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Is it Time for a Knee or Hip Replacement?

08/13/2015

There’s something comforting in a medical test that yields a clear recommendation. A positive strep test? Prescribe antibiotics. See a fracture on an X-ray? Time for a cast or surgery. But there’s no simple test to determine when a joint replacement is the best next step to alleviate a patient’s hip or knee pain. That’s because a patient’s subjective tolerance for pain is often the crucial factor in the decision. 

There appears to be some genetic influence on how joints wear, but for the most part, knees and hips find themselves in need of replacement due to simple wear and tear. A member of the Tufts Medical Center’s Total Joint Replacement Program, says that physical activity over many years causes a joint’s cartilage to wear down, like tires on a car. Once you’ve worn through the cartilage, you get to the bone. It can also set off a chain reaction, with the body producing a fluid that causes inflammation and swelling, which reduces motion and sets off even more pain. 

Primary care physicians can start to address joint pain by prescribing physical therapy and oral pain medication. If those remedies don’t help, or if they stop working, it may be time to refer the patient to an orthopaedist.

Community-based orthopaedists provide excellent care for otherwise healthy patients considering a joint replacement. Tufts Medical Center’s Total Joint Replacement Program specializes in caring for patients with complex conditions, such as diabetes, obesity, and cardiovascular issues.

For patients thinking about a joint replacement, there are two other important considerations to factor into the decision.Even though the median age for a joint replacement is 65, patient ages can range from their 20s to 85. Those on the younger side have to weigh the possibility that they might one day need a replacement for their replacement. That’s because, depending on  their age and their level of activity,  there’s a chance they could wear  through their artificial joint as well.

Patients should also keep in mind that recovering from joint-replacement surgery includes a period of pretty intense pain, as well as weeks of physical therapy.

If my knee is fine, why does it  hurt so much? 

Believe it or not, there are times when someone will come in and say that their hip or knee hurts, and it’s actually their back that’s the problem. They could have a pinched nerve in their back and it’s radiating pain elsewhere. Similarly, a patient’s knee pain can sometimes really be a problem with their hip. There are times when it can be hard to convince a person where their actual problem is. I have had people come in with knee pain, and  I’ve explained that the knee is fine, that I have X-rays showing a worn-out hip. But when I move their hip, it hurts in their knee. It can be challenging  to convince them that a hip injection or a hip replacement is going to solve their knee pain.

The reason for all of this is that pain flows downhill so to speak. People with back problems can experience pain anywhere from their back all the way down to their toes. People with hip problems can have pain in their hip or their knees. This radiating pain is usually related to a nerve. Diagnostically, it can be a challenge. If necessary, we can do a ‘diagnostic injection’ of pain medicine to see if it cures the problem. We can do that right here in the office. It’s simple, it’s cheap, it’s minimally invasive, and the results can be powerful.

Not ready for a total hip or knee replacement? 

Modify your activities. Identify what’s causing you pain and either look for alternatives to those activities or do them less often. For instance, if jogging every day causes your knee to swell, try walking or jogging less frequently.

  • Use a nonsteroidal anti- inflammatory pain reliever such as Aleve, Motrin, or  Advil (talk to your primary care physician because these can cause upset stomach). Another option is 500 mg of Tylenol Arthritis.
  • Get a cortisone  injection in the joint.
  • Try an assistive device such as a cane. 
  • Consider a “joint salvage procedure,” otherwise known as a “scope”. Only certain patients are good  candidates, however—those who are younger and who have milder conditions.

Out of Joint

For people suffering from debilitating hip pain, a replacement can mean relief and  a return to an active lifestyle. Even better, some hip-replacement patients  are candidates for a version of the surgery that results in an easier  recovery process: direct anterior hip replacement surgery.

Direct anterior hip replacement surgery differs from the traditional, or posterior,  method in two important ways. The first is that the incision is made in the front  (anterior) of the hip rather than the back (posterior). The second is that the  anterior procedure goes between muscles rather than through them.

The traditional posterior hip replacement continues to deliver excellent  results for many patients, but for those who are good candidates,  anterior hip replacement can have them back up on their feet in no time.

Anterior hip replacement patients are often walking and even working with Tufts MC physical therapists on the same day the surgery is performed, and many  of them are able to leave the hospital the next day. Posterior hip replacement  patients often spend three days recovering in the hospital.