Online Health Chat with Trevor Murray, MD
October 24, 2012
Cleveland_Clinic_Host: 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 known as an autoimmune disease.
When hip and knee pain interferes with everyday function, replacement surgery may be recommended. Based on the amount of arthritis or wear on your joint, there are different replacement options available. For many individuals, replacement surgery can drastically improve the quality of life.
For More Information
On Cleveland Clinic
Cleveland Clinic's Orthopaedic & Rheumatologic Institute offers expert diagnosis, treatment and rehabilitation for adults and children with bone, joint or connective tissue disorders. The Department of Rheumatic and Immunologic Diseases at Cleveland Clinic, which treats rheumatoid arthritis and other diseases, is ranked second in the nation by U.S.News & World Report, and is top ranked in Ohio and Cleveland Clinic’s Department of Orthopaedics is ranked third in the nation by U.S.News & World Report, and is top ranked in Ohio.
The Orthopaedic & Rheumatologic Institute launched its first multidisciplinary clinic combining the expertise of nonoperative orthopaedists and rheumatologists in one location at Cleveland Clinic’s Arthritis & Musculoskeletal Center. This center offers a convenient and integrated approach for the evaluation of patients with joint pain due to arthritis and associated musculoskeletal problems.
Our evaluation and treatment center brings together experts so the cause of your joint pain can be quickly and appropriately diagnosed. In some cases, the problems require evaluation and treatment by more than one member of the team or the problem may require a timely referral to other specialists within the Cleveland Clinic. Our doctors have a specific interest in joint pain problems and can work efficiently within a multidisciplinary team to provide you with the highest level of care so you can return to your usual level of activity.
Cleveland Clinic’s Arthritis & Musculoskeletal Center team includes rheumatologists, nonoperative orthopaedic physicians, musculoskeletal radiologists, physical and occupational therapists, brace technicians and musculoskeletal patient educators.
Within Cleveland Clinic’s Department of Orthopedic Surgery is the Center for Adult Reconstructive Surgery (Hip & Knee) for the latest surgical treatment of orthopaedic diseases and trauma. Treatments include total and partial joint replacement, revision of previously replaced joints that have worn out with normal usage and arthroscopic surgery.
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.
In reconstruction surgery, joints that are uneven or worn away are replaced with artificial implants.
On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: firstname.lastname@example.org
A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult
To make an appointment with Dr. Murray or any of the other specialists in our Center for Adult Reconstructive Surgery (Hip & Knee) within Department of Orthopaedic Surgery at Cleveland Clinic, please call 866.275.7496. You can also visit us online at clevelandclinic.org/ortho
About the Speakers
Trevor Murray, MD, is an orthopaedic surgeon specializing in hip and knee surgery and replacement. Dr. Murray completed an adult reconstruction fellowship at Rush University Medical Center in Chicago. Dr. Murray completed his orthopaedic surgery residency at Cleveland Clinic after graduation from Case Western Reserve University School of Medicine in Cleveland.
Let’s Chat About What You Need to Know About Hip and Knee Replacements
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic expert Dr. Trevor Murray. We are thrilled to have him here today to discuss Hip & Knee Replacements. Let’s begin with some of your questions.
Hip Replacement and Medications
neildiane: I want to know what protocol is used in hip surgery when a patient is on Coumadin® and needs to discontinue it for the surgery? How is an aortic valve replacement patient treated relative to anti-coagulation when one undergoes this type of surgery? Also, does Cleveland Clinic have experience in this area?
Dr_Murray: Typically, patients are admitted preoperatively for a bridge from their Coumadin®. Depending on why patients are on Coumadin®, this may not be necessary. We send all our patients in this type of situation to vascular medicine and/or cardiology for their recommendations. We have significant experience with patients with these types of co-morbidities here at Cleveland Clinic.
Neildiane: My situation is that I have a prosthetic mechanical valve, and I have not been satisfied with what I have been told. Is there a specific protocol that is used all the time successfully?
Dr_Murray: Each situation is unique and handled on a case-by-case basis. The management of this type of situation is done by our cardiology colleagues.
Surgical Approach to Hip Replacement and Implant Choice
jamesb: What are the benefits and drawbacks of the anterior approach to hip replacement? What is your best recommendation for surgical hip replacement?
Dr_Murray: Some of the proposed advantages are decreased pain, shorter recovery time and decreased dislocation rates. Potential drawbacks include increased rate of intraoperative fracture and nerve injury. I personally use the posterior approach. I think the most important factor is to go to someone who does a lot of hip replacements (i.e., more than 50 per year) and is comfortable with the approach they use.
LJK: My hip replacement is 21 years old. I am 77 years old, and this is the second replacement on that hip. Is there any alternative to having a full replacement for it?
Dr_Murray: Yes. Often the ball and liner can be exchanged without changing the stem and cup. This ultimately depends on the type of implant you have and what your x-rays show.
jlu800: I am a 71-year-old man with severe osteoarthritis of my left hip. One doctor suggested that I should have hip resurfacing surgery, and another doctor suggested that I should have total hip replacement surgery. Which surgery is the best solution for me, so I can avoid a second revision surgery if I live beyond 90 years old?
Dr_Murray: Patients who appear to benefit most from hip resurfacing are men who are 55 years old and younger. The data for other groups show equivalent or inferior results for hip resurfacing. In my opinion, a total hip replacement would give you a reliable long-term result, and should last you the rest of your life.
tell_me: How do you know when to use ‘ceramic-on-ceramic’ or ‘ceramic-on-polyethylene (poly)’ for a hip replacement? When is ‘dual mobility’ recommended?
Dr_Murray: A lot of those choices are surgeon preference. Studies show very low rates of wear when ceramic-on-polyethylene bearings are used. Ceramic-on-ceramic is also promising, but there are reports of fracture and squeaking. Dual mobility in general is reserved for patients at increased risk for dislocation. It has only been approved and used for a relatively short period of time here in the United States.
jlu800: How many hours does it take for hip replacement surgery? What is a typical time for an experienced surgery doctor? How much blood loss is in the normal level range for a total hip replacement?
Dr_Murray: In general, a hip replacement takes about an hour with about 200 cc of blood loss.
Hip Replacement Risks, Infection and Blood Loss
jlu800: Will a low level of infection in the teeth cause a big infection danger in a hip resurfacing or total hip replacement surgery?
Dr_Murray: The answer is yes. Infection anywhere puts any joint replacement at risk. This should be addressed immediately.
jlu800: Which technology is the best to minimize blood loss during a total hip replacement, e.g. Cell Saver®, TissueLink™, Aquamantys® or cautery?
Dr_Murray: We actually performed a randomized trial looking at blood loss and the use of TissueLink® and Aquamantys® in total hip replacements, which showed no difference. There are certain specific cases where the technologies you mention are used but not in straight forward hip replacements. Electrocautery is used in every case.
LJK: Is it always necessary to have a blood transfusion when getting a total hip replacement?
Dr_Murray: No, in fact, the rates of transfusion following a primary total hip replacement are very low, somewhere from 10 percent to 20 percent.
mannyp: After total hip replacement of my left hip, I got gout in my left toe and foot, but the blood test did not show uric acid. Is it possible that the pain medication that I was taking for the hip replacement caused the gout? I am no longer on the Oxycontin® and my last gout flare-up was six months ago.
Dr_Murray: People with gout often have a normal uric acid level. It is also common for patients to have a gout flare following surgery.
Hip Replacement and Exercise
LJK: With an old hip replacement that is showing some signs of wear, is it still a good idea to walk a mile every other day?
Dr_Murray: Yes. Staying in good cardiovascular health is very important. Low-impact exercise should not reduce the longevity of your implant. You should have x-ray surveillance of your hip replacement every six to 12 months though.
Knee Replacement Consultation
sher: How is the determination made as to whether a knee replacement is necessary?
Dr_Murray: It is based on several factors. We use x-rays, history and physical examination. Patients with arthritis on x-ray who have significant disability due to pain and have failed nonoperative treatment are candidates. The decision to proceed is essentially made by the patient.
RDH1965: I had a total knee replacement in 2010. I have seen my doctor at least four times for pain and stiffness. He sent me for physical therapy three times. I have used Pennsaid® and had a knee manipulation in July, but I am no better. I just do not know where to go from here.
Dr_Murray: I would recommend a second opinion. It is always a good idea to have someone take a new look at the situation.
patilaj: I am 32 years old, I have consistent pain in my left knee. However, X-ray does not show any cartilage degeneration symptoms. What are the tests to confirm osteoarthritis of the knee?
Dr_Murray: Typically standard X-rays are the most useful tool to evaluate arthritic changes. The next level of imaging for someone with unexplained knee pain would be an MRI.
Dynamite: My knee not only buckles—I know it's bone on bone, but also when I stand for a short period of time, the knee stiffens up and then hurts. There isn’t pain when I first stand. I'm wondering about a knee replacement. I'm 84 years old.
Dr_Murray: Instability, pain, and complete loss of cartilage are all good indications for a total knee replacement. Barring any major medical issues, you would likely benefit from a total knee replacement.
Other Knee Diagnoses
art_therapy: I had a blood clot behind my new knee about 13 months after knee replacement. Ultrasound and knee x-ray showed a Baker’s cyst. What caused this?
Dr_Murray: Baker’s cysts are often present in the setting of knee arthritis. Total knee replacement does not cure this condition, and they can often recur following joint replacement surgery.
browna20: Does tumoral calcinosis of the knee usually result in knee replacements? This always invades the soft tissue, correct?
Dr_Murray: Typically tumoral calcinosis causes calcification of soft tissues. I personally have not replaced someone's knee due to tumoral calcinosis.
Dynamite: Is the gel offered by Cleveland Clinic Florida (Weston Clinic) worth the effort? Will it help a knee that buckles and does not support standing?
Dr_Murray: I presume that the gel in question is a form of viscosupplementation (intraarticular injection of hyaluronic acid). Some studies show a significant decrease in symptoms following these injections. A less symptomatic knee may then help with buckling. I would recommend physical therapy to strengthen your leg muscles to help with the buckling, possibly combined with the injections.
show_me: How long can you take Euflexxa® or cortisone injections before surgery?
Dr_Murray: There is no set limit to these types of injections. However, prolonged use of cortisone can begin to have detrimental effects. With regards to timing between injections and subsequent replacement, we typically wait two to three months after the last injection.
Knee Replacement Surgery and Implant Choice
arnold: What is your opinion of a partial knee replacement vs. a total knee replacement?
Dr_Murray: Partial knee replacement is a great surgery in the right person. It is a faster recovery and a more natural feeling knee. The arthritis and symptoms must be isolated to a single compartment of the knee.
Knee Replacement Revision
RDH1965: Is it possible to redo a knee replacement?
Dr_Murray: Yes. Revisions (or redos) are necessary for multiple reasons. Thousands of these are performed annually with the rate increasing each year.
Knee Replacement Risks and Side Effects
charge_it: How do you know if you have an infection of the knee replacement?
Dr_Murray: Typically, you will experience increased pain and swelling. The diagnosis, however, cannot be made without objective laboratory data.
vivianCline: What are the risks of nerve injury in total knee replacement?
Dr_Murray: In short, very low. Major nerve injury is well under a 1 percent risk. Often, patients experience an area of numbness over the front of their knee, which may or may not improve.
sher: What causes infection in knee replacements?
Dr_Murray: There are different types of infection. One is due to some level of contamination at the time of surgery. The other is when there is an infection somewhere else in the body causing bacteria to get into the blood which then seed the joint, causing infection.
Knee Replacement Failure
good_times: What can cause a knee replacement to loosen (i.e., fail)?
Dr_Murray: There are many causes of failure, including infection, instability and loosening. As far as loosening is concerned, it can be secondary to infection or caused by the plastic wearing out. This causes a process that leads to bone loss and, ultimately, can loosen the prosthesis.
patilaj: Is a diabetic patient more prone to implant failure?
Dr_Murray: A diabetic with poor glucose control is at more risk for wound healing issues and infection.
Knee Replacement Recovery
sher: What is the recovery period for a full knee replacement?
Dr_Murray: The best generalized answer is two to three months, but people can see improvements up to 18 months to 24 months following their surgery.
Knee Replacement and Exercise
parker54: Are there any exercises you would recommend for prospective knee replacement patient who is now bone-on-bone? How should she prepare for surgery?
Dr_Murray: Maintaining good cardiovascular health will be of benefit. Specifically, exercises that improve range of motion and quadriceps strength are most helpful.
master_chef: Does the continuation of exercises (e.g., hip extension, bicycle, step-ups and elliptical) shorten the life of a knee replacement? I exercise five days of the week, but do not participate in athletic activities.
Dr_Murray: We typically recommend low-impact exercises, which is what it sounds like you are doing. It is hard to know what level of activity will wear out your hip quicker. We do know that at the extremes, activity or lack thereof does have an impact. I tell my patients that the goal of surgery is pain relief and a return to activities, so I would encourage your current activities.
caseas: How long should one wait after knee replacement surgery before resuming normal activities like bowling?
Dr_Murray: Patients are on their feet right away. I would say in general, for activities like bowling, two to three months is a good estimate.
brain_food: Does taking calcium prevent the need for joint replacement?
Dr_Murray: Appropriate nutrition is good in general, but there is no data to suggest that calcium can prevent the development or progression of arthritis.
caseas: Can products like Trigosamine® help to ward off knee surgery?
Dr_Murray: Glucosamine chondroitin products have been found to decrease knee symptoms. However, no studies show an ability to slow down the progression of arthritis.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic expert Trevor Murray, MD is now over. Thank you Dr. Murray for taking your time to answer questions today about Hip and Knee Replacements.
Dr_Murray: Thank you everyone for your insightful questions. I hope this helped answer many of them. I look forward to another opportunity to interact in this way.
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