Transcription:

Bill Klaproth (Host): Your knee and hip pain has become unbearable, so are you a candidate for joint replacement surgery? And if you are at Eisenhower, patients are encouraged to participate in an education class prior to their joint replacement surgery which sounds like a great way to make sure people understand what to expect before, during and after surgery. Here to help us understand joint replacement surgery and prehab as it’s called, is Dr. John DeSantis and Dr. James Bell. Both are Board-Certified orthopedic surgeons with Eisenhower Health. Dr. DeSantis and Dr. Bell thank you so much for your time today. Dr. Bell, let’s start with you. Some patients can be concerned about whether they have enough strength to manage the recovery period. Tell me a little bit about prehab, which I was talking about in the open. How can patients build strength before joint replacement surgery?

James Bell, MD (Guest): Well the more strength and fitness that they have prior to surgery; they really do better after the surgery. So, if they can do any type of aerobic exercise or even strengthening exercises prior to surgery; they do better. They recover quicker and so they could be just walking. They could do cycling. They could do swimming. Any activity that would improve their overall fitness; certainly would improve their outcome postoperatively.

Host: And Dr. Bell has this been proven to make the recovery easier after surgery?

Dr. Bell: Absolutely. I think the patients who are more fit and in shape before surgery certainly seem to recover faster and do better.

Host: And Dr. DeSantis, what about patients who are significantly overweight? I understand some people might be encouraged to lose weight before surgery. Can you explain a little bit about how weight impacts our joints?

Dr. DeSantis: Well the more you weigh, the harder it is on your joint. Some people think that just overweight people get arthritis, but that’s not true. Skinny people get arthritis too, but it’s easier for them to do the exercises pre and postop and it’s easier for them to get through the surgery. And it’s actually technically easier for the surgeon to operate on somebody that doesn’t have a lot of excess body weight.

Host: Well, that makes sense. Dr. DeSantis let me stay with you. Have you ever seen a patient do so well with lifestyle improvement that they were able to postpone surgery?

Dr. DeSantis: You know most of the people they are at end-stage arthritis and losing some weight is going to make the whole process easier. But I wouldn’t say it’s typical that someone comes in, they need a total knee, they go, and they lose 30 pounds and now they don’t need it anymore. But it is easier for them to get through the surgery.

Host: Well that makes sense. And Dr. Bell, what is the difference between partial and total knee replacement and how do you determine if a patient needs a partial or total knee replacement?

Dr. Bell: Well a partial is you are just replacing part of the joint. So, basically, we’re talking usually at the knee joint, not the hip. And we divide the joint into three compartments. Typically, a patient will either wear out their medial compartment or their lateral compartment and if that’s the only place where they have arthritis; then they could get away with just having a partial replacement. But if all the joint is involved in the arthritic process, then a total joint is the way to go.

Host: Dr. DeSantis, following up on what Dr. Bell was just saying some people wonder if it’s too soon to get surgery. How long do artificial joints last these days and do you try to wait until the patient is a certain age before performing surgery?

Dr. DeSantis: No, age isn’t really a criteria. The criteria is that the patient is having severe pain or loss of function because of the pain, like they can’t walk around Costco anymore or they can’t go to the grocery store without having to sit down. So, the criteria are the severity of symptoms and their x-rays are bad enough that you can do a total joint. Age isn’t a criteria. I’ve done people as young as 28. I’ve done a fellow that just had his knee destroyed in an accident ten years earlier. He was 28 and he was bone to bone arthritis. I’ve done a total hip on somebody that’s 28 for avascular necrosis. But typically, our patients are between 50 and 90.

There is no age criteria in which I will tell somebody you can’t get it done. Now the advantages, if they get it done at 70, it’s more likely it’s going to last someone their whole life. If they get it done in their 40s, there’s a chance it might not last their whole life. Implants last a lot longer now than they used to because of the quality of the material. But I’ve seen total joints done in the 90s that have lasted 30 years, and the materials now are much better. So, we can expect I would say 20-30 years from some joints.

Host: Well that’s really good news and Dr. Bell, can deterioration of a joint happen rapidly. I’ve heard of people who have had imaging done on a knee for instance and it doesn’t look too bad and in a relatively short time the deterioration is significant and suddenly they are a candidate for joint replacement. I know everyone is different, but do you see patterns among patients in terms of that deterioration?

Dr. Bell: It’s again, like you said, it’s very variable between patients, but there are those cases where it doesn’t look like they are really that significantly involved but a lot of times, then there is some traumatic event and they’ve either fallen or have been in an accident or something and their symptoms can suddenly change. Even a patient who really has a significant amount of arthritis but really is not experiencing significant dysfunction; if they suddenly experience trauma, their joint can become totally different and much more painful and more difficult for them and sort of speed up the process of our decision making as to when they need their joint replaced.

Host: Dr. Bell, let me stay with you and let me ask you this question. For a while we were hearing a lot about customized knee joints for men and women by gender. Is that standard now?

Dr. Bell: It’s out there. A lot of people use it. It’s not exactly the standard for everyone. We are all trained a little bit differently and we all have our particular choices of how we do things and so, it just depends on what the surgeon is comfortable with and how he decides to do the surgery. We’ve had changes in some of the stuff that we do and say in a total hip; that has changed significantly in the last few years where we used to do for years it was metal on poly in the joint surface. Then we tried metal on metal which really didn’t work out well and now we’ve all switched into ceramic on poly which we hope is going to be much more successful and lasting for many more years.

Host: And as Dr. DeSantis was saying, some of these knee replacements, hip replacements will last 20-30 years which is really good news. Dr. DeSantis, we’ve talked with your colleagues and I know that some knee replacements are being done on an outpatient basis where the patient is home in less than 24 hours. Is this the same thing happening with hip replacement surgeries?

Dr. DeSantis: Yeah, I would just like to make a comment on the last question to Dr. Bell about custom knee or hip replacements. I’ve done a lot of custom knee replacements and I’ve stopped doing them because the custom knee replacement fits the diameter of the knee, the femur and the tibia perfectly, but the main thing wrong with a knee that isn’t working out is if the balance, the space in extension and flexion are off; and we can balance knees better I think, if we are not using a custom knee because there’s guides that allow much more variation if you need to change the extension and the flexion.

Host: Dr. DeSantis great point. Thanks for adding that on. We appreciate it. Dr. DeSantis let me stay with you for a minute. We’ve talked with your colleagues and I know that some knee replacements are being done on an outpatient basis where the patient is home in less than 24 hours. Is this the same thing happening with hip replacement surgeries?

Dr. DeSantis: Yes, it is happening and it’s going to happen more. I actually did a patient this week, she went home the same day of the surgery, that afternoon. I think it’s actually easier for hip replacements to go home earlier than it is for knee replacements. But what drove the change to knee replacements as being outpatient is a lot of knees were being done in clinics or facilities or hospitals owned by doctors and the main thing that makes outpatient knee surgery work is having good outpatient homecare and therapy and so those centers, where they were doing outpatient knee replacements kind of drove the issue that they could do them as an outpatient and it went from Medicare not accepting outpatient total knees to now they advocate it, and in fact, we have to prove if someone has to be admitted to admit them to the hospital. So, most knees are now categorized as outpatient procedures.

Host: Wow, that’s interesting and Dr. DeSantis do you foresee that this will happen more often in the future?

Dr. DeSantis: I think there will be a day where hardly anybody is overnight in the hospital. I don’t know if that’s going to be in five years or in ten years, but I think as time goes on, what’s going to happen, is the outpatient side of physical therapy and homecare is going to be improved to the point that they can care for somebody in their home as good as people are being cared for in the hospital now.

Host: Wow, that’s really interesting. Dr. Bell, what expectations do you like to set for your patients who are particularly active about getting back to their sports or hobbies after joint replacement?

Dr. Bell: I like to get my people back as soon as possible. So, again, we get them going the same day of surgery in therapy. They are up. They are moving. We want them working hard to regain motion, regain function and regain strength so, that they can be back to their activities well within a year, hopefully less than that. Either in three to four months even six months. Most people are actually doing quite well by then. But the things we don’t want them to do is any kind of high impact events. So, people say well can I go back to jogging and can I go back to running and we really discourage that, because it just adds more wear and tear to the prosthesis and would cause it to maybe need to be revised earlier than otherwise.

Host: So, Dr. Bell somebody that likes to play tennis where there’s really impact, pounding on the joints and running too. You would generally advise against that then.

Dr. Bell: Typically, if they are playing doubles it’s better. A lot of people are now enjoying pickleball and so I think that’s a fine activity. Again, it’s most of them are playing doubles and so those things are really okay to do for the most part.

Host: Well tennis players that are listening to this are rejoicing. At least they can still play doubles or pickleball which is good news. And Dr. DeSantis if you could wrap this up for us, what do you think will be the biggest change in the next ten years when it comes to joint replacement surgery?

Dr. DeSantis: You know there are so many changes that have happened from ten years ago to now, I would never think that I could be doing a total hip in a three inch incision which we’re doing now. It’s going to be a change in the way the doctors are able to do surgeries, the different approaches. It’s going to be a change in the technology that’s available to the doctor. And it’s going to be a change in the postop care that allows us to do patients and get them out of the hospital and have them just staying at home.

Host: Really good information Dr. DeSantis and Dr. Bell. I’ve enjoyed talking with both of you. Thanks for really good stuff today. Thanks for your time and for more information and to learn more about the physicians and services at Eisenhower Desert Orthopedic Center, call 760-773-4545, that’s 760-773-4545 or visit www.eisenhowerhealth.org/edoc. One more time for you www.eisenhowerhealth.org/edoc. This is Living Well with Eisenhower Health. I’m Bill Klaproth. Thanks for listening.