When is it appropriate to have a knee or hip replacement?

Transcript

Scott Webb (Host): Unless you were a fan of the $6 Million Man, and I was, most of us don’t want new knees and hips. And typically, though it’s a matter of need when our joints are bone on bone and our quality of life is suffering. And joining me today to discuss the latest technology and surgical advancements in joint replacement is Dr. Brian Burnikel. He’s an orthopedic surgeon with Prisma Health.

This is Flourish, a podcast brought to you by Prisma Health. I’m Scott Webb. So, doctor, thanks so much for your time today. As we get older, our knees start to bother us. Our hips start to bother us. And many of us wonder, maybe we’re a candidate for a hip or knee replacement, so great to have you on. And as we get rolling here, what are the signs of us needing a hip or knee replacement?

Dr. Brian Burnikel, MD (Guest): First of all, Scott, thanks for having me on. I’m, I’m delighted to be talking with you today about this topic. It’s a question in the mind of a lot of the patients that I see, but also the patients, you know, out in the community, they have a friend who says, you know, geez, my knee hurts, I had it replaced. I’ve done fantastic. So, when is the time to have your knee replaced? Is it, after you’ve been running 10 miles you have knee pain or is it pain when you, you know, get up from the couch and you walk to the refrigerator. So, I’ll go through some of the things that I discuss with my patients and give them, you know, the best information I can as to when to proceed with surgery.

Host: Yeah. Sounds good.

Dr. Burnikel: I think a couple of things. One is I think knee replacement, hip replacement, I think they’re a little different. One of the things that we first of all look at both for hip and knee replacements is on your x-rays are you to the point where you’re bone on bone. So, that means you’ve worn through that perfect, nice, smooth cartilage of our joints that allow them to move freely. So, once you’re at that point, then we look at a couple of things. One is what is your pain level? And it’s really pain with function that’s going to determine, okay, when is it time for me to replace the knee? And so the other part of that, as I mentioned is function. So, if you’re finding that this joint is stopping you from doing the things that you enjoy and that are important to you in your life, then it may be time to consider having that joint replaced.

Host: Yeah. And it does seem that it comes to that quality of life, right? For most of us, as you say, if your knee is bothering you after you’ve been out for a run, maybe that’s to be expected, especially if you’re of a certain age, but if your knee hurts walking the fridge, maybe that’s reason for concern, right?

Dr. Burnikel: That’s definitely true. The other thing that I think people experience, and I may not realize it particularly with their knees and not so much with the hip is, they may be losing some of their motion in their joint. And with knee replacement, we can restore some of that motion, but if the joint has gotten extremely stiff, it’s very difficult to get that back to the normal range of motion function.

So that’s one of the things I advise my patients with knee arthritis to also pay attention to. Sometimes when the joint starts to become arthritic, we just don’t move it as much because it may be painful. So, then what happens is the joint gets very stiff and that can actually impact the result after having a joint replacement and many times patients will ask, can I wait too long?

You know, can I put this off too long? And that’s probably the one scenario where that can be a problem. If they’ve lost a significant amount of their range of motion, meaning not being able to straighten the knee out and not being able to bend it very well, that can compromise the result after surgery.

Host: Yeah, and as you say, is it possible to wait too long? And in some respects, it sounds like it is possible. And is there an optimal age range, let’s say, where the outcomes are best to when we think about replacements?

Dr. Burnikel: Yeah, that’s a question I get a lot. One extreme is, am I too old to have this procedure done? And I tell my patients, you know, it’s really not as much about how old you are chronologically, but really what your physiologic age is. So for example, I may happen to have a 93 year old who was actually healthier than some of the 65 year olds that may be coming into me with arthritis.

So, it’s really more based on their health rather than their chronologic age. So, then the other extreme, you know, my youngest hip replacement patient is 13 years old. So, it’s really not based on how young they are or are they too young, but it’s, what is this problem doing to the lifestyle?

So, if I have a 13 year old, whose hip is so severely deteriorated, that they can’t walk from class to class without using crutches. You know, they have nighttime pain that awakens them. So it’s having a significant impact on their life. You know, even a 13 year old’s going to get a joint replacement. And it’s a matter of, you know, quality of life.

Host: It’s interesting you mentioned that. My daughter has a friend who’s 15 years old and she was a competitive gymnast, dancer, all that type of thing. And she just had to have a hip replacement, daughter is trying to get her mind around this. She’s like, I don’t just don’t understand. Well, I said, well, it’s family history, genetics, what she’s done to it, you know? And it just happens. Her hip just deteriorated and she can’t function without a new hip. So, even though it’s kind of, you know, a little strange for a 15 year old, as you say, anywhere from 13 on up, if you need it, you need it right?

Dr. Burnikel: Yeah. That’s exactly right. It’s unfortunate that, you know, there are young people that need to have this type of procedure, but it does allow them to get back to pain-free activities. The concern with a young person is, you know, she may live to 95 years old, so that implant may have to last, you know, 75 to 80 years.

And is it capable of doing that? And in some cases it may, in some cases it may not, but again, it’s about quality of life and getting people back to do the things that they enjoy doing.

Host: Yeah, definitely. Along those lines, I wanted to ask you how long do these new joints last? Maybe it’s different for knees and hips, but generally is there a ballpark for, you know, will something like that will her hip last 75 years?

Dr. Burnikel: It’s possible, you know, the data that we currently are going by, so, the hip I’m currently using now has been around about 16 years and it has been extremely successful. It has about a 99% survivorship in 15 years. So that means, over that 15 years, we’ve only lost only about 1% of those implants have failed, but, if we’re going to track that over time, and that’s exactly what we have to do. We have to track them over time, but let’s say one implant suddenly starts to fail at year 19 and they all fail. We don’t know that for 19 years. Because current implants are so successful, we make little changes. We may not know for 15 or 20 years. Hey, was that a better implant change? Was that a good idea? Was it a bad idea? But in general, I tell patients about a 90% chance that their implant is going to be working for them in 20 years, regardless of their age.

And so I think that’s a good number for, for patients to fall back on. A lot of patients come in and they’ve all heard all this is going to last me for 10 years. Well, that’s really not true anymore. You know, certainly there are instances where the implant fails in 10 years, but a good number is 90% of those are still going to be going in 20 years.

That’s good

Host: to know. And that’s a comfort to know that they should ideally last at least 20 years, maybe longer. And I’m wondering, and it seems logical. There’s probably things that we can do when it comes to behavior, lifestyle, things that we can do to promote that, to help them last longer. Right?

Dr. Burnikel: Yeah. And there’s some things we can do to delay needing it as well. So, activity level. I think patients can be really quite active after their knee or hip replacement. Sometimes I mention to them, you know, it’s kind of like how you drive your car. If you’re a very aggressive driver and you’re, you know, you’re spinning your tires, you’re taking the corners fast. You’re going to wear your tires a little faster. Well, the same analogy probably applies to joint replacements. You know, if we really abuse and overuse it, we’re probably gonna wear our implant out a little bit sooner. So, what I encourage my patients is I don’t really want them to be marathon runners.

You know, if they’ve had a desire to run marathons. Now’s not the time to start doing that. So if they want to run some, they want to bike, they want to kayak. They want to hike. All those things are appropriate. If they want to play tennis, golf, pickleball, pickleball has been just an exploding sport in my area. But all those things are fine, but I just like to plant in their mind that, you know, the more they do this thing is going to have more activity on it. And it’s going to likely have more wear. When we, throughout a normal year, we move our hip or our knee between three and 5 million times. So, you multiply that by 20 years. That’s a lot of cycles through range of motion on that artificial material.

Host: I’m just trying to get my mind around that, three to 5 million. That’s a big number.

Dr. Burnikel: Yeah, absolutely. Which really shows how these implants, the design and the engineering that we’ve learned over time to make them so successful. They’re really amazing and they really have a tremendous impact on our patients’ lives.

Host: They really are. And if you think as much as we’re going to move and use these things, if they’ll last 20 years and maybe you live long enough to need another replacement, maybe that’s not such a bad thing. Right? Because just think about the technology 20 years from now, right?

Dr. Burnikel: Yeah. And the redo surgery, has had a lot of scientific interest. And I think we are much better at the redo surgery than we had been historically. So they can be redone and, and the result is usually not quite as good, but it usually still is very good functionally and the main thing we’re looking for is pain relief.

And that, that also is very good. You know, before patients require a joint replacement though, you know, I like my patients to have gone through the conservative treatment. So, the non-surgical treatments and a big one of those is weight loss, you know, if you’re 30, 50 pounds overweight. Think about carrying a 50 pound weight around every single step.

So of those three to 5 million steps that you do in a year, you’re carrying an extra 50 pound weight. And so weight loss, particularly for the knee, I think is very beneficial. And so a lot of my patients who have been able to lose a significant amount of weight, see that their joint pain has actually improved.

And so the other things that we try, you know, are the non-steroidal anti-inflammatory medicines, physical therapy, injections, and bracing. And I tell my patients, okay, if we’ve done these things, you’re bone on bone and you still are not at a level where you’re satisfied with your function and your ability to do the things you love to do, then that’s the time to do the joint replacement. And I don’t tell patients when it’s time to do the joint replacement. My job is to inform them and educate them. And they tell me when it’s time to do the replacement. And usually it’s a pretty easy decision. If they’re kind of hemming and hawing, like, I’m not really sure if I need to do this, then you’re probably not ready to do it yet. There are certainly complications that can happen. It’s important for patients to know what those are because that’s part of the decision process. Okay. I’ve got maybe a half percent chance I’m going to get a blood clot. I got a two tenths of a percent chance I’m getting an infection. Those are important things to include in that decision process.

Host: Yeah. And it sounds like you do everything you can to help educate patients to, you know, as you say, when they know when it, when they’re ready, they’re ready. And you know, I think a lot of us have this idea that surgeons just love to perform surgery. They just can’t wait to, you know, cut people open. And it’s, just really not the case in talking to a lot of surgeons, you know, exploring those non-surgical options first, exhausting all of them. But if you’ve done all of that and you’re bone on bone and you feel like you’re ready, then that’s the time. Right?

Dr. Burnikel: That’s exactly right. And that’s why I’m so glad Scott, that you were doing this podcast. And again, thanks. Thanks for having me on. I probably spend more time talking patients out of a joint replacement, then kind of steering them towards having a joint replacement done. And a lot of that is because they just don’t know when it’s time to do it.

And our knee replacements work very well. But I tell my patients, you know, it’s not as good as our God given knee was. It’s going to be a lot better than your worn out knee but it’s not like our original and some patients still have some pain. It’s not a very high percentage. But a vast majority will come in and say, you know, it’s much better than my old one was. And I’m so happy that I had it done.

Host: Yeah, that seems to be the consensus. I told you before we got started, my mom had a knee replacement surgery and you know, the PT was tough right after the surgery. But once she got past that, no, she’s not out running marathons, but she wasn’t running marathons before the knee replacement, you know? And as you say, it is a knee replacement. It’s not your original knee, it’s never going to be as good as your original knee, but if you’re relatively pain-free and you’ve got that, you know, sort of independence back and quality of life back, then it was probably a good decision. So, doctor, I really appreciate your time today. This was really educational. Thanks so much. And you stay well.

Dr. Burnikel: Thank you much, Scott. Have a great day.

Host: For more information and other podcasts, just like this one, head on over to PrismaHealth.org. This has been Flourish. A podcast brought to you by Prisma Health. I’m Scott Webb. Stay well.