Have you recently been told that you absolutely must get joint replacement surgery? Dr. Derek Amanatullah of Stanford University discusses frequently asked questions regarding the necessity of joint replacements, under what circumstances a patient really needs a joint replacement, and how he determines whether the surgery will help or hurt a patient. Listen to the audio or read the transcript below!
Hi Dr. Amanatullah! How are you?
You’re a specialist in joint replacement, so under what circumstances does someone need a joint replacement?
This is the question that we get very often. Patients will come in and talk about the fact they’ve been told that they need a joint replacement. I think I have an interesting take on that. There’s two reasons patients get told that.
One is because someone who does joint replacements might not want to do a joint replacement on that patient and they want to send them to somebody else. That can be done for various different reasons.
The second reason is because the primary care doctor is referring someone for a joint replacement. In that particular setting up I would tell you it’s probably true with the person probably hasn’t had all the other things that come before surgery optimized. Knowing those two things I would tell you really nobody needs a joint replacement but lots of patients want one and might have all the indications to get one that it might fit into their life and make their lives better.
The unfortunate reality is that knee replacements or hip replacements or any joint replacement isn’t for a life threatening thing, and so when we talk about need, we really talk about how it would fit into somebody’s life and whether the risks of a joint replacement would be worth it for the benefits that might provide.
Got it. You mentioned that there were a couple of key indications that someone would need them. What are a couple of the big ones that are red flags to you?
Dr. Derek Amanatullah:
For needing a joint replacement, so we talk about needing a joint replacement, so somebody who might want one who could benefit from them was we want to see someone who is active enough to benefit from a joint replacement, which basically means they’re walking around, ambulatory, not necessarily wheelchair bound or sometimes we can help those patients. But, ambulatory in general but has pain that affects their activities of daily living or gets in the way of the things that they want to do.
Additionally we want to also know that we can that they’ve tried everything to manage their pain. When I talk about everything, there’s really three other things that need to happen before you talk about a joint replacement.
One would be we’ve tried lifestyle modifications meaning weight loss, low impact exercise, maybe using gait aid. Some of those things I realize are easier said than done having tried them. Another one there might be physical therapy or a brace.
After that anti inflammatory medications — we’ll want to see the patient as tried that. Lastly I would say an injection. An injection is really important. I would tell you it’s important because if your pain doesn’t go away within injection, it also means that might not go away with the joint replacement.
That’s a really hard thing for people to understand. The reason that’s true is because the injections normally have an anesthetic agent and a steroid, at least for steroid or cortisone injections.
The anesthetic agents should work, and it should take the pain away right away. It just might not last because different patients have different symptoms and different types of arthritis in different activity level, so the steroid might not last.
And oftentimes people mistake the injection lasting for it working, and I think what we want to see is that the injection worked, but it didn’t last.
So in the face of trying to modify in a relatively active person sometimes, healthy are not healthy, but at least mobile, whose tried anti inflammatories and had injection work but doesn’t last three months or so, we might entertain surgery to increase that patient’s function, relieve their pain, and get them back to the activities that they want to do, because they’ve exhausted everything else that’s reasonably possible, and the risks of surgery may or may not be worth it but least be entertained in that setting.
Got it. So surgery, it sounds like, a sort of the last-ditch effort. You’re not gonna try that unless you really have tried everything else.
Dr. Derek Amanatullah:
Yeah, I mean, you would never imagine a prophylactic knee replacement or hip replacement. The reason for that is knee and hip replacements, despite being amazing, aren’t natural. And I would never take a person with a mild pain, subject them to a surgery, they could end up with more pain than they began. So knee and hip replacements aren’t perfect. They aren’t the panacea and they can have complications when we want to really use them for treating pain and disability related to pain because that’s where those treatments will work the best.
And so of course we don’t want to entertain the risk or put them that joint replacement in a scenario where it’s not going to benefit the patient.
What I would say is that a lot of patients come in with really bad arthritis but they are not having a lot of pain.
We don’t treat — or I would never treat xrays alone. We treat patients. Patients have pain, and that’s the thing that we want to make better. We don’t wanna make X-rays look, perfect because if those X-rays look perfect and they’re painful in the patient’s painful, we didn’t help anyone.
Right right right right. How often do you see someone coming out of surgery and say something like, “I’m already in less pain than before I went into surgery.”
Dr. Derek Amanatullah:
Every case, and I think it’s because we use the injection as a very good threshold. We try and make sure that patients understand the risks and benefits. I think I’m fortunate that nobody’s really woken up and said “my pain’s worse than before.”
Most patients with a hip replacement will find all their groin pain gone instantaneously after surgery. That’s not to say there’s no pain; it’s just different. They’ll feel like they got hit kind with a baseball bat kind of in your behind.
And then knee placements: they also what they’re pain, they’ll notice their arthritic pain in their knee is gone. There can be something in the front of the knee related to the incision. So they’re not pain free. The pain caused by the arthritis after the surgery is gone instantaneously, and we trade that pain for an incisional based pain which goes away over time with the next couple of weeks.
Got it! Well, thank you so much for your time today.
Dr. Derek Amanatullah:
Absolutely thank you very much for having me.