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Joint Replacement in the 21st Century – A Less Painful Approach

Robert H. Malstrom, M.D., May, 2005

Knee and hip osteoarthritis are two of the most disabling conditions an active individual may face. Post-traumatic osteoarthritis or hereditary osteoarthritis may develop in middle-age during the most productive time of an individual’s life. Many people will have disability precluding them from performing activities of daily living and will usually have problems with sleep as well as inability to a perform normal job. Older patients in their sixties, seventies and eighties find they become unable to walk and participate in community life.

In the 1960s, Sir John Charlie in Manchester, England, developed a procedure to replace the hip joint using a plastic socket cemented into the pelvis and a metal ball cemented into the upper leg to replace the normal hip. This revolutionized the treatment of hip arthritis. In the 1970s, similar ideas were used to develop knee replacements such that the upper and lower bones of the knee and undersurface of the kneecap were covered thus eliminating the arthritically damaged surfaces.

Knee and hip joint replacement surgery have become the most successful surgical procedures of all time. Over 600,000 of these operations are performed annually and most people have dramatic improvement in their life following the procedure. The disadvantages of the surgical procedures have involved the stresses of the surgery itself which would frequent require blood transfusion and multiple days in the hospital, a prolonged period of time to regain strength and function in the extremity as well as long-term problems with loosening or wearing out. Those issues have been addressed during the past twenty years.

Joint replacement in the 21st Century is focusing on making already excellent surgical procedures even better and less stressful. Evolutionary improvements in the hip and knee devices as well as improved surgical techniques have resulted in the procedures being performed on younger individuals with greater expectations for resumption of more strenuous activities including some sports. The current focus of joint replacement is both on decreasing the amount of surgical trauma from the operation as well as decreasing the amount of pain that the individual will experience following the surgery. This allows increased rehabilitation speed and quicker return to normal activities of life.

Pain reduction is something that everyone can empathize with. Nobody wants to feel pain whether it is from an arthritic joint or from the surgery needed to replace that joint. We are currently going to extraordinary lengths to decrease the amount of postoperative pain particularly during the first several days following surgery. The techniques involved include using regional anesthesia which improves the duration of pain relief following the surgery, longer-acting oral pain medications, use of an indwelling epidural catheter when appropriate for hip patients for 24 to 48 hours and use of local anesthetic injections to augment the other analgesic modalities. By the above combinations the total amount of pain that most patients experience following surgery has been dramatically reduced. Most patients will get out of bed with physical therapy and walk the same day of surgery. Many younger patients will be able to leave the hospital the day after surgery or, in any case, the second day after surgery. Although elderly patients, particularly patients who live by themselves, may require staying in the hospital three days with transfer to a skilled nursing facility, they, too, will have less pain and easier ability to regain independence. The focus on pain management has shifted so that we are looking not just at pain management in the immediate postoperative several hours but rather postoperative pain management for the first several days after the surgery. Patients will have better pain control, less nausea and vomiting and faster return to ambulation. Patients who have had a knee or hip replacement several years ago and have had recent hip and knee replacements note a dramatic difference in the amount of pain they experience and also the ease with which they have been able to regain their ability to walk, sit, stand and perform activities of daily living.

Decreasing the surgical trauma during the actual operation goes hand-in-hand with pain relief. Hip replacement is now being done through dramatically smaller incisions. Much of the time hip replacement can be done through a three to four inch incision as opposed to an eight to ten inch incision previously. People that are heavy will still tend to have a larger incision than people that are thin but, in general, everyone will still have a smaller incision. The difference in the amount of surgical trauma is really not the length of the incision but rather the amount of cutting of tissue about the hip joint itself, specifically the amount of tendon and muscle that is cut. There are multiple different techniques for decreasing this trauma. All of them seem to make a dramatic difference. A classic back of the hip approach through an incision into the hip that is about 50% as long as previously, an approach to the hip from the side or an approach to the hip from the front, all reduce the amount of surgical trauma.

Minimally invasive knee surgery has been developed in the last several years. It also reduces the length of incision required in the skin but more importantly it eliminates cutting into the upper thigh muscle, the quadriceps and its tendon. The way that knee replacements were performed until only a short time ago involved cutting into this muscle to allow the kneecap to be moved to the side to gain access to the front of the knee. We now avoid cutting that muscle and instead do more from the side. By not cutting the quadriceps muscle and tendon, a dramatic decrease in the amount of postoperative pain, swelling and irritation in the knee is realized by most patients. Most patients that have had a knee replacement several years ago and have had a recent knee replacement note that it was dramatically easier for them to regain full motion as well as strength. It is also much easier for them to regain normal ability.

Continuing research is occurring in the development of improved techniques of hip and knee replacement. During the coming years it is quite likely that improved surfaces of the replacement devices as well as additionally improved surgical techniques will be developed. Currently, the procedures we use have improved dramatically in the past several years. Most people that undergo them are quite able to resume a normal non-strenuous life very rapidly and are able to return to moderately strenuous use of their legs within a relatively short period of time. Tri-Valley Orthopedic Specialty surgeons are committed to the improvement of hip and knee replacement surgery and committed to decreasing the amount of pain following the surgery and to making subsequent rehabilitation easier and quicker.

Tri-Valley Orthopedic Specialty surgeons, Drs. Malstrom, Behzadi, and Jupina, are collaborating with local hospitals and physical therapy centers to develop a comprehensive approach to the surgical treatment of hip and knee arthritis. We are committed to state of the art techniques as well as to reducing the pain for patients as much as possible and improving the speed with which patients can resume their normal lives.

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