Joint Replacement: A Quality of Life Decision
June 22, 2022
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Having pain in your knee or hip doesn’t mean that you need joint replacement surgery. Many issues are resolved with treatment like medication or therapy. The most common reason that knee or hip replacement is performed is due to osteoarthritis. Steven Fitzgerald, MD, Chief, Division of Adult Reconstruction at University Hospitals explains what goes into the decision to have surgery and why every patient is unique based on age, health history and desired postoperative quality of life.
Macie Jepson
Pete, get this. I know three people who just underwent hip replacement surgery. And I have another friend who’s having knee replacement surgery this fall. I mean, admittedly, we’re all getting older, but these people are not old. We’re talking mid-40s. One is in early 50s. 60.
Pete Kenworthy
Yeah. It doesn’t sound like what you think of when you hear joint replacement surgery. Right? Like I used to think of the elderly having surgery as a last resort, right, after like years of pain. But listen to this. Knee replacement surgery is performed about 800,000 times a year here in the United States. And that number grows every year, while the age of the patients goes down. So, it got us thinking. Who’s the right candidate for joint replacement. And when is the right time to get it done? Hi, I’m Pete Kenworthy…
Macie Jepson
…and I’m Macie Jepson. And this is Healthy@UH. Now, I confess my knowledge about joint replacement is based on what I have heard. And now what I assume. They don’t last long. So, you should really put them off as long as possible, or perhaps it’s best to avoid them all together. I mean, after all this is major surgery. So, here to educate me and all of us is Dr. Steven Fitzgerald, Chief of Adult Reconstruction and Director of High Reliability Medicine for Total Joint Replacement at University Hospitals in Cleveland. Thank you for joining us, Doctor.
Dr. Steven Fitzgerald
Glad to be here.
Macie Jepson
So, before we talk about who is a candidate for joint replacement, tell us what exactly it is and why people need new joints in the first place.
Dr. Steven Fitzgerald
Yes. The most common reason that we perform both hip and knee replacement is for patients who have advanced osteoarthritis of their joints. So, everybody, you know, has questions in clinic exactly what arthritis is, but we all have some nice, shiny, smooth cartilage that covers the surface of our large joints. And arthritis is just a breakdown of that cartilage over time. And it causes pain and inflammation and decrease in quality of life and inability to do the things that you want to do. So, that’s the main reason that we perform joint replacement is for osteoarthritis. So that we do perform it for other reasons, osteoarthritis is the most common one.
Pete Kenworthy
And you’re talking knee and hip here?
Dr. Steven Fitzgerald
Yep. Knee and hip.
Pete Kenworthy
So, who is a candidate for this total joint replacement? Is there like an ideal age for this?
Dr. Steven Fitzgerald
Yeah. I mean, that’s a common question and age is kind of relative, right? So not every 80 year old is the same in terms of their medical history and what else they have going on. And not every 55 year old is the same in terms of their medical issues and the activities that they want to perform. So, we perform joint replacement in a wide range of ages in patients, depending on what they want out of life and what their current circumstances are. So, you know, you want somebody who’s healthy and doesn’t have a lot of medical comorbidities and who is a good candidate for any surgical procedure. It’s kind of the same for joint replacement. But there’s a wide spectrum of those patients and who’s acceptable to have a joint replacement.
Macie Jepson
You mentioned quality of life. And so can you be too old to get a replacement? Comorbidities is one thing, but also really too old to have a quality of life after you get it?
Dr. Steven Fitzgerald
No, I think it’s, it’s a decision that you have to make having a conversation with the patient and what they want to do currently at their current state in life. I mean, to give you an example, I did a hip replacement in a gentleman who was 102 a few years ago. But, you know, physiologically, he was much younger than that. And he was still driving his car by himself back and forth to New York every week. So, it just depends on the, on the person’s situation really.
Macie Jepson
Well, Americans are living longer. So, is that why we’re seeing more people getting them?
Dr. Steven Fitzgerald
Yeah, I think it’s a combination of the aging population, how long we live. And I think it’s also that, you know, as a society, we kind of expect more now. We want to be more active after we retire, after we get older and participate in the things that maybe we didn’t have time to participate in earlier. And we want to hang onto that and be as active as we can.
Macie Jepson
So, the American Academy of Orthopedic Surgeons data showed that the average age of patients undergoing hip replacement surgery from 66 to now just under 65; the average for knee replacement from 68 to just under 66. Is that risky? I mean, these things don’t last forever, do they?
Dr. Steven Fitzgerald
Well, I mean, there’s a lot of myths about that. I mean, current technology that we’re using and how much life expectancy we expect to get out of the joint, I tell my patients that the hope is between 20 to 30 years. So, you know, a lot of patients come in and say, I heard this is only going to last for 10 years. And that just really isn’t true anymore. The technology has changed. The longevity, the materials that go into the joint replacement has changed. So, with that, yeah, we have moved the bar a little bit in terms of doing it in younger and younger patients. But you do want to put off any major surgery for as long as you can to get as much life out of it as you can so that you don’t have a risk of having or needing further surgery down the road. But if you’re at a point where you can’t do the things you want to do, there’s no point in exchanging quality of life years now for what’s going to happen 25 years from now.
Pete Kenworthy
Let’s play a little bit of Devil’s advocate here. Let’s talk about someone in their mid-50s, say, and you said, I think, I remember you said arthritis is the main reason for doing this, right? So, let’s say they have, you know, early, that would be early arthritis, right, in your mid-50s, I would think?
Dr. Steven Fitzgerald
Yeah. I mean, there’s, you know, if you look at the population over the age of 50, you know, 30 to 50% of the population will have arthritis to some degree. And as we get older, the numbers go up. But we see plenty of patients who are in that age range who have advanced arthritis in their joints, and there’s a genetic component to it as well. And they may be ready at that age to have their joint replaced.
Pete Kenworthy
So, maybe this is a silly question, but let’s say at 55, you decide to have knee replacement, and it does wear out in 20 years, and you’re still active at 75, can you have a second one?
Dr. Steven Fitzgerald
You can. So, the, I mean, the most common thing that happens is the plastic part that goes in the knee replacement can wear or wear out. And you can go in and exchange that plastic. So, you don’t have to redo the whole knee replacement that time. You can just change out the modular part that’s wearing out. You know, it’s still another surgery. Every time you have surgery, the risks of things like infection or residual pain or scar tissue and things like that go up. And you still have to get into the joint to replace the part, but it’s definitely possible to have more surgery or an additional tire tread rechange on your joint down the road.
Macie Jepson
Could you walk us through the process of getting to that point where this needs to be done? I mean, how much pain does someone need to be in? And then they may decide in their minds that it’s time. But I would think maybe some PT is in order. You don’t just like jump right into this stuff, right?
Dr. Steven Fitzgerald
Yeah. Sure. I mean, we always try to exhaust all conservative measures before having somebody have a joint replaced. And there’s a lot of options. So, there’s, you know, there’s, anti-inflammatory medications; there’s different types of injections; there’s physical therapy; there’s bracing. And all of those things kind of go into the conservative arm before you get somebody ready for surgery. And there’s really kind of two parts to the surgical part. One, they have to have the indications for the surgery, right? So just because your knee hurts, if you don’t have the problem that we’re trying to fix. So, arthritis, joint replacement’s not going to solve those problems. So, there may be something else going on in the knee or the hip. If you have tendonitis or some sort of tear in the cartilage that can be repaired, things like that, you might not be a candidate for total joint replacement yet. So, one, you have to have the indications for the surgery itself. And then really the only reason to have your joint replaced is for pain. I mean that, that’s why we do it. So, you know, once patient’s pain is at a level where they can no longer perform the daily activities that they want to do, then, you know, we start thinking about surgery, as long as they have the indications for the surgery in the first place.
Pete Kenworthy
That’s a great point. So, let’s say we’re there, then. Let’s say we’re at that point where, where someone has decided to have this surgery. They can’t bear the pain anymore. They want more quality of life. Tell me what people can expect. So, how long is this surgery, hospital stay? What’s the recovery like? And what’s involved in that in terms of physical therapy? You know, what comes after that?
Dr. Steven Fitzgerald
Yeah. Sure. So, I mean, we, you know, patients come into clinic, we have a kind of a general surgical discussion of what to expect and risk and benefits and go over what the implants are going to look like and kind of really map out their care path from the minute they hit the door to three months to six months to nine months from now.
Pete Kenworthy
And that’s different for everyone, I assume?
Dr. Steven Fitzgerald
It is. It’s a little bit of a moving target. So, there’s a lot of things in terms of recovery. You know, I tell all my patients that there’s really no set calendar that, in terms of recovery, that you need to be doing this by week one and this by week two. It’s different. It’s a moving target. So, it depends on how old you are or how mobile you are coming into the surgery; what kind of shape you’re in; what other medical problems you have. All of those things go into it. So, you know, a lot of patients will compare themselves to a neighbor and the progress they’ve made, and they feel like they’re behind or I’m ahead. And it doesn’t really work that way. It’s a really an individual journey. Yeah, they come to the hospital, they have the surgery. For most standard hip or knee replacements, the surgery itself takes about 45 minutes to an hour. By the time they’re in and out of the operating room, it’s about an hour and a half. Typically, they’ll go to the recovery room from anywhere from a half an hour to an hour where they’ll kind of recover from their anesthesia. And then pretty quickly, as soon as they’re able, they’re up and walking with physical therapy.
Pete Kenworthy
Whoa.
Dr. Steven Fitzgerald
So, within hours of the surgery for either a hip or a knee replacement, they’re up and walking, you know. They’re with a walker and a therapist at that point to guide them and make sure it’s safe for them, but we get people moving really fast.
Macie Jepson
Can I stop you right there? Because that’s not the way it used to be, right?
Dr. Steven Fitzgerald
It’s definitely not. Things have changed, you know, within the last 10 years or so. Part of it’s, as we’ve learned, different techniques in pain management. And part of it is just realizing that we can do this, that people can move this fast after their joint replacement. You know, the days, you know, when I was a resident, you know, people were in the hospital for five to six days. And we wouldn’t even get them up and moving within the first couple days. And there’s a lot of things that can happen because of that. So, the more sedentary people are, the risk for blood clots go up, the risk of having respiratory issues going up. So, there’s a lot of benefit to get people moving fast. So, I mean, right now, if you look at it, we’re probably doing somewhere between 45 to 50% as an outpatient, too. So, you’ll have surgery early in the morning, do your physical therapy and then go home late afternoon, early evening. So, you don’t even have to stay the night in the hospital.
Pete Kenworthy
And my guess is the other 50% who don’t go home the same day are going home the next day.
Dr. Steven Fitzgerald
Correct. I mean, the average hospital stay for everybody is less than 24 hours, and a very small percentage of patients will need to go to a rehab facility afterwards. You know, we try and get everybody home after the surgery, as long as they have enough social support at home to do that. Cause patients just recover better at home. They want to be home in their own bed, around their friends, their family. And they just recover better that way.
Macie Jepson
And then they’re going right into PT. And is that also inside their home? Or do they need to get, have someone get them, because obviously they’re not driving, do they have to get to PT?
Dr. Steven Fitzgerald
A majority of patients will have in-house PT, and that generally gets set up either before the surgery or while they’re in the hospital so that the first couple weeks they don’t have to leave their home. And they can have their physical therapy sessions in the comfort of their own home. And then when they’re ready to be a little bit more mobile and want to venture out, we can transition them over to outpatient physical therapy and they can continue their therapy there. There are patients that do so well that they don’t need additional outpatient physical therapy, and they’re done with it at home. But there are also a few small number of patients who will jump right into outpatient physical therapy and not do it at home, but those patients are generally really motivated and have some sort of other reason that they want to do that. So, there are patients that have social reasons where they don’t want somebody to come into their home. We ran into that a lot during COVID where people were resistant to come into their house. But majority of patients will have therapy at home.
Macie Jepson
For how long?
Dr. Steven Fitzgerald
It varies. There’s no recipe. So again, there’s no calendar in terms of recovery. So, your therapist will see you at home, identify what your needs are, where you’re at kind of on day one and really kind of customize a program to what your needs are. But it’s a little bit different for everybody. There’s no, you know, general protocol that everybody follows. It needs to be formed and created for the individual patient.
Pete Kenworthy
So, the reason people are doing this is so they can get back to what they remember themselves doing, right? Things they were doing or pain free, whatever that case may be. What’s the average full recovery, right? And my guess is this is a range, too. But even that range, is it one month to six months? Like what are people looking at to back to full independence again?
Dr. Steven Fitzgerald
So, in general, I tell my patients that, you know, the first three weeks after the surgery are really kind of the toughest part where you’re really getting over the pain from the surgery itself. And you have plenty of medications and ice machines and a lot of things to help you get through that part. And your therapist will help with that as well. But you at least need to have about a six week period where you can lay low and recover if you need it. And if you’re ready to be more mobile earlier, you can do that. But again, it’s a communication with your therapist and your doctor and what you’re ready to do. Driving’s a big one. So, people are concerned about when they can drive. And the biggest thing is you can’t be taking any pain medication and drive.
But most people it’s around four to five weeks before they’re kind of thinking about driving. And most people use a lot of common sense in terms of being honest with themselves that they’re not ready yet.
But to fully recover to the point where you’re really not thinking about it anymore, so, you really kind of get used to it. So, at the end of the day, you’re like, ah, I kind of forgot about the fact that I had knee hip surgery this year, it’s really about six months. In some patients, it can be a year. And you’re not in pain for that whole period of time. It’s just you getting used to the new joint. But again, it’s a moving target. So, it depends on how mobile you are coming into it, what your other issues are. But that’s kind of the general timeframe.
Macie Jepson
Doing some research. I saw some scary stuff out there. So, you know, people who are listening, they’re seeing it, too. So, let’s just go ahead and talk about that. I mean, what can go wrong? What do people need to legitimately be concerned about?
Dr. Steven Fitzgerald
The main things that we worry about at the top of the list is always infection. The good news is that the chance of you having an infection after a total joint replacement is way less than 1%. So, it’s a very small number. And we’ve gotten much better at choosing who we do surgery on. So, if you have uncontrolled diabetes, we’re going to modify that risk factor before you go to surgery to decrease your risk of having an infection afterwards. If you have issues with obesity, we want you to try and lose weight before you have your joint replaced. If you’ve got cardiac issues, you know, all of that needs to be worked up and evaluated beforehand. And all of those things go into making a decision to have surgery. But people go through a large and an extensive screening process for us to make it as safe as we can for them. And anytime you go into surgery, there are risks having anesthesia that things can happen to your heart or your lungs or your kidneys around the time of surgery. But the good news is with modern techniques, good screening practices, different types of anesthesia, those risks are incredibly small. And the chances of having a complication around your joint replacement is really small.
Macie Jepson
And Doctor, I’ve been thinking about this since your first answer, so I want to go back to it, because I believe that people are going to want to know, what is it exactly that you’re going to put into their body?
Dr. Steven Fitzgerald
Yeah. The most common materials that joint replacements are made out of is some combination of metal and some plastic. So, majority of hip replacements be made out of titanium. And we give the person a new ball on the end of their femur, which is either made out of metal or a ceramic material that rotates with a piece of plastic in the hip. And these are pretty similar. Most knees are made out of what’s called cobalt chrome, but there’s also a plastic component to the knee replacement as well. And these materials are all inert. Your body doesn’t react to them. There are some very rare cases where patients will have allergies to metal. But it’s very rare. And most patients coming into surgery will already know that, because they’ve had reactions when they were younger to jewelry or other things so they know they react to metal. And we have some different types of implants that we can use in those patients. But yeah, metal, plastic, ceramic, those are the most common types of materials that go into joint replacements.
Pete Kenworthy
All right, before we let you go, any final thoughts, final takeaways for everybody.
Dr. Steven Fitzgerald
Yeah. I think the most reasonable thing to do is if you’re having concerns that you have arthritis or pain and you’re considering or thinking about the fact that maybe joint replacement is right for me, talk to your doctor or get a referral to your orthopedic surgeon so they can take a look and see what the answer is. You may not be a candidate for a joint replacement. There may be something going on that’s much simpler to solve. There may be, you know, an easy solution to, and you don’t need surgery. I mean, that’s one of the best appointments you have when somebody comes in with some hip pain or some knee pain, and it’s tendonitis or something else, and they’re coming in expecting that they’re going to have to go to surgery the next couple months, and they don’t have to. But just seek out the information. I mean, there’s lots of providers in the system who do joint replacement and can come up with some answers for you and look at your case, get some, x-rays, talk to you about what your options are, which again are not always surgery and evaluate what the best care path is for you. It really should be a conversation between you and your doctor about what the best treatment plan is. But if you have any sort of concern or inkling in your mind that maybe this is the direction that I’m headed, make an appointment. Let’s have a discussion and figure out what’s going on.
Macie Jepson
Yeah. Life is too short to live in pain. Too many options out there. Thank you, Doctor.
Pete Kenworthy
Dr. Steven Fitzgerald, Chief of Adult Reconstruction and Director of High Reliability Medicine for Total Joint Replacement at University Hospitals in Cleveland. Thank you for joining us.
Dr. Steven Fitzgerald
Thank you for having me.