Cleveland_Clinic_Host: When osteoarthritis or injury to the knee or hip causes constant pain and stiffness, surgery can restore quality of life. Osteoarthritis (OA) may 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. Osteoarthritis actually develops as cartilage cushioning the joint wears away, allowing bone to rub against bone and spurs to develop. Depending on the degree of joint damage, when conservative measures no longer help, individuals may be eligible for partial or total knee replacement, total hip replacement or hip resurfacing. Join us online as Peter Brooks, MD, and Viktor Krebs, MD discuss joint replacement and resurfacing options in the knee and hip.
Cleveland Clinic's Orthopaedic & Rheumatologic Institute offers expert diagnosis, treatment and rehabilitation for adults and children with bone, joint or connective tissue disorders. The institute blends the strengths of Cleveland Clinic's Orthopaedic Program and Rheumatology Program, both ranked among the top three nationally by U.S.News & World Report (the top rankings in Ohio)
Cleveland Clinic orthopaedic surgeons perform more than 7,000 hip, knee, shoulder, ankle, elbow, wrist and finger joint replacements per year – one of the highest volumes in the United States – for severe osteoarthritis and rheumatoid arthritis, trauma and other conditions. Cleveland Clinic orthopaedic specialists have pioneered innovative techniques and technologies that are now used worldwide for a range of orthopaedic problems. A joint resurfacing option for hip and knee replacement is one of these techniques.
Using innovative joint replacement and bone grafting methods, Cleveland Clinic orthopaedic surgeons reconstruct thousands of hip and knee joints each year. Our specialists care for a variety of joint problems, including joints that have been fractured or damaged by arthritis. Following surgery, specially trained physical therapists provide individualized care to help ensure long-term success.
Today, join us as Viktor Krebs MD, MPH, Director of the Center for Joint Replacement in the Orthopaedic & Rheumatologic Institute and Peter Brooks, MD, an orthopaedic surgeon at Cleveland Clinic specializing in total joint replacement of the hip and knee, and hip resurfacing, discuss the latest techniques.
Viktor Krebs, MD, is the Director of the Center for Joint Replacement. Dr. Krebs has interests in hip and knee replacement, hip arthroscopy, and hip and knee revision. Dr. Krebs received his medical degree from the Ohio State University College of Medicine in 1992, where he was named to the Alpha Omega Alpha Medical Honor Society. Dr. Krebs is a member of the American Medical Association, the Ohio State Medical Association and the American Academy of Orthopaedic Surgeons. He is the author of a number of publications and has given several presentations at local and national conferences.
Peter Brooks, MD, is an orthopaedic surgeon at Cleveland Clinic who specializes in total joint replacement of the hip and knee, and hip resurfacing. He also has an active interest in arthroscopy of the knee. Named to the Alpha Omega Alpha Medical Honor Society he is also a fellow of the Royal College of Surgeons and of the American Academy of Orthopaedic Surgeons, as well as a member of the American Orthopaedic Association. Dr. Brooks is interested in pain-free joint replacement, hip resurfacing in younger patients and outcomes of arthroscopic surgery in patients over age 60. He has written numerous articles and book chapters and has made nearly 50 presentations. He graduated from University of Toronto Faculty of Medicine, completed his internship and residency at Brigham & Women's Hospital in Boston, and then completed his fellowship from Mount Sinai Hospital in Toronto.
To make an appointment with Dr. Viktor Krebs, Dr. Peter Brooks, or any of the other specialists in the Orthopaedic & Rheumatologic Institute at Cleveland Clinic, please call toll-free 866.275.7496 or visit us online at www.clevelandclinic.org/ortho
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Viktor Krebs, MD and Peter Brooks, MD. We are thrilled to have both physicians here today for this chat. Let’s begin with questions about hip and knee joint replacement.
Hip Pain Overview
bellerive: What are the differences in symptoms between hip problems and sciatica?
Speaker_-_Dr__Viktor_Krebs: One of the most common mistakes is to attribute groin pain to sciatica. This is actually very rare. Sciatica in general is pain down the back of your leg and maybe into the foot and toes. Hip pain does not usually go beyond the knee. Sciatica has tingling or shooting pain and numbness that might get worse if you cough or sneeze. A doctor should be the one to tell the difference.
hippopper: What can cause numerous joint popping? This started in one day and has continued for 2 years – 5 pops per minute (hip joint).
Speaker_-_Dr__Viktor_Krebs: It can be caused by loose bodies in the joint and/or tendons around the joint snapping during movement. If this is painful, you should be evaluated by an orthopaedic surgeon and an MRI scan of the hip may be indicated.
boomer: Is joint replacement a viable option for persistent recurrent Trochanteric Bursitis? I am tired of this hip pain and tired of not being able to exercise.
Speaker_-_Dr__Peter_Brooks: No- joint replacement is not considered to be an option for treating persistent recurrent trochanteric bursitis (hip pain.) We would recommend an evaluation by a hip surgeon familiar with this problem, as there are other non-surgical options.
pattyoh: How do you repair a dislocated hip? Is there a difference in treatment for younger vs. older people?
Speaker_-_Dr__Peter_Brooks: Treating a dislocated hip depends on age of the person, cause of dislocation, and if it is a natural or artificial hip. Pattyoh, is this a total hip or a normal hip joint? The answer will be different in each case.
Hip Resurfacing Procedure
ml41kris: What is the difference between hip replacement and hip resurfacing? I have read that it is for younger people, but what exactly is the criterion?
Speaker_-_Dr__Peter_Brooks: Arthritis of the hip, in most cases, is primarily a wearing away of the cartilage on the ball and socket of the hip joint, leading to painful rubbing of bone on bone. Rather than replacing the entire hip joint, as in a total hip replacement, hip resurfacing involves shaving and capping only a few millimeters of the joint surface. Since this approach preserves more of the patient’s natural bone, it reduces postoperative risks of dislocation and inaccurate leg length.
Speaker_-_Dr__Peter_Brooks: The criterion for whether replacement or resurfacing is appropriate is more due to bone quality than actual age, but in general <65 yrs old we would try resurfacing.
Speaker_-_Dr__Peter_Brooks: Hip resurfacing procedures have been approved by the FDA since 2006.
hippain: How risky is the resurfacing procedure in terms of loss of use?
Speaker_-_Dr__Peter_Brooks: There is a 1-3% risk of femoral neck fracture, many of which need more surgery to heal.
Speaker_-_Dr__Peter_Brooks: But if a hip resurfacing ever fails, which is unlikely, the surgery to correct it may be as simple as doing the lower half of a primary total hip replacement. Importantly, hip resurfacing needn’t be looked at as a temporary procedure, inevitably leading to hip replacement down the road. Results from long-term data show that it can last just as long as hip replacement in young, high-demand patients, with only 1 or 2 percent needing further surgery after ten years. Those patients who do need a second surgery have the excellent results of first-time hip replacement, with the stability and range of motion of a large metal on metal hip joint.
hippain: After a hip resurfacing procedure, how long until the patient can return to normal activities? Activities such as walking, cycling, and swimming.
Speaker_-_Dr__Peter_Brooks: One advantage of patients with hip resurfacing is that they can return to all of their previous activities, including running, climbing, and competitive sports. Most people with traditional hip replacements versus resurfacing procedures cannot achieve this.
Speaker_-_Dr__Peter_Brooks: For activities such as walking, cycling and swimming, I would say six weeks is optimal. But strenuous exercise and sports have to wait at least a year.
hippain: After resurfacing procedure, if the patient told you they wanted to continue to run, what would your response be?
Speaker_-_Dr__Peter_Brooks: It is recommended to wait one year before beginning high impact exercise such as running.
hippain: What is the normal return to work after hip resurfacing. I work in an office environment where I occasionally drive my car.
Speaker_-_Dr__Viktor_Krebs: We do not allow driving until you are off crutches, at 6 weeks. If you have someone to drive, you can return to work after 2-3 weeks.
elw1706: How do you determine if a person's bones are strong enough for hip resurfacing?
Speaker_-_Dr__Viktor_Krebs: Sometimes you can tell just from the x-rays, but if there is any question we will do bone density testing, especially in women.
Hip Replacement Procedure
domvelotta: I am 68 yrs. old and have had osteoarthritis for the past 10 years. I have managed to live with the pain up to now. What type of joint replacement product do you recommend and also what type of surgery anterior or traditional?
Speaker_-_Dr__Peter_Brooks: I would recommend a Cementless titanium implant and an anterolateral approach for the surgery.
elw1706: I am an active 62 yr old female. An x-ray showed thinned cartilage in my right hip. After PT (physical therapy) I have more flexibility, but still have pain walking. Should I consider hip replacement sooner or later?
Speaker_-_Dr__Viktor_Krebs: When it starts to affect your lifestyle, you should consider joint replacement. Dr. Brooks has resurfaced joints for women in their 60's - it all depends on bone quality.
Peaches: How much time between hip replacements, since it is not recommended to have both done at once?
Speaker_-_Dr__Viktor_Krebs: It can range from 1-3 months depending on your medical condition and your health.
hipster3872: Do total hip joint replacements wear out? Or is it the bone next to the joint replacement that wears out?
Speaker_-_Dr__Peter_Brooks: It is actually the bearings that can wear out (plastic etc) and the nearby bone can deteriorate as well.
grace: With a hip replacement, does the incision have to be long? Will both legs still be the same length?
Speaker_-_Dr__Peter_Brooks: Most surgeons now do minimally invasive surgery. Most incisions are usually 3-4 inches, but if you are overweight it will be longer. Remember - there is no incision short enough to compensate you for a complication. Unequal leg lengths are one of the more common complications of hip replacement. Most don't notice if it is small.
elw1706: What are some of the complications of hip replacement surgery?
Speaker_-_Dr__Peter_Brooks: In a joint replacement center where these procedures are being done routinely, these complications are extremely low. The complications that do occur include infection, blood clots, bleeding, dislocation, nerve injury, leg length inequality, and fracture. These are the early complications. Late complications are loosening, wearing out, bone loss, and late infections.
elw1706: Would I be able to do mountain hiking and backpacking after a hip replacement?
Speaker_-_Dr__Viktor_Krebs: Yes, after a one year recovery.
beckyK: After a hip or knee replacement, will it feel normal again?
Speaker_-_Dr__Peter_Brooks: Many people feel normal. Some forget they even had surgery. The reason you are having a replacement is to improve on something that hurts all the time. The surgery is designed to reduce this pain. You should feel 'more' normal after the replacement.
Knee Surgery: All Things Considered
ashleyb: How often can you have steroid knee injections?
Speaker_-_Dr__Peter_Brooks: You should only have steroid knee injections 2-3 times per year.
kevinm6: How long has the knee resurfacing procedure been around and is this commonly available across the area?
Speaker_-_Dr__Viktor_Krebs: Total knee replacement has been around for 40 years. It is actually is a resurfacing procedure.
oldgoalie: I am in my 40's but have bad knees from years of being a hockey goalie. I still want to snow ski - but the pain is becoming unbearable. Would knee resurfacing the way to proceed if I still want to be active? I have hung up my goalie skates, but I am not ready to give up on everything.
Speaker_-_Dr__Viktor_Krebs: Take X-rays, if the knee is totally worn out have a TKR (total knee replacement.)It would not be advised to return to impact sports with a TKR. People who have skied in the past and are proficient are allowed to return to skiing on groomed flat slopes, but are still at risk for any injury that can affect a knee joint.
oldgoalie: In a normal knee, there is bursa containing synovial fluid to prevent grinding of the knee’s bones. In a knee replacement, is the natural bursa retained? If not, how do the artificial parts work without grinding?
Speaker_-_Dr__Peter_Brooks: Yes - the natural bursa remains post knee replacement and continues to lubricate the joint preventing grinding bone to bone.
GRAMMYRUTH: How do you feel about having both knee replacements at the same time?
Speaker_-_Dr__Viktor_Krebs: If you are medically healthy and you have a significant deformity you will recover better and more quickly. This has been proven in outcome studies here at the Cleveland Clinic. If you have medical problems, it is safer to do them one at a time.
redoylloyd_2: Greetings: I had a complete knee replacement 9 months ago. Three weeks after the operation I had a hematoma in the new knee. A minute sample later showed the blood in the knee to be very dark in color. I am still having pain and wonder whether the normal lubricant (synovial fluid) was contaminated and an artificial substitute like the injections from the rooster's crown would help?
Speaker_-_Dr__Viktor_Krebs: Nine months after a knee replacement, pain should be improving. We do not feel that injections into the knee are indicated and may actually cause more problems, like a deep infection. You should speak to your surgeon about the continued pain and/or seek another opinion if you do not get the answers to your questions.
redoylloyd: Besides the hematoma, early on I developed a Baker cyst in back of the knee replacement. I believe it contributes to the pain I'm having. Can it be removed?
Speaker_-_Dr__Peter_Brooks: Almost everyone has a baker's cyst after surgery, but at 9 months, it should be going away and not getting worse. You should have your surgeon take another look.
cassie: If you have spinal stenosis, can you have knee surgery?
Speaker_-_Dr__Viktor_Krebs: It is recommended that you have your spine managed prior to dealing with you lower extremities. If your physician feels that your spinal stenosis is in control, a knee replacement can be considered.
clumsy_carrot_top: Recently I tripped and fell very hard onto my knee caps. After a total knee replacement surgery will it hurt even more? Could I damage the artificial knee with a similar fall?
Speaker_-_Dr__Peter_Brooks: After TKR (total knee replacement) pain management has improved significantly over the past few years, although it may even be painless, it is well tolerated and patients do exceedingly well. Experiencing a similar fall would damage an artificial knee.
jazzydog: I had a bullet go through my knee (after breaking my femur) in 1989. I have reached the point that pain is significant after extended periods of walking. My leg is not straight, due to the injury and one leg is almost 2 inches shorter than the other. Obviously, surgery could be complicated... who in your practice would be best to consult with and perform replacement surgery?
Speaker_-_Dr__Viktor_Krebs: Either of us would be happy to see you. Our contact information was presented at the beginning of this chat. If you signed on late, go to the transcripts for that information, or contact 866-275-7496 for appointments.
Marshall: After a 15 foot fall, my knee cap was cracked. Surgery was done and arthritis is present. There is still pain and the knee gives out some. Is it possible I will need a partial replacement in the near future?
Speaker_-_Dr__Viktor_Krebs: You should have your knee evaluated as you can be a candidate for a patella femoral partial replacement or a total knee replacement.
MrKN: Total knee replacement – how long is the rehab stay? Will I need help at home? How long?
Speaker_-_Dr__Viktor_Krebs: Most people in 2009 are discharged to home after a total knee replacement. Therapy occurs at home for the first 2 weeks and then out-patient therapy begins. In the situation that you are debilitated or do not have help, rehabilitation is an option, but not the standard.
kneeBgone: Someday I’ll need a knee replacement, should I avoid ever kneeling on it now?
Speaker_-_Dr__Peter_Brooks: No, there is no need to avoid kneeling.
frankie: My artificial knees are 10 years old. Why I am not supposed to kneel?
Speaker_-_Dr__Peter_Brooks: Go ahead and kneel. It is not a problem to the artificial knee.
mcclosky: Can you use biological coatings rather than cement on artificial knees?
Speaker_-_Dr__Viktor_Krebs: There are biological coatings that can be used instead of cement for a knee replacement. This is similar to a cementless total hip. Bone grows into the metal. The reason these are not used as frequently as cemented replacements is that the long term results are not as good at this time.
meenamehtapa_2: Can you address minimally invasive micro surgery and who does it?
Speaker_-_Dr__Viktor_Krebs: Here at the Cleveland Clinic, we all do minimally invasive joint replacement. Again it depends on your size and the deformities being corrected. As far as micro surgery goes, that would imply using a microscope or an arthroscope. Dr. Miniaci has developed a partial replacement system that can be done arthroscopically in the knee and shoulder.
Gender Knee Replacement: What is it?
twinkletoes: Would you discuss “Gender Knee” replacement? I have heard there is one specific for women. I am a dancer and also like to garden.
Speaker_-_Dr__Viktor_Krebs: Several models take female anatomy into account, and we use them. The gender specific issue is actually a marketing tool and currently several total knee systems take into account the different bone sizes in males and females.
Joint Resurfacing: Does Age Matter?
samdisalvo: Is there an age cutoff for joint resurfacing?
Speaker_-_Dr__Viktor_Krebs: It is more of a bone quality cut-off, than age. In general, the older you get the weaker your bones get and a replacement would be recommended.
Arthritis and Supplements
elw1706: What is your opinion of Glucosamine and Chondroitin?
Speaker_-_Dr__Viktor_Krebs: There is no scientific proof that these nutritional supplements have benefit for the treatment of arthritis. It does not reverse arthritis or make cartilage grow back, as stated in ads. We have seen people get pain relief from it, and do not discourage its use.
Prophylactic Antibiotics after Joint Replacement
desi124: I had a total right hip replacement in 2004. Must I continue to take pre-medication prior to dental work and/or other procedures?
Speaker_-_Dr__Viktor_Krebs: We would both favor antibiotics for all dental procedures. This is supported by a recent statement of the American Academy of Orthopaedic Surgeons in February, 2009, and can be accessed on their website at http://www.aaos.org/about/papers/advistmt/1033.asp.
Cleveland Clinic Arthritis and Musculoskeletal Treatment Center
jm_osborn2003: I have had pain in every joint 24-7 for 8 years or more. I have had 3 surgeries on my spine in 6 years. I have Fibromyalgia and Degenerative Disc Disease and Osteoporosis. I also have symptoms of Rheumatoid Arthritis (RA) but not in my blood tests. How do I find a new RA who can handle my problems?
Speaker_-_Dr__Viktor_Krebs: The Orthopaedic and Rheumatologic Institute launched its first multidisciplinary clinic combining the expertise of non-operative orthopaedists and rheumatologists in one location at the new Arthritis & Musculoskeletal Treatment Center. This center offers timely, "one stop shopping" for the evaluation of patients with joint pain due to arthritis and associated musculoskeletal problems. It is committed to providing state-of-the-art diagnosis, treatment and rehabilitation for adults and children with rheumatic and immunologic diseases. These diseases vary from the simple to complex and mild to life-threatening. They include bursitis/tendonitis, osteoporosis, osteoarthritis, rheumatoid arthritis, gout, pseudogout and multiple other forms of arthritis, systemic lupus, vasculitis, fibromyalgia and others.
Speaker_-_Dr__Viktor_Krebs: To schedule an appointment, please call 866.275.7496 or visit the web at clevelandclinic.org/ortho.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Krebs and Dr. Brooks is now over. Thank you again for taking the time to answer our questions about total joint replacement and resurfacing options today.
Speaker_-_Dr__Viktor_Krebs: Thank you for participating and submitting your questions. If you have further questions, please feel free to contact out department.
For more information about Cleveland Clinic Orthopaedic and Rheumatologic Institute, you may visit clevelandclinic.org/ortho. To make an appointment with Dr. Viktor Krebs, Dr. Peter Brooks, or any of the other specialists in the Orthopaedic & Rheumatologic Institute at Cleveland Clinic, please call toll-free 866.275.7496; or visit us online at clevelandclinic.org/ortho.
- Some interesting articles about this topic from Cleveland Clinic may be found at the following link:
- A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsultHome
- If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.44.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
- Some participants have asked about upcoming web chat topics. If you would like to suggest topics for 2009, please use our contact link clevelandclinic.org/webcontact to submit your suggestions. In the question/comment section, choose Health/Disease Information so that we receive your comments.
This chat occurred on May 28, 2009.
© Copyright 1995-2010 The Cleveland Clinic Foundation. All rights reserved.
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.