You’ve used analgesic creams, ice, heat, exercise, physical therapy and assistive devices. You have tried all the pain medications, even opioids. Maybe you’ve even lost 20 pounds. But your joints are still so stiff and painful that you can’t drive your car or participate in hobbies you enjoy.
Should you consider surgery? If so, what are your options? Before you say “no” to surgery, consider that more than 1 million joint replacement operations are performed in the United States each year.
Weighing the pros and cons
It is important to understand that joint surgery is not a quick fix and is not without risk. Serious complications, such as blood clots and infections, can occur. In addition, the road to recovery can be difficult and time-consuming, particularly with joint replacement surgery.
But many people who undergo joint surgery experience less pain as well as significant improvements in psychological well-being and quality of life. Despite the risks of surgery, the expense, and the substantial commitment of time required for recovery, the potential rewards for your physical and mental health are great.
Many people put off joint surgery even when their doctor assures them that surgery is appropriate. Often they feel their pain isn’t bad enough to warrant joint repair. But studies show that waiting until pain and loss of function are substantial can make joint surgery more difficult and reduce your chance of regaining good function.
If you are interested in having joint surgery and your doctor thinks you might be a candidate, you’ll need to find a surgeon. When you speak with surgeons, be sure to ask how many procedures they do each year, what their success rate has been, and where they perform their surgeries.
If possible, select a board-certified orthopedic surgeon who has performed the type of surgery you will have at least 30 to 50 times. Studies show that surgeons who do the most operations each year generally have the highest success rates. Moreover, hospitals that are affiliated with medical schools (teaching hospitals) tend to have the best track records. Because infections may occur after joint surgery, be sure to ask about the hospital’s infection rate.
Types of surgery
At your first office visit with your surgeon, the two of you will determine whether surgery is right for you. If it is, the next decision is to determine which type of surgery best meets your needs.
• Arthroscopy An arthroscopic procedure involves making a tiny incision in the skin through which the doctor inserts surgical tools and an arthroscope—a thin, lighted tube with a camera attached to one end. Arthroscopic surgery can be performed on the knee, hip, shoulder, elbow or hand. Arthroscopy is less costly and less painful than the other types of joint surgery, and the recovery time is shorter. An orthopedic surgeon performs the procedure in a hospital operating room or an outpatient surgical suite.
Arthroscopy may be used diagnostically (to determine the type of arthritis or the amount of damage) or therapeutically (to perform debridement or lavage). Debridement involves smoothing roughened cartilage and bone, whereas lavage involves flushing out the joint to remove debris such as loose pieces of bone and cartilage.
Studies have shown that neither debridement nor lavage is an effective treatment for knee osteoarthritis, but arthroscopy may still be useful for some people who have large pieces of debris or torn cartilage in a joint.
Evidence suggests that people who undergo arthroscopic surgery and later have knee replacement surgery have less satisfactory results than their counterparts who haven’t had arthroscopy. Consequently, most patients who have arthritis that is severe enough to warrant knee replacement should avoid arthroscopy if at all possible, and if surgery becomes necessary, they should proceed directly to knee replacement.
• Osteotomy (“bone cutting”) In osteotomy, the bones are cut and realigned. An osteotomy requires a long recovery period, but it also relieves pain and the results are more long lasting than those seen with other procedures. Recovery is 80 percent complete in about six weeks and 100 percent complete within six months.
• Hemicallotasis In this procedure, the surgeon realigns the bone by making it longer on one side. This is done by cutting the bone and attaching an external fixation device to it with pins. The fixation device must remain in place for about 12 weeks, during which time the patient turns screws on the device to increase slowly the distance between the cut ends of bone. The body then produces new bone in this area, allowing the bone to lengthen by about one millimeter a day. The most serious complication of hemicallotasis is infection at the site where the pins enter the body.
When arthroscopy, osteotomy or hemicallotasis is not feasible, your doctor may recommend arthrodesis or joint replacement.
• Arthrodesis In arthrodesis, the surgeon fuses two bones in a finger, wrist, ankle or foot joint. Although the operation results in a loss of flexibility, it relieves the pain caused by two bones rubbing against each other in a damaged joint. The fused bone is also more stable and better able to bear weight.
Arthrodesis is an alternative to joint replacement for people whose bones are not strong enough to support an artificial joint or who have frequent joint infections that rule out the use of an artificial joint. It may also be used in small joints, such as in the thumb, where replacements are performed less often. Arthrodesis is effective for controlling pain, but fusing the joint limits function.
• Joint replacement (arthoplasty) The most common type of arthroplasty is total joint replacement. In this procedure, the entire diseased or damaged joint is removed and replaced with an artificial one (a prosthesis) to relieve pain and restore function
Arthroplasty requires hospitalization and, usually, general anesthesia. In some instances, however, such as knee replacements, regional anesthesia (spinal, epidural or nerve block) may be used to numb the lower body.
Most joint replacement surgeries (80 to 90 percent) are done on the hip and knee, although joints in the elbow, hand, foot, shoulder and ankle also can be replaced. New technology and improved operating techniques and materials have made joint replacement the best treatment for many people. In general, hip and knee replacements last at least 10 years, and newer ones may last 20 to 25 years or longer.
Even though recovery can be long and sometimes painful, most people who have this kind of surgery report being “very” or “completely” satisfied with the results. If you choose to have arthroplasty, be sure to get as much information as you can about the procedure, the recovery time and the rehabilitation process. In one study, people who participated in a two-hour educational program prior to knee replacement showed markedly greater and faster improvement after surgery than did nonparticipants. People in the educational program also spent an average of two days less in the hospital and required fewer sessions of physical therapy to recover fully.
To ensure optimal satisfaction from arthroplasty, you and your surgeon should discuss the activities, including sports, that you intend to continue afterward. The information will help the surgeon select the most appropriate prosthesis, implantation technique and rehabilitation program, and will make you aware of the risks and limitations of your activities.
Recommended activities after surgery include golfing, swimming, cycling, bowling and sailing. On the “not recommended” list are sports such as running, racquetball and basketball.
Complications of joint replacement
Significant complications occur in about 40 percent of people who undergo joint replacement surgery. The most frequent is blood clots in leg veins. Surgeons take precautions to prevent this by prescribing blood thinners and using leg compression equipment (typically an air pressure device that repeatedly inflates and deflates to massage the leg and keep blood flowing).
A potentially more serious but less common complication is infection in the surgical wound or in the joint. Most infections can be treated with antibiotics, but infections deep in the joint may require removal of the prosthesis. Eventually, your surgeon can reimplant a new prosthesis.
Individuals who undergo arthroplasty must guard against infection for as long as one to two years by taking oral antibiotics for even small infections and before dental work or urinary examinations. With preventive measures, the infection rate is typically no more than 2 percent.
Hip implants can loosen. In general, this problem develops no sooner than 10 years after surgery. Although a loosened hip implant can cause pain, some people do not experience any symptoms.
Consequently, it is important to see your surgeon every year or two to check for problems, even if you are not experiencing symptoms.
Physical therapy after joint replacement
Successful joint replacement, especially of the knee, requires a considerable investment of time and energy in rehabilitation. Rehabilitation begins in the hospital, usually the day after surgery. During this period, a strict timetable of exercise, rest and medication is crucial to the success of the surgery.
You may feel considerable pain immediately after the surgery (from muscles disturbed during the operation, rather than from the joint itself), and that can make rehabilitation difficult at first.
Recovery from knee, hip and all other types of joint replacement requires a series of sessions with a physical therapist. Physical therapy exercises focus on building strength and regaining flexibility. The physical therapist may also use techniques such as massage and application of cold to minimize swelling, which interferes with flexibility. In addition, every patient receives a regimen of exercises to perform at home. Use of continuous passive motion therapy using a machine for rehabilitation has not been shown to increase motion or to accelerate recovery.
With rehabilitation, recovery from a knee replacement is usually 80 percent complete within four weeks. Full recovery usually takes a year, sometimes even longer. Recovery from a hip replacement is usually 80 percent complete within about four weeks and 100 percent complete within about six months. You can increase your chances of having a successful recovery by keeping excess weight off.
Less invasive types of joint replacement
Surgeons continually seek ways to make joint replacements and repairs easier, safer and less arduous for the patient. Some surgeons have started performing hip and knee replacement surgery through very small incisions, a procedure called minimally invasive joint replacement. Minimally invasive procedures are more difficult to perform than standard joint replacements, however, and researchers don’t yet know whether the long-term results will be as good. In addition, not everyone is a candidate, including individuals who are obese.
An alternative to a total knee replacement is a unicompartmental knee replacement, which involves replacing only the damaged section of the knee. This may be an option for individuals with limited knee damage. It is very effective for only a small percentage of people with arthritis, however.
Another less invasive option is resurfacing, also referred to as joint resurfacing. It involves removing damaged cartilage at bone ends in a joint and then capping the surface with metal. Surgeons don’t often use this procedure, however, due to a lack of information on long-term outcomes.