Online Health Chat with Michael Bloomfield, MD, and Juan Suarez, MD
Wednesday, August 20, 2014
Is it time for a hip or knee replacement? If you and your doctor are considering a joint replacement, you are not alone. More than one million Americans will undergo a joint replacement this year, and that number is expected to grow rapidly in the future. The good news is that there are more effective treatment options available for joint pain today than ever before. If you are considering joint replacement surgery, get your questions answered by our hip and knee surgeons who will discuss possible causes for pain, diagnosis and treatment options.
Hip and knee pain can have many causes such as osteoarthritis, bursitis and tendonitis in the knee, and hip fractures.
There are other possible causes of hip and knee pain; be sure to seek medical help if you:
- Can’t walk normally because of the pain
- Can’t bend your hip or knee
- Experience hip or knee pain for more than a few days
- Notice a deformity or swelling in your hip or upper thigh or knee
- Experience hip or knee pain at night or while resting
- Develop a fever, with redness and warmth over the hip or knee
About the Speakers
Michael Bloomfield, MD, is an orthopaedic surgeon specializing in primary and revision hip and knee replacements and the direct anterior approach for total hip replacement. Dr. Bloomfield graduated from medical school at Northwestern University and completed his residency in orthopaedic surgery at Cleveland Clinic. He then went on to complete a fellowship in adult reconstruction of the hip and knee at Thomas Jefferson University Hospital.
Juan Suarez, MD, is an orthopaedic surgeon whose specialty areas include degenerative and inflammatory arthritis of the hip and knee, complex primary and revision hip and knee replacements, minimally invasive direct anterior hip replacements and traumatic fractures of the lower extremities.
Dr. Suarez graduated from the University of Puerto Rico School of Medicine in San Juan. He completed his orthopaedic surgery residency at Jackson Memorial Hospital-University of Miami School of Medicine and later completed his adult hip and knee reconstruction fellowship at OrthoCarolina in Charlotte, North Carolina.
Let’s Chat About Answers on Hip & Knee Surgery
Moderator: Welcome to our chat today with Cleveland Clinic orthopaedic surgeons Michael Bloomfield, MD, and Juan Suarez, MD. We are thrilled to have both surgeons available to share their knowledge and expertise about hip and knee surgery.
Moderator: Let's get started with our questions...
wjsg: When is knee replacement a good option for an 80-year-old woman with bone-on-bone pain?
Juan_Suarez,_MD: It would be a good option after conservative measures have been exhausted and her quality of life is limited by her knee pain. In general, patients above 80 years old may take longer to recover; however, chronologic age may not correlate with actual physiologic age. Therefore, patients need to be evaluated individually.
cyn3: My mother has bad knees, quite painful, and is in her 80s with heart issues (triple-bypass three years ago) and osteoporosis. However, she is still very active. Is there a cut-off age or health criteria cut-off for knee replacement?
Juan_Suarez,_MD: Certainly age and medical comorbidities (co-existing chronic diseases or conditions) are taken into consideration. Recovery can be longer for older folks, but if the cardiac risk is acceptable then it can be done safely. I would ask for a cardiology evaluation to determine her risk.
mikep: I've heard both success and failure stories about knee replacements. I'm hesitant to take the risk. I'm 71 and can walk and do stairs, but with pain; the same with riding a bike.
Juan_Suarez,_MD: The satisfaction rate after total knee replacement is between 80 percent and 85 percent. It is important to understand that a knee replacement is not a normal knee, therefore it has limitations. The expectations have to be realistic.
MoR: What conditions determine whether a full or partial knee replacement is desirable?
Juan_Suarez,_MD: The location of the arthritis. Partial knee replacements are performed for isolated medial or lateral disease.
nojo: How long can I expect my knee and leg to be swollen? I'm 10 weeks post-surgery and it’s still swollen. Is there anything I can do about that?
Michael_Bloomfield,_MD: After a knee replacement, the knee can stay somewhat swollen and warm for a year or more after surgery. The swelling and pain should continue to improve as time goes on. If not, you will need further evaluation.
LCL: I have been told that both of my knees need to be replaced. I am 64, have a BMI (body mass index) of almost 37 and have high blood pressure that is controlled with medication. I have pretty severe contractures in both knees, making it impossible for me to straighten either knee. I also have spinal stenosis, which has proven excruciatingly painful in the past. It has improved with physical therapy and yoga. One surgeon's opinion follows several months of physical therapy to improve a part. Another surgeon suggested that he would replace both knees simultaneously. Depending on the range of motion in each knee, he would replace each knee separately, three months apart, which would require a stay in a rehab facility for about 10 days. Which approach would you recommend and why? Thank you.
Michael_Bloomfield,_MD: Severe flexion contractures in both knees are a good reason to have both done at the same time, but there are many factors that go into deciding which approach is best. The risks are higher for bilateral surgery, and I reserve this for patients who are healthy. Your preference is also important.
wmw1962: I'm on Pradaxa®. Can I have a knee replaced?
Juan_Suarez,_MD: You would need to come off of Pradaxa.
sam5000: My wife, who is 65 years old, has a very painful right knee. As exercise is important, is walking better than an exercise bike?
Michael_Bloomfield,_MD: Biking, elliptical and swimming are the best exercises for patients with knee arthritis.
hig: About one year ago, I fell in the bathroom at a golf course, and my right leg was bent backward when I fell on it. It hurt quite a bit but I thought it would be okay later. It swelled and hurt me on and off (mostly on) for one year. At times, I could hardly walk. Initially, it seemed like most of the pain was on the outside of my right knee. My internist said if it was on the outside that usually it was not treated. But then later, the swelling seemed like it affected my whole knee. It felt like there was a torn piece moving around, and it usually got worse with lateral movement. Now for about one month, it has quit swelling and there is no pain. Although now sometimes, I feel like a small pop in my right knee but there’s no pain or swelling. What would you recommend at this point?
Michael_Bloomfield,_MD: I recommend an evaluation with a knee surgeon who will do an exam and X-rays. An MRI can be ordered if needed.
hipandleg: What are the criteria for hip resurfacing? What activities are prohibited after total hip replacement?
Juan_Suarez,_MD: For hip resurfacing, we do know that female patients have a higher risk of failure mainly due to poorer bone quality. Also, resurfacing is a metal-on-metal articulation, so we do not recommend it in females of childbearing age or those with known metal allergies.
Moderator: Information regarding activities allowed after hip replacement and during rehabilitation may be found in the following article: my.clevelandclinic.org/orthopaedics-rheumatology/treatments-procedures/hip-replacement.aspx.
LJK: I am a 78-year-old female, and I have had two prior hip replacements on my left hip. The last replacement was 23 years ago. I sometimes have pain now and wonder if there is a way to avoid another full replacement.
Juan_Suarez,_MD: It is very important to follow up and get X-rays for a full evaluation. Pain can be a symptom of a mechanical failure that may need to be addressed surgically. I am unable to answer whether a full revision is required without looking at an X-ray.
Itsagoodday: If a previous hip replacement metal stem and ball are intact but the plastic acetabulum is shot, is the same side incision the best and necessary means of access?
Michael_Bloomfield,_MD: Usually for revision surgery we use the same incision, but this is highly dependent on the specifics of the situation.
Twila: What do you consider recovery time following a total hip replacement surgery?
Juan_Suarez,_MD: In general, it takes between two to three months for recovery. However, we are being more aggressive with early therapy, and by three weeks most people are moving around without assistive devices.
jennyanne1121: I am a 38-year-old female with degenerative arthritis in the right hip. My orthopod says I will need a hip replacement. Any ideas of other treatment options to delay the need for a replacement? I really don't want to have to have surgery.
Michael_Bloomfield,_MD: Non-operative treatments for hip arthritis include anti-inflammatories, activity modification, assistive devices (cane) and, occasionally, an injection. If these are not helping and your quality of life is suffering, you would be a candidate for replacement, but only when you are ready for it.
jb1371: Are there any restrictions on running after recovery from a total hip replacement?
Michael_Bloomfield,_MD: Different surgeons have different opinions. I caution my patients against long distance running for fear of repeated impact-loading causing wear of the polyethylene (plastic). Other than that, I don’t place formal restrictions.
idkwtiw: What, if any, effect does hip replacement have on vulnerability to future hip fractures? I'm guessing that this depends on what other conditions the patient presents. However, if osteoarthritis is the primary factor leading to joint replacement, does the new joint provide any added protection against fracture?
Michael_Bloomfield,_MD: Fractures can happen around joint replacements with trauma, just like in native joints. To my knowledge, having a replacement does not protect against having a fracture in the future.
Barbara: Can a pinched nerve in the back cause severe hip pain?
Terrence: I have been identified with arthritis in my right hip. I'm 61 years old and am a competitive long distance runner. (I run upwards of 90 miles a week.) I want to continue running as much as possible. I've had a cortisone injection, prolotherapy and PRP (platelet-rich plasma). I had some positive results but still not fluid movement. I'd like to avoid surgery if possible. Would stem cell injections be the next best thing to try? Hip resurfacing? Acupuncture? Do you have any other suggestions?
Juan_Suarez,_MD: Stem cell injections are debatable, and there are not many scientific papers on it for hip arthritis. Hip resurfacing is an option; however, it can have some drawbacks, mainly because it is a metal-on-metal articulation. If you can still run 90 miles a week, you don't need a hip replacement.
SteveH: My right hip hurts only while sleeping in bed after a few hours. What's the best non-surgical treatment?
Michael_Bloomfield,_MD: You can try taking an over-the-counter anti-inflammatory (like Aleve) before bed as long as you don't have a contraindication (check the bottle).
SuzeNAZ: Could lack of flexibility of the hip/leg where bone-on-bone has been seen be helped with physical therapy? I have pain when lifting that leg or climbing stairs, but could some of it be the stiffening of the muscle as I avoid these motions. Resting at night is also bad and I'm up to three to four Aleve’s per day, depending on my activity.
Michael_Bloomfield,_MD: This cannot be helped with physical therapy, and I usually don't recommend physical therapy for severe hip arthritis because it tends to aggravate pain rather than help. However, you should try and stay as active as possible until surgery.
cyn3: What are the best steps to take in the weeks/months prior to the operation to help make it more successful, such as weight loss, muscle strengthening, etc.?
Moderator: Information about hip surgery and preparation prior to the surgery may be found in this article: my.clevelandclinic.org/orthopaedics-rheumatology/treatments-procedures/hip-replacement.aspx.
willes: I am a 77-year-old female who has had no exercise for the last five years. I now have bone-on-bone knees, little cartilage in both hips and spinal stenosis. I need to know what the best exercises are to do prior to possible surgery. Also, what types of medications can I take to help with this? Which surgery should be considered first when it involves both knees and both hips? Am I causing any further damage to my knees that are bone-on-bone when I do stairs that hurt me?
Juan_Suarez,_MD: Exercises to maintain joint motion are the best, as well as quadriceps-strengthening exercises. We recommend doing the hips first to avoid alignment problems. It is difficult to avoid stairs in our society, but I don't think it causes more damage.
donnak: Why is it important to get physical therapy before knee replacement? How long, realistically, is recovery from knee replacement to where ambulating and change of position (getting in and out of a chair) are normal looking?
Juan_Suarez,_MD: Physical therapy prior to knee replacement is not absolutely necessary but can help you understand what to expect after surgery. Recovery may take up to three months, but you will see improvements during the whole first year.
willes: Should a test for metal allergies be done prior to surgery?
Michael_Bloomfield,_MD: True allergies to metal are very rare. If you have skin symptoms after wearing nickel-containing jewelry, you may have a test prior to knee replacement. (Most hip replacement components do not contain any nickel.)
jimlu: 1) For an osteoarthritis patient, which surgery is better: a total hip replacement or a hip resurfacing? 2) To choose a surgeon for a total hip replacement, which is better: a posterior surgeon or an anterior surgeon? 3) What type of technologies exists to reduce blood loss during a total hip replacement surgery? How many CCs, on average, of blood are lost during a total hip replacement? 4) Besides a major surgery like total hip replacement and hip resurfacing, are there any effective methods to treat a bone-on-bone hip problem? Does hip surgery require a blood transfusion?
Michael_Bloomfield,_MD: Hip resurfacing is an option for males under 60 with osteoarthritis. Although resurfacing has some theoretical advantages compared to replacement, it is also a metal-on-metal device, which introduces some risks as well. The results in males under 60 years old are comparable between resurfacing and replacement. The results in all other patient populations are better with replacement. If you are considering a resurfacing, you will need to have a detailed discussion with your doctor.
The long-term results after hip replacement are the same regardless of the approach used (posterior, anterior, direct lateral). I recommend choosing a doctor you trust and having him or her do the surgery they are most comfortable with.
There are several strategies used to prevent blood loss during joint replacement. At Cleveland Clinic, we use a comprehensive blood management program that includes treating anemia preoperatively. We also routinely use a medication during surgery that many studies have shown prevents blood loss. Average blood loss is probably around 250cc but depends on many factors. There are no efficacious procedures to treat severe arthritis other than joint replacement.
Juan_Suarez,_MD: I do an anterior approach in Florida, and our transfusion rate is less than two percent. The main improvement has been the use of tranexamic acid, a medicine that reduces blood loss in orthopaedic surgery. We typically lose between 250-400 ml of blood in a hip replacement procedure. The recovery after an anterior approach is faster.
cyn3: How long do knees and hips last?
Juan_Suarez,_MD: Fifteen to twenty years if all goes well.
cyn3: Are there advantages to not using general anesthesia during the procedure, and if you don't and run into complications, can a person be "knocked out" mid-way to not have to hear what is going on? Okay, I know it is a long-shot, but a concern nonetheless.
Juan_Suarez,_MD: Regional anesthesia is associated with less blood loss and decreased risk of thromboembolic events. It is definitely possible to convert to general anesthesia during the procedure, if necessary.
cschi: 1) Which replacement procedure would you recommend? I understand there are two different approaches. 2) I know about the Stryker litigation for replacement parts. How can I be sure that I am not getting defective parts inserted into my body?
Michael_Bloomfield,_MD: The actual replacement procedure is the same regardless of the approach (which is the window to access the joint). I do the anterior approach or lateral approach depending on the situation.
Stryker (and other manufacturers as well) had problems with one specific implant design. I do not use implants of that design, and the implant designs I use have an established track record. Ask your surgeon for details and do your homework!
SuzeNAZ: What are benefits/risks of anterior versus posterior hip replacement?
Juan_Suarez,_MD: The anterior approach offers faster recovery, improved component positioning and a decreased dislocation rate.
hipandleg: I'm a candidate for total hip replacement, but my biggest complaint is knee and leg pain with the knee collapsing at times. However, there is nothing medically wrong with the knee. Could this be caused by the hip?
Michael_Bloomfield,_MD: Hip pain is often referred down the thigh to the knee. If there is any doubt, an injection into the hip could be helpful to confirm that the pain is coming from the hip and not the knee. If your knee symptoms go away in the couple of hours after the hip injection (from the local anesthetic numbing the joint), then you have your answer.
kasper: I have seen an orthopaedic doctor, and he tells me I have bone-on-bone in my hip. My discomfort is in the side of my knee when I walk. I also cannot walk a long distance. Would I be a candidate for surgery? Is there any way to avoid surgery, as I have PVC's (premature ventricular contractions) with my heart and I am not sure if that could be a problem with surgery. I have no real pain but walk with a slight limp. Thank you.
Juan_Suarez,_MD: If there is any question regarding whether the hip is the source of pain, I would recommend an intra-articular hip diagnostic injection. If pain resolves, then it would be safe to assume that the hip is the main reason for the pain. Regarding having heart issues, you would need to be cleared with a cardiologist prior to surgery.
katita: I am 52 and in good shape except for a deteriorating left hip joint. My left knee is now starting to hurt because of my limp. When do I know when to go ahead with a replacement?
Juan_Suarez,_MD: Your knee pain is most likely referred pain from the hip. A decision for surgery should be based on your quality of life.
donnak: I had hip replacement at 53 years old due to osteoarthritis. Now at age 60, the lateral knee of the opposite leg is bone-on-bone. Valgus formation is present and deformity is increasing. I had a cortisone knee injection, which helped, and I am presently without lateral pain. How far is it safe to let valgus formation continue if knee pain is controlled? When does valgus become very difficult to fix? I was told by a Cleveland Clinic orthopaedic surgeon to hold off for as long as comfortably possible due to total knee being a difficult surgery to have and with recovery also being difficult.
Juan_Suarez,_MD: In general, the more severe the deformity, the more challenging the surgery. However, in the right hands these deformities can be handled properly with successful outcomes. I would base the decision for surgery on pain and not deformity.
donnak: I will possibly be checked for avascular necrosis (AVN) due to the sudden nature of knee pain after a baker's cyst ruptured. How is AVN diagnosed and why is it important to distinguish it from deterioration due to osteoarthritis?
Michael_Bloomfield,_MD: AVN in the knee is rare and can be diagnosed by reviewing X-rays. The treatments are generally the same as with osteoarthritis.
donnak: I have also been diagnosed with snapping of the sartorius muscle and hamstrings over each other in the medial knee after the baker's cyst ruptured. I was told this is a rare problem, and I would like to know if this can be repaired when the knee is replaced?
Michael_Bloomfield,_MD: Correcting your alignment (i.e. getting the leg straight again) will probably help with the muscle issue.
nailivic: My wife, who is 72, has stage five kidney disease, the last stage before dialysis. The cause is an autoimmune disease. The kidney situation is stable and not getting worse. She is in need of a knee replacement. My question is: is there a risk to her kidneys in having such a replacement, and is it advisable for her to have the replacement in view of her kidney situation? Thank you.
Juan_Suarez,_MD: The main concern would be the increased risk of infection in someone with kidney disease in dialysis. Certainly, the trauma of surgery can be threatening to renal function. However, with proper medical management, this risk should be minimized.
Asaf: I have excruciating knee pain. After looking at the X-rays, the doctor says I need a knee replacement. However, I cannot have surgery now because I had a stent put in December 2013, and my cardiologist tells me I have to wait at least one year. That is four months from now. I take aspirin and Plavix®. In desperation I had an intra-articular injection of sodium hyaluronate last week and it has greatly helped my pain. I am scheduled for one more injection today and one more next Tuesday. Any thoughts?
Juan_Suarez,_MD: Plavix (clopidogrel) is used to prevent unwanted blood clots for certain heart or vascular conditions. You need to wait a year until you can come off the Plavix before having surgery. It seems you are doing the right thing with the sodium hyaluronate injections, and those injections will probably help.
cyn3: I know individuals who have had knee replacements who have gotten blood clots. What makes you most likely to get a clot, and how best can you prevent getting one?
Juan_Suarez,_MD: Some patients have genetic predispositions to getting blood clots, and we treat these patients more aggressively. The best way of avoiding clots is by early mobilization and ambulation with therapy. We also use pneumatic devices and different medications to help avoid these issues, but the risk is never zero.
Sandie: Is the bursa removed when a hip replacement is done? I have been having a problem with hip bursitis for the past year. One orthopaedic doctor advised a hip replacement, another orthopaedic doctor said a hip replacement would not help the bursitis problem. I have had two steroid injections into the bursa with only minor help, have gone to therapy and am living on Motrin. This is impacting my way of life as I cannot walk very far. I am 74 years old, have always been active and do have some degree of osteoarthritis in the hip and back.
Michael_Bloomfield,_MD: Bursitis can be caused by hip joint arthritis, but can also occur in otherwise normal joints. I would not recommend replacement unless there is also coexisting arthritis. If there is any question where the pain is coming from (bursitis or arthritis), an injection into the hip joint can be helpful to differentiate how much of the pain is coming from each component.
Cormorant: What are the potential complications with a knee replacement operation and having three aortic aneurysms (ascending, descending and one at the diaphragm hiatus)? The aneurysms (4.3 cm diameter) are being monitored currently so nothing yet has been done about them. I am a female in my 60's, physically very active, 5 foot, 2.5 inches and 120 pounds.
Michael_Bloomfield,_MD: Although there are always theoretical risks, knee replacement could probably be done safely after consulting with your other physicians.
Itsagoodday: If I have had triple bypass surgery, how long do I have to wait for revision of my 19-year-old shot left hip prosthesis?
Michael_Bloomfield,_MD: I would leave this up to your cardiac surgeon to decide when your heart is ready for hip surgery.
gsjw: I am currently on an amount of pain medication for severe spinal stenosis and knee pain. Will this affect the administration of anesthesia during knee replacement surgery? And will it affect pain medication management during the immediate post-op period? Should I wean off my current pain medication before surgery?
Juan_Suarez,_MD: Chronic narcotic use makes pain management more difficult after surgery, and it would be advisable to wean off of it prior to surgery. Spinal stenosis may prevent the use of spinal anesthesia.
cyn3: I am comfortable with the idea of the actual operation, but my two concerns are the infection rate (I have RA and I'm on Humira/methotrexate) and the best rehab protocol afterward, as I'll be cold turkey off my RA medications awhile before and after the operation. Doctors can be checked out, but what about a hospital's infection rate and the best rehab centers? Where do I get this information?
Michael_Bloomfield,_MD: You are at higher risk for infection from both the RA and the immunosuppressant medications. Hospital infection rates are publically reported and can be found on the Internet. Ask your surgeon about the best rehab centers.
idkwtiw: Do you recommend supplements such as glucosamine chondroitin for joint health? Calcium? Others? And in what dosages?
Michael_Bloomfield,_MD: I don’t usually recommend that patients take glucosamine/chondroitin. Studies are conflicting. If you are taking it and think it helps; however, feel free to continue.
cyn3: I know an individual who actually helped develop one of the knees currently in the marketplace. He made this statement to me: Don't get a knee until you really, really need one, but I'd advise you to get a hip as soon as you think you need one. Are there more inherent advantages to a hip replacement versus a knee replacement?
Michael_Bloomfield,_MD: Using broad generalizations, total hip patients are often happier than knee patients. The recovery is easier and more predictable, therapy is easier, and the joint is more likely to be completely pain free after a hip replacement. Many hip replacement patients remark that they wish they wouldn't have waited as long. Also, my personal opinion is that non-operative treatments (including injections) are more effective in the knee than in the hip, and surgery can be delayed for longer with knee arthritis.
sam5000: Is there an increasing trend toward avoiding knee and hip surgery?
Juan_Suarez,_MD: The opposite is true. The rate is increasing and the patients are getting younger.
saxt: What treatment is available for iliotibial band dysfunction other than physical therapy?
Juan_Suarez,_MD: Steroid injections or prolotherapy. Proper stretching exercises and proper footwear and training techniques are best to allow avoidance of overuse.
Moderator: I am sorry to say that our time with Dr. Bloomfield and Dr. Suarez is now over. Thank you, doctors, for sharing your expertise and your time with us today to answer some important questions about hip and knee surgery.
Michael_Bloomfield,_MD: Thanks everyone for your good questions!
Moderator: On behalf of Cleveland Clinic, we want to thank you for attending our free online health chat. We hope you found it to be helpful and informative.
To make an appointment with Dr. Bloomfield in Ohio or any of the other specialists in the Orthopaedic & Rheumatologic Institute at Cleveland Clinic, please call 866.275.7496. You can also visit us online at clevelandclinic.org/ortho.
To make an appointment with Dr. Suarez in Florida, or any of the other specialists in the Orthopaedic & Rheumatologic Center at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at clevelandclinicflorida.org.
For More Information
On Hip and Knee Conditions
There are a number of health articles about joint replacement that may help to clarify some common questions. You may also visit clevelandclinic.org/health.
Cleveland Clinic Treatment Guides
Chronic hip or knee pain can change your life by limiting your ability to walk, sit comfortably or perform normal daily activities. When the pain interferes with your ability to do the things you need to do each day, it's time to seek medical advice.
Download our free guides that discuss common conditions and available treatment options by our specialists at Cleveland Clinic.
Don’t let hip or knee pain slow you down. See how Cleveland Clinic orthopaedic surgeons combine the latest innovations with surgical expertise for excellent outcomes. Our free DVD offers information on joint replacement surgery with patient stories.
On Cleveland Clinic
At Cleveland Clinic’s Orthopaedic & Rheumatologic Institute, located in Cleveland, Ohio, and Weston, Florida, we have designed our services so that all the specialists you need – including orthopaedic physicians and surgeons, rheumatologists and physical therapists – work together to help you return to an active lifestyle.
Using state-of-the-art diagnostics and decades of experience, we evaluate the cause of your joint pain and then tailor the most appropriate treatment for your individual needs. Cleveland Clinic’s Orthopaedic and Rheumatology programs have a long history of excellence and innovation, and are consistently ranked among the top five programs in the nation by U.S. News & World Report.
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