Transcription:
Making the Decision to Get a Knee Replacement

Melanie Cole (Host): Knee pain can be debilitating and keep you from taking part in the activities that you enjoy. When this type of pain begins to interfere with your daily life, it might be time to see a physician to assess your pain. My guest today is Dr. Jason Hochfelder. He's an orthopedic surgeon at St. John's Riverside Hospital's Dobbs Ferry Pavilion. Welcome to the show, Dr. Hochfelder. So what are some of the most common causes of knee pain that you see?

Dr. Jason Hochfelder, MD (Guest): Oh well thanks for having me. Yes, probably the most common cause of knee pain that I see on a day-to-day basis is people with osteoarthritis, which essentially means that their knee joints, or the cartilage in their knee joints, has started to wear away and deteriorate.

Melanie: We hear a lot about ACL injuries in girls. Tell us a little bit about the difference between acute pain versus chronic pain like you've just discussed with osteoarthritis.

Dr. Hochfelder: Well you know, there certainly is a difference, and acute pain often is from an injury whether it's playing a sport, or just even a quick movement. But even chronic pain, sometimes people can have pain that's been lasting for months and months, or even in many cases, years. It can become worse or exacerbated by certain activities. Sometimes people even just say that they got out of bed one day and took a step, and they don't even know what happened, and all of a sudden their pain became worse. So it's not uncommon that in especially degenerative or chronic conditions, they can just become worse almost out of nowhere seemingly.

Melanie: So what is the first line of defense for knee pain? Are you someone who advocates bracing, or ice, or NSAIDS, injection therapies? We've heard about those, so what do you tell patients is the first line of defense for knee problems?

Dr. Hochfelder: Well you know, obviously the first line of defense is trying to prevent the knee problems themselves. The best way is to really do that part to maintain a healthy body weight. Obviously being overweight is going to put more pressure on any of the joints in our legs. Keeping the legs in good shape, the quadriceps muscles which are in the front of the thigh, those are very important to keep strong doing things like bike riding, walking, some gentle squats or leg extension exercises or lunges, which can be done without any equipment. All of those are important in trying to prevent it from happening.

Once pain starts to settle in, obviously if you can pinpoint a certain activity that bothers it, that's usually the thing you want to try to avoid. Usually with knee pain, the old adage of 'no pain, no gain' usually doesn't apply and we tell people if there's something that hurts whether it's going up and down stairs, whether it's squatting down, whatever it is, you should try to avoid it.

And then you know, icing obviously is a good way to start. And then occasionally taking some anti-inflammatories or Tylenol if those are okay with your medical condition or with your primary care doctor, things like Aleve or Advil are anti-inflammatories, and then Tylenol is a pain medication so sometimes a combination of the two is a good first line of defense.

Melanie: When does surgery for replacement become the discussion? How bad does the pain have to be for you to discuss this with the patient?

Dr. Hochfelder: Right, well you know, it's different for every person. And you know, what one person calls pain, another person may call stiffness, or soreness, or discomfort. So you know, I don't have a specific level in mind when I talk about how bad the pain is. Really for me, the key is when the pain, or discomfort, or whatever the individual patient calls it, when your knees get to the point where they're affecting your life on a relatively daily basis- and when I say affecting your life, I mean you find that there's things that you would normally do that you're now avoiding, certain activities that you are not doing anymore because of your knees, then usually it's time at least to bring it up as part of the discussion, when it's interfering with your quality of life and nothing else is really helping to get rid of the pain.

Melanie: So then what's the difference between a partial replacement and a total replacement? How do you make the decision and what real expectations should a patient have?

Dr. Hochfelder: That's a good question, and that's a question we get asked a lot about the difference between a partial and a full knee replacement. The best way for me to describe it is that the knee has three different compartments. It has the medial, which is the inside part of the knee, the lateral, which is the outside, and then the part underneath the kneecap.

If somebody gets to the point of talking about replacement, and they only have arthritis in one of those three areas, then we sometimes will talk about a partial knee replacement and replacing only one of those three areas. If somebody has arthritis in all three areas, a lot of times we won't even discuss partial knee replacement because replacing only one area when all three areas are involved would be kind of pointless.

So in people who have arthritis in one area, they can actually be a candidate for a partial or a full knee replacement. And when they have arthritis in all three areas, we only will talk about full replacement, because as I said, replacing only one of three damaged areas wouldn't make any sense.

And then in terms of expectations, and what people can realistically hope to get out of the knee replacement, well the main purpose and goal of a knee replacement is to get rid of pain and get people back to their life and doing what they want to do. So for the most part, if there are certain activities that people are avoiding, whether it's bike riding, walking long distances, squatting down on the floor to play with their grandkids, whether you're an active person and enjoy skiing, tennis, golf, and so forth, most people can get back to the activities that they want to do.

Melanie: Tell us about the replacements, the implants themselves. Do they come in different sizes? How long do they last? Tell us a little bit about them.

Dr. Hochfelder: Yeah so whether you're talking about a partial or a full knee replacement, each of them have multiple pieces to them. A partial replacement generally has three parts, and a full replacement generally has four parts. And each one of those individual parts comes in many different sizes. In some cases, they come in even narrow and wide, just like a shoe might. And essentially, there are so many different combinations that it's rare that you get multiple people in a row with the same sizes. And in fact, nowadays we have so many new technologies where we can actually use computers, robots, and other resources such as 3D printing where we can actually pick and choose the correct sizes for people prior to the operation.

We can obviously make adjustments at the time of the surgery if we need to if it doesn't fit how we expect it, but we actually can generally nowadays go into the surgery having a pretty good idea of what sizes and what positions the implants will fit best in.

In terms of how long they will last, because I think that you asked that as well, for the most part, I tell people when they're having a full replacement, that a full replacement should last their whole lifetime as long as they're above the age of let's say fifty or so. We used to tell people that they would only last about ten or fifteen years, but nowadays we're seeing even the older implants, the ones that were designed probably thirty or forty years ago, even those we're seeing lasting a lot longer than we expected.

So generally whereas in the past people used to be told, "Oh you're too young, you need to wait because you're going to need to have multiple operations and it's going to wear out over time," we're not really seeing that with the new modern implants. And for the most part, we're telling people, "If you have a problem and a knee replacement is the right answer, age really shouldn't be a factor. You should just have the proper operation in order to get back to your lifestyle," and the goal and the hope would be that it would be able to last for the rest of your lifetime.

Melanie: Dr. Hochfelder, at the beginning of the segment I asked you about first line of defense, and you said first line of defense is prevention. So here's your chance. What is your best advice about keeping healthy knees and preventing hopefully needing a replacement in the first place?

Dr. Hochfelder: So in some cases it just really can't be avoided. Some people are born with certain genetics, and their legs in a certain shape, those legs are sort of at a specific angle or in a specific shape that they're just doomed almost to wear out regardless of what you do. That being said, I think in my mind, that the most important things are maintaining a healthy body weight, maintaining low impact activities. That means things like swimming, water aerobics, bike riding. Those are the activities that I really like the best as opposed to high impact activities like jumping, running. Deep squats are always things that I tell people to avoid because they put excess pressure on the back of the knee that can tend to wear out first.

So you know, there's no one thing that works for everybody, but I think maintaining a healthy lifestyle, maintaining joints that are mobile, and stretched out, and strong, and not letting yourself go in terms of weight and activity. I think that's sort of the key is just maintain a well-balanced lifestyle whether that's what you eat or what you do.

Melanie: Thank you so much for coming on today and sharing your expertise, because knees are part of our base, and they're so important, and can really affect your quality of life. Thank you again for being with us. You're listening to Riverside Radio HealthCast. For more information please visit www.RiversideHealth.org. That's www.RiversideHealth.org. This is Melanie Cole, thanks so much for listening.