Search for tag: "knee replacement"

Interviewer: Experiencing pain or swelling on the outside of your knee might not be a problem with the knee itself, but rather the IT band. And to better help us understand more about this tendon, how it can be injured, and how to ultimately treat it, we're joined by sports medicine specialist, Dr. Chris Gee.

Let's start with the basics. What is the IT band?

Dr. Gee: Yeah. So the iliotibial band is basically a big thick band of tissue that . . . Well, I shouldn't say thick. It's a wide band. It attaches on your ileum, which is your pelvis, so kind of the side of the upper part of your hip, goes down across the bony hip bone on the side, and travels all the way down and attaches on the side of your leg or your tibia. And it's got a little bit of muscle called the tensor fasciae latae that sits within it, and it basically kind of holds things into the side of your leg, is what it does.

Interviewer: And what causes IT band syndrome? When somebody says, "Oh, I've got IT band problems," what were they likely doing that led to that?

Dr. Gee: So IT band syndrome is generally an overuse kind of problem. What it does is, since it is over the side of the hip and over the side of the knee and it's kind of holding things in, every time you bend the knee or bend the hip, it has a potential to kind of catch on some bony prominences that are there.

So it's most common in the knee, and what'll happen is every time you flex your knee, the IT band kind of swings back and snaps over the side of the femur.

Now, you can imagine if you are running or doing some other activity that there's a lot of kind of knee bending over and over and over, that's going to start to potentially get that area inflamed and it'll cause some pain in that area.

There can be a little bursa that sits underneath it. The bursa is a little sack that has very little fluid in it, and it's there to decrease friction, but that'll sometimes get inflamed and it makes it painful to run and walk, and it starts to get very tight feeling on the side of the knee or the hip.

Interviewer: So it would be similar to if you had something rubbing on your skin constantly over and over and over again. Eventually, that would start to irritate your skin. Is that kind of what's going on, except for it's on the inside?

Dr. Gee: Exactly. It's kind of like if you're wearing a backpack and that backpack has a strap that's rubbing on your shoulder. And over time, you're going to try to adjust that backpack. But with the IT band, you can't. It's still there and every time you're moving, it just keeps on snapping and catching and causing that pain.

Interviewer: That sounds like a design flaw that it would rub like that when you're doing something like running or moving.

Dr. Gee: Yeah, it's sort of a structural stabilizer and we need it, obviously, to kind of maintain things. But, well, it can be very painful at times and be quite limiting, particularly to runners or people that are in running sports like soccer.

Interviewer: So is there a reason why some people might have IT band syndrome? Two people doing the exact same thing and some people might experience IT band syndrome and some people don't?

Dr. Gee: A lot of it depends on kind of structural differences. Some people tend to be a lot tighter in their joints and they'll have tighter muscles in general. And that little tensor fasciae latae that sits within that can be a little tighter in some people, and so it'll pull on that a little bit more and it'll cause it to potentially snap in that area.

So that's number one, is that you're just sort of set up for it by your musculature and your tension. But number two, sometimes the way people run or their activity, if they're maybe rotating their leg in a certain way and just causing that to be a little more tight. So if their leg almost bows out a little bit, it will kind of put more tension onto that IT band, and just cause it to kind of catch and snap a little bit.

Interviewer: So if somebody's experiencing knee pain and it's caused by the IT band issue, it sounds like perhaps some of the treatments might include some exercises to strengthen the glutes and other muscles or some . . . I don't even know. What would you call that, where you're teaching your body how to fire muscles in a different way? What's that called?

Dr. Gee: Yeah, we mostly just say strength or dynamic control, is kind of what the term I'll use with people. It's not about just firing that muscle. It's more about getting it to fire with others in concert so that as you're moving that joint, they're all firing together and supporting that joint a little better.

Interviewer: And there are exercises that can help teach the body that?

Dr. Gee: Yeah. So a lot of times we'll work on something called clamshells, if you've heard of that. Those can be really helpful. They basically strengthen the lateral glutes and hips.

Interviewer: What about stretches? Actually, before I say stretches, I want to talk about foam rolling.

Dr. Gee: Yes.

Interviewer: Because I've heard people that have IT band syndrome, they swear by foam rolling. Is that helpful or is that not helpful?

Dr. Gee: So I find it very helpful, both personally and with patients. So you want to try to stretch this area out. Like we talked about, the IT band is a little tight and it's snapping over the side of the knee on the hip and it's going to cause pain, but it's actually a very difficult thing to stretch.

Even if you look up different kinds of stretches and do them, it's hard to really get a good stretch in that area. It's not like when you stretch out your quad muscle, you do the little hurdle or stretch or whatever, and you can really feel it pull that muscle. Sometimes it's harder to feel much of a pull on the side of that IT band.

And so what foam rolling does is you basically use the weight of your body against a roll and you're kind of rolling it back and forth and it's helping to loosen that tissue and to break up some of the tension that's in the muscle there and allows that to calm down. And that can be significantly helpful for people.

Interviewer: So the band itself is stretching when you foam roll, and then you're also stretching that attachment muscle that you mentioned earlier. What was that called? The . . .

Dr. Gee: The TFL.

Interviewer: The TFL, yeah.

Dr. Gee: Tensor fasciae latae. Yeah.

Interviewer: Yeah. And you're kind of stretching that as well. Is that what that foam rolling is doing?

Dr. Gee: Yeah, you're kind of putting some tension on it so that it releases and relaxes. Foam rolling can be a little painful for sure as you start off doing it. And depending on how painful it is, you may have to adjust how much weight you're actually putting on it.

I see high-level athletes that put their whole body on it and they're putting a lot of force in it, and sometimes you have to adjust and, "Okay, I can't quite put all of my force onto the side of my leg because it's so painful." But as you build that up, it feels better and you're able to work through more and more of the foam rolling.

Interviewer: What about percussive therapy, like Theraguns or something like that? Is that a good thing to use on your IT band?

Dr. Gee: Those can be helpful as well. What you're basically trying to do is just to get the muscle, the tensor fasciae latae in there, to release a little bit. If it has too much tension, it's going to pull too hard on that tissue and make it tight. And so, effectively, you're trying to hit that or cause it to break so that the tension in that releases a little bit. That can be helpful in that area.

As you get further down towards sometimes where the IT band attaches on the knee or the side of the leg, there's not as much tissue there, and so those Theraguns are going to cause more pain in that area. So you probably can't use them that well there. But up higher on the side of the hip, you can definitely do it and that can be helpful there.

Interviewer: And then knee braces, are those something that you find success with as well?

Dr. Gee: For IT band, not quite as much. Sometimes if they're having more anterior knee pain, so the kneecap tracking is an issue, you can put a brace on. It almost looks like one of those that has a hole in the front, like a neoprene sleeve with a hole in the front. Those basically are designed to kind of hold the kneecap in place so that it doesn't slide around and cause pain. The IT band doesn't quite have a good brace for it.

But most of the time what I will tell people is working on those muscles, like we talked about, and sometimes even doing something like a running gait analysis can be helpful. What that is, is you basically put a patient on a treadmill and then you film them and then you slow down the video and you kind of watch, as they're running, what they're doing.

So I tell people nobody teaches us how to run, we just start doing it, and sometimes we do things that aren't really helpful for our bodies. It can cause some pain. So sometimes speeding up the way we run, meaning we take shorter steps, so we're taking fewer steps, can help. Sometimes the way our foot hits the ground is a problem, and so adjusting maybe the type of shoe you wear or the way you bring your foot down can help.

And so there are a lot of different things that we can find on that that sometimes we can help patients to work through. They're a runner or running sport and they're having a lot of IT band issues, we can kind of work through some therapy, work through a running gait analysis, and get them back to their activity, where they want to be.

Interviewer: And then are kind of the treatments that you would use for IT band therapy very similar to what somebody might want to do to prevent it from happening in the first place or to keep it from coming back?

Dr. Gee: Yeah. This can be very much a chronic issue, and so patients that have this, I kind of tell them, "Hey, this is something you're going to have to be really good about, even after you get it feeling better, maintaining that length on there. And so working on stretching, working on doing some IT band things."

And this was something I had mentioned before. I've personally struggled with this. I have to foam roll after I run. It's just to make it so that it doesn't hurt the next day and things like that. And when you do that, you can maintain that really well.

And so I tell people, "Yeah, having some good stretches that you do when you run can be helpful to prevent this from becoming a problem or help maintain it once you've kind of got it under control."

Interviewer: And I know when somebody comes in, everybody is different and everybody has a different level of injury. Generally, though, when somebody starts doing some stretches, some exercises, what kind of recovery time are you looking at where the pain starts to go away?

Dr. Gee: It's probably going to take a few weeks for a muscle injury to recover. If it's a bad muscle injury, it can be up to six weeks or so. And so I advise people when they come in and they have sort of a lower grade muscle injury, maybe they've kind of strained a muscle, I tell them, "Give it a couple of weeks of avoiding that activity."

So maybe if running was your thing, you're trying to avoid lower extremity stuff. Maybe you're getting in a pool or swimming or something like that so that you're not impacting that for a couple of weeks. Allowing that to calm down and then gradually working your way back into your activity is probably the best way to prevent that from lagging on and to allow it to recover.

Interviewer: And do you recommend any sort of ibuprofen or anything like that for the inflammation?

Dr. Gee: One thing I should probably point out, and maybe I should have pointed this out before, but whenever we are exercising, what effectively we're doing is we're putting a strain on the muscle or the tendon. And to clarify, the tendon is a piece of tissue that attaches the muscle to the bone. So it's kind of like a rope holding the muscle to the bone.

But we're stretching those tissues to the point that if you could see it, you're going to see these tiny little tears in the muscle or the tendon. And the point is that when you tear it like that, your body goes back and strengthens it, makes it stronger.

But if you're doing that repeatedly, sometimes that will cause it to . . . you'll get too many tears, too many of those little tiny tears in there, and that's where pain comes in.

And so, at that point, decreasing some of the inflammation with ibuprofen, with ice, some rest, just to allow the muscle to kind of calm down and let your body's healing processes catch up, will allow you to then feel better.

Now, when it's healed, generally it's stronger. And so now you're going to be able to go out and lift more, you're going to be able to work more, you're going to be able to do more, than you were before, and that's the point of getting stronger with exercise.

Interviewer: And when is it time to see a sports medicine doc or a physical therapist if you're experiencing knee pain that you suspect might be IT band?

Dr. Gee: First of all, if you ever get an effusion in your knee, meaning the knee is really swollen, that's usually a concern that something more is going on.

The other thing is if you have tried some of the things I've talked about, so you looked up some stretches, you did some icing and anti-inflammatory and it's still really bothering you, then definitely getting in and seeing us could be helpful.

Sometimes we have to try some different studies and other imaging, X-rays, or things like that to see if something else is going on, or even other treatments like injections sometimes to kind of calm down the inflammation because ice and anti-inflammatories just haven't been enough to get on top of it.

So IT band is something that can definitely affect a lot of different kinds of athletes, and it can be very limiting to the point that you can't run and you can't be active in the way you want to be.

But the good news about it is that it's something that can be treated with good stretching, anti-inflammatories, icing, and even sometimes some physical therapy to get on top of it.

Ideally, we want you to be able to work through it and we want you to be able to stay active. And so if you're having issues managing it, definitely getting in and seeing a provider and getting on top of this is the way to go. And we can get you to a point that you can work through this and enjoy your sport or your activity without pain.

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.

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'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: 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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