Evo Terra (Host): Joint pain is a common complaint for many. And if it's not for you yet, well, wait a while. For those of us with it, how do we move on from joint pain? Let's find out, with Dr. Scott Miller, an Orthopedic Surgeon at Health First and Health First Medical Group. This is Putting Your Health First from Health First. I'm Evo Terra. Dr. Miller, thanks for joining me. I have a slew of questions here for you, so let's start out with the cause. What are the causes of joint pain?

Scott Miller, MD: Joint pain itself is really a multifactorial problem and obviously there's differences in joint pain if you're 16 and hurt yourself or if you're 65 and you've just lived a bit of a hard life. Essentially our knees and our hips and most joints are covered in special cartilage. Given enough accumulated damage, that cartilage starts to cause inflammation and swelling and that's essentially the baseline cause of most joint pain. Now, we can get into the specifics about rheumatoid type joint pain or psoriasis, but for the vast majority of people listening, that pain is going to be wear and tear and inflammation.

Host: Makes sense to me. Now, I know that you are an Orthopedic Surgeon, but can you talk about some non surgical ways we treat joint pain?

Scott Miller, MD: Yeah, I think that the non surgical ways are probably the most important because not everybody with joint pain actually needs a knee or a hip replacement. Non operative treatment starts with the most basic of things. It's modifying activities. It tends to be that heavy duty weight bearing exercise tends to exacerbate and irritate joint conditions.

And so, that's the first step, decreasing some of the things that bother us. From there, you want to make sure you're maintaining a healthy weight. Weight has a cumulative effect on our joints. Additionally, we can actually start to use pharmaceutical type interventions. So, an anti inflammatory is kind of our front line first real deal intervention and those anti inflammatories work to decrease inflammation in the joint.

It helps with swelling and pain. And then you can get into specific, individualized treatment like corticosteroid injections and visco supplementation and PRP and stem cells and all down the line. And so, after you've gone through pharmaceutical interventions, there's bracing and cane usage, there's so, such a long list of things that we try to use to avoid surgery.

Host: That's great to hear. So let's say that someone has tried many of things or they're trying those things. How do they know when they are ready for joint replacement surgery?

Scott Miller, MD: I like to think that when you start to use your hip or your knee pain as like one of the primary driving forces on what you can or can't do or will or won't do in a given day; if you're starting to plan your life around your knee pain and there's an opportunity to make a more substantial improvement, then I think that's a good time to say, well, it's time for me to do something more. I've tried everything and I can't do what I want anymore.

Host: Are there any criteria that someone needs to you to qualify for before they get joint replacement surgery?

Scott Miller, MD: You need to make an honest effort for non operative treatment for some amount of time, whether that's three months or six months. And I think it behooves all of us, before we undergo a big surgery like joint replacement, that we've tried the simple stuff.

If the simple things like injections and anti inflammatories make a difference, great. If that gives us six more years without a major surgery, that's not such a big deal.

Host: Well, let's get into that surgery. Talk to us a little bit about what the process of joint replacement surgery looks like. What do you do?

Scott Miller, MD: Yeah, so, you know, there's like sometimes maybe a misconception that joint replacement involves making some large cut and removing like the whole knee or the whole hip and putting in what basically looks like the same thing and that's, it's variable for each joint that's being replaced. The knee replacement itself is almost like a resurfacing.

What we're doing is we're taking a shape and reshaping it such that we can cap it off. You almost think of a knee replacement like capping two teeth and putting a plastic disc in between the two of them. Um, a hip is perhaps a little bit different in that, a hip is a ball and a socket joint and so, for a hip, we're going to remove the ball and we're going to clean out the socket and resurface that socket before we anchor in a new ball.

So the act of doing joint replacement is basically getting rid of the diseased parts and putting in new pieces so that we can have a more functional joint without as much pain.

Host: Let's talk about longevity for a moment. Someone's had a joint replacement, they've had a new knee, or a modified knee, or a new ball added to their hip joint. How long will this sort of surgery last someone?

Scott Miller, MD: We have a lot of historical data to help us make that answer but I guess the relevance here is the piece of plastic that we stick inside any joint, so in every single joint that's being replaced, there's a piece of plastic. The longevity of the joint, independent of infection or fracture or things like that, is how long will the plastic last.

And over time, we have gotten much better at manufacturing plastic. And we have learned more about bearing usage. And so, how long will it last? We say 15 years. Do we say 20 years? Do we say 25? I think it, a little bit of it is. How much are you going to put the plastic through while you have it?

A younger patient probably has a perhaps slightly different lifespan of their plastic than an older patient. But the metal pieces will last a long time. And so if you and your surgeon are working together to monitor your care after the fact, and you see the plastic wearing out, fixing that is a much easier problem, as long as people are paying attention to it, almost like a tire change.

Host: Nice. That's, I think reassuring for people who wonder that they have to go through the entire process once again. So, thank you for that. So we've talked about hips, we've talked about knees uh, but maybe a broader, I know there's more to it than that. What conditions can you treat with joint replacement surgery?

Scott Miller, MD: We're finding more and more joints that are replaceable, so to speak. I mean, we've got the joints in the back, like disc replacements. We've got the shoulder. We've got ankles. We've got knees and hips. Elbow replacements as well. It's a little bit harder to replace some of the smaller joints of our fingers and our, on our toes.

Though, I mean, there are certainly people that do procedures like that, I think that the major big joints in our body are the ones that are most conducive to being replaced right now.

Host: Makes sense. The benefits, I mean, to me, there's a primary benefit to having a joint replaced, and that is no more joint pain. Is there more to it than that?

Scott Miller, MD: I think the benefits that we really look at, if we get down to it for hips and knees specifically, the primary benefit would be the alleviation of weight bearing discomfort. So with a hip or a knee replacement, you should be able to get up and walk from point A to point B and not have to be thinking about your hip or your knee as the reason you can't do it.

But that's just the start. So if you've now modified your life because you can't walk or you can't move quite as much, it opens the doors to doing more things. Perhaps the ability to get your hip replaced allows you to focus on cardio activity. And then maybe we get some improvement in heart and we can go with weight loss and diabetes control.

So there is certainly a cascade of events that happens when people have bad joints and reversing those events take time, certainly, but I mean, with a reasonably placed joint replacement, I would hope that people can return to all the activities they want to.

Host: Yeah. That's a great goal to have, and then, done right, we would certainly see that. We've been talking about benefits for a while, maybe we should talk about risks for a moment. What are the risks associated with joint surgery?

Scott Miller, MD: Sure. I mean, risks go from the smallest of small, right? The incision, it sometimes has a hard time healing. We have to pay extra special attention to that. Some incisions are smaller these days, they are more stretched. So I think if you get down to it, the most common issue with joint replacement are probably wound issues which seems small but can be irritating.

But then, we're sawing, we're hammering, we're cutting. Things that we don't want to cut can get cut. Things that are not supposed to break, can break. And so a lot of the act of doing knee and hip replacement specifically, is about respecting the tolerances of bones and soft tissues and knowing where you're supposed to be and doing things in the most reproducible manner possible.

Further down the line, we get to more medical considerations like blood clots. Everybody's heard of somebody that's had a blood clot and certainly joint replacement surgery does carry that risk with it. And to the end that we'd like to treat in preventative fashion before that occurs.

So everybody that has their joint replaced generally goes home on some sort of medication to help with that. I mean, we can get into really extreme examples of stuff that can go wrong in a joint replacement, but suffice to say that kind of covers some of the more particular issues.

Host: I wonder, you know, we live in an advancing society here where technology continues to evolve at a rapid pace. How has the technology impacted your job as a surgeon? Do we have everything on an operating table with knives still, or do we have new things?

Scott Miller, MD: Joint replacement surgery perhaps lags a little bit behind some of the more interesting advancements in, say uh, surgery inside the abdomen. But if we think about what has changed for me over the past 20 years, knee replacements, still a knee replacement. What we're figuring out how to do is how do we decrease the soft tissue injuries when we do surgery?

How do we accelerate rehab? How do we control pain? And then, you know, more contemporary changes are robotics in joint replacement. We now have the ability of using those robotic surgeries to help perhaps eliminate some of the variability that surgery can present. Computer navigation and robotic assisted surgery certainly can help to that end.

Host: Well, it's great to hear that technology continues to advance. Let's go to the other side of this. Surgery's over. Great. What's recovery look like?

Scott Miller, MD: Recovery is hard. Um, I mean, you know, it's kind of like a flippant thing and I make probably the same general statement to all my patients, you know, this is tough. It is normal for some point over the next couple of weeks for you to not care for me. You will not like me at some point in this recovery process because it's going to challenge you.

However, knowing that there is going to be some level of adversity can make a big difference. Full recovery from a knee replacement is probably an 18 month experience. Maybe a little bit less for a hip replacement because the mechanics are different, but you know, the beginning, the hard part is your first six to 10 weeks.

Your body's working very hard to adapt to what's been done to it. And you're working very hard to not let your body get in the way. So you have to work hard to get your motion back and get your swelling down before your body has something else to say about it. And so, that part of the recovery can be challenging.

Everybody's got a story about physical therapy, like, oh, they were the people that tortured me, but they made a big, almost everybody likes their therapist in the end because they kind of come to an agreement.

Host: Just a quick question. What you see today, you know, obviously the goal, as you said it earlier, was for someone to return to the things that they could not do before they had the joint replacement surgery. How likely is that?

Scott Miller, MD: I think we all have a sense of a person. We all think we do. And I think each person has a sense of what they think they can accomplish. A positive attitude walking into joint replacement makes a big difference. Can I tell you with certainty that an 85 year old that gets their knee replaced will go back to running marathons?

No, that would be kind of challenging, but I no longer tell them they're not allowed to. I have patients that have completed triathlons. They've gone on to play competitive tennis. They are active in the golf community. They're surfing, they're traveling the world. They're doing all the things they want to do.

So I think the likelihood of returning to what you want, has a little bit to do with how much time you've waited to get to surgery. Um, for every person that wants their surgery done sooner than it needs to be, there's probably five people that are waiting longer than they should. And in the time that they wait that's extra, they put more stress on their body, they become more decompensated, their muscle function diminishes.

And so now they're left with perhaps a bigger hill to climb than maybe if they had just sorted it out in the beginning. And unfortunately, a lot of that comes down to people hearing from someone that this is a bad surgery, or that it takes too much time, or that it hurts too much, and so they get scared. And pretty soon they're left a bit of a bind.

Host: Yeah. Anything I didn't ask that you wanted me to cover?

Scott Miller, MD: No, I think that really touches bases on a lot of things. I mean, the only thing I would say is if you are dealing actively with joint pain find a doctor to talk it over. Simple x-rays can go a long way in diagnosing most significant arthritis problems. And that's something that can be, can and should be done for people that are dealing with activity limiting joint pain.

Host: Great advice. Dr. Miller, thank you very much for being on the program today.

Scott Miller, MD: Thanks for having me.

Host: Once again, that was Dr. Scott Miller, an Orthopedic Surgeon at Health First. Enjoy more moments that move you. Learn more about joint replacement surgery at Health First and schedule an appointment with an Orthopedic Surgeon at hf.org/ortho. And if you found this podcast episode helpful, please share it on your social channels and check out the full library of topics of interest to you.

I'm Evo Terra. This is Putting Your Health First from Health First. Thanks for listening.