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Who Needs a Joint Replacement? | Dr Christopher Meckel, MD
Articles Who Needs a Joint Replacement?

Who Needs a Joint Replacement?

Whether you need a joint replacement or not depends more on how you feel than what your x-rays look like. I have patients come to my office with x-rays of their knees that look terrible. The cartilage is almost all gone and there are bony spurs protruding all around the joint. Sometimes these patients come in with severe pain sometimes only mild discomfort. X-rays only tell you the condition of the joint, not the condition of the patient. It is the condition of the patient that drives the decision to proceed with surgery.

There are many options to treat arthritic joints. I like to think of it as a spectrum of options that starts with ignoring the pain and ends with a joint replacement surgery. If ignoring the symptoms doesn’t work, then the next step is to try some over-the-counter pain medications like Tylenol or Ibuprofen (check with your doctor first). These can often relieve enough of the pain, in the early stages of arthritis, to continue to be very functional with only a small decrease in the quality of life.

If over-the-counter medications fail to provide adequate pain relief, physical therapy can be used to help improve pain and function. Physical therapy works in a couple of ways to improve pain. We know that stiff joints can be painful. A good physical therapist can slowly and gently stretch out the soft tissue around your knee to improve your range of motion which can relieve some pain. Also, when the muscles that support your knee are weak and atrophied due to disuse, this can cause instability and pain as well. The therapist will work to increase the strength of the muscles that support your knee without aggravating your knee pain. There are some very specific exercises that can achieve this and it is the physical therapist who can implement a program to improve your lower extremity strength and hopefully reduce your pain. If physical therapy is not helping, then we will start to look at injections as an option.

There are two main types of injections that are traditionally used to help reduce the pain of arthritis in joints. First is a steroid injection. The steroid is mixed with a local anesthetic and both are injected into your joint. The steroid acts to very potently reduce inflammation and thus pain. A very good result from a steroid injection is about three months. Unfortunately, sometimes it doesn’t work at all and sometimes it lasts longer than three months. You must let about three months pass before you can get another steroid injection. We usually will not do more than 3 to 5 injections before we move on to other options. The second injectable option is hyaluronic acid. This is a material that was originally isolated from a rooster’s comb but is now synthesized as well. There are many companies that make this product and they each have a different name (Synvisc, Supartz, Orthovisc, etc…). The bottom line on these products, much like steroids, is that they sometimes work and sometimes don’t. The American Academy of Orthopedic Surgeons reviewed the literature on these materials and concluded that they couldn’t say if they reliably worked or not and so recommend to try it if other options have failed. The hyaluronic acid injections work to lubricate the joint, reduce friction and thus reduce pain. It is unclear whether these products actually nourish the remaining cartilage cells. It is known that it does not grow new cartilage. If injections fail to relieve your pain then we consider surgical options.

Just because we reach the surgical end of the spectrum of care for arthritic hip and knee joints does not mean that surgery “needs” to be done. It is up to the individual and their perception of the quality of their life. This evaluation of personal quality varies quite a bit depending on the individual’s lifestyle demands. Some people are non-stop active and don’t wish to slow down at all, so they will request to proceed with joint replacement sooner than the person who is more sedentary. The sedentary person does not rely on their joints as much and typically will wait longer. The caveat to this is that weight gain usually occurs with such a sedentary lifestyle and this can increase joint pain.

So, in the end, as surgeons, we need to treat you and not your x-rays. You should never have a surgery because your “x-rays look bad” and if this is what your surgeon is telling you, I recommend you find another surgeon. Joint replacement surgery is a great option for those who have a definite diagnosis, have tried multiple non-surgical options, and continue to have a poor quality of life (as determined by them). When you evaluate the option of surgery in this fashion, you will see great results.

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