When you have arthritis of the hip or knee and your orthopaedic surgeon introduces the topic of surgery, you probably never want to hear that undergoing surgery may be the right choice to return you to an active lifestyle. Surgery is an alternative to failed conservative measures to control pain and return mobility. Even though surgery is usually avoided if possible, pain and limitation of activity can create such a roadblock to comfort and doing the things you enjoy, it may be worth considering instead living the rest of your life with progressive worsening of pain.

   Most importantly, knowing what to consider when deciding whether to have surgery is powerful information. The more you know about what to expect when considering joint replacement surgery, the more comfortable you will be in your decision to proceed. With that in mind, let's discuss total joint replacement, specifically of the hip or knee.

   In the early to moderate stages of arthritis, it may be possible to simply to alter your activities a bit. Reducing impact activities and increasing non-impact activities is a good start. Adding over-the-counter analgesics and anti-inflammatory medication may be good for a while as well. When it's time to visit with the physician, he/she can prescribe stronger NSAIDS and physical therapy. You can consider receiving a cortisone injection to reduce inflammation. Specifically for osteoarthritis of the knee, you could try viscosupplementation (see article on Viscosupplemention) for a series of injections designed to decrease pain and at the same time provide extra shock absorption for the joint. You can protect the joint by using a cane and keeping your weight down. Joint replacement is introduced when these types of modalities have failed.

   Joint replacement, or arthroplasty, is a surgical procedure in which the diseased parts of the hip or knee joint are removed and replaced with new, artificial parts. These artificial parts are called the prosthesis. Joint replacement of the hip or knee has an excellent track record to eliminate or reduce pain and improve function of the affected joint.

Are You a Candidate for Joint Replacement Surgery?
   The most common reason people undergo joint replacement of the hip or knee is for the pain and immobility that results from the wearing down of the cartilage in the joint from osteoarthritis (OA), rheumatoid arthritis (RA), avascular necrosis (AVN) (loss of bone caused by insufficient blood supply), and less common types of arthritis. Injury can also lead to the breakdown of the joint and the need for TJR.

   In the past, joint replacement was reserved those people over 60 years of age. Typically older people tend to be less active and put less strain on the artificial joint. In recent years, however, younger people can consider this option as well. New technology has improved the artificial parts, allowing them to withstand more stress and strain. Most importantly, overall health and activity level of the person is the best indicator for the success of a joint replacement once you've chosen an experienced surgeon who can provide you with the artificial joint.

   Some people worry they are "too old" to consider joint replacement surgery. Again, it's the health of the patient that determines who is a candidate and who is not. For example, people who suffer from extreme muscle weakness or Parkinson's disease may not be candidates. Those in poor health generally are more likely to be a higher risk for complications or to recover successfully.

What to Expect Before Surgery

   When you see the surgeon in the office for an evaluation, he/she will obtain your medical history and perform a physical examination that will include x-rays and a visual analysis of your gait. Once you and the doctor have agreed that surgery is the next step, your doctor will do the scheduling and help arrange for your pre-operative blood work, electrocardiogram (EKG) and chest x-ray. If needed, you may also donate some of your own blood (autologous blood donation) in case you need it during the procedure.

The Surgery

   During joint replacement surgery, the surgeon removes the diseased bone tissue and cartilage from the joint. The healthy parts of the joint are left intact. In the hip, the ball is removed and socket cleaned out; in the knee, the damaged knee surfaces are removed. Once the joint is prepared, the surgeon replaces the removed parts with the artificial components. The new joint is made from man-made materials that allow a natural, gliding motion of the joint. Surgery time varies with the experience of the surgeon and difficulty of the surgery and can range from 45 minutes to a couple of hours.

   The artificial parts are kept in place through the use of bone cement or inducing bone growth into the prosthesis. The process of natural bone growth can cause thigh pain for several months after surgery. Because each person's condition is unique, the bone strength variable, the decision of which is best for you should be discussed with your doctor.

   The primary disadvantage of an uncemented prosthesis is the extended recovery period. Sometimes, people must limit activity up to three months while the cemented prosthesis allows more mobility much more quickly.

   Research has proven the effectiveness of the prosthesis to reduce pain and increase joint mobility. This mobility is noticeable immediately after surgery. Cemented replacements are much more frequently used for older people and people with weak bones, such as those who have osteoporosis.

In the Hospital

   On average, you can expect four to five days of hospitalization, depending on your personal situation. Everyone is different. It is important to evaluate a patients' abilities and difficulties beforehand to be sure they receive all the help necessary while in the hospital.

   The day after your surgery, you can expect to be out of bed with the assistance of a physical therapist. No excuses will be permitted! The physical therapy is required-your work after surgery is necessary to get you home as soon as possible. There will be some limitations and these will be discussed with you as you go along. Positioning is important; we'll show you all the moves! With practice and a little time, you'll be walking and exercising with minimal or no assistance and can look forward to being discharged from the hospital.

   You will have several discharge options depending on your personal situation. You may be sent home with your family to assist you, or with arrangements for home care; you may be discharged to an extended care rehabilitation center or skilled nursing facility. Family support, your physical strength and motivation are all factors to be considered.

   After surgery, you will spend a few weeks on an assistive device such as a walker or crutches. Daily exercises will strengthen the muscles around the new joint having been weakened from nonuse. Once you return to the doctor in his office for x-rays and an evaluation of your new joint, you will be able to plan your return to activities.

The Future
   Remember, your artificial joint is just that. In the long term, you can do just about any activity that has a "gliding motion," as opposed to a "direct impact." For example, you can walk, dance, bowl, bicycle, golf, swim…but if you have plans to jump, jog, run or ski, this impact loading type of activity can place extra stress on the joint and put it at risk. That's not to say some people with joint replacements don't do these things-they do. But just realize that such activities could cause harm to your joint, ruining all the good work you've done.

   Patient care begins with education and extends into rehabilitation and follow-up. Your role is to educate yourself, understand the purpose of surgery, what to expect before and after surgery, including a discussion of the risks of the surgery and long term outcomes of undergoing total joint replacement. Neither the doctor nor the patient is totally responsible for a successful joint replacement; it is a shared responsibility. Together, you will work for the best possible results. In the long run, you should be able to enjoy many years of comfort and an active lifestyle. Now, that is worth considering.

About the Author:
   Arizona orthopaedic surgeon, Dennis Armstrong, M.D., is board certified in orthopaedic surgery and specializes in arthritis reconstructive surgery. He received his medical degree from the Wayne State School of Medicine and completed his orthopaedic residency at Henry Ford Hospital in Detroit, Michigan. Dr. Armstrong has been involved in several clinical investigative studies researching the surgery and care of those undergoing total joint replacement, and has authored numerous talks/papers on options for knee and hip pain.

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