What you need to know before having a knee or hip replaced

Dear Reader,

One of the largest demographic groups in U.S. history is graying fast—and demanding treatments to keep active and mobile. That has made knee and hip replacements a booming surgery for the baby boomer generation. Experts estimate that 7 million Americans by 2010 had had one or more.

Doctors have improved both. Once reserved for dire cases or those, like athletes, with special needs, joint replacements aren’t as dramatic as they once were.  Especially with Uncle Sam footing the bill for seasoned citizens, knee and hip replacements have become more affordable. But just because a surgery also is more routine, accessible, and generally effective, it doesn’t mean it should be taken lightly.

I don’t usually talk about my trial work in this newsletter, but by coincidence, last month I spent two weeks in a District of Columbia courtroom showing a jury exactly how an orthopedic surgeon had botched my client’s knee replacement, which eventually required an above-knee amputation. (More on the lawsuit and verdict here.)  Those kind of hideous results are fortunately rare, but it’s still worthwhile for all of us to focus on the pros and cons of joint replacement, and how we patients can help ensure the best outcomes.

Cautions on the path to joint replacement

Pain provides one of the clearest indicators of worsening knee or hip trouble for most patients. As we age, longtime stress and damage to these complex marvels of body engineering can make them lose their flex and become agonizing to move. Growing discomfort sends millions to doctors’ offices.

Some patients find the relief they need with rest and reduction of joint stresses, knocking off at midlife or older playing as rambunctiously as they once did in their late teens and 20s. They strap on braces or supports, launch into rehabilitative exercises and physical therapy, and, yes, they may take drugs for chronic pain and stiffness.

Experts can’t stress enough these days the caution with which patients and doctors should approach pain remedies:  Common, often over-the-counter, non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen, and naproxen carry risks, including bleeding, for some. Many more powerful painkillers—without skilled, measured prescription— have proven to be addictive, fuel for an epidemic of abuse, and gateways to even more potent, illicit, and illegal opioids.

Wary about therapies

Some knee and hip treatments also raise concerns. Few of us are sports superstars. But some of us want to be like Kobe Bryant, Tiger Woods, or Rafael Nadal, and follow their lead in seeking fancy treatments for bad hips or knees, such as electrical stimulation or injections of platelet-rich plasma. Some doctors may shoot patients’ achy knees or hips with hyaluronic acid, a substance similar to what is found in the body’s own natural lubricants.

Be cautious about joint therapies—the full evidence isn’t in that they’re broadly effective. You may pay a lot for a placebo effect, the powerful belief that a given treatment will work makes it so.

You also may fork over hard-earned cash to get your knee or hip needlessly “scoped.” Orthopedists nationwide have pushed more patients with pain to consider a laparoscopic (“key hole”) procedure for “impingement” in the hip. It is recommended as a precursor for the more major hip replacement, with orthopedists saying femoroacetabular impingement (FAI) procedures let them go in to clean up cartilage and bone problems that cause pain and impair flexibility in the joint. Although many surgeons push this operation, independent studies on its effectiveness are mixed, especially in contrast with physical therapy.

Meantime, a growing body of research on knees is debunking orthopedists’ extensive use of specialized tools—including an arthroscope that lets them, via a keyhole incision, peer into a joint—to perform “minimally invasive” surgeries. Doctors claim that arthroscopy allows them to go in, and to clean out debris and damaged tissue, including to repair a “torn” meniscus (the rubbery patch alongside each side of the knee). As many as 400,000 of these procedures are performed annually on Americans at a cost of $5,000 each. They are, as one recent meta-analysis described them, “useless,” and British practitioners recently have issued a major recommendation against their use.

‘Routine’ surgeries can and do go wrong. Hospital, rehab stays also can go awry.

At some point, knees and hips can become so painful and limiting that patients and their doctors will agree they need replacement. This decision may be age-related. Because doctors know that replacements themselves have time limits (roughly two decades of effectiveness), they had waited, if possible, before cutting on knees and hips. Advancements have reduced these concerns. The surgical choice still should involve appropriate testing and imaging studies, usually X-rays, and lots of careful discussion between doctor and patient.

Conventional wisdom holds that, with joint replacements so common and typically successful—they’ve become some of the most performed surgeries annually in U.S. hospitals— patients shouldn’t fret at all. Don’t believe that. Every surgery carries risks. And you can do smart things to decrease yours, including by knowing that things can go wrong, very badly wrong, in any operating room and in the medical follow-up to any surgery.

In the lawsuit I recently tried, the orthopedist’s first mistake was in failing to appreciate that my client had blood flow restrictions in his leg that required a different technique. He put a tourniquet on my client’s thigh to squeeze off all blood flow for hours as he did the knee replacement, exactly the wrong thing to do in a patient who had a stent propping open the major artery in that thigh. A simple consultation with a vascular surgeon would have prevented the disfiguring amputation that followed.

What to expect

To be sure, many joint replacement operations go well and without complication. Your surgeon should give you a clear idea of what kind of care you will get, including whether you will need lab tests and preparation. You will, for example, be asked to get in as optimal as possible health before surgery, including perhaps, by losing weight. In brief, during the procedure an orthopedist goes in and cuts away damaged bone and cartilage from the joint. He then puts in prosthetics made of metal, ceramic, and plastic to re-create a smooth, durable joint. The orthopedist may keep parts of the damaged joint, resurfacing as needed in what’s called a partial replacement.

With hips, orthopedists vary as to whether they make their incisions in the front or back of the joint. Some surgeons say they work in “minimally invasive” fashion, with smaller incisions, and maybe with robotic assistance. It is important, no matter the technique, that the surgeon must secure the prostheses and ensure the new parts fit and work together smoothly and comfortably.

Joint replacement operations go relatively quickly, typically taking as little ash an hour and a half. But patients then need to recover and rehabilitate. And here there is both more risk and new controversy.

Although your overriding interest will be in getting your painful knee or hip fixed, you also will get exposed to the changing fee structure of medicine with your joint replacement. That’s because Uncle Sam, through Medicare, is paying for so many of these operations that he’s insisting on greater cost controls, safety, and efficiency with them. The federal government, for example, has tried to move medical providers away from an array of fees for various services you will need, favoring instead a “bundled” charge (see more below). The feds also have put in place a big system of incentives and penalties to get doctors and hospitals to protect patients better from infections they acquire in health care settings and to prevent errors, poor treatment, and other factors that can lead to patients’ costly readmission.

Infection woes, errors

These measures, without doubt, have helped. But not nearly enough. Hospital-acquired infections and medical errors, studies show, claim as many as 685 American lives daily, making them the third leading cause of death, lagging only heart disease and cancer.  Every time you’re hospitalized, and especially when you undergo a significant procedure—including now “routine” knee or hip replacements—you subject yourself to medical risks. Doctors and hospitals have tried to reduce this by carefully monitoring and caring for patients after joint surgeries, including by giving them powerful antibiotics, anti-clotting, and pain-killing drugs. Because hospital care can be pricey, orthopedists typically have recommended that joint-replacement patients get moved in a few days to specialized rehabilitation centers. Those facilities, as hospitals do, struggle to keep patients free of infections and other harms. Still, as many as a third of their patients develop health care-acquired infections, a rate comparable with hospitals and skilled nursing facilities. You may go in the hospital for a straightforward operation and end up battling complications. Medical experts say these occur in an estimated 2 percent of knee replacements—that’s still an unfortunate 14,000 or so cases per year. Because hip surgeries can be more complex, they can come with more complication risks, not only for infection but also necessary readmission for adjustments to the joint or to care for dislocations. Patients also have experienced major issues with materials in the hip implants and the devices’ effectiveness, leading to tens of thousands of product recalls and long-running lawsuits.

Uncle Sam and some surgeons are contemplating a major alternative: Some orthopedists want patients sent home to recuperate there as fast as possible and, studies suggest, with fewer infections and comparable rates of other complications. It is a much cheaper alternative, because roughly half of the $16,500 to $33,000 cost of a knee replacement is due to post-operative care. This alternative may be inconvenient, as compared with a hospital or rehab facility stay, requiring single patients to plan carefully and thoroughly for their extended home rehab. Those who live with others also will need their increased care and forbearance. But home recuperation also may become a norm because many doctors increasingly are striking out on their own, leaving expensive hospitals to set up free-standing specialty surgical centers. Orthopedists in these centers don’t have to compete for operating time. They don’t cover a share for the overhead of a big hospital building with lots of staff. If they can get Uncle Sam’s approval, they will alter medical practice so many joint replacements will become outpatient procedures.

But will orthopedists face new and different economic and practical pressures, conflicts that may grow when they sink their money into and must keep full and busy their own centers—packed with highly trained practitioners and expensive equipment, including  pricey imaging technology? Will entrepreneurial orthopedists need to pay for advertising and marketing to hype themselves, their techniques, and their hardware, including by trying to dazzle confused patients with different makes and models of replacement knees and hips? Some blue-collar workers in Southern California, part of a $500-million medical fraud case, can attest to how quickly and sadly orthopedists can veer off course for economic gain. Droves of patients are reeling still from worker compensation-related procedures, in which some orthopedists and hospitals implanted in them specialized screws, rods, and plates. These devices were shoddily manufactured knock-offs. They are breaking apart in their bodies, causing them debilitating pain and big health risks.

Safeguards, follow-throughs that matter

Choose your surgeon and hospital carefully, and know that they work with some real economic and practical constraints.

Ask your regular doctor for referrals. Talk to friends and medical caregivers whose views you value. You may wish to consult online resources that rank both hospitals and doctors, especially for procedures like knee surgeries and hip replacements. You may wish to look at comparison sites that offer insights on hospitals’ infection and readmission rates. Some institutions issue their own data on their orthopedic departments’ volumes and outcomes, and this is valuable information. You may want to look, with due care, at a journalistic project that pulled together data sources to let patients better evaluate surgeons, including orthopedists.

All these metrics can be daunting: Don’t be swayed just by reputation or price. Studies show few differences in quality and efficiency in care between high- and lower-price physician practices, and the perceived edge for big-name hospitals in joint replacements may be “smaller than might have been envisioned historically.”

Because you’ll have time to prepare for knee or hip surgery, put your mind to rest in advance about your procedure’s cost. Talk to your doctors or their staff and research online about your insurance or Medicare. Although you may not end up footing much of the bill due to this coverage, you should know if the start-to-finish costs of your surgery will be “bundled,” or if you will receive a barrage of individual statements from all the providers involved, including the medical testing lab, radiologist, imaging center, surgeon, anesthesiologist, hospital, and rehab facility. This can become daunting if your care is unbundled, aka “fee for service.” As discussed earlier, Uncle Sam is pushing more hospitals to act as the central deal-maker, paying them a lump sum and getting them to negotiate with all the given medical providers on a single cost for a joint replacement, and taking care of their payments.

You also may learn a lot about your orthopedist’s practice: Are their privileges at hospitals that have standardized joint replacements and other similar, common surgeries, such that your doctor will, for example, use the same surgical parts that all his peers do? Or will you be pitched about how he prefers certain prostheses, whose benefits he will extoll without necessarily telling you that he may earn extra money from medical device makers?

Rx for optimal outcomes

It can’t be overstated: Follow your doctor’s orders, not only during your recovery but also in your rehabilitation. You may look at the numbers and find that, with a little help from loved ones and friends, you’ll be better off, thank you, getting out of the hospital pronto and staying out of a rehab center. You can undo any benefits of your home recovery, however, by failing to follow through on a full regimen of infection-fighting antibiotics or with poor wound care. Your body needs time to recover from joint replacement—a key point of this missive is to remind you that you’ve undergone a major surgery. That means you shouldn’t play superwoman and jump out of bed, racing back to work or home duties. Expect that your recuperation will take time and may involve pain. You may be showering in a week or two after a joint surgery, walking with a cane or assistance in a few weeks, back to office work and driving in a month and half or two, and hitting full recovery in six months to a year.  During rehab, you’ll also need to get accustomed to your new joint and its optimal workings. You’ll need to build strength in an area of the body that has just undergone medically related trauma. This doesn’t occur overnight and without diligence. Don’t skimp on the physical therapy. It can be a boon to your recovery, especially to ensuring your new knee or hip lets you enjoy life as fully as you wanted.

Here’s hoping that if you have joint replacement, it goes well, without complication, and so successfully that I see you out biking, golfing, swimming, gardening, playing tennis, running around, and being as active as any healthy teen!

Protect your joints from undue harm

Who wants to get cut on? Aren’t their ways to minimize or avoid knee or hip damage and so avoid surgery?

Experts say appropriate exercise can play a key role. Keep moving—it’s good for the mind, spirit, and body. It can help us from carrying excess weight that stresses our joints.

But we need to play in the right ways: When participating in joint-stressing exercise, take appropriate protections. If you’re going to ski, get in shape first, particularly with pre-slope workouts. If you insist on playing soccer, basketball, football, tennis, or other games in which you must stop and cut quickly, again, ensure you’re in shape and wear protective gear. Get professional training to ensure your form in games like golf doesn’t end up harming your lower back, hips, or knees. Good form, as well as moderation, can be beneficial for runners. Warm up, and stretch gently.

Over time, you also may wish to give up joint-punishing activities, like running or aerobics. Consider swimming or cycling instead. See if yoga or tai-chi offer benefits.

Give yourself rest time for your aging joints. Use sleeves, braces, or other protective gear, knowing they can provide support and valuable warmth. Try elevating a sore joint, putting ice or heat on it, and maybe even testing acupuncture. As mentioned, use pain relievers, including over-the-counter products, sparingly and with care.

If you’re eating a well-balanced, nutritious, healthful, and moderate diet, skip the supplements touted for bone or joint health, unless your doctor recommends otherwise. You may get a placebo benefit from glucosamine chondroitin or calcium. But they are over hyped for too many of us.

The woes of arthritis

Arthritis is one of the most common debilitatingconditions, afflicting more than 50 million adults and 300,000 children. Its harms cost the United States an estimated $128 billion in 2003 alone.

Experts have identified more than 100 different types of arthritis-related conditions, including: degenerative varieties that damage cartilage and lead to loss of joint mobility; and inflammatory types (rheumatoid and psoriatic) that lead the body’s own systems, due to environmental and genetic causes, to attack joints and organs.

As America grays, arthritis research continues to be a central concern, with, for example, the National Institutes of Health budgeting $248 million in 2017 for studies of the disease at universities, academic medical centers, hospitals, and other research sites nationwide.

When it comes to arthritis-damaged knees and hips, medical scientists hope to advance pain relief and efforts to regenerate key tissues like cartilage and bone. Americans’ sobering experiences with the epidemic of prescription painkiller abuse, however, has provided a harsh reminder about why Big Pharma and the public need to advance with these medications cautiously.

Meantime, be skeptical and take extra care with trendy treatments that may not be fully studied and truly ready for wide use, such as stem cell injections hyped to repair or regenerate damaged knees and hips. The evidence isn’t yet to show that these procedures reduce pain or improve joint function. They can create health risks. It may be, someday, that medical science will make sufficient progress so the body fixes knees and hips on its own, with stem-cell reprogrammed tissue or by building around injected substances. That’s the hope, not yet the reality.

HERE’S TO A HEALTHY 2017!

Sincerely,

Patrick Malone
Patrick Malone & Associates