- What restrictions do
I have after total joint replacement?
- There are very few restrictions
for patients after surgery.
The only activity we do not recommend for patients is jogging for
exercise as it accelerates the wear on your new joint. Patients with hip replacements are
told not to cross the operative leg over the other leg at the knees as
this can put you in a position where you could potentially dislocate. You
can cross at the ankle and bend all the way down as long as the legs are
apart at the knees. You can resume all other activities based on your
comfort and confidence level.
- Do I need to take an
anticoagulant after surgery?
- All of Dr. DiGioia's
surgical patients are to have Lovenox injections for 2 weeks
postoperatively and then ASA (aspirin) for 2 weeks. Some patients have a
higher risk for blood clots and have to take the blood thinners for a
longer time.
- How soon after my
total joint replacement can I return to work?
- You may return to
work as soon as you feel comfortable. Following a normal TKR/THR a
patient should be out of work no longer than 4-8 weeks, but many patients
can return to work in as little as 3 weeks.
- Will I be able to go
to a rehab facility after surgery?
- 99% of our patients
are able to return home after surgery without any problems. You are full weight
bearing the night of your surgery and are able to climb stairs right away
as well. For 2-5 days
following discharge, a physical therapist will come to your home to work
with you, and you will attend outpatient therapy for 2 to 4 weeks at a
physical therapy location close to your home. On occasion, however, if there are medical or surgical
issues, patients will be sent to a skilled nursing facility, but we
always prefer for our patients to go home. For the most part insurance companies are no longer
covering stays in rehabilitation facilities after joint replacement.
- How
do I know when I am ready for surgery?
- When
you have endstage or "bone on bone" arthritis, injections are helping the
pain less than three months and your pain is affecting your quality of
life then you will be a surgical candidate. Until you reach this point Dr. DiGioia will continue
to advise conservative treatment.
- Why
have I been asked to lose weight prior to my surgery?
- Knee
and hip replacements wear out just like your regular knees and hips. For every pound of extra weight
that is six pounds of pressure on both your knees and hips! If you are 10 pounds overweight,
that is 60 pounds on your knees and hips! If you would wear out your new
knee or hip, it would require a revision or redo surgery which can have
more complications and higher risks. We know it is hard to lose weight
because of pain, but the role of the injections is to relieve pain and
allow you to be more active. Dr. DiGioia wants you to be in the best shape possible
before your surgery so that you can have the best results afterwards.
- What
is arthritis?
- Cartilage
acts as a cushion for the weight bearing surfaces of the joint. When arthritis sets in, the
cartilage between your joints begins to wear over time, and eventually the
bone wears down too.
This causes the inflammation and pain which prevents you from
maintaining your active lifestyle.
- What
is minimally invasive total joint replacement?
- This
surgery is not truly "minimally"
invasive, but, more accurately, "less" invasive. There is a smaller incision and less muscle work
involved, but the implants are still the same.
- What
medications do I stop prior to surgery?
- All
medications with ASA base (aspirin), blood thinners, NSAIDs (such as Aleve and ibuprofen), all arthritis medications (except for Celebrex) and
vitamin E. Please ask about
any herbal supplements you may be taking.
- Can
I take Tylenol?
- Yes.
- Can
I take Celebrex?
- Yes.
Unlike other arthritis
medications, you can take Celebrex right up to the day of your surgery.
We also use Celebrex as a pain medicine after surgery.
- How
long can I expect my total joint replacement to last?
- 75%
of people are still with their original implants in place and doing well
at 15 years. This is not to say that once it is year 15 that you will
start having problems. TJR can wear out just like your normal knee, and
the longer you have the joint replacement the greater the risk wear. Also, the modern implants are
modular systems so we can often catch wear early enough and replace ONLY
the part that is worn. This is why we recommend that you get new x-rays
every three years!
BACKGROUND INFORMATION:
In
the last decade, there has been increasing evidence that a significant number
of Pennsylvania physicians are choosing to practice in other states, are
retiring early, or are no longer performing high-risk procedures. This is especially true for
specialists, such as orthopaedic surgeons, obstetricians, gynecologists,
neurosurgeons, cardiologists and cardiothoracic surgeons. The reason for this decline in
Pennsylvania physicians is due to the surging malpractice insurance costs
coupled with low private insurer reimbursement. Not only are Pennsylvania physicians choosing to leave the
state, but graduating residents are choosing not to practice in this state at
all.
Data
from a study conducted by the U.S. Bureau of Health Professions and the
American Medical Association revealed that between 1985 and 2002 Pennsylvania
lost 143 orthopaedic surgeons, a reduction from 892 to 749, or 16%. Furthermore, the number of orthopaedic
surgeons per 100,000 population dropped from 7.42 in 1997 to 5.83 in 2002, the
lowest in the 18 years studied.
This decline in specialists paired with the increased demand as baby
boomers age, is putting patient access to medical care in jeopardy. In addition, the high turnover rate of
specialists is extremely disruptive to the care of patients, especially those
with chronic illnesses.
Physicians are not only leaving the state but those who stay are restricting their practice to lower risk procedures. For example, according to the American Association of Orthopaedic Surgeons, rising liability premiums have caused 55% of orthopaedic surgeons to avoid certain high-risk procedures, with 6% eliminating all surgery. Some physicians are choosing to not "take call" for hospital emergency room departments to minimize their risk of lawsuits. In extreme cases, emergency and trauma centers are even shutting down completely.
SO WHAT IS FACT FROM FICTION?
Doctors
are no longer performing complex or high-risk medical procedures due to medical
liability. The unrestrained
escalation of jury awards is driving up doctors' liability insurance premiums
and even forcing some insurance companies out of business. According to the Physicians Insurance
Association of America (PIAA) the median jury award doubled from $157,000 to
$300,000 from 1997 to 2003. This
in turn has caused insurers to stop selling medical liability insurance
altogether. The June 2003 GOA report found that in 2002 nearly 40% of
orthopaedic surgeons in Pennsylvania were not able to renew their coverage with
the same carrier and 31% did not find new coverage. In 1999 jury awards in Philadelphia alone exceeded the total
amount of jury awards for the entire state of California.
Doctors
are not only avoiding high-risk patients, but also even practicing defensive
medicine, which involves ordering a battery of tests to reduce their exposure
to malpractice liability.
Demand
spike is also promoting the increased MD shortage.
The baby boomer generation
is one of the main factors adding to this increased demand. Between 2001 and 2030, the demographics
of the baby boomer phenomena will quadruple, leaving the elderly with the greatest
shortages. It is predicted that
there will be a shortage of between 27-43% physicians by 2020, with the
shortage in orthopaedic surgery in the range of 40-50%.
WHAT ARE SOME SOLUTIONS TO THE MD SHORTAGE AND MEDICAL LIABILITY CRISIS?
We
need to minimize insurance premium increases and provide damage caps so that
physicians not only want to stay in this state, but so we can attract
physicians from other states. By
stopping the medical liability crisis, we will enable more physicians to be
here to handle the increasing demand that is inevitably going to come as the
baby boomer generation ages. In
order to provide appropriate and fair compensation to those who are truly
injured, but also protect physicians from excessive damage payouts, the
Pennsylvania Orthopaedic Society has developed several goals, including:
- Amending the Pennsylvania Constitution to adopt caps on
awards for non-economic damages of $250,000.
- Ensuring a stable liability insurance market and
reducing costs to high-risk specialty doctors, such as orthopaedic
surgeons.
- Lowering mandatory malpractice insurance
coverage levels to $250,000 per occurrence and $750,000 per annual
aggregate.
- Establishing a no fault medical liability
proposal, which would limit lawsuits to those cases involving death,
serious impairment of bodily function, or permanent disfigurement.
- Permanent MCARE abatement, the state run
insurance program, which provides catastrophic medical liability
insurance. By providing
high-risk specialists like orthopaedic surgeons with 100% abatement
through a cigarette tax to pay the doctors' premiums, orthopaedic surgeons
have saved $109,000 in the past few years.
Both physicians and patients need to work together to change state policies concerning medical liability. If we do not change liability policies soon, we will face a future with limited access to healthcare. Once the physician shortage occurs, there could be pressure to decrease demand by increasing co-pays, denying care to certain groups, physicians not accepting new patients and increasing the use of physician assistants and nurse practitioners. Patients would be forced to wait longer to see doctors, have shorter physician visits and possibly be denied care altogether. Patients might even have to travel out of state to seek specialty care. This would then force patients to use the already overcrowded emergency rooms for routine primary care.
For more information, please visit the American Academy of Orthopaedic Surgeons (AAOS) www.aaos.org or the Pennsylvania Orthopaedic Society www.pasociety.org.
Patients can get involved by contacting the Patients And Physicians Alliance (PAPA) at 215-271-9590.
For anyone who isn't familiar with this program, Dr. DiGioia
runs a terrific educational series called the Bone and Joint Health Series. It
is FREE and open to the public. You can even download the handouts
that were used at past programs. The last Bone and Joint Health Series
event was held on March 1st and was entitled YOUR JOURNEY TO WELLNESS,
Hip and Knee Arthritis and Joint Replacement Surgery: Fact and Fiction.
To
get more information and to see past handouts visit http://amd3.org/patients/bjhs.htm.
The following is a patient's own account of her activity level since having two total knee replacement surgeries.
When friends ask me how I am doing since my total knee replacements, I proudly tell them about the 14 hour flight for my long-delayed dream trip to China where I climbed The Great Wall, or about my new bicycle and the joy of riding again, or how I am able to walk the long platforms at train stations up and down the East coast.
Before my second knee replacement only a year before going to China, and my first knee replacement five months before that, I couldn't even walk across the street and up a hilly driveway to visit my elderly neighbor. But one recent morning I had an epiphany! After finishing breakfast and climbing up the stairs to my bedroom on the second floor, I suddenly realized I had left some important mail from the previous night on the kitchen counter. Without thinking, I whirled around, trekked back down the stairs and got the mail. When I got up the second time, my eyes filled with tears of gratitude. I realized the true miracle of my knee replacements was in what physical therapists call ADL-- "activities of daily living."
After not being able to cook a simple lunch without sitting on a stool, I was once again able to stand all day preparing our family's favorite dishes for Thanksgiving and Christmas dinners. When I wanted a particular ingredient that was available at only one store, I parked in the only spot I could find, in the last row of the parking lot, and trudged into the big store and walked to the last shelf in the last row of the store to get the item I needed. In addition, not only have I resumed going to the basement to do laundry, I do several loads in the same day. I can even run the vacuum cleaner without having any pain. I never imagined that I would be so excited about vacuuming!
Ironically, the artificial joints that Dr. DiGioia put in my knees have made me feel like my real self again!
I love being able to ride my bicycle once again.
I was able to climb The Great Wall of China because I had knee replacement surgery.
****Following up for routine x-rays
prevents future problems!**** RECOMMENDED ROUTINE OFFICE VISITS: Year 1 ü 1
month ü 12 months After 1 year ü Every 3
years
o Year 4 o Year 7 o Year 10 After 10 years ü Every 2 years o Year 12 o Year 14 o Year 16 o And so on.... When you need to follow-up sooner: After Hip replacement: v Persistent groin or thigh pain v Feelings of looseness After Knee replacement: v Persistent knee pain or swelling v Grating sensation v Increase in clicking (occasional
clicking without pain is normal!!) ***Never
hesitate to call with any questions or concerns!
|
|
How Do I Get the Most Out of My Total Joint Replacement?
Total joint replacements can "wear out" just like a normal hip or knee. For this reason, we stress the importance of doing low impact activities. All of the recommended activities listed are low impact, and the activities that are not recommended are high impact. There are some activities that should be performed only with experience to decrease your risk of a fall or other injury. High impact activities over time could prematurely wear out your total joint replacement.
For these reasons, we encourage patients to focus on low impact activities when exercising.
We know that the goal of a total joint replacement is to get patients back to an active and pain-free lifestyle, which is why we encourage exercise and aerobic activity to make your new knee or hip feel good, but also to promote overall health.
If
you have any questions about specific activities, feel free to call the
office.
Addressing your questions and concerns
"I had my left hip replaced a month ago and everything is going well except that I feel off-balance, like my left is now longer than my right."
"My Physical Therapist told me that the leg that was operated on is longer than the other. What am I supposed to do about that?"
"Now that my right hip has been replaced, I use a lift in the heel of my left shoe to balance out my legs. My doctor prescribed the lift for me to make me more comfortable."
A common concern that patients have after total hip replacement surgery is a feeling that their legs are different lengths. This is called limb length discrepancy (LLD). The following information will explain the different types of LLD, possible explanations for its occurrence, and treatment options for patients who are uncomfortable with a LLD.
The Different Types of LLD
Apparent LLD: Some people have an "apparent" LLD which may make the affected leg seem longer than the other leg. There are several factors that can contribute to this feeling. Most commonly, contractures or shortening of the muscles surrounding the hip joint and pelvis make the involved leg feel longer even when they are really the same length. Also, contractures of the muscles around the lower back from spinal disorders (i.e. arthritis, spinal stenosis), curvatures of the spine from scoliosis, and deformities of the knee or ankle joint can make one leg seem longer or shorter. In the general public, some people have an "apparent LLD" as long as one half inch but usually don't notice it because the LLD occurs over time.
True LLD: A "true" LLD is where one leg is actually longer than the other. Patients can have unequal leg lengths of ¼ inch to ½ inch and never feel it too!
Combined LLD:
You can also have combinations of "true" and "apparent" LLD's.
Adjusting Leg Lengths in Surgery
During total hip replacement surgery, the surgeon may "lengthen" the involved leg by stretching the muscles and ligaments that were contracted, as well as by restoring the joint space that had become narrowed from the arthritis. This is usually a necessary part of the surgery because it also provides stability to the new hip joint. Your surgeon takes measurements of your leg lengths on x-ray prior to surgery. Your surgeon always aims for equal leg lengths if at all possible and measures the length of your legs before and during surgery in order to achieve this goal. Occasionally, surgeons may need to lengthen the operable leg to help improve stability and prevent dislocations as well improve the muscle function around the hip.
Right after your surgery it may feel like the leg that has been operated on is longer. One reason is that as opposed to the months to years that it took for your leg to shorten and muscles to become contracted, your surgeon has "lengthened" them in a very short period of time. It may take time, but your muscles usually readjust to their new position. Usually, it takes between 8 to 12 weeks for you to feel re-balanced.
Important: You must also understand that leg lengths and the potential for dislocations after surgery go hand in hand. Ideally, surgeons always aim for equal leg lengths and a very stable hip. However, at times, because of findings during your surgery, the surgeon may elect to make the operative leg a bit longer in order to tighten up the joint and prevent a possible dislocation. Small differences in LLD are usually well tolerated by patients given time. However, it is most important to understand that it's better from your perspective to have a slightly longer leg if necessary to prevent dislocations rather than a hip that is at risk for dislocating.
Treatment Options for Feeling "Off-Balance" after Hip Surgery
Most of the time, patients never feel this difference and therefore no treatment is needed. As previously stated, it may take a few months for your muscles to readjust. In the early months after surgery, interventions like stretching and strengthening exercises may actually speed the natural course of re-balancing. Factors that will influence whether you continue to feel the difference include arthritis of the opposite hip, spinal muscle contractures, scoliosis, and deformities or stiffness of the ankle and knee joints.
When patients continue to notice symptoms of LLD, treatment usually consists of inserting a "lift" into the shoe of the shorter leg. In some patients, one or two of the simple over the counter Dr. Scholl's-type heel inserts can be enough. Occasionally, patients may need a thicker insert. The goal of treatment and size of the insert is always based on how you feel and we recommend that you use the standing blocks as the best way to measure what makes you feel you feel balanced, rather than tape measures or x-rays.
We hope this information has been useful to you. If you have questions about LLD after surgery, please don't hesitate to ask your surgeon or assistant.
(from The Journal of Bone & Joint Surgery, Volume 89-A, Number
12, December 2007)
·
The upward trends in the utilization of total hip and
knee replacement between 1969 and 2003 detail the national need for these
procedures.
·
The age and gender-adjusted incidence per 100,000
person-years significantly increased from 1971 to 2003, representing a greater than 400%
increase in the incidence of total knee replacement (as compared with a 55%
increase in total hip replacement during the same period).
·
There was a significantly higher utilization rate
for women.
·
The incidence increased with the patient's age for
total knee replacement, except in patients more than eighty years old.
·
The largest percentage increase was in patients less
than fifty years old.
·
There was a significant increase in the proportion of
total knee replacements performed for the treatment of osteoarthritis, from 51%
during 1971-1975 to 92% in 2000- 2003.
·
This also reflects a reduction in the incidence of
total knee replacements performed for the treatment of rheumatoid arthritis
over the same period.
·
It is projected that the number of primary total
knee replacements will increase from 450,400 to 3.48 million by 2030,
compared with a growth in the number of primary total hip replacements
from 208,600 to 572,100 during the same interval.
·
The volume of revision total hip replacements is
projected to grow from 40,800 in 2005 to 96,700 in 2030 (a 137% increase).
·
The volume of revision total knee replacements is
projected to grow from 38,300 in 2005 to 268, 200 in 2030 (a 600% increase).
·
The continued and rapid growth of utilization of total
knee replacement reflects a trend that will require additional resources in the
future.
·
This dramatically increased demand for replacement
procedures will require additional discussions regarding the distribution of
economic resources; the allocation of surgeons, facilities and resources; and improved
operative efficiency.
·
Additionally, given the growth in the number of
procedures in the younger, more active patients, implant longevity will require
further enhancement.
In the news over the past few months, the relationship between physicians and implant manufacturers has received much attention, due to the litigation between the companies and the government. You may have seen an article in the newspaper that listed certain implant companies and the dollar amount that physicians have received from these companies. These articles tend to be misleading and confusing to patients. For example, many times physicians are working directly with implant manufacturers to develop new implants, implement educational programs, and to conduct research leading to the development of new surgical techniques and technologies that may improve joint replacement surgery for patients. When physicians are working with the implant company, and receive some form of compensation, this is not an indication that the physicians have done anything wrong or violated any standards or professional codes. In fact, physicians are not rewarded for using a certain companies' implants nor are they obligated to use a certain implant. Any compensation received is for services and input that the physician provides to the company to improve the surgical process and the patient's overall outcome. Physicians are permitted to offer "consulting" services to implant companies to improve patient care. Many types of professionals are able to provide this same type of service, including those involved in engineering, law, or business, to name a few.
SO WHAT IS FACT FROM FICTION?
- The American Academy of Orthopaedic Surgeons supports the use of financial disclosures about the relationship between physicians and implant manufacturers, but would like the nature of the relationship to be disclosed as well so patients are not mislead as to why physicians may receive payment.
- The recent agreement between implant companies and the government does not have anything to do with how physicians interact with patients or patient care.
- Many different relationships exist between physicians and implant companies, including consultation, research, education, and developing new medical devices.
- These relationships have led to improvements in the prosthetic devices themselves, as well as improved the surgical techniques, allowing total joint replacements to last longer and improve the quality of life of millions of patients.
- The United States continues to be a leader in the development and improvement of orthopaedic procedure secondary the collaborating efforts of physicians and implant manufacturers.
- The surgical technique and the approach to care are at least as important, if not more important than the type of implants.
- Surgeons are happy to share with patients the type of implants used, and some patients even receive implants from two different companies.
- Most physicians are not obligated or rewarded to use a certain company, but rather the compensation received is due to some type of work performed for the company.
- If you are concerned about the type of relationship between your physician and an implant manufacturer, physicians will be more than happy to disclose this information to you.
