Search for tag: "joint replacement"

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.

Dr. Miller: Artificial joints and infection, 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 is a Professor of Orthopedic Surgery here at the University of Utah in the Department of Orthopedics. For patients and people who have prosthetic joints or artificial joints, are they at higher risk of having an infection in that joint?

Dr. Gililland: Well, the joint itself we put in is a metal and plastic joint. It inherently doesn't have its own immune system like our own joints do. So if you get an infection, even an innocuous infection in the blood stream that would have normally been cleared, there is a chance that could get to the joint and take over and so you are at more risk of that joint becoming infected.

Dr. Miller: So how does one become infected? I mean, is that due to a cut or some other site in the skin that could be infected or is it some other way that you are infected? How does that happen?

Dr. Gililland: The answer is, probably most of the time we don't know how it happens. It comes about as an infection that we probably wouldn't have picked up otherwise or have been aware of otherwise. Sometimes we are aware, they had a bad urinary tract infection or they do get an infection in the skin and that then gets to the joint, but most of the time we don't know and these come on seemingly out of the blue.

Dr. Miller: How often does it happen? I mean, it's not common, right?

Dr. Gililland: It's not common. We would say that in most big registries, infection in any given practice should be about 1% to 2%. There is difference in infection that happens right around the time of surgery which would be a surgical site infection which can come from either the wound itself.

Dr. Miller: The wound itself, healing, the incision.

Dr. Gililland: Exactly and that's different than infection that ensues say two or three years down the road in an otherwise well-functioning joint.

Dr. Miller: So you see infection more commonly after surgery or two or three years down the road?

Dr. Gililland: Generally what we see here is our infection rate here at the university is very low. It's less than 1% of our own infections and in cases that happen here in terms of patients getting surgical site infections, but we definitely see infections coming in from outside or infections in patients that have had well-functioning joints and that's probably a bigger problem in terms of dealing with those long-term.

Dr. Miller: So dealing with an infection in a prosthetic joint is a different kind of beast than having an infection in a joint . . . in a normal joint.

Dr. Gililland: Correct. Dealing with an infection in a prosthetic joint is rather difficult because now you have a piece of metal in there that's infected and we are starting to learn more about infections and the way that they form and bacteria is just a single bacteria creating infection. They create a big environment of what we call a biofilm that's almost . . .

Dr. Miller: Sticky.

Dr. Gililland: Right.

Dr. Miller: They stick to the plastic and the metal and . . .

Dr. Gililland: Exactly. They almost create their own colony and their own surface that sticks to the metal and it's almost impossible to get rid of with just antibiotics.

Dr. Miller: So I think most people would believe that you might just take an antibiotic for a few weeks and then the infection would go away, but that's not really true in this situation.

Dr. Gililland: Yes, it's very, very unlikely that that's going to be successful and often we get patients that have come in and have been on antibiotics for a long period of time and that's been rather unsuccessful for them and it makes our job somewhat harder because now these bacteria can be somewhat resistant to some of these antibiotics.

Dr. Miller: Well, let's talk about the patient who might have an infection. What signs would they look for, what symptoms would they have that would alert them to the fact that they might have an infection in that new prosthetic joint?

Dr. Gililland: Yeah, the biggest thing is pain. Most of these patients are patients that were functioning well, doing well with their arthroplasty, their joint replacement, and then they started to develop pain down the road. And whenever that happens, the patients need to go and be seen and be evaluated to make sure the parts aren't loose and there is no fracture, and most importantly, they don't have an infection.

Dr. Miller: But there could be other reasons for pain aside from the infection.

Dr. Gililland: Absolutely. Pain in and of itself does not mean infection, but it's certainly something that we ought to be looking for. Any painful joint that comes in that was otherwise well functioning always gets an infection workup in my clinic.

Dr. Miller: Would there be other things going along with the pain? So would the joint be swollen or red or will the patient have fever or chills? What kinds of things are you typically seeing in these infections that occur two to three years out?

Dr. Gililland: Yes. So certainly there you can have swelling about the joint, redness. You can get drainage from the wound or start to develop draining sinus tracts or sites of drainage.

Dr. Miller: That would be bad.

Dr. Gililland: Yeah, that's obviously, obvious signs of infection. Patients can have fevers or systemic symptoms where they start to feel sick, nauseated, lightheaded, those kinds of things. That could be a sign that they are becoming septic from this. Those are the things that are . . .

Dr. Miller: What is septic?

Dr. Gililland: Sepsis is when the body system actually becomes infected, it gets into the bloodstream and you start to have multi-organ involvement from the infection.

Dr. Miller: Fever, chills, sweats, dizziness . . .

Dr. Gililland: Blood pressure issues . . .

Dr. Miller: . . . nausea. That's actually a very severe infection and of course should be treated quickly.

Dr. Gililland: Absolutely.

Dr. Miller: So what do you do if antibiotics alone are not going to fix this problem? You as an orthopedic surgeon intervene and what are the things that you do to cure that infection?

Dr. Gililland: Generally, this chronic situation where the patient has been well functioning but now has an infection, the likelihood is it's usually an infection that's probably been there for longer than we think. We treat those infections, it's a rather invasive process. Meaning, we need to go in, we need to take out all the metal because again the metal has the slime layer that's created by the bacteria that we can't just get rid of. We think we can scrub it, but reality is our data which show that we're not very good at that. So we go in, we take all the parts out.

Dr. Miller: So this is a real big deal and somebody who has had a hip replacement, now their prosthetic is removed and they're going to need a new one at some point.

Dr. Gililland: Absolutely. In our minds most of the time it involves the two-stage process. Meaning, we take out all the parts, we put in a temporary joint replacement usually made out of cement with antibiotics impregnated in that cement that gives antibiotics to the bone, to the tissue. And after a period of IV antibiotics and a period of time off the antibiotics, if everything looks like it's been eradicated successfully, then we go back and try to rebuild the joint.

Dr. Miller: You talk about a period of time, how long is that actually?

Dr. Gililland: Usually three months minimum.

Dr. Miller: The other thing that comes to mind is now that the prosthetic joint is out, how does the patient get around? What do they do?

Dr. Gililland: That all depends on what we put back in. Usually we can put back in something that functions. Meaning, they have structured limb and they can still use the limb, but most of the time we don't let them put much weight on the limb, so they're using a walker or crutches to get around and trying to keep the weight off of it because again we are putting in a temporary part that's really not designed to be structurally sound for a long period of time.

Dr. Miller: So they're also on long-term antibiotics during this time, is that correct? Once you take the hardware out.

Dr. Gililland: Absolutely. They're usually on a period of six weeks of antibiotics IV and then after that if everything looks like it's getting better and their labs are normalizing, then we'll stop that, we'll give them what we call an antibiotic holiday to see if their labs remain low and make sure the infection does not recur once they're off of their antibiotics.

Dr. Miller: Once you complete this treatment and get to the point where you're going to put a new joint in, how successful are you in terms of really knocking out that infection, making sure it doesn't come back?

Dr. Gililland: That's a tough question to answer. I think everybody thinks we're better at than we really are. If you look at the literature, it's probably somewhere in the realm of about 75% success with that type of a two-stage process. But I think it really has to do with the patient and the patient's medical comorbidities and it has to do with the bug and how receptive that bug is to the antibiotics, what kind of bug it is, how virulent it is and then how many times they have attempts at prior surgeries.

We sometimes have patients that come in that have had four or five other attempts at surgery and at that period of time, he got an infection that's been really dwelling in there for many upwards of several years and it's very, very difficult for us in those cases to get rid of it. And I would say sometimes during the realm of about 50-50.

Dr. Miller: Obviously, this is a very big deal for somebody who has had a prosthetic joint put in. What tips would you give to patients or what advice would you give patients to prevent infection if that's possible?

Dr. Gililland: Absolutely. I think that's the ultimate crux to this is how do we prevent the problem from happening in the beginning. There are several things that we know put patients at risk for infection. Uncontrolled diabetes is a big risk. Being a smoker is a big risk. Morbid obesity with body mass index is probably somewhere above 40 puts you at risk. Other risk factors for infection such as rheumatoid arthritis or being on immunosuppressive drugs can put you at risk.

All these things need to be evaluated by your surgeon preoperatively before you have the initial joint replacement and that's something that we do very vigilantly here at the university. We make sure that we try to mitigate any risk factors that we can preoperatively to avoid infection in the beginning.

Dr. Miller: What about little cuts and nicks on the skin? Does that bother you?

Dr. Gililland: No, I don't think. I mean, if you have a little cut and nick on the skin, as long as it's healing well and it doesn't show any evidence of infection, I don't think you have to be extra vigilant about everything in life. I mean, I think most people have a well-functioning joint and get along very, very well and we're talking about a small percentage of people here. But I think it just takes a reasonable approach.

Dr. Miller: So bottom line is if you have a hip or a knee that's been replaced, and you have pain, you should have that checked out by your orthopedic surgeon or another competent provider that can actually look to make sure that you don't have an infection as a cause of that pain. And if you have infection, that needs to be treated aggressively.

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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.

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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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Interviewer: You found out you have tendonitis. Probably wondering what treatments are available, what do you need to know about them and what to expect afterwards. We're going to talk about that next, on The Scope.

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Interviewer: Dr. David Petron is an orthopedic sports medicine specialist at University of Utah Health Care and is also the chief medical officer for the Utah Jazz basketball team. So he knows what he's doing and today we're going to talk about tendonitis.

Dr. Petron: Well first let me say what tendonitis is. There can be confusion about it. Tendon is muscle connected to bone. So at the end of the muscle, that's where the tendon is and then the tendon ultimately attaches to the bone. -Itis infers that it's an inflammation problem, when in fact most tendonitis is really what we call tendonosis because it ends up being a chronic problem. Usually in the first few weeks or maybe the first month we might call it tendonitis. After that it really is not an inflammatory problem, but it's more of a tissue break down problem and then we call it tendonosis.

Interviewer: And that's something that's not going to go away without some sort of intervention. Is that correct?

Dr. Petron: Frequently that's the case and generally the older the patient is, the longer it can take to go away. But even sometimes with prolonged rest, as soon as somebody goes back to doing their usual activity, the tendonosis problem comes back again.

Interviewer: So something's going to have to happen, what are the options? Typically are there a lot?

Dr. Petron: There a lot of options. The one thing that all these options have in common is they do something to disturb the tissue. So it gets in a chronic pattern where it won't heal itself and we need to do something to disturb that tendon to try to get the body to feel like it's an acute injury so that it can ultimately heal itself.

• Rest and ice

  Early on the treatments are conservative, later on they can become more interventional. Some of the early treatments of course are just rest and ice, and relative rest. So say it's a swimming problem and a shoulder problem, you might be able to stay in aerobic shape by running or riding a bike, working on some shoulder exercises while you ease your way back into the pool. So that can be some of the most simple treatment, just relative rest and then gradual return to activity.

• Anti-inflammatories

  Frequently people take anti-inflammatories and they're helpful for the pain, but they're not really helpful for healing. In fact there are some studies that show that they may actually slow down healing. Cortisone is something that people frequently may run into at their doctor's office. And I think that's okay when you're in the -itis phase, so the inflammatory phase. But later on we actually know that cortisone can slow down healing and cortisone in a tendon can actually weaken the tendon, so we've got to be careful about that.

Some of the more advanced treatments I'll just talk about briefly.

• Focused aspiration of scar tissue (FAST)

  There's something called FAST or focused aspiration of scar tissue. This is a newer treatment where you use a percutaneous needle that vibrates about 2000 times a second and then it has irrigation that goes in and fluid that sucks out the necrotic tissue. So it's a way of removing the scar tissue just kind of through a poke hole through the skin's surface.

• Platelet rich plasma (PRP)

  Some of you may have heard of PRP or platelet rich plasma. That's where we draw your own blood off, spin it down, remove the platelets, which have some healing properties, and then re-inject that back into the tendon. Again to disturb the tissue and try to give it a jump start to ultimately heal itself. Even some use of stem cells now using in a similar way as PRP.

• Astym

  Sometimes physical therapists will do something called Astym where they're using—I call it a butter knife—but it's basically some tools that they're rubbing, kind of like a deep tissue massage. Again to try to disturb that tendon to try to get it to turn over and heal itself.

• Extracorporeal shock wave therapy

And then one other thing that we do is called extracorporeal shock wave therapy, which is kind of like a de-tuned lithotripsy. Same kind of technology used to break up a kidney stone. But you do that on the skin surface, again to disturb the tissue, break up the degenerative tissue along the tendon to get that to heal. So there are a few of the more advanced treatments that are being used now for tendons to heal.

Interviewer: My head's spinning. There's so many of them.

Dr. Petron: There's a lot out there, and like most things when there's a lot of different ways to approach it, not one way is perfect. So the physician needs to evaluate the patient and see what might be best for their situation.

Interviewer: Yeah that really sounds like you do need an expert. I mean you can do a little reading on the internet, but it sounds like an expert really needs to decide what is going to be best for your situation.

Dr. Petron: Right, in the early phases though relative rest and gradual return to activity in a lot of patients do well. But once you've had this for three months or six months or longer, probably ought to see a physician.

Interviewer: So getting in early is always the better option.

Dr. Petron: Right, if you start to feel some breakdown say in an Achilles tendon or a rotator cuff in your shoulder, stop. Because once you get into that tendonosis phase, it can be very difficult to get better.

Interviewer: What are some common questions people have about these treatments?

Dr. Petron: One of the common things is when one of these treatments is done, is it going to instantly be better? And the answer to that is no. So some of that might be lowering the expectation. Because again, really the body still has to heal itself. So even with these treatments, it can usually be three months or so until they're healed.

Interviewer: So in three months, back to 100%? I mean is that fair?

Dr. Petron: Usually at least back to activity, their usual activity.

Interviewer: And then how do you prevent—

Dr. Petron: But there are some areas that really have a lousy blood supply, like the Achilles tendon. Once that's really inflamed, that can be even longer than that to return to play.

Interviewer: So I get the treatment, I'm back to activity. How do I prevent this from now happening again and being a vicious circle?

Dr. Petron: Well the most important thing is start out slowly. All of these problems are not traumatic injuries, they're overuse injuries. So it's doing too much too quickly. So in general, the older the athlete, the slower you ought to ease into your particular sport.

Interviewer: And then eventually your body is going to be able to handle anything you throw at it?

Dr. Petron: The body adapts to the stresses put upon it. So just like a weight lifter gradually lifting more and more weight, muscles get bigger, tendons get stronger. That can happen to every part of your body. Bones get stronger, tendons get stronger, ligaments get stronger as you put stress on it. But the key is you need to do that in a controlled manner.

Interviewer: Let's wrap this up with the final thought. What do you think the big takeaway is?

Dr. Petron: Prevention is always key, so if you start to get feeling of tendon pain then back off on that activity. Relative rest, which means you can still stay active but don't overuse that tendon. If you do overuse it and you have the symptoms for say three months or longer, probably should seek the care of a physician.

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updated: February 12, 2019
originally published: April 8, 2015

Interviewer: What should you expect after your total joint replacement, whether you had a knee or hip replaced? The surgery is done and now we're going to talk about the recovery process. We'll also discuss some other things you need to know after your surgery.

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Interviewer: We're with Dr. Chris Pelt. He's a joint replacement expert at University of Utah Health Care in the orthopedic center. So let's talk about after the surgery. I'm out of the operating room, how long am I going to be in the hospital now before I get to go home.

Dr. Pelt: One of the things we'll start with is how long is the surgery. Its two hours or so. You're going to be gone from your family member for about three to four hours total. Then you're going to be going to the inpatient floor. On average most of our patients will be in the hospital for one to two days. The average length of stay is about two days. Some patients are able to go home the day of or the day after surgery. And it's rare that patients need to stay longer than two days. So, expect an average length of stay about two days. And most patients afterwards will be able to go home.

What we want to inform patients about is what is it going to be like while I'm in the hospital? What am I going to be doing? For the most part, what we're trying to do is make sure your pain is well controlled, that you're able to get up and walk around. You'll be able to do that on your own, transfer in and out of your hospital bed. In fact, we're going to get you up and walking on your joint the day of the surgery. You're going to able to put as much weight as you feel comfortable putting on it. You'll have a therapist working with you. They're going to guide you through the processes to make this safe for you and prevent you from having a fall or something else.

But you'll be able to do all these things primarily under your own power. You're not going to have somebody that's going to be lifting you. So our goals are to make sure your pain's well controlled, that your medically stable, that your blood pressure, your pulse, your breathing is all well controlled. And that you're able to sort of do the things you're going to need to be able to do when you leave the hospital on your own. Eat, drink, go to the bathroom, all the routine things we need to do in life.

Interviewer: So, when somebody leaves the hospital, then what are they going to expect when they're at home? You got a lot of support at the hospital. Will you still continue to have that at home?

Dr. Pelt: We find that the best outcomes are when our patients are able to return home. There are very few patients that will require a need to stay in the rehabilitative center, a skilled nursing center for example. When we have our patients able to go home, they're able to have access to resources still.

We're going to send a home-health care company, potentially, to your home if you need that. That will have a physical therapist that will visit you in your own home. Some patients may be able to visit an outpatient physical therapy center with their family driving them, perhaps in the first few days where they're going to receive physical therapy.

Early on, once you're out of the hospital you're going to be able to still get physical therapy. They're going to be working on strengthening gently without major resistance and not lifting weights on the day that you leave the hospital. But just starting to use gravity, using the weight of your leg to get a little bit of strengthening of the muscles and getting those moving again. And a little bit on gentle range of motion, especially in the knee. We're working and making sure that our knee gets all the way out straight, and that we start gently working on flexion.

We're not going to ask you to leave the hospital and jump on an exercise bike all on the same day. We're going to ask you to take it slowly, but we're sort of working on gentle strengthening, gentle range of motion, and walking and moving around the house and doing the activities of daily living. And then it's going to be a slow progression after that.

Interviewer: And the joint itself is strong, the process of what you're doing at this point is re-strengthening the muscles?

Dr. Pelt: That's right.

Interviewer: Am I correct on that?

Dr. Pelt: In hip replacement it takes about six to eight weeks for our body to incorporate the implant. Our body grows bone into the implant. That's how it's going to be stable for the rest of our lives. So, we don't want to do too much too early. But the activities of daily living and average weight bearing activities are not going to impact that at all we've found.

Similarly with the knee, most knee replacements may have some bone cement. Some of them may also have some bone ingrowth as well. Activities of daily living are not going to impede the bone healing process. So, you're able to do things gently, but maybe not running a marathon in the first six or eight weeks.

Interviewer: Sure. Put that off for a couple of years afterwards. Maybe not even that long.

Dr. Pelt: Yeah, maybe not. Most patients may be able to get back to many activities that they want to do within three to four months of the joint replacement actually.

Interviewer: After I get home, how long do you require that I have a family member there?

Dr. Pelt: We really think it's important again, we've mentioned this before, that family is really important to this. Bringing family, friends, somebody that cares about you that will be able to potentially be around again. This is not a person that's going to need to pick you up and physically move you around your home. You're going to be able to do all those things yourself. You're going to be able to get yourself to and from the bathroom, to and from the kitchen if you need to.

But what we'd like to have is somebody that's going to be around that can do some light housework, help prepare some meals, and take some of that burden of being at home off of yourself. They may not even need to be present 24 hours a day. Somebody that can check in on you throughout the day might be just adequate enough. But for at least three days it's really great to have somebody around, and many patients will feel comfortable having someone that can take about a week or so and spend time with them.

Interviewer: Yeah, even if its for mental or emotional support I suppose, that's important as well.

Dr. Pelt: Absolutely, absolutely.

Interviewer: So when does the physical therapy start? You mentioned after the surgery you're going to do some body weight type stuff. Just getting up, standing down helps start that process. When does the physical therapy kick in?

Dr. Pelt: Yeah, so you're going to start physical therapy the day of your surgery. You're going to have a physical therapist getting you up and helping you walk around and start moving. They're going to start showing you exercises that you're going to be performing. When you're in the hospital, the same exercises are going to be the ones you're going to do when you get back home. Therapy's going to continue. Again, it's going to start slowly, but you're going to continue to increase that with the activities that you're doing over the course of the next six weeks or so.

In the first couple of weeks, like I said, we may have some patients that will need some resources to have therapy come to their house. Others will be able to go to outpatient physical therapy. Ultimately most patients will transition at some point to the outpatient physical therapy setting where we have more resources. There's more exercise equipment and gym stuff that's available to them. More resources for them to have an optimal outcome.

Interviewer: How crucial are those stretches and those exercises to the recovery process? If you have two equal patients and one is really good about it and the other one is kind of okay, does it make a huge difference?

Dr. Pelt: It makes a huge difference. Therapy is vital to the outcome. We know that the patients that do the best are those that have had a physical therapy program and rehabilitative things. Patients that suffer the most are those that don't move it. They lay around. They aren't getting up and active, and they have more pain, they have less motion. Their outcome suffers as a result.

At the same time, we mentioned, we don't want to over do it. Doesn't mean I want you to run out of the hospital and start doing Arnold Schwarzenegger lifts and things. We're not talking about that. We're wanting you to just sort of follow the guidelines and your experts with their therapy department and your surgical team will lay out some exercises that are approved with the therapists that we work with. So that we're undergoing this in a very protocolized way to optimize your chances for a great outcome.

Interviewer: Some people are worried about taking pain medication, so what can they do to make sure they manage their pain effectively?

Dr. Pelt: Well first it's important for patients to know that these surgeries are painful. There invasive surgeries and pain is part of this. We're going to be working our very best to minimize pain. We may not be able to eliminate it, but we're going to try to make it as minimal as possible and hopefully allow it to be tolerable. It's going to improve each day after the surgery gets better.

And that's one of the most important things. The first day or two might be the toughest. And the first two weeks after a knee or hip replacement might be harder than the later four weeks for example. But, as you'll see as time progresses your body will be healing and your pain will be lessened.

After the first two maybe four weeks we're hoping most patients will are able to get off their narcotic pain medications, and moving toward Tylenol and anti-inflammatories. And eventually after the first 6, maybe 12 weeks, they might be able to get off of everything all together and really controlling it with other methods like, ice.

Elevation is incredibly important, especially in knee replacement. Getting the toes up so that blood is running out of the leg and really getting a lot of the swelling down is very important. It's one of the ways to help minimize pain without having to take any medications.

So, we're going to show you the things that we feel are important to help you decrease your pain. We're going to provide you with medications. And we're going to be there as a support for you as we help you taper off of those over the course of the next couple of weeks after your surgery. We're available to answer phone calls and really going to be there throughout the process with you, through this whole experience.

Interviewer: Some people probably don't mind the extra few days off work, but some people just really want to get back to their life. How long after the surgery can you kind of get back to work, walk, drive, those sorts of normal things?

Dr. Pelt: That's a great question. So, the average what we tell patients is that you'll be walking the day of the surgery, you're going to be around at two weeks, the skin is healing but still kind of swollen phase. At six weeks most patients are doing things they need to do in life. So that means most people are getting back to work. It might depend what on what kind of work you do to figure out if you're going to be able to go back then or maybe before.

Some patients with desk jobs that aren't going to have to be on their feet or lifting things all day long, might be able to get back to work in the two to four week range. People that are on their feet or carrying things more might be in the four to eight week range for when they can return to work. Really heavy laborers, people that are up on high ladders or climbing up and down things all the time, it might be a 6 to even 12 week range for those patients.

It's going to be different for different patients and it's also going to be different depending on what your job description and duties are. But those are the average time points. I tell most people they're able to do the things they need to do, including most job duties by about six weeks.

Driving fits into that time frame fairly similarly. Some of the research that's been done suggests that in the four to six weeks range it's probably safe to drive. It depends on a couple of factors. You cannot be on narcotic pain medications, because that's driving under the influence so we want to avoid that. So getting off the pain mediation is important to be able to drive. And it almost might depend on which side of the body, if you have a right sided knee replacement compared to a left sided. Most of us drive automatic transmission vehicles today, and it might take you a few extra weeks on the right side. You have to be safe driving.

And so, to think about that, imagine a little kid running out and front of you to grab their little tennis ball or something, and you need to be able to slam on the breaks and control your car with absolute certainty. We often recommend patients go a parking lot of the local church or grocery store where there's no other vehicles or people around, before they start going out on the road just to make sure they feel comfortable.

Interviewer: Yeah. You really got a learn how to drive, just like you have to learn how to do everything else.

Dr. Pelt: You do, you do.

Interviewer: How has this hip or knee replacement going to change my life?

Dr. Pelt: Going back to what are the goals of hip and knee replacement. We're trying to decrease pain and improve function. Hip replacement has outcomes that are 90-95% good to excellent results, meaning patients have significantly decreased pain and they're very satisfied with their outcomes.

Knee replacement, as we mentioned, is a slightly different surgery. About 90% of patients will have good to excellent results, have decreased pain. That means there might be a 10% or so group of patients that might still have some residual pain. Some of that, again, is setting expectations. Making sure patients realize that our goal is to decrease pain and improve function, but perhaps cannot make it a perfectly pain free joint. We hope it will be, but some patients may have residual symptoms. So it's important for them to realize that.

Ultimately we want to get them back to the things they enjoy doing, and the things they need to do in life. We think that on average, of about three months after joint replacement, most patients are getting back to some of the activities they enjoy doing. Golfers, are starting to chip and putt at this point.

People that like to ski might be thinking about groomer skiing again, on the easy greens may be to start, but you'll be able to do more and more perhaps as time progresses. Getting to and from the grocery store. Doing more of the things you wanted to do happen in that three month range. You're going to be healing for about a full year afterwards.

Whether its a hip or knee replacement, our body does take time for those soft tissues to get used to the implant, and for the trauma and the swelling in the things, to improve from this surgery. Also, to rehabilitate the muscles that may have been weak or deficient coming into the surgery, because of the pain and arthritis and the lack of function they had coming in as well.

So we're working on all of those things for even up to a year, and some patients maybe even takes a little bit longer than that. But there's going to be a healing process that will continue to go on throughout the course of that time frame. But ultimately we're looking to get people back to doing the things they need to and want to do in life.

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