:        Yes, you certainly can and if you're hurting, you can't mow your lawn and you like to mow your lawn then I'm sending you to the orthopedist.  Well, I'm making an appointment for you today.

DR. PETER SALGO:    Today.

DR. JOHN BAUM:        Today.

DR. PETER SALGO:    Leslie, you had that experience - not the billboard experience but the pain got to the point where you asked for this didn't you?

LESLIE VISSER:        Yes.  I was our number one side line reporter at CBS and last year I did the first game of the year.  It was Baltimore at Philadelphia a year ago and I could not even travel around the field, which as you all know a ball field is physically a large plant and I was at the point I said I can no longer do my job.  I cannot do my job and I went back to see Nicholas and I said give me some of that bone grease or whatever that was and he said no - or he recommended - you have to have a hip replacement.

DR. PETER SALGO:    This is in light of the advise you got from the famous orthopedic surgeon, Mike Ditka.


DR. PETER SALGO:    What on earth are you going to do?  You're going to replace the hip.  We do this occasionally that we have these lying around that you guys use.  Can you tell me what this is and how this goes into somebody's hip and changes things?

DR. ALAN BOYD:        You think of a hip as a ball and a socket and perhaps if you are looking at a skeleton that helps a little bit, but, again, you have a ball that goes into a socket which is part of your pelvis and so the surface of that ball has become very, very rough and you've lost the normal circular shape of that and so when it's become rough and you have the ball grinding into the socket you have to remove the ball and you have to put a new surface inside the socket and then you put a new ball which is attached to a stem which goes inside the bone.  If you think of your thighbone and your femur as hollow you have to put something inside that and this implant - hip replacements these days are essentially four pieces and they're modular.  Modular means that these pieces come apart and so you have a stem which goes inside your thigh bone and you have a ball that takes the place of the ball which has become rough which is perfectly smooth.  This particular ball is made of a ceramic material which is a new
material which is very smooth, very hard and doesn't wear out as quickly as other types of materials and you have a socket which again is a metal surface and it has a plastic liner in this case and if you see the surfaces of this it has what looks like a rough coating, which is a coating that is designed to allow your bone to grow and bond to this implant.

DR. PETER SALGO:    And then it all just sort of swivels.

DR. ALAN BOYD:        It swivels like this that the ball - again, they're not locked together.  They simply rest together and your muscles around this device hold it in place and it will move like a natural hip.

DR. PETER SALGO:    Well, I can tell you what Roger said.  When his surgeon asked him why didn't you come here earlier - he went back and talked to his doctor, his rheumatologist, and the rheumatologist said I was waiting to the last possible moment so that you didn't have to have another hip replacement too early when this one wears out.

DR. LISA HARRIS:    Here we go back to old information again.

DR. PETER SALGO:    Why is that old information?

DR. JOHN BAUM:        I don't worry about wearing out anymore.

DR. PETER SALGO:    Anymore - should you have worried about it at one time?

DR. JOHN BAUM:        Oh yes.

DR. ALAN BOYD:        There are two general problems with these.  One is they can get loose and that's one problem and it's not much of a common problem anymore with the implants that allow bone to bond to it.  In the old days they were cemented in and the cement sometimes would break or get loose, but the problem was for many years, or still is a problem, is this liner which is made of a plastic, a very strong plastic, just the daily use can wear this plastic away.  The efforts have been to design a material that will withstand that kind of daily use and ceramic is one of the ones that's currently felt to be better at doing that.

LESLIE VISSER:        People might think the surgery is a hundred years old but it's not.

DR. MAC EVARTS:        Actually it isn't and particularly in the United States the first hip was done by John Charnly where the first recognized hip by John Charnly in 1960 and that was in England -

DR. PETER SALGO:    Where was the first one done in this country?

DR. MAC EVARTS:        Well, I think we did one of the first ones I think Cleveland Clinic -

DR. PETER SALGO:    I was going to ask who did the first one in this country?

DR. MAC EVARTS:        I'm not sure I did the first one, but close to that maybe.

LESLIE VISSER:        Many of us, myself included, have been able to continue work because of this surgery and it was not available even as recently as four or five decades ago.

DR. MAC EVARTS:        It's just been a remarkable chapter in the history of orthopedic surgery because you've gone from not being able to help the patient very significantly to now being able to pretty much give superb pain relief and increased function and long term results.

DR. PETER SALGO:    What is Roger, when he crosses the threshold into that operating room risking?

DR. ALAN BOYD:        Well, just having the anesthesia alone and having surgery carries the risk of heart problems, strokes.  Any number of major medical problems can come with an anesthetic, especially if you're older and not very healthy.  Then there's specific complications that come from just putting the device we were looking at into someone and you can fracture the bone when you're putting it in.  It can dislocate.  You can get a blood clot.  You can get an infection.  These are some of the more common things.  Common meaning categories, but the frequency of them is very low, like in the one percent range.

DR. PETER SALGO:    In general does it work?  Does it work well?  Compared to the risk is it worth doing?

DR. ALAN BOYD:        It does.  I think this has a ninety plus percent if you want to use a number.

DR. PETER SALGO:    Let me tell you what happened to Roger.  Roger was told that he was a good candidate for surgery.  He was the right weight.  He was in otherwise good health and that he was going to get one of these ceramic implants.  It was going to last for thirty years.  Were there and are there other products on the market that aren't that good and might he have, had he gone to some other surgeon gotten one of them?  Is that possible?

DR. ALAN BOYD:        Certainly it's possible.  I think you have to be careful about defining what's good and what's not.  There is a natural assumption, there's a hierarchy of the implants which are not so good and there's the premium implant, or better implant.  Some of that is based on speculation.  Some of it's based on laboratory testing but these things are so new that they haven't been used for ten or fifteen or twenty years and most orthopedic surgeons like to see data that really supports the recommendation for something.  So we like to think that ceramics are going to last twenty, thirty years but do we absolutely know that?  No, we don't.  And yes he could have gone somewhere else and had what would have been a traditional implant with a known lifetime of wearing out at some point versus an alternative implant with the possibility of lasting longer but we're not sure.

DR. PETER SALGO:    Let's take just a moment over here and sum up where we are.  Joint replacement is serious surgery.  There are serious risks.  You need to know about the surgeon's skill.  You should research that.  The facility's success rate is available.  You should research that and also about the hardware that's being put in your body.  All of these things greatly affect your outcome and to some degree it's up to you to educate yourself about all of them.  Well, guess what, I'll tell you a little bit more about Roger.  Roger can't mow his lawn.  He decides that's enough, he's going to have the operation, so he has the surgery.  Now, you had this operation.  It's number one, postoperative day one.  What is he feeling like right away?

LESLIE VISSER:        On morphine if he's lucky.


LESLIE VISSER:        They get you up fairly quickly, at least in my experience.  They got me out of the hospital bed almost right away.  I found that the physical therapy was very effective.

ELISSA ORLANDO:        Was the pain better right then or did you not get -

LESLIE VISSER:        I couldn't tell right away but the groin pain was gone immediately, immediately, immediately, which had finally driven me back to Dr. Nicholas.  Being at that football game I could not take one step without staggering pain and now athletes that I know who have all had hip replacements said they were in the same situation is when their groin - they couldn't take a step.  That they finally sought relief.

DR. PETER SALGO:    Here's the ironic thing.  Perhaps the first person in this country to have done a hip replacement had a hip replacement.  I'm not sure I would have wanted to be the surgeon doing your hip replacement at that moment.

DR. MAC EVARTS:        He didn't want to be either, actually.

DR. PETER SALGO:    What was it like for you?  You had pain going in.  What was the first post-operative day like?

DR. MAC EVARTS:        Absolutely spectacular.  It was better than I had told my patients because I had immediate relief of pain.  The only pain was a little surgical incision pain.  Altogether a different kind of pain.  I could move.  Went to therapy.  As you said, start moving around and it's been amazing.

DR. PETER SALGO:    What's in store for Roger now?  He's had his hip replacement.  He actually felt better the morning after.  He didn't have the stem pain that you complained of.  His experience was more like yours, that instant relief from that arthritic pain some surgical pain and that went away fairly quickly.

DR. MAC EVARTS:        But he has to pay attention to it.  Alan would I hope would go along with this.  That is, he has to pay attention to making sure he gets the full range of motion back in that hip.  So it means exercises, measured exercises, very simple exercises but you keep moving and working on and that just moves you right along.

DR. PETER SALGO:    That sounds like a lifetime commitment.  Are you doing all of that rehab and stuff?

LESLIE VISSER:        Well, I finally gave up running.  I finally did.  I have found walking is very pleasurable and does the job and swimming.  It is a commitment, though.

DR. PETER SALGO:    Let's go back to Roger.  He's had one hip done.  The other hip still hurts and he's going to do these exercises, at least he claims he is.  What's the road ahead like for him?

DR. ALAN BOYD:        Well, he's going to have pain in his other hip if it's arthritic and the hip he had replaced is going to feel good, so he should have a diminishing pattern of pain on his newly replaced hip as weeks go by.

DR. PETER SALGO:    Let's take a short pause over here and review where we are.  Rehabilitation after joint replacement is a lifelong commitment.  It will make the long term difference to living with restored function and little or no pain provided you stay with the program.  So, with all of that, Leslie, how are things going?

LESLIE VISSER:        It's less than a year ago for my hip replacement and I have great pain from the stem, so maybe you could address that.  I have no problem with the hip.

DR. ALAN BOYD:        There is a small percentage of people who do have some discomfort in their thigh with their implant and part of it is due to the fact that you have an implant that your bone has to grow and bond to it and that bonding is very, very slow.  It can take one or two years to fully be complete.

DR. PETER SALGO:    Roger tells the story and I'm going to guess you've got the same one.  He goes to airports and can't get through the metal detector.  Tell me about this.

LESLIE VISSER:        I've had the same experience, although mine, it's a little bit of a Seinfeld episode because I do set off the detector and appropriately so.  I have the added pat down and then they'll ask me for an autograph.


DR. PETER SALGO:    I think the image I'm going to be left with is getting wanded in an airport.  Excuse me, you're a terrorist and how about them Bears?  I want to thank all of you for being here.  This has been a terrific, terrific discussion.  You know, we've covered a lot of ground today, so let me just sum up some of the key things to remember.  Exercise, physical therapy, medication, other therapies for arthritic or injured joints can relieve the pain and maintain or restore function.  Joint replacement is serious surgery so you need to know about the surgeon's skill, the facility's success rate and also about the hardware that's being put into your body because all of these things greatly affect your outcome and rehabilitation after joint replacement is a lifelong commitment.  It's going to make the long term difference about living with restored function and with little or no pain.  Very, very important stuff.  And, of course, our final message is this - taking charge of your health means being informed and having quality communication with your doctor.  I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

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