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Interviewer: As technology and practices have improved, more people than ever are receiving joint implants. In fact, "The Journal of Rheumatology" projects as many as 600,000 joint replacements in the U.S. by the year 2030.

With more folks receiving an implant, how do you take care of it and ensure that it lasts as long as possible? To answer those questions, today, we are joined by Dr. Mike Archibeck. He is an associate professor with the Division of Adult Reconstruction at University of Utah Health.

Now, Dr. Archibeck, for someone who has just barely received a replacement joint, whether it be a knee or a hip or something like that, what do they need to know about taking care of it for, say, the first year after surgery?

Dr. Archibeck: Yeah. So I think I'm primarily going to talk about total knees and total hip replacements. That's kind of the purview of the Adult Reconstruction Division in the Department of Orthopedics. So we do total knees and total hips as well as revision total knees and total hips.

And so there are a few things that are generic in regards to how to maximize your recovery early after surgery. Most would consider the first year as kind of the recovery period. It's been shown that both hips and knees generally do improve over that year, even though the vast majority of the improvement is in the first few months.

And during that first year, there are a few things you can do to kind of maximize the outcome and protect it from the dangers. Early after surgery, one of the most common complications is a blood clot in the leg or something that we call a deep venous thrombosis. So, usually, patients are prescribed some form of blood thinner. It could be aspirin. It could be something stronger. So being sure to do bed exercise during the day, get up about every hour or so, and go for a short walk.

You also want to be sure that the wound heals. So one of the concerns early after surgery is infection. Try not to overdo it such that the knee or hip area becomes too swollen, that can slow or compromise wound healing, and being sure to avoid any other types of infections that you might get early after surgery, like a urinary tract infection or a skin infection.

So if any of those things develop, or dental issues, you want to touch base with your surgeon and be sure those are treated so they don't potentially get into the bloodstream and make it to the hip or knee replacement.

And then recovery-wise, some patients participate in formal physical therapy. And more commonly now, more and more patients are doing kind of directed physical therapy, but working on whatever the tasks might be that the therapists direct you to do.

So with a knee, early after surgery, one of the high priorities is working on range of motion. A hip, less of a concern range of motion, but with both, starting to work on gait training initially with a walker, and then subsequently, weaning to a cane, and gradually off. Usually, that process is coached by the therapist or the surgeon and his team.

And trying to avoid overdoing it. Like I mentioned, you can really set yourself back if you do too much too soon. You can get swollen, wound healing can be slower, and it can just be more painful and kind of slow the recovery process.

So, again, the main things to be careful about are watch for the signs of blood clot, which would be significant swelling in that leg that does not respond to elevation, protecting the wound from infection, and just being an active participant in your recovery and physical therapy.

Interviewer: For someone who has received a joint replacement or is about to have joint replacement surgery, the recovery takes anywhere from 10 months to a year. So when will they see the most improvement? I mean, when will they start walking again?

Dr. Archibeck: Yeah. So, with both, you'll really be walking the day of surgery, obviously to a limited degree, and you'll be using a walker typically. But with both, you're generally able to place as much weight on that implant or that extremity as you want.

But like you mentioned, the first few months, the improvement is very rapid. So week to week, you see a significant improvement.

The improvement after those first few months is a little more subtle. So you may not notice dramatic changes like you do early after surgery, but it will continue to improve, and you gain more confidence in it, and you think about it less as time goes by.

But most people kind of describe the first six weeks as the majority of the recovery, so that's really the time frame when the focus is on avoidance of complications. So blood clot, infection, things like that.

Interviewer: Wow. So after the first year, the body is healed up, we've made sure that the wounds are not getting infected, we're not getting clots, etc., but now we have a piece of hardware in our body. What do we have to do to make sure that we're taking care of the implant and make sure that we get as long of a use out of that implant as possible?

Dr. Archibeck: There are several things that are important to know. So one is how do these things fail? And there's a little bit of a difference with knee replacement and hip replacement, but in general, they can still fail by infection. So, obviously, that's a life-altering event if it occurs.

And generally, it's felt that that is caused by a remote infection that then enters the bloodstream and finds its way to the joint replacement. So, unfortunately, a chunk of metal like a hip and knee replacement is always more susceptible to infection than a native healthy joint.

So you just want to take generally good care of yourself. Keep your dental work up to date. That can be a potential source of infection.

Interviewer: Really? Dental work?

Dr. Archibeck: Yeah. In the past, they used to recommend antibiotics prior to any dental work, and that still is a bit of a controversial topic, but that's not felt to be absolutely necessary unless you're high risk or have multiple joint replacements. But again, that's a topic you'll get different opinions about.

Any other bacterial infections, so common ones would include urinary tract infection, skin infections on that leg or other areas, obviously sinusitis, pneumonia. As you typically would if those things develop, you just want to be diligent about getting them looked at and treated, and more so if you have prosthetic joints.

I mean, obviously, we're talking about hip and knee, but there are elbow replacements, ankle replacements, and others. So any bacterial infection can potentially go to those areas. So just kind of taking good care of yourself like you generally would.

Implants can wear out. So, luckily, hip and knee replacements, the materials that we use have significantly improved over time over the last couple of decades. And so, even at 20 years, most are still functioning well, but they do wear and tear.

So a few things you can do in that regard. It's generally recommended that you avoid repetitive, high-impact activities, such as running, for exercise or aggressive cutting and pivoting sports. Things like walking, hiking, biking, swimming, golfing, dancing, most people feel like skiing is fine, are all activities that are absolutely fine to do and don't need to be limited at all. You can do as much as you want.

Then there are those in-betweeners, like tennis, pickleball, skiing, where some of those the risk is more the risk of a fall. But generally speaking, those activities are felt to be okay too, just avoiding the really high-intensity cutting and pivoting type things.

The other thing that can help add to the longevity of an implant is maintaining a good body weight. So it's been shown that the risk of wear and tear . . . and by that, I mean the plastic can wear or parts can loosen. The risk of those issues arising increase a bit as your BMI, or body mass index, increases. So trying to maintain a good body weight is helpful. Avoiding high-impact activities.

And then another rare cause of failure would be an injury of some type. So the implants themselves are very durable. But obviously, the bone adjacent to the implant can be susceptible to fracture or injury.

Especially as you get into your advanced years, being careful to avoid situations that might put you at risk for a fall or an injury, making sure your home is safe in regards to no obstacles on the floor or edges of rugs, and just kind of doing your best to minimize the risk of a fall. A fracture around an implant obviously is considered a failure and typically requires surgery to correct.

With that being said, though, like I mentioned, when patients ask, "How long do these things last?" we give a relatively simple answer, like, "Hopefully 15 to 20 years." But to be honest, even at those intervals of time, the vast majority are still functioning well. Yeah, they're pretty durable implants.

Interviewer: What I'm hearing is after you get your joint replacement, if you take care of your body, your health, your weight, and so on, that your implant can last as long as 15 to 20 years?

Dr. Archibeck: Yeah, I think that's fair to say. The other thing that I should mention is that even if a joint replacement is functioning well, it's wise to see your physician. And recommendations vary, but I would say probably about every five years.

So the first year, there's a regimen of post-op visits. Usually two weeks, six weeks, maybe three months, a year. After that, though, we usually let patients go for a while. And it's wise, though, to return and get an X-ray and be evaluated, I would say, anywhere from every five to ten years.

The reason being is that there are things that can occur with the hip replacement or knee replacement that aren't always painful. So if you get a little bit of plastic wear, that might be something that we would be able to see on X-ray, but may not be a painful problem.

And sometimes, if caught early enough, the solution to that issue is relatively simple. If caught late, when it's maybe resulted in loosening of an implant, it can be a much more problematic issue to correct.

So routine follow-up, even after that first year, is wise. Especially as you get to the 15- to 20-year interval of time since surgery, then it becomes even more important because that's about when our concern kind of increases a little bit in regards to the risk of some of these wear-and-tear type mechanisms of failure.

The other thing that's worth mentioning is beyond just having it last a long time, obviously all patients want it to be as comfortable and functional as possible. And it's true that a hip replacement and a knee replacement probably will never feel like a totally normal joint, but the closer we can get it to that, the better.

And typically, hip replacements, for whatever reason, seem to approximate a normal hip more closely than a knee replacement. In other words, it's much more common to have some residual symptoms with a knee replacement.

But the most common reasons we see patients back who maybe had a knee replacement or a hip replacement five years ago, 10 years ago, and just somehow, again, feel concerned that it's not as comfortable as possible, or as they were hoping it would be, include weakness.

So that early post-op time frame, like we mentioned, it's important to work on strengthening. Maintaining that strength is equally as important to allow that hip or knee to function as good as it possibly can.

Again, maintaining a good body weight. It's been shown that if your BMI kind of creeps up a little bit, sometimes the patient's satisfaction level with their replacement decreases. So even though it's not intuitive that that would be the case, maintain a good body weight, maintain good strength.

And obviously, if it really seems like something is wrong, if it's painful and it seems to be not resolving or worsening, then you definitely want to see your physician to kind of rule out any concerning findings.

But again, continuing with those strengthening exercises, maintaining a good body weight, those things can help the joint replacement function most effectively for a long period of time.

Interviewer: Now, going back to that idea of satisfaction, if a patient gets a replacement and is able to take care of it for those 15, 20, or more years, what kind of improvements in quality of life can they expect after receiving a joint replacement?

Dr. Archibeck: That's a good question. The good news is that the vast majority of patients, even though they may have some residual symptoms, feel as though they're dramatically improved when compared to their status preoperatively.

So like I mentioned, it's often the younger patients that maybe notice the limitations or the shortcomings of joint replacement because of maybe their demands of it or their expectations of it.

Because they're just by nature more active, they may notice those limitations a little more than a very elderly patient that maybe isn't as active. Those patients often feel like, "Hey, this does feel pretty normal to me," whereas, maybe the younger, more active patient feels that they're still a little limited by it.

But like I mentioned, most patients, younger or older, generally feel significantly improved after surgery.

And as I mentioned earlier, they should expect to be able to participate in those activities that I mentioned without significant pain: walking, hiking, biking, swimming, things like that. The more demanding activity is, so things like stairs, squatting, walking up or downhill, long hikes, it's not uncommon to still maybe develop a little fatigue or a little ache in the joint. And those things, unfortunately, may persist.

So, with knee replacement, it's been estimated that about 15% to 20% of patients continue to have some degree of what they describe as pain, even though most patients are still very satisfied. Hip replacements, it's a little less. So maybe 5% to 10% of patients still have occasional pain. So, yeah, unfortunately, not a totally normal joint, but definitely typically a significant improvement.

Although the things that I mentioned, like infection or injury, are extremely scary and worrisome, they are very, very rare. And most people do very well after hip or knee replacement in regards to a significant improvement in their quality of life, both in regards to the level of pain that they have as well as their level of function and the activities that they're able to participate in.

Interviewer: You pulled your hamstring. You might have been playing a competitive sport, you might have been just playing something with your friends, you might have been running around with your dog, and you feel a pain in the back of your leg. It's possibly a pulled hamstring. Is that something you can handle on your own, or is it something that you really should seek help for? We're going to find out the details on how to heal a pulled hamstring today.

Travis Nolan is an athletic trainer at University of Utah Health. Travis, how does somebody know if they pulled their hamstring? What are the symptoms? Where would you feel the pain and that sort of thing?

Travis: Usually, the signs and symptoms are going to be sudden onset of pain in the posterior thigh or sort of in that back thigh musculature just below your buttocks. And so you're going to have a sudden onset of pain, most of the time sharp, very pinpoint, and local, so you can pretty much point to one spot in that area. It's not going to be your entire muscle belly. And also decrease of motion, decrease in strength in that muscle belly.

Those are some of your immediate signs and symptoms that you're definitely going to notice right away.

Interviewer: And if somebody does pull their hamstring, is that something that they can then take care of on their own, or should you really see somebody?

Travis: Most of the time, when you do have a strain or a pull, you can actually take care of that on your own. You can take care of that at home, as long as you know what you're doing and know your exercises.

And really, the biggest guiding principle through rehab with a strained or a pulled hamstring, it's going to be listen to your body. Listen to those pain levels and don't push through any kind of pain, because that is essentially your body trying to tell you, "Hey, we're trying to heal this area, and you are making it worse for us." And so you're just going to prolong your recovery and prolong your rehabilitation process by pushing through pain.

Interviewer: So if somebody has already pulled or strained a hamstring, and they've seen a professional, and they have some stretches or some exercises, and this feels much like the last time, then they could just get those exercises and stretches and proceed as normal.

If it's a first-time situation, would you really recommend going to see a physical therapist or an athletic trainer to get those exercises and stretches?

Travis: I would recommend for the first-time patients to go and get those exercises and stretches, a little bit of guidance, because sometimes those exercises, to a person, might seem a little tricky. They might seem complicated. And when patients run into that, even unknowingly, they can sort of get this noncompliance with their rehab program. It can be frustrating when you don't know exactly what you're doing.

And so when you're doing things appropriately and correctly, it's going to feel a lot better, and you're going to feel like you're actually making progress with this, and then you're not just going to maybe quit, because it's like, "Oh, man, it's not getting better. The pain is continuing."

So, yes, I would definitely recommend for those first-time people that maybe don't even know if it is a hamstring strain and maybe they're struggling trying to determine if that is what's going on, definitely go get it checked out by the right professional.

Interviewer: And those exercises and stretches, does that actually speed up the healing time?

Travis: Yes. By actually completing rehabilitation, so exercise, stretches, and using some modalities and these things you can find at home, such as ice, heat, different things like that, it is going to accelerate your healing process.

And most importantly, if you are an athlete or maybe just a recreational athlete, you will need to complete some exercises in order to build strength back in your hamstring, get the same length back in your hamstring that you had previously. Because there will be scar tissue formation from the injury, and that scar tissue formation is not only going to affect our range of motion, it's also going to affect the muscle strength and the sort of force production that our muscle is able to generate. And so, by doing rehab and exercises, you are going to return back to the level that you were previously before your injury.

Interviewer: So doing nothing, just resting, not necessarily the best idea.

Travis: No, not necessarily the best idea. Will it get better? Yes, it totally will. Will it return to the same level of function prior to your injury? Most likely not if you're just hanging out and sort of resting, and that's all you do in order to heal it.

Interviewer: And then if somebody has already been in and they pulled or strained it, and they have implemented the exercises and the stretches, how long does it generally take if you're being good about that and icing and heat to recover?

Travis: So the recovery process for a strained/pulled hamstring is quite varying, honestly. And that is probably one of the most debated things in research when it comes to pulled hamstrings and things like that. Specifically, when we're looking at athletes, there's the return-to-play timeline. It can range, honestly. And research has shown it can range from 7 to 50-plus days.

And so it really depends on the progress of the individual person. Everyone heals differently. As well as sort of the initial injury. Was it a Grade 1 hamstring strain? Was it a Grade 2 hamstring strain? And then it also all depends on sort of the level of athletics or the level of sort of recreational stuff that you're trying to get back to. That can sort of determine your return-to-play timeline, if you will.

Interviewer: And if somebody wants to have their hamstring pull looked at, the walk-in clinic at University of Utah Health would be a great option. If that's not an option, just any physical therapist or athletic trainer, would they be able to help with a hamstring pull like this?

Travis: Yes, definitely. And I know there are a lot of physical therapists that you can schedule appointments with, go see, get this checked out. And so, yes, this is definitely something that getting in to somebody, in my opinion, especially for the general population, it's only going to accelerate your healing process and your recovery time and getting back into those activities that you actually love doing.

Interviewer: When should you have your hip pain checked out by a doctor? Dr. Matheau Eysser is an orthopedic surgeon. What's your advice?

Dr. Eysser: Well, hip arthritis is a common condition that causes hip pain. Hip arthritis is characterized by wearing away of the cartilage of your hip joint. Symptoms of hip arthritis include pain in the hip joint that may include pain in the groin, outer thigh or buttocks, pain that is typically worse in the morning and lessened with activity, and some patients even have difficulty walking or walking with a limp. Sometimes the pain worsens with vigorous or extended activity and stiffness in the hip or limited range of motion. Hip arthritis symptoms tend to progress as the condition worsens. What is interesting about hip arthritis is that symptoms do not always progress steadily with time. If you are experiencing these type of hip symptoms, please see your doctor.

updated: March 17, 2021
originally published: March 13, 2019

Announcer: Seven question, seven answers. It's Seven Questions for a Specialist on the Scope.

Interviewer: It's time for another edition of Seven Questions for a Specialist. Today we have Dr. Chris Peters. He's an orthopedic surgeon who specializes in knee and hip replacement. Are you ready for Seven Questions?

Dr. Peters: I'm ready. Go.

Interviewer: All right. What's the best thing I can do for my knee or hip health?

Dr. Peters: Staying active, maintaining ideal body weight, and avoiding cliff jumping. I don't know, joining a . . .

Interviewer: What's the best thing I can do after a joint replacement surgery?

Dr. Peters: Go out and live a full, active life.

Interviewer: What's the most common knee and hip problem that you encounter?

Dr. Peters: Arthritis.

Interviewer: What's one thing you wish people knew when it comes to joint replacement?

Dr. Peters: It's not as painful a thing to go through as most people think.

Interviewer: Knowing what you know about hips and knees, you cringe a little when you see someone doing what?

Dr. Peters: Marathon running.

Interviewer: Really? Expand on that a little bit.

Dr. Peters: Well, that's not really fair, because, you know, if you look at it, marathon runners are usually super-fit. They're slight people, and they're highly conditioned, and there's actually not a lot of evidence that says running well into your 50s and 60s leads to arthritis, but it gets to the point of overuse in very vigorous athletic activity, so for instance, NFL players tremendously high rate of hip and knee arthritis. So extremely high-impact, competitive athletics, I think, is very hard on your hip and knees

Interviewer: How can I prevent common knee and hip injuries?

Dr. Peters: It's common sense, you know? And I think, to a certain extent, you can't eliminate that if you want to live a full life, you know? So I hear parents a lot of times asking me, "Well, should my kid play football?" "Should my kid not play basketball?" Well, no. We have to accept that there are some risks in the things that bring enjoyment in life, and recreation's one of those things.

Interviewer: What do I need to know about nutritional supplements that say that they will help my joint health?

Dr. Peters: Save your money. In most cases, a once-a-day multivitamin is probably all that you need.

Announcer: If you like what you heard, be sure to get our latest content. Sign up for weekly content updates at thescoperadio.com. This is The Scope, powered by University of Utah Health Sciences.

Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you. Get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question on The Scope.

Interviewer: Today's listener question is what should somebody look for in an orthopedic surgeon when they're having a knee or hip replacement done. We're talking with Dr. Chris Pelt. He's an orthopedic surgeon and an expert in these types of replacements at University of Utah Health Care. What do you tell somebody if they were to come up to you at a party and say, "What should I look for in a doctor when I'm considering this kind of surgery?"

Dr. Pelt: I tell them to find a surgeon that they feel personally comfortable with, someone that they connect with.

Interviewer: Even if they're really, really good at it, if you're not making that connection you say go find somebody else.

Dr. Pelt: Yeah, exactly. I think that's an important thing because this will become a lifelong relationship with a surgeon. We will follow it for the rest of your life, so you want to be able to connect with that surgeon. But the other thing is you want to find someone who's technically very, very skillful. That's often with experience. Surgeons that perform over 100 hip or knee replacements a year tend to have a better outcome than surgeons that perform fewer surgeries per year, and so often is an important question to find out how many of these types of surgeries your surgeon performs.

Interviewer: And that's something you could just ask. You can just ask, "How many do you do a year?"

Dr. Pelt: Absolutely. And if a surgeon is offended by that question, the patient may want to take pause. Most surgeons that are experienced and comfortable with their own skill set will have no problem answering a question like that.

Interviewer: Beyond the surgeon, where you go, does that make a difference, kind of like the philosophy of the surgical center you do go to?

Dr. Pelt: Just like the surgeon, the facilities are very important both in their quality and cleanliness, their infection rates. A surgical center that does more of the same types of procedures will be better at what they do, so high volume centers that perform high numbers of hip and knee replacements annually will have better outcomes than places that do it more uncommonly.

Announcer: Have a question? Ask it. Send your listener question to hello@thescoperadio.com.

Dr. Miller: When hip pain is not arthritis pain. I'm Dr. Tom Miller and I'm here with Dr. Steve Aoki. He's a professor of orthopedic surgery here at the University of Utah, in the Department of Orthopedics. Steve, hip pain isn't always due to arthritis. If that's the case, what can it be due to?

Dr. Aoki: So it's interesting when I went through my training ten years ago, often times we didn't quite know what . . . we'd have these young adults come in that had hip pain. They'd have this radiating pain right in their groin region. We'd look at them, we'd look at their films, and we wouldn't see any arthritis, and we'd say, "You strained your groin" or "You pulled a muscle," and we'd send them out.

I think that what probably happened over time was they'd get disappointed, and wouldn't have a good answer, they'd go see someone else, and everyone kept telling them, "No, it's a pulled muscle or it's a groin injury," and they just weren't able to get back to their activity. So what's interesting, it's surprising that we took so long to kind of understand the young adult hip pain problems, but what we've realized . . .

Dr. Miller: Do you think that's because it just did not show up on an x-ray, like arthritis shows up?

Dr. Aoki: No, it actually, once you start looking at the films and the radiographs a little bit closer, you start looking at shape issues, and we've noticed that bone shape, whether it be the ball or the socket side of your hip joint, that the shape of the joint plays a big role in what we understand . . .

Dr. Miller: So joints are like individuals. They're different from one person to the next.

Dr. Aoki: Sure. Everyone's built a little bit differently, exactly, and that shape of your hip joint plays a role in different causes of groin pain and hip pain. So what we've gotten to understand is a concept of what we call "femoral-acetabular impingement," or "hip impingement," where the ball and the socket get a pinching with activity and range of motion.

I would think of it somewhat where there's a mismatch between the ball and the socket, where if you have a cup that's round and you have a ball that maybe didn't form quite as round as we'd ideally like it, as you do activity you twist, pivot, you squat, you force the area of the ball that's not round into that round socket, and it starts to pinch. Over time that repetitive pinching can cause discomfort and start causing hip pain.

Dr. Miller: Are there certain activities that bring this out, that precipitate this more than others?

Dr. Aoki: Yes, so what we've noticed is that in general, athletes tend to have more discomfort and shape issues in their hip joint, and that's probably a combination of the way that their hip joint formed and the shape of their joint on top of their increased activity with competitive sports.

Dr. Miller: Would it be more running, or basketball, or . . .

Dr. Aoki: It tends to me more cutting, twisting, pivoting, deep squatting type of activities. So what happens, most likely what happens and what we think is going on is that, when you are going through those early teenage years, the growth plate around that hip joint is still open, and with stress to that growth plate, we can see kind of a stimulation of extra bone in that area around that growth plate which makes the ball so that it's not as round as it ideally should be.

Dr. Miller: How common is the physical therapy to solve the problem for most athletes?

Dr. Aoki: I think it can be helpful for some people. I don't think it's one of those parts of our process that I see people get better with the pinching type pain, the deep squatting groin pain. But treating the muscular pain can be helpful, and if I can get you to a point, regardless of what's going on in your hip joint, if I can get you comfortable where you say, "It's reasonable and I can do the things that I want and it's more comfortable and I can tolerate the pain," to me that's worth sitting on it for a little while and not rushing into something surgical.

Dr. Miller: When that person finds that the pain is not getting better, or their function is not where they want it to be, what are the next steps?

Dr. Aoki: So if we've given it a chance at non-operative treatment, which includes activity modification within reason, maybe anti-inflammatories, maybe a course of physical therapy, but time if it's not getting better, then continuing with the workup of looking at the shape of the joint, maybe getting an MRI plus or minus a CT scan to look at the shape of the bones of the joint.

Dr. Miller: So you use, when you say "a scope," you mean a little device making a small incision?

Dr. Aoki: Yeah, a small incision.

Dr. Miller: No large incisions?

Dr. Aoki: Two or three incisions about the size of a button shirt hole, and then we go into the joint and we evaluate the cartilage, clean it up, repair the tissue if it's torn and unstable, and then I think a big part of this whole process is reshaping the joint, taking the ball of the joint and making it rounder so that it doesn't pinch as much into the socket side of the joint.

Dr. Miller: Now as an operator, how hard is that to do? It sounds like sculpture.

Dr. Aoki: Yeah, it's a little bit. I think a lot of what we do with orthopedics is like a jigsaw puzzle. We take broken bones and we piece it back together and it's like a jigsaw puzzle. I would look at what we do from the standpoint of hip arthroscopy and femoral-acetabular impingement, we're doing a reshaping. It's almost more like pottery. You're reshaping it and you're trying to get it to be round and ideally a shape that doesn't pinch.

Dr. Miller: That sounds like quite an art.

Dr. Aoki: I think so.

Dr. Miller: So after that surgery, then talk about the recovery.

Dr. Aoki: Yeah, recovery after it's an outpatient same-day surgery so you go home the same day. I typically put people on crutches for a few weeks, typically around four weeks where you're gradually increasing your walking and putting a little bit more weight on there as you start to tolerate. I get you started in physical therapy after a couple of weeks, mainly to have some guidance and have them work on just motion and some gentle exercises, get you on the stationary bike. I really reserve those first three months of this whole process to just get more comfortable with your daily routine, the things in life you have to do.

I typically think of that after three month process as being getting or starting to do more of the things you want to do in life, some jogging, some lighter change of direction activities. I'm not necessarily releasing you to full activity until about that four to six month mark, and at that point it's really dependent on how comfortable you are. Everyone's always a little bit different as far as how quickly they recover, and some people just don't feel ready yet at the four to six month mark. But pain's a pretty good guide.

Dr. Miller: So prior to surgery you have this detailed discussion with them about what to expect after surgery. It's not launching back into their activities that they want to do. It's a steady process.

Dr. Aoki: It's a steady process.

Dr. Miller: They're involved in that.

Dr. Aoki: Yeah, and hopefully the surgery itself is not something that you feel laid up and you feel like you're laying in bed and six months later you're ready to go. This is a gradual process of continuing to increase your activities, you're getting on the stationary bike pretty quickly, you're increasing your strengthening as you go along, as you get more comfortable. So this is not a surgery that hopefully you feel laid up or you feel like you're not able to do some function.

updated: May 20, 2020
originally published: October 25, 2016

Dr. Miller: Two approaches to have your hip replaced, which one's best for you? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Jeremy Gililland. He's a professor of orthopedics here at the University of Utah in the department of orthopedics. What's the best way to have your hip replaced, from the back or from the front?

Dr. Gililand: The honest to goodness truth is you should have your hip replaced by a surgeon who knows what they're doing from what approach they're using.

Dr. Miller: That's pretty good basic advice. Know your approach and know it well.

Dr. Gililand: Exactly.

Dr. Miller: So talk to me about the differences because patients do assume that maybe one approach is better for them, maybe it's less invasive, requires less time in the O.R. I just don't know.

Dr. Gililand: Sure. So I think there are two major approaches in hip replacement today and that is either the direct anterior approach or the posterior approach. Both have been around for a long time. The anterior approach is not a new approach. It's been around since the 1950s, It's just taken a hold, I would say, in the last decade as a . . .

Dr. Miller: Mainstream procedure.

Dr. Gililand: Mainstream procedure. Exactly.

Dr. Miller: Why would one do an anterior approach or why did the posterior approach become ascendant?

Dr. Gililand: So the posterior approach has always been a very nice approach with very good visualization, good access to the pelvis and to the femur and it's quite extensile. Meaning if there's any troubles during surgery, you can get access to everything you need and fix any troubles there. However, with the posterior approach, we've had issues with dislocation and dislocation is a big problem for patients if you have a dislocation.

Dr. Miller: So once the hip's replaced then the patient post-operatively has a higher risk of dislocation than in a patient who's had an anterior approach.

Dr. Gililand: Well, we like to think that. We like to think that the anterior approach has mitigated some of the dislocation risks. So that's really where the surge and popularity of the anterior approach came in as well as it being a little bit less invasive, smaller incisions and patients like to think that's it's muscle sparing as compared to the posterior approach. So that's really what's driven a lot of the popularity of this approach.

Dr. Miller: Now, you do the anterior approach in your practice?

Dr. Gililand: Correct, I do.

Dr. Miller: Do you do primarily an anterior approach?

Dr. Gililand: I would say it's about 90 to 95% of my patients that I do hip replacement on get anterior approach and a small percentage will get posterior approach based on certain factors.

Dr. Miller: But other surgeons in your practice will utilize primarily the posterior approach.

Dr. Gililand: Absolutely.

Dr. Miller: So how does a patient choose?

Dr. Gililand: There's a lot of stuff on hype on the Internet, a lot of information that I would be careful of reading. I think that patients need to talk with their surgeon. They need to feel comfortable with their surgeon and they need to really listen to what their surgeon has to say in terms of their expertise and their feelings of the surgery.

I think for approach one versus the other, there are benefits potentially the anterior approach. Patients sometimes feel like in the first six weeks they're up on it quicker. It's a little easier and less painful for recovery. There's definitely less concerns for positions of the hip in terms of dislocation.

With the posterior approach we give you certain precautions or positions to avoid for dislocation. With the anterior approach there's less of those precautions. However nowadays with a well done posterior approach or a well done anterior approach, dislocation risk is very, very low and patients can do well with both.

Dr. Miller: So it comes back to what you were saying earlier which revolves around the surgeon's expertise in that particular approach, their ability to perform that particular procedure over and over again and do it really well. So I think for the patient who's looking to have a particular approach, they should listen to what the surgeon does mostly or what the surgeon recommends and not try to push him in a direction that the surgeon is not comfortable with or less comfortable with.

Dr. Gililand: Absolutely. One of the problems we've see with the anterior approach is that it has become a marketing tool for surgeons. So surgeons will use that to bring patients into their practice and start saying, "I do the anterior approach, please come and get your hip done with me."

The problem being is they may have a very low number of hips in their experience there. It's got a significant learning curve, probably around 100 hip replacements before you really are competent with the approach, and so patients may not know that their surgeon has had very little experience on the approach yet says that they do the approach and the surgeon may say that they prefer that. So I think it's wise for patients to always ask their surgeon what's your experience with this approach, why are you saying that I need this approach and be educated on that.

Dr. Miller: What's nice in your practice or your group practice is that you have surgeons doing both. Have you had a patient request a posterior approach that you've then referred to your colleague or vice versa?

Dr. Gililand: Absolutely. I think that . . . and I'll have patients come to me that request an anterior approach and I'll tell them I don't think they're a good candidate for it for x, y or z reasons. If they are not comfortable with it, they can find somebody else who may be comfortable to do that approach but we offer all approaches here at our practice. I think we all have very very good success with our hip patients regardless of approach. Again I think it boils down to surgeon's comfort and patient's comfort with their surgeon.

Dr. Miller: On the redo prosthetics of patients will come back and they'll need a new hip after a number of years. Either approach or one in particular?

Dr. Gililand: I think the posterior approach is generally the workhorse for us when it comes to going for revision surgery. They are certain cases when I will do revision surgery through an anterior approach but that really is somewhat select. Most of the time we're using the posterior approach, again, because of the nature of it being a more extensile approach that gives us better visualization of both the pelvis and the femur.

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Dr. Miller: When's the best time to get that hip replacement? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller, and I'm here with Dr. Chris Peters. Chris Peters is a professor of orthopedic surgery here at the University of Utah.

Chris, the old saw was, well, at least when I trained in medical school, if you had to have your hip replaced, or your knee replaced, you ought to wait as long as possible, maybe even until the time that you're crawling, because there was some concern that the surgery was a little risky. That's not the case now is it?

Dr. Peters: No, you're right, Tom. There has been a very profound change over the last, I would probably say the last twenty years. When hip and knee replacement was first begun in the late 1960s and 1970s, those initial cases were done on people who had kind of disastrous arthritis, and they were folks who were predominately wheelchair bound.

Dr. Miller: They were the worst of the worst.

Dr. Peters: Yeah, the worst of the worst. Over time, what we have seen is that there's been a slow, steady change, and a realization that actually waiting is perhaps detrimental to overall patient health in many cases, and so I think now we realize that, for instance, if a patient's in their early 60s and has some health problems, which is common these days, diabetes, high blood pressure, and their functional status is profoundly impaired, that is they can't go out and recreate, they can't go for a walk around the block, they can't go play with the grandkids comfortably, those patients are probably better off treated with surgery earlier, rather than the old conventional wisdom of waiting as long as you possibly can.

Dr. Miller: Well, technology and techniques have improved, I would think, remarkably since the first joint implants had been done, right? So a lot has changed in terms of the functionality of the implants, and the time to recovery, and the physical therapy that's done afterwards so that people can get back to do many of the things that they were doing previously sooner.

Dr. Peters: Absolutely, and again, back in the '70s and even into the early '80s and '90s, we had concerns about implant longevity. We used to tell patients, we hoped this would last, that a hip or a knee replacement would last ten years. And what we found is that the longevity of the current generation of prostheses that we use is probably more likely 15 to 20 years. And so again, that patient who's in their early 60s is likely to see a hip or a knee replacement last the rest of their life, and they're likely to see their functional status be quite good throughout the last several decades of their life.

Dr. Miller: Now is it true the longer one waits, the kind of weaker the ligaments and muscles around that particular joint become? I would think, if that was the case, that rehabbing that area after surgery would be even harder.

Dr. Peters: Right, and what we find is that patients who wait too long come to us in what we call a deconditioned state. So we start to see deterioration in other organs, and often what goes along with that is obesity, weight gain. And many of these things can be reversed. When you restore ambulation, you restore the ability to get out and exercise. So I think patients often today are much better to have an arthritic hip or knee replaced sooner rather than later.

Dr. Miller: So Chris, when will the right time be? I mean, it's individual. Obviously it's an individual decision, but how do you advise patients?

Dr. Peters: The optimum time obviously is individualized for every patient that we see, but if a patient comes to us and they have X-ray or radiographic evidence of arthritis and can describe to us a significant impairment in their life, whether that impairment is the inability to go out and play nine holes of golf after work, or whether that impairment is an inability to go to the zoo with their grandkids on the weekend, and they're experiencing significant pain, and they've gone through a period of time using the standard medications that people use for pain, such as anti-inflammatories, if they've gone through that process and they're in that position, they're probably ready for a joint replacement.

Dr. Miller: Do you ever recommend that they do some of these other treatments such as injections into the joints of lubricants or prednisolone, something to calm the joint down before you make that decision?

Dr. Peters: Sure, there is absolutely a role for what we would call conservative or non-operative therapy. And there's evidence that, for instance in the knee, that corticosteroid injections can provide short term symptomatic relief, and we'll use those fairly commonly in patients in the earlier stages of arthritis. But once you get to significant bone on bone contact, and the whether it's in the hip or the knee, those modalities tend to be just very short term pain relief, really aren't the long term strategy for treating the patient.

Dr. Miller: They just don't last, do they?

Dr. Peters: Right.

Dr. Miller: The primary reason to do a hip replacement, as I understand it, is to reduce pain and to increase function, but it's so much more than that, isn't it Chris?

Dr. Peters: Right, and it's really a fascinating thing. As orthopedic surgeons, we start a little bit with this tunnel vision. You've got a patient comes in with an arthritic hip or knee joint and we get excited about replacing that, because we know that there's a pretty predictable improvement in pain and function when we do a hip or a knee replacement, but what we found over time is that there's incredible added benefits to the patient as well. So their overall health tends to improve.

We see patients who come in to us as a diabetic, and who are significantly overweight, and now they can get back out and exercise, they can get on their bike, they get into a Zumba class, they lose weight. Often they'll go from an insulin dependent diabetic to on to an oral agent controlled diabetic. We see we see significant improvements in overall health just resulting from the ability to be more active after a hip or a knee replacement.

Dr. Miller: So it's so much more than just improving function and decreasing pain.

Dr. Peters: Absolutely, yeah. I mean, I think it's one of those things that joint replacement surgeons didn't appreciate very much until, I would say, the last decade or so, but now we can, I think very reliably, with good literature support, tell patients that not only is their arthritic hip or knee going to feel better, but likely their overall well-being will be better.

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Dr. Miller: Can you do everything you always wanted to do after your knee or hip replacement? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today, The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Chris Pelt. He's an orthopedic surgeon in the Department of Orthopedics here at the University of Utah. Chris, what do you tell your patients after they've had a knee or hip revision or replacement? Can they do just about anything that they used to do or wanted to do but couldn't because of pain or limited range of motion?

Dr. Pelt: So, patients will undergo hip and knee replacements at younger ages than ever before today.

Dr. Miller: What is an average age, by the way?

Dr. Pelt: So, the average age is actually around the mid-50s, whereas, if you think about the 1960s, '70s, and '80s, when joint replacement was in its infancy, the average hip replacement or knee replacement would be done on patients in their upper 60s, 70s, and 80s, and that age has been pushed down further and further as our outcomes have improved with joint replacement surgery, and patients today are more active at a . . . later into life with higher intensity activities, and they really want to be able to do those things that they've always loved doing later into life, and so . . .

Dr. Miller: Well, I remember there used to be more restrictions, or at least thought to be restrictions, on what activities could be done following a joint replacement, but that's changed a little bit. That thinking has changed with the new, I guess, prosthetic devices. Is that right?

Dr. Pelt: Our implant technology has definitely improved over the years. Our bearings are wearing at a lower rate and lasting longer now, and, like I said, we're doing them in younger and younger patients who want to be more active. So, we used to tell patients that they should be more sedentary, that they should avoid doing certain activities, and as time has progressed, we've pretty much relaxed most of those restrictions on our patients. We have patients that snow ski 300 days out of the year if they can. They will . . .

Dr. Miller: What about playing tennis or racquet sports?

Dr. Pelt: They love to do it, and they will do it, and we tell them it's okay. There are some . . .

Dr. Miller: And they shouldn't worry that they're going to wear down that prosthetic joint?

Dr. Pelt: I don't think so, and if it did, there may a revision option available for them in the future, but we really haven't seen significant failures of our implants due to patients being more active. In fact, if anything, I think an overall patient's outcome is improved when they're more healthy and active into their later years as opposed to being sedentary. So, I would encourage most patients to be more active and do those fun things that they want to do, so, golfing, tennis, hiking, skiing.

Dr. Miller: Running is maybe one you're not so clear about?

Dr. Pelt: Running is the one activity I might tell a patient that if they did that as their activity of choice for exercise, that perhaps they could choose a lower impact activity.

Dr. Miller: Cycling?

Dr. Pelt: Cycling, swimming, elliptical, any of these would be lower impact and perhaps a little bit easier on the implant. But ultimately, we do have patients that still love to run. They run whether they're playing basketball or racquet sports, like you mentioned.

I've done a hip replacement on an 80-year-old woman who enjoyed running marathons, and she had come in to see us at our six-week appointment and had already run a half marathon, which is a little bit premature. We do have to let the implants grow into the bones, but people want to be active, and they will do things. When they feel better after having their arthritis pain relieved by the surgery, they will become active again, and we want to encourage them to do that.

Dr. Miller: So, if you're getting an implant, let's say at the age of 50, how long if you're still cycling or skiing might that implant last?

Dr. Pelt: We expect 15 years on the average for a knee replacement and maybe 30 years for a hip replacement, even when a patient's really active. The differences there have to do somewhat with the type of bearing, where a hip replacement is sort of a round against round, versus a round against flat bearing of a knee replacement. But many knee replacements we see back in follow-up at 20 plus years, still doing quite well, and many of these patients have been active for much of their lives.

Dr. Miller: Do you see the technology evolving in the future, where the implants will last even longer eventually?

Dr. Pelt: Yeah. I believe it's coming out soon. I mean, there's new improvements. May not be in the next 5 years, but perhaps in the next 10 years we'll see some improvements for longer-lasting bearings in implants as surface coatings and the types of materials that we're using start to improve. The bearings that we use may evolve slowly and continue to show improvements.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.

Dr. Miller: Your coach tells you you have a groin pull. Is that really what it is? We're going to talk about that next on Scope Radio.

I'm Dr. Tom Miller and I'm here with Dr. Travis Maak, an orthopedic surgeon here at the University of Utah and he's in the Department of Orthopedics. Travis specializes in sports medicine. Travis, talk a little bit about that whole issue around groin pain. Is there such a thing as a pulled groin muscle or is that something else?

Dr. Maak: It could be and many athletes are very used to this type of injury and being told by their trainer or their coach that you bent down or you were running and just kind of exploded off the blocks if you're a running athlete. And all of a sudden, you have pain in your groin and you're told you pulled your groin and you need to take a little bit of time off, stretch it, out walk it off, take some anti-inflammatories like Aleve, ibuprofen, Advil and when the pain goes away, you get back doing what you were doing.

Yes, there are muscles, to your point, that you can literally pull in your groin. Those are called the adductor muscles. They are on the inside of your hip. Frankly, multiple groin pulls are not common.

Dr. Miller: They're not common?

Dr. Maak: They're not common.

Dr. Miller: Contrary to what everybody hears.

Dr. Maak: That is true.

Dr. Miller: We always talk about a groin pull. For the audience, I think that a groin pull is pain on the inside of your upper leg towards the pelvis, right?

Dr. Maak: That is correct.

Dr. Miller: If it's not a pulled muscle, then what is it?

Dr. Maak: Well, a person who's prone to groin pulls and has a history of playing sports from their childhood and being told they pulled their groin, they pulled their groin, they pulled their groin and it never seems to get . . . it will go away temporarily, but then it comes back. One of the other diagnoses, which can cause this, is something called femoral acetabular impingement or FAI.

Dr. Miller: That's a big word. What does it mean? What does that look like?

Dr. Maak: So the femur, that's the thigh bone

Dr. Miller: That's the big bone in the thigh?

Dr. Maak: That's the big hole in the thigh. Acetabulum, that's the socket or the ball and the socket of the joint. So the ball is the femur, the socket is the acetabulum. Just the two bones of the hip joint. And then impingement is a fancy word for the two bones hit together.

Dr. Miller: They rub?

Dr. Maak: They rub.

Dr. Miller: When they rub, they cause pain.

Dr. Maak: That's exactly right.

Dr. Miller: Are certain people predisposed to this problem?

Dr. Maak: They are. It tends to be a Northern European type of injury or at least the way the bones are shaped. Although it can happen in any type of ethnicity or group of population. Interestingly, we also have some evidence that specific sports put people at risk for this.

Dr. Miller: Do tell, which ones?

Dr. Maak: Lacrosse tends to be a fairly high incidence of sport, football, hockey.

Dr. Miller: Now, why lacrosse as opposed to basketball or soccer?

Dr. Maak: Interesting question. We believe it has to do with the rotation with the stick. Part of this, there's a current theory that this has to do with the growth plate of the hip and small growth plate injuries that occur over time can make your hip shaped a little differently.

Dr. Miller: So if this happens, you have this pain, this discomfort. How is one reliably to separate this out from actually a pulled muscle or tendon versus you know this is a problem with the hip joint.

Dr. Maak: Sure. So the history is actually fairly classic here. So while the initial acute stabbing pain of a pulled groin can happen quickly, particularly when you're exploding off the blocks or you twister you get tackled, and then it goes away within a few days and basically you return to normal. With FAI, there's typically a subtle, continued discomfort, particularly when you sit for long periods of time. If you find yourself going to the weight gym and your coach says, get down, get deep and squat this weight and every time you find yourself not going . . .

Dr. Miller: Get discomfort.

Dr. Maak: Right.

Dr. Miller: What do you do then? What are the treatments?

Dr. Maak: Well, the first treatment is physical therapy so athletic trainers are very good at this. Many physical therapists are as well. As long as you have the diagnosis, going and learning how to lift a little bit differently, avoiding deep squatting exercises and strengthening the muscles around the hip as well as a little an-inflammatory, like Aleve, ibuprofen, Advil can help you. When those fail, sometimes other interventions can help you.

Dr. Miller: How often is this a game changer for the young athlete?

Dr. Maak: So I can tell you is if this ultimately gets diagnosed in the athlete finds himself limiting their athletic participation because they're groin hurts when it's treated, the beautiful thing, while no one wants to get surgery, if it ends up getting surgery . . . and the surgery is basically to make the ball of the hip round again, it's done with a camera. It's minimally invasive and three little, tiny poke holes. And you go in and basically reshape the ball to make it round again. It's curative, it does not return and effectively, they return to their sports at a higher level without pain.

Dr. Miller: One of the things you started out with is the potential to have this problem misdiagnosed. So what would be your recommendation be to an athlete that has groin pain?

Dr. Maak: The first thing is probably to not worry about it initially. If it's a first time you're told by your trainer that you have a groin pull, odds are you probably did. That being said, if it continues to happen and you have a one or two or three or even four groin pulls that keep happening, my recommendation would be to go get an X-ray of your hip. It's nothing fancier than a simple X-ray of your hip and you can diagnose this problem.

Dr. Miller: They could very well do that through their primary care physician?

Dr. Maak: Absolutely.

Dr. Miller: So, in summary, this groin pain may not actually be a groin pain, it could be an impingement in the actual hip joint itself and that that ought to be checked out if you have repetitive groin pains.

Dr. Maak: That's exactly right.

updated: March 9, 2022
originally published: August 9, 2016

Dr. Miller: You've had a hip or knee replacement and need a revision, we're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists," with Dr. Tom Miller, is on The Scope.

Dr. Miller: Hi, I'm here today with Dr. Chris Pelt. He's an orthopedic surgeon here at the University of Utah in the Department of Orthopedics. Chris, talk a little bit about how long a hip or knee replacement lasts. Obviously, that's pretty variable. But when that begins to wear out, and I'm sure in a certain percent of people it does, what's the next step?

Dr. Pelt: Historically, a hip replacement would last 10-15 years. Newer technologies have been developed, which allows the hip replacements to be lasting closer to the 30-year time point, when we look at these on wear simulators, we haven't had the technology 30 years now, but when we look at the available information and literature it looks like it could last much longer than historically.

Dr. Miller: So when they wear out, does the actual prosthetic device wear out or do they come loose? What actually happens? What's more common?

Dr. Pelt: There are three main wear mechanisms or failure mechanisms. One is that the bearing will wear out so the plastic liners can get worn and you can replace the plastic liners. More commonly, however, what we find is that the implants can get loose from the bones or the worst of all of the complications would be infections of the implants. And a lot of the referrals that we do see come from outside in the community hospitals, they refer to us for complications related to infections.

It's one of the more common failures in early time points when a joint replacement fails, but it can happen later in life as well, it can happen when bacteria get into our bloodstream and they find their way to the artificial joints. Metal and plastic do not have an immune system so when bacteria are in our bloodstream, whether it's from an infection in our mouth, dental work, an infection of a toe or any other type of infection in our body, a bacterial infection, it can find its way to our hip replacements. We want to be careful about that when patients are undergoing treatments for other medical issues.

Dr. Miller: Well, based on how patients present with either one of those three things, I guess you craft the repair or surgery to meet that problem. I would imagine a revision surgery is probably a delicate or complex surgery compared to an initial hip replacement or knee replacement.

Dr. Pelt: It's quite a bit more complex. It takes a little bit more expertise and skill because it can be very easy to have a revision surgery and have things go wrong.

Dr. Miller: How long, then, does that revise tip last? Does it last as long as the initial implant or are people looking at a little less lifespan on the hip or knee?

Dr. Pelt: It depends. It depends on what the problem is that we're treating and what implants we have to use to deal with that reconstruction. But, on average, they should last similar time frames to the initial index operation. Some of these will be, hopefully, the last surgery the patient needs to have in their lifetime.

Dr. Miller: Now, patients who present with the infected hips, I think you probably take the old device out and then either put in a new device or wait until the infection has been treated. But I imagine that treatment goes on for several weeks with antibiotics. Is that right?

Dr. Pelt: That's right, yeah. We've taken a lot of pride and created a significant team around the treatment of joint replacement infections here at the University of Utah. We have infection disease specialists, our internal medicine colleagues, ourselves as orthopedic surgeons, our nurses, physical therapists, physician assistants and a bunch of other people that help us take care of our patients. But yeah, the surgery is required initially to take the device out and get rid of all the bacteria out of the joint.

We place a temporary antibiotic-laden or antibiotic-containing spacer with some temporary parts that'll allow the hip or knee to still move the way it typically would and after about three months of treatment with antibiotic and a drug holiday, we often will be able to take the temporary device out and replace it with a permanent device again.

The typical revision joint replacement surgery we may not allow to bear weight on the limb that was just operated on right away. Often, after a primary hip or knee replacement, we have the patients up and walking, with full weight bearing, the day of the surgery. With revision surgery, depending on what it is we are doing, but with most revision surgery, that often is delayed. So we won't let them . . .

Dr. Miller: Both knees and hips?

Dr. Pelt: Both knees and hips. Typically for about six weeks. And the reason is as we mentioned when we are dealing with bone loss and having to accommodate or account for that with bigger and larger implants, sometimes, we need biology to be on our side.

Dr. Miller: It's almost like a fracture that needs treatment so you can put weight on it.

Dr. Pelt: It's almost like treating a fracture. Exactly. So we're waiting for bone in-growth to happen to the implants before we start putting too much weight and start making micro-motion or something that could compromise the stability or fixation. So typically, they're going to be at least six weeks behind where they might have been after their index or primary joint replacement surgery.

After which time, we start ramping up some more of their physical therapy, start getting walking on it, start getting them to strengthen their muscles with some weight and resistance modalities finally, where they probably have not been doing those in the first six weeks. And so they can just expect a little bit long time point until they get back to their maximum improvement point.

Dr. Miller: Initial replacements, they are out of the hospital pretty quickly these days. How long would they expect, on average, to be in the hospital after a revision?

Dr. Pelt: Our typical primary joint replacements will go home the next day, sometimes the latest two days after surgery. A revision surgery has an average length of stay of around three days. Some patients will go home around day two, others around day three, sometimes even day four, but about a day or two longer in the hospital. That's mostly because they're trying to account for the weight bearing restrictions, the mobility needs that they have to get used to after having the revision surgery. So our physical therapists are going to be working with them in the hospital, trying to get them to do the things that they'll need to be able to do when they get out of the hospital

Dr. Miller: Now, you have patients coming from cities distant to Salt Lake. So, interestingly, once they leave the hospital, how do you make sure that the therapy they are getting in their hometown is going to be adequate?

Dr. Pelt: So we have patients that fly in from northern Montana, Wyoming, Idaho, Nevada, Colorado, Arizona, New Mexico all to have their surgeries done here with us. And it is difficult. We do have, like I said earlier, we do have a big team, including some of our care coordinators and our nurse coordinators that help kind of reach out and make sure our patients are doing well after surgery. We call our patients pretty frequently.

We write pretty strict and standardized protocols and instructions to send home with our patients when they leave the hospital so the physical therapists are able to follow those directions pretty closely. And that way, we don't compromise anything that may be a difference in how they treat things in one place vs how we do here. We try to give them those instructions so it is very clear on what our expectations are when they leave the hospital. And then our team of care coordinators and nurses are going to be calling and ensuring that everything is going right as the weeks progress.

Dr. Miller: So their therapist, no matter where they would be, would be able to contact your care team to figure out if there we any things that they need to modify or revise in terms of the treatment?

Dr. Pelt: Absolutely.

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