Joint Replacement: What, How and Who

By: Edward G. Loniewski, DO, FACOS, FAOAO

What Is It?

Joint replacement is a resurfacing and re-alignment procedure for your arthritic joint, where an angled joint is straightened and a new surface is placed on either end of the joint. The joint is opened through an incision and the arthritic portions of the joint are removed with specially designed instruments and tools to place a new surface on either end of the joint while the surgeon balances the joint through normal range of motion.

How Does Knee or Hip Replacement Work?

You are admitted to a hospital or surgery center the day or your surgery. Incisions are made over the joint in a manner designed to preserve the normal function of the joint. Special cuts are made on the bones of your joint to allow proper placement of the new joint and to restore normal mechanical alignment of the joint. These joint replacements are made of metal such as titanium and cobalt chrome and they articulate with a high density and durable plastic liner. Most knee replacements are glued to your bones with a special bone cement. Most hip replacements are designed to wedge within your current bone after reaming the bone to a specific geometry. Your own bone grows into this replacement to further stabilize the fixation.

Most patients stay in a hospital or surgery center for 1-2 days; however, a few select patients may leave the day of surgery. You will require constant care 24 hours a day for seven days a week up to three weeks following the surgery. Patients can expect to be ambulatory the day of their surgery, but will require someone to help them with simple activities such as dressing, meal preparation and bathing.

Ideal Candidate

Although this is not a complete list, it is a general guideline to help you understand who may be the ideal candidate for this procedure. You and your surgeon will always find exceptions since not every patient responds the same to each treatment.

• Documented arthritis on X-ray or MRI
• Deformed or angulated joints
• Severe loss of motion of the joint
• Failure of multiple treatments such as injections, therapy and weight loss
• Loss of activities of daily living such as shopping, dressing and walking
• Medically stable to undergo anesthesia, the surgery, and rehabilitation
• Lack of any active infections
• Able to have someone take care of you at home 24 hours a day, seven days a week for at least two weeks following the procedure (ideally three weeks)
• Willing to participate in the pre-operative preparation classes and appointments
• Willing to participate in physical therapy for 6-8 weeks

Safety Of This Procedure

We take steps to help identify and reduce complications, but there are complications that can occur. Luckily, most of these complications can be treated successfully.

In a recent study entitled “Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database.” by Courtney, PM[1] the author performed a retrospective review of 169,406 patients receiving either a total knee or total hip replacement. The overall complication rate was 16% for inpatient joint replacement. Patient age over 70, malnutrition, cardiac history, smoking history and diabetes increased the risk.

Another very large study looking at the trends of adverse outcomes after total hip replacement entitled “Adverse outcomes in hip arthroplasty: Long term trends.” by Brian Wolf[2] found that between 1991 and 2008, 1,405,379 total hips were performed with a decreasing trend of adverse outcomes from 4% to 3.4%, however, of the 337, 874 revision (re-do) hip replacements, there was a trend towards an increase in adverse outcomes from 7% to 10.9%.

Efficacy Of The Treatment

Overall, many patients are very happy they had the procedure performed. The knee and hip society reports that most patients have 95% pain relief and that over 80% of these joint replacements will last over 20 years.[3]

Another study entitled “ Patient-level clinically meaningful improvements in activities of daily living and pain after total hip arthroplasty: data from a large US institutional registry” [4]looked at 6,168 total hips from two to five years after their surgery. Clinically meaningful reduction in pain was reported in 94% of patients with moderate pain and 91% of patients with severe pain. Only 4% of patients with moderate limitations and 17% with severe limitations reported severe limitations on their activities at two years after the surgery. Thus, these procedures can be reliable, reproducible and durable.

However, recent studies such as “A Review of the Clinical Approach to Persistent Pain Following Total Hip Replacement” by Lam, YF et al.[5] reviewed that 27% of total hip patients had persistent pain after their hip replacement. In addition, Wylde et al. also reviewed similar findings in total knee patients.[6]

In summary, total joint replacement is the standard of care for severe arthritis with a good track record of relieving pain, but comes with some potential for complications and persistent symptoms.

Convenience Of The Procedure

Prospective patients must visit their primary care physician for a checkup. Some patients with pre-existing medical issues, such as heart or lung disease, may need to visit a specialist and undergo special testing.

There is a mandatory pre-operative orientation meeting you must attend with the person appointed as your coach, and this is a half-day event reviewing the entire procedure in detail. You will have a history and physical exam, in addition to informative lectures and a chance to ask questions. You will then be admitted to the hospital for 1-3 days, with most patients leaving in 24 to 48 hours following the procedure. A few select patients will be able to leave the day of surgery.

If you are not progressing in healing following the procedure, you may undergo physical therapy lasting up to eight weeks. All patients must have someone who can help them get up from a chair and into their bed or bathroom, as well as help them with dressing, bathing and preparing foods for approximately two to three weeks following surgery. This person(s) must be able to commit to being with you 24 hours a day, seven days a week. Some patients heal faster than others and may be independent in these critical activities of daily living sooner, but patients should expect three weeks of recovery time.

Some patients can return to sedentary jobs within 2- 3 weeks; however, it may take up to three months for patients to make a full return to physically demanding occupations.

If you have the procedure performed on your right leg, it is recommended that you not drive for six weeks following your surgery. If you have the procedure on your left leg, this may be reduced to two weeks, so long as you are not currently taking narcotics.

Pain Associated With The Procedure

Joint replacement surgery is a major surgical procedure and may require some sort of pain control for up to three months. However, we have made tremendous improvements in pain management that allow easier recovery in more rapidly.

We use a multi-modal strategy to help relieve pain, which means we use numerous different methods to reduce and/or block your pain. This approach normally results in a reduction of the complications that can occur with these treatments as well.

This multimodal approach uses a mixture of numbing nerve blocks combined with anti-inflammatories, anti-nausea, anti-anxiety, and cryotherapy (application of ice). Most patients are discharged from the hospital with a narcotic medication that is used for three to six weeks after the surgery.

Cost

Although most insurance plans cover the cost of a joint replacement, many plans have deductibles, co-insurance, co-pays and other uncovered services. The average charge by a hospital for a joint replacement is approximately $35,000. The average out of pocket cost for Medicare recipients in Lebanon New Hampshire was $4,275 in a survey conducted in 2011.[7]

Bear in mind, the charge and cost are not related to each other. The charge is what the hospital hopes to receive from an insurance carrier, and normally, they receive one half to one third this charge.

Consumers Report published the average fair cost as $21,626 for a total knee replacement (CPT code 27447) and $21,698 for a total hip replacement (CPT code 27130) in their 2017 Healthcare Blue Book. When calculating your expenses, prospective patients should also factor in the time lost from work as an opportunity cost. Most patients are off work an average of two to three weeks for a sedentary job, and up to three months for a physically demanding job. These expenses may be reimbursable through qualified Health Spending Accounts (HSA), Flexible Spending Account (FSA), Medical Savings Account (MSA), or Health Reimbursement Arrangement (HRA). Please contact your plan administrator for details

If you are interested in learning more about your options for arthritis with Dr. Loniewski, you can easily schedule a consultation by either calling 810-299-8552 or make an online consultation request.

[1] Courtney, PM et al. Complications Following Outpatient Total Joint Arthroplasty: An Analysis of a National Database. JArthroplasty, 2016 Dec 14[2] Wolf, B et al, Adverse outcomes in hip arthroplasty: Long term trends. Journal of Bone and Joint Surgery, 2012, July 18, 94(14) 8.[3] https://hipknee.aahks.org/total-hip-replacement/[4] Jasvinda A. Singh et al, Patient-level clinically meaningful improvements in activities of daily living and pain after total hip arthroplasty: data from a large US institutional registry” , Journal of Rheumatology (Oxford), 2013, June 52 (6), 1109-1118[5] Lam, YF et al., A Review of the Clinical Approach to Persistent Pain Following Total Hip Replacement, HongKongMedJ , 2016 Dec: 22(6): 600-7[6] Wylde, V et al, Total Knee Replacement: Is it Really and Effective Procedure for All?; Knee, 2007, Dec 14 (6): 417-23[7] http://health.costhelper.com/knee-replacement.html