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Advances in Hip&Knee Surgery

Online Health Chat with Dr. Bernard Stulberg

June 27, 2011

Introduction

Osteoarthritis (OA) and rheumatoid arthritis (RA) both cause joint pain and limit movement. OA results from wear-and-tear of the cartilage cushioning the joints, typically after injury or with advancing age. RA is a less common form of arthritis and is an autoimmune disease.

When hip and knee pain interferes with everyday function, surgery may be recommended. Based on the amount of arthritis or wear on your joint, there are different surgical options available. Recent advances have allowed for better comfort, function, and alignment.

Bernard Stulberg, MD, is an orthopaedic surgeon specializing in hip and knee surgery and replacement. Dr. Stulberg graduated from University of Michigan Medical School and completed an orthopaedic residency and an orthopaedic research fellowship at Hospital for Special Surgery in New York City.

To make an appointment with Dr. Stulberg or any of the specialists in the Department of Orthopaedic Surgery at Cleveland Clinic, please call 866.275.7496. You can also visit us online at www.clevelandclinic.org/ortho.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Bernard Stulberg. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Knee Replacement

grenada: If you are knock-kneed, should you replace both knees at the same time for better alignment?

Dr__Bernard_Stulberg: Replacing both knees at the same time is more of a safety issue than a mechanical one. If both knees are contracted (stuck in a bent position), that would be a definite reason to consider double replacement. For some patients, however, doing both knees at the same time is not as safe as doing a single knee replacement procedure.

cran333: What is your opinion of ligament-sparing total knee replacement?

Dr__Bernard_Stulberg: Arthritis can result in damage to the knee ligaments. If they are spared, it is nice to try to use them. If not, it is better to use devices and designs that don't rely on them.

keep_on_it: Are there a variety of implant sizes to fit various knee sizes?

Dr__Bernard_Stulberg: Yes there are. However, statistically, there may always be 5 percent of patients whose geometry is not exactly matched to the size of the implant. There are techniques to address this surgically, so designing a custom part for that patient "outlier" isn't really necessary. (We tried that in the past. It doesn’t seem to make a difference clinically.)

picture_this: If you replace your knees, are you setting yourself up for problems with your hips?

Dr__Bernard_Stulberg: No. (That's the quick answer.) Hip arthritis and knee arthritis are often not related, but they can be found in the same patient. Statistically, knee arthritis is five times more common in women, whereas hip arthritis is about 50-50.

copy_cat: What type of infection can affect a knee replacement? How do you prevent it?

Dr__Bernard_Stulberg: Any bacteria (bug) can cause infection around an artificial device. It is to be avoided at all costs. That being said, it is impossible to avoid infection 100 percent; and the more complicated the surgery, the higher the risk. In the best of hands, infection should be a 3/1000 incidence for primary joint replacement, with the national quality standard set at less than 1 percent (10/1000). Ask your surgeon what steps he or she takes to minimize infection.

time_machine: Are foreign body reactions still a problem with joint replacements? Is it true you can never cross your knees again? My doctor specializes in knee replacements; for hips, is it important to choose accordingly?

Dr__Bernard_Stulberg: Allergy to implants is very rare. All implants are, in theory, "foreign bodies." Implants are very well-tolerated because the materials are non-allergenic alloys. When implants begin to deteriorate due to wear, the body will react to them, but it is due more to the wear process than to an allergy.

Some doctors see only knee patients, some only hip patients, and some both. Make certain your physician has sufficient experience and practice in doing the respective surgery so that you get the quality outcome you want.

id_kit: Can you do knee replacement surgery without anesthesia? I’ve heard of doctors who do the surgery with a spinal. My husband has Alzheimer’s disease, and he needs both knees replaced. However, they won’t do the surgery because of anesthesia and rehab. He is in pain every day!

Dr__Bernard_Stulberg: That is a very tough call. It can be done, but one knee at a time, with whatever anesthesia he is comfortable with. It does have significant risks associated with it.

wake_up: What can be done for a full knee replacement that stiffens during sitting and becomes painful?

Dr__Bernard_Stulberg: You need to be evaluated to answer that question.


Knee Replacement Options

NAD_1: What is the difference between a full and partial replacement?

Dr__Bernard_Stulberg: Partial replacement addresses only the part of the knee that is diseased, a common phenomenon of osteoarthritis of the knee, the most common form of arthritis. There are strict "indications" for the use of partial arthroplasty, which requires and preserves all ligaments. If those aren't functional, or if the arthritis is more widespread, a complete replacement is a better choice. Roughly 15 percent to 20 percent of patients with knee arthritis are estimated to be candidates for partial knee arthroplasty.

NAD_1: What are some noninvasive procedures for dealing with arthritic knees?

Dr__Bernard_Stulberg: EXERCISES, medications, injections, arthroscopy, and sometimes partial replacements can be used.

NAD_1: If the knee is bone-on-bone, can the noninvasive procedures be of benefit?

Dr__Bernard_Stulberg: No, but if it has few side effects and is non-surgical, it may be worth a try. Percentage-wise, they may not be that successful.

anita: My husband was diagnosed with primary knee osteoarthritis. He is 66 years old and very active. Is there a new surgical procedure that is less invasive being done at Cleveland Clinic? What do you recommend? How long is the recovery time? He is still working.

Dr__Bernard_Stulberg: It may be possible that he could manage with a partial knee replacement, which is less invasive. There are specific criteria that the surgeon will use to determine if that is appropriate. While we do them at Cleveland Clinic, my present arthroplasty fellow will be returning to Haddassah Hospital at the end of August and can evaluate you there if you wish. His name is Dr. Gurion Rivkin.

ChristinaB3: Is there a device currently being used or on the horizon either for partial or total knee replacement that allows for running (distance) post-surgery? It seems that after joint replacement the advice is ‘minimal activity.’

Dr__Bernard_Stulberg: The advice is not minimal activity. In fact, in many ways, the more active you are the better. IMPACT activities are the ones we worry about the most (things like running and jogging), and much of that is based on laboratory and theoretical issues of wear on the bearing surfaces. With the newer technologies, this may not be as true. Having said that, many patients do, indeed, do whatever they want, and many are very active (doubles tennis, singles tennis, jogging, etc.). However, there are a few restrictions for patients with modern devices with current materials.


Hip Replacement

ahmc: I am an active 59-year-old female with osteoarthritis and deterioration of cartilage in the hip. Do you recommend hip replacement or resurfacing? Is there an optimum age for surgery, or is it always when you can't tolerate the pain any longer?

Dr__Bernard_Stulberg: I recommend total hip replacement - no question. There is a lot of controversy about hip resurfacing, which is best reserved for the young, active male. Still, there are questions of longevity and metallurgy to worry about with resurfacing.

VI: What was the cause of the J&J hip recall? Was it just more of their quality problems in general?

Dr__Bernard_Stulberg: The J&J recall was specifically for one product - the ASR - which is a metal-to-metal hip implant. There are still many unanswered questions about this specific implant and the metal-on-metal hip replacement in general.

J&J has provided the orthopaedic world with many excellent products. Please don't confuse this product with their entire product line, which many surgeons have used for more than four decades - safely.

VI: How long after hip replacement surgery should you wait before bending less than 90 degrees at the hip. This case is a 72-year-old male with reasonable leg muscle tone?

Dr__Bernard_Stulberg: I don't want to interfere with your doctor's recommendations, as the implanting surgeon will know best what is important for each specific patient. With current devices, I have been much less restrictive, and I allow patients past 90 by the time they leave the hospital (although my nurses scold me about doing so).


Age

crs: What is the upper age limit for knee replacement?

Dr__Bernard_Stulberg: That depends on physiologic status of the patient. Occasionally, a patient in their late 80s or 90s is an acceptable risk. We like to consider partial replacements in some of these patients, if it is possible.

concerned1: I had the first meniscus repair on my right knee in 1967 and the second repair in 2008 on the same knee with no outcome other than surgeon (at the VA) telling me my knee was "screwed." Currently, I have bone-on-bone with pain that goes along with it. My knee is misshapen, locks up from time to time, and produces a loud POP when moved. I was told by the VA that I'm too young (64) for replacement, as I would probably need to have replacement surgery done again in later years, and I should wait as long as possible before considering the next step, whatever that might be. The VA does provide me with pain medicine and a hinged brace. What are the criteria for knee replacement, and is 64 years ‘too young’?

Dr__Bernard_Stulberg: Knee replacement can be done safely and effectively for patients in their 60s. The decision to proceed is a "quality of life" decision. ‘How much pain and how much functional loss do I wish to endure?’ If properly done, total knee arthroplasty (TKA) can be successful for up to 20 years or more. As with all surgery, there are risks and benefits, and your doctor can discuss those with you so that you can make an informed choice.

It may also be possible that a partial knee replacement can be used. You may wish to ask your doctor about that option as well.

DMurph: I'm 54 and was first advised to have a total hip replacement 10 years ago. Second and third opinions advised me to wait as long as possible, preferably until I'm 60. I've managed pain through various techniques, but it's increasingly difficult. Do you agree with waiting until 60 for a very active person? What is the estimated life for a hip replacement?

Dr__Bernard_Stulberg: Theoretically, the longevity of a hip implant is better if you are less active, and patients who are over 60 are likely to be less active. Current designs, techniques, and materials may make this a less significant issue. Surgeons have a wide variety of opinions (biases), and I have mine. It is a quality of life issue for many patients, and I think current technologies provide me the tools to predictably get 20-year results for patients, with reasonable fall-backs if they get into trouble. That is the discussion I have with my patients. It's their choice after that.

just_do_it: Why is 50 too young for knee replacement? I would think that being younger and healthier would make for better outcomes.

Dr__Bernard_Stulberg: Good point. Statistically, the outcome should be better, but the data suggest that young males often do worse. The other side of the coin is that the under 50-year-old may very well do better and then will use that device more vigorously, risking it wearing out or otherwise getting into trouble. For selective patients under age 50, a total knee arthroplasty is a quality of life restoring operation. We don't deny those patients if they understand the issues.

gotta: Could an 89-year-old get a hemicap for her knees?

Dr__Bernard_Stulberg: Maybe, but it is experimental in my book. It is better to do a unicompartmental replacement.

call_me: What is the upper age limit for “joint resurfacing?”

Dr__Bernard_Stulberg: I reserve joint resurfacing for male patients under age 50, but the published numbers are women under age 55 and men under age 60. There are resurfacing enthusiasts who may push those numbers for some patients.


Hardware

VI: What are the best hip replacement materials for a very active 72-year-old male with only one kidney?

Dr__Bernard_Stulberg: Titanium implants for fixation (acetabular shell and femoral stem), highly cross-linked polyethylene (called UHMWPE), and highly polished metal head (or perhaps ceramic head - the "ball") would be most appropriate.

VI: Do you know if any hip replacement suppliers are using Chinese titanium, which has been shown to be highly suspect in other applications.

Dr__Bernard_Stulberg: I sure hope not. I have operated and taught in China, and they are behind us on the curve of design and implantation. Many US and European manufacturers are currently selling in China. However, if the devices pass the FDA regulations, they are probably OK.

DMurph: Earlier you provided specifications for hip replacement materials for an active 72-year-old with one kidney. Does that advice apply to all ages; specifically, in my case, a very active 54-year-old without other major health issues?

Dr__Bernard_Stulberg: If you want to consider new bearing materials in the age 50ish population, then most orthopaedists doing total hip arthroplasty or resurfacing will offer you those options. This is a very controversial area of total hip arthroplasty right now, as the metal-on-metal bearings are taking a hit (although many of us have patients who are doing very well with them). For the younger patients, the risk versus benefits side of the discussion is a little different. There is no doubt, however, that the safest bearing surfaces to go with in 2011 are either metal or ceramic on polyethylene, with ceramic on ceramic next.

NAD_1: Is there a knee replacement that uses ceramic and is good for 30 years?

Dr__Bernard_Stulberg: I dislike the ad about the 30-year knee. Any device properly implanted, properly used, and properly designed has the potential to go 30 years.

rugger: Will excessive exercise wear out artificial knees quicker (ceramic replacements)? I was told my knees will last approximately 10 years. I’m into my fifth and sixth year already.

Dr__Bernard_Stulberg: Chances are pretty good you will get to 15 to 20 years if you use them properly. Many doctors told patients they last for only 10 years. That doesn't have to be the case at all.

last_scene: Why can’t they use metal instead of plastic in knee replacement?

Dr__Bernard_Stulberg: They do, but a metal-to-metal articulation won't work. The knee does all sorts of motions that a hip doesn't do, and metal articulations can't successfully resist them.


Recovery

jackpot: If you are 85 years old and in relatively good health, how well will you recover from a total hip replacement? What are the most common problems to be expected at this age?

Dr__Bernard_Stulberg: Physiologic age is most important. If you are 85 but have well-managed medical conditions and are active, hip replacement can be a very safe and effective operation. In our experience, the most common problems for those over 80 are problems with the heart (usually in those patients who have pre-exiting heart conditions) and urinary tract problems. Many patients in their 80s are thrilled with their results and the experience.

bjh: What are the average ‘recovery times’ from full knee replacement and partial knee replacement? What should a patient do to minimize recovery time?

Dr__Bernard_Stulberg: This is a really good question. Recovery is a lot about how you, as a patient, prepare yourself for and work to have an excellent result. Preoperative strengthening (perhaps with physical therapy support) has been shown to result in faster postoperative recovery.

In general, I tell my patients it takes about three weeks to become ambulatory without a walking aid with a partial knee replacement, and up to six weeks for full knee replacement. These are only estimates, as some patients can be fully ambulatory within two weeks with either approach. Range of motion is usually easier to recover after partial versus full knee replacement. Partial arthroplasty recovery averages between six to eight weeks and complete knee replacement recovery is about three months, with some patients needing up to 6 to 12 months for recovery (a bit more variable).


Advances and Research

miracles: Is the Clinic growing the patient’s own cartilage to replace the worn out cartilage in his or her knee?

Dr__Bernard_Stulberg: Yes, but for very isolated lesions of the cartilage. This is currently done by our sports medicine surgeons, if at all.

NAD_1: Is any research being done on an injection that can get between the bones and provide cushioning so that surgery doesn't have to be done?

Dr__Bernard_Stulberg: Yes, but I am probably not the best one to provide you with an update on it. Any of those solutions, to this point, are only temporary and may only be effective in the very earliest stages of the disease.

pretend: What happens after 20 years in a wheelchair? Can there be a second operation? Is there any research in growing bone material as you grow skin?

Dr__Bernard_Stulberg: Patients who have been in a wheelchair for more than 20 years are likely to have a very difficult time walking. I am not certain replacement approaches have been very successful in restoring walking capabilities to this population of patients, although it can be helpful in addressing pain. There is plenty of research being done on growing bone materials, but again, this is not my area of expertise and I think success has generally been in the younger patient population (i.e., younger than 20).


General Questions

ChristinaB3: What are your thoughts on prolotherapy for cartilage regeneration? I know it is unproven but promising. I am 47 years old, have been running for 27 years, and CT shows I have only 50 percent cartilage in one of my knees. I want to keep running, of course!

Dr__Bernard_Stulberg: I was a runner myself at one time, so I understand the desire. Prolotherapy does no damage, so if it works, and you can afford it, it seems OK to me. Just be realistic about your goals. (That’s never easy for a runner. It wasn’t for me!)

ChristinaB3: We have many great medical facilities here in Detroit, MI., such as Detroit Medical Center, Beaumont, University of Michigan, Henry Ford, etc. In general, is it best to seek this type of surgery closer to home or is it worthwhile to travel four hours to Cleveland Clinic? Sometimes it’s hard to choose your doctor and hospital.

Dr__Bernard_Stulberg: I'm a Cleveland Clinic doctor, what am I supposed to say? I have many friends and colleagues in your area who do a very nice job. Make certain they are experienced in the area and you trust them.

ChristinaB3: Do glucosamine sulphate and MSM mainly help with pain in terms of arthritis or can they reverse the disease or prevent additional progression of the disease?

Dr__Bernard_Stulberg: They do not address cartilage health at all, which is too bad. My thinking is, if you're more comfortable when you take them, and you don't mind the price, they are a very safe way to treat your joint pains. The data is solid, however, that there is no clear benefit.

playmates: What problems arise with revision of a replacement?

Dr__Bernard_Stulberg: Now that's a tough question to answer in less than 60 minutes. Forty percent of my work is revision surgery. There are all sorts of problems, and the better we understand them before we get started, the less likely you are to experience them.

ChristinaB3: Why aren't hip and knee replacements done from donors, similar to organ transplants (heart, kidney, etc.)? If donors had healthy knee or hip joints or cartilage, why can't they be used?

Dr__Bernard_Stulberg: In youngsters they are. However, we currently do about 600,000 knee replacements and 300,000 hip replacements a year. There aren't enough donors. Also, you avoid disease transmission and many other problems you encounter when dealing with donated tissue.

NAD_1: Do you see both knees and hips? Which do you prefer or which do you do more often?

Dr__Bernard_Stulberg: I see both. And as I said previously, about 40 percent of my practice is dealing with failed procedures/parts. My practice is equally divided between hips and knees.

tranie: Are you causing more damage the longer you wait for a replacement? If you lose weight, can you avoid surgery? Will I limp?

Dr__Bernard_Stulberg: There is no problem waiting, if you can stand it. Losing weight, if you need to, will help everything.

NAD_1: Are the 40 percent failed procedures the ones you did or other doctors or both?

Dr__Bernard_Stulberg: I've lived long enough, mostly others, but none of us is perfect, and if the implants have been in place for 20 years or more (and I have been doing these for 30), then they will fail.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Bernard Stulberg is now over. Thank you again, Dr. Stulberg, for taking the time to answer our questions today about advances in hip and knee surgery.

Dr__Bernard_Stulberg: Thanks for your thoughtful questions. I hope this was helpful.


More Information

To make an appointment with Dr. Stulberg or any of the specialists in the Department of Orthopaedic Surgery at Cleveland Clinic, please call 866.275.7496. You can also visit us online at www.clevelandclinic.org/ortho.

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This chat occurred on June 27, 2011

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