Explore Latest FACTS (and Fiction)

in Non-Operative and Operative Treatments of Hip, Knee and Back Arthritis

By Paula Deasy

ARTHRITIS IS THE LEADING CAUSE OF DISABILITY IN THE U.S; 42.7 MILLION AMERICANS HAVE ARTHRITIS AND MORE THAN A THIRD REPORT THAT ARTHRITIS PAIN LIMITS THEIR DAILY ACTIVITIES.  For many, anxiety or fear of the unknown prevents them from seeking help that could improve their quality of life. 

On Saturday, June 21, Dr. Anthony M. DiGioia, III, a leader in Patient and Family Centered Care and one of the pioneers of less invasive and computer assisted orthopaedic surgery, will chair an event for patients in the Bone and Joint Health Series entitled Let Your Journey to Wellness Begin!  Boomeritis: Help for those Aching Hips, Knees and Back. The Bone and Joint Health Series presents four events each year.  The upcoming program on June 21 will be held at the CCAC Boyce Campus and is open to the public and free of charge! 

"In this age of having massive amounts of information available at one's fingertips, patients and families can have a hard time sorting through it all," said Dr. DiGioia, a practicing orthopaedic surgeon at Renaissance Orthopaedics and founder of The Orthopaedic Program at Magee-Womens Hospital of UPMC.

"The program on June 21st is designed for patients and their families who have an interest in learning more about those aching hips, knees and back," DiGioia explained. "The goal is help people sort out fact from fiction and let them hear directly from the experts about the non-operative as well as the operative treatments. Our hope is that these events will improve communication and knowledge and reduce anxiety so that patients can make informed choices regarding treatment and maintenance of health."

A keynote presentation entitled "Patient and Family Centered Care: Reducing Anxiety and Providing Exceptional Care Experiences and Outcomes" will be given by Dr. DiGioia. He will be joined by orthopaedic and spine surgeons, a rheumatologist and a physical therapist to discuss the evaluation, diagnosis, treatments and exercise possibilities for those suffering from hip, knee and back pain. In addition there will be an "Ask the Doctor" panel discussion as part of the program.

Another resource for those seeking help for aching bones and joints is the blog at

www.amd3.org/ROblog. "The site was created on the advice of our Patient and Family Advisory Council and in response to all of the information about bone and joint health, " DiGioia continued. "We have a 'Fact & Fiction' column that can help patients obtain current and accurate information, and the blog site enables people to learn from patients' stories and to ask questions of patients and families living through similar experiences."

For more information or to register for the June 21st event, visit www. boneandjointhealth. org.

For questions, call 412-683-3260 or send an email to info@ boneandjointhealth. org. 

• 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! 

 (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.

• 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.

• The smaller incision and less muscle work may allow for faster rehab and recovery

• Usually less bleeding

• Shorter hospital stays
  

• Quicker recovery
  

• Smaller incisions also means that the bones are harder to visualize, which can result in placing the implants in a less than optimal position, and also increase the risk of fracture and nerve injury.

• Make sure you see a surgeon who is well trained in the less invasive techniques to ensure the best possible outcome.
  

• The potential adverse effects are the same as for the traditional hip or knee replacement.  These include, but are not limited to:

• Infection

• Bleeding
• Blood clots
  
• Pneumonia

• Nerve injury or blood vessel injury
  

• Fractures and stiffness

• Renaissance Orthopaedics and the Orthopaedic Program at Magee Hospital have a special approach to total joint replacement surgery to make this experience as pleasant and anxiety free as possible.  We call our approach: The Patient and Family Centered Care Approach (PFCC).

• Patients chose to have TOTAL JOINT REPLACEMENT SURGERY in order to regain a higher quality of life, but remember EVEN THE LESS INVASIVE TECHNIQUES are only one part of a much larger process.
• The Patient and Family Centered Care Approach is designed to make the process as easy and pain free as possible for patients and their families.
• We promote a positive experience and a successful outcome with our "Complete" approach!!

• The surface replacement theoretically removes less bone than a hip replacement, but only on the ball part of the joint

• The cup part (acetabulum) is the same as used for a total hip replacement

• May have a lower rate of dislocation compared to some types of total hip replacements secondary to the larger head, but the new total hip replacement systems also have the larger heads

• Revisions of the femoral component only (ball part) may be easier than the revisions of some types of hip replacements, but there are no differences on the cup side

• Metal on metal articulation, which may decrease wear, although the metal on metal articulation is now available in a total hip replacement

• Best candidates are patients under 50 years old with good bone stock and no cup deformations

• The contraindications to having a hip resurfacing:

• Severe bone loss and bone cysts

• Small or bone deficient hip socket
• Age greater than 65
• Obesity
• There are very few studies about the long-term efficacy and safety of hip resurfacing and the long-term outcomes of subsequent revision surgeries
• Problems include femoral neck fracture, which is related to the surgical technique and the type of patient. There is no risk of femoral neck fracture with a total hip replacement, which removes this bone.

As you may have seen on the news or in magazines, orthopaedic companies have started marketing a knee replacement made specifically for women.  They claim that it will fit women better, feel better, and improve knee mechanics.   The companies are basing this claim on the fact that women TYPICALLY have narrower knees from side to side, a thinner knee in the front, and a greater angle at which the knee cap tracks the best.  Implant companies have been marketing the "female specific" knee, which may address the above differences between men and women.   

SO WHAT IS FACT FROM FICTION?

THEORETICAL BENEFITS:

• The new implant is designed to "better" match the anatomic differences of females
• An implant that is not as wide
• Different angle to improve knee cap tracking
• Wider range of smaller sizes
• The companies believe that these slight changes in the implant will improve outcomes for women

• Implant companies are charging a lot more money for the implants even though the "new" design has only slight changes in the geometry
• There is no evidence that the female implant improves knee function, range of motion, or pain levels
• There are no long term studies which show improved overall outcomes, including better patient satisfaction
• There is no evidence that the subtle anatomic differences between men and women even warrant separate implants
• Every patient undergoing a knee replacement undergoes precise measurements to be fit for the prosthesis, so patients get a personalized knee, rather than one associated with gender
• There are many other factors that are likely more important than these very minor changes in the implant, such as surgical technique, pain management, rapid rehab protocols, and your involvement in the process,
• Studies have shown that patient and family centered care (the holistic approach to a joint replacement from start to finish) can improve overall outcomes, and for all implants