Online Health Chat with Trevor Murray, MD; Eric Ricchetti, MD; Gregory J. Gilot, MD

August 19, 2015


Are you and your doctor considering replacement of your hip, knee or shoulder? You are not alone: more than a million Americans will undergo a joint replacement this year, and that number is expected to grow rapidly in the future. If you are considering joint replacement surgery, get your questions answered by joint replacement surgeons who will discuss possible causes for pain, diagnosis and treatment options.

Hip and knee pain can have many causes such as osteoarthritis, bursitis, 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

Shoulder pain is extremely common, whether due to aging, overuse, trauma or a sports injury. Shoulder pain and injuries alone account for nearly 20 percent of visits to the doctor’s office. When the shoulder pain interferes with carrying groceries, participating in your favorite activities or getting a good night’s sleep, it’s time to seek medical advice.

Shoulder pain has many causes. Some of the most common conditions include:

  • Osteoarthritis – This is the wearing down of cartilage that allows bones to glide smoothly within the joints. It can occur with aging, trauma or an overuse injury.
  • Rotator cuff injuries – These include tendonitis and rotator cuff tears and are the most common causes of shoulder pain and activity restriction.
  • Bursitis – This is inflammation of the bursa and is most often caused by repetitive motions (overuse), or repeatedly bumping or putting pressure on the area.

About the Speakers

Trevor Murray, MD, is an orthopaedic surgeon specializing in hip and knee surgery and replacement. Dr. Murray graduated from Case Western Reserve University School of Medicine. He went on to complete an orthopaedic surgery residency at Cleveland Clinic. Following his residency, he completed an adult reconstruction fellowship at Rush University Medical Center in Chicago, Illinois.

Dr. Murray’s specialty interests include hip and knee replacement, including complex primary and revision hip and knee surgery, and knee arthroscopy.

Eric Ricchetti, MD, received his medical degree from University of Pennsylvania School of Medicine. Dr. Ricchetti completed his internship and residency in orthopaedic surgery at the Hospital of the University of Pennsylvania and also completed a year of dedicated research in the McKay Orthopaedic Research Laboratory at University of Pennsylvania. He completed a fellowship in shoulder and elbow surgery at Thomas Jefferson University Hospital, the Rothman Institute.

Dr. Ricchetti's interests in shoulder pathology include joint replacement and arthroscopy, rotator cuff tears and other tendon and ligament problems, sports injuries, and trauma. Dr. Ricchetti is very active in shoulder and elbow research and has authored a number of publications and book chapters, including presenting at regional and national conferences.

Gregory J. Gilot, MD, is a board certified orthopaedic surgeon with a specialization in adult reconstructive shoulder surgery. He started with Cleveland Clinic Florida in Weston in 2007 to later become the chair of the Department of Orthopaedic Surgery three years later. In 2013, Dr. Gilot was named director of the Orthopaedic and Rheumatologic Center at Cleveland Clinic Florida, which includes the Departments of Orthopaedic Surgery and Rheumatology and the Sections of Sports Health and Podiatry. His leadership roles also include Fellowship Program Director and Patient Experience Champion.

Dr. Gilot completed his fellowship in adult shoulder surgery at the University of Texas Health Science Center in 2004. He attended medical school at Pennsylvania State University College of Medicine where he graduated with distinction. He went on to complete his residency in orthopaedic surgery as chief resident at Louisiana State University Orthopaedic Department. Dr. Gilot is a fellow of the American Academy of Orthopaedic Surgeons and a diplomat of the American Board of Orthopaedic Surgery.

Let’s Chat About Joint Replacement

Moderator: Welcome to our chat about Answers on Joint Replacement Surgery with Cleveland Clinic orthopaedic surgeons and joint specialists, Dr. Trevor Murray and Dr. Eric Ricchetti from Ohio and Dr. Gregory Gilot in Florida. Doctors, thank you for taking the time to be with us and share your expertise about joint replacement options.

Replacement Parts

Allergic1: Hello. I will be needing knee and hip replacements due to having osteoarthritis. Because I am severely allergic to nickel, I am afraid to have metal joint replacements. Orthopedists I have seen do not address my concerns about nickel, saying "there is just a small amount of nickel" in replacements containing metal, and saying that "most" people do fine. I had surgery some years ago, and surgical steel staples were used to close the surgical site. However, the surgical staples had to be removed because of my nickel reaction. I have postponed joint replacement because of this, and I have not been able to find much information about alternatives to metal replacement joints. I do not want to risk joint replacement failure since I have a nickel allergy and am not in the best of health otherwise. What are the latest and/or best alternatives to having metal joint replacements. Thank you for the opportunity to ask my question.

Trevor_Murray,_MD: It is true that we do not fully understand the impact of nickel allergy on the outcome of total joint replacement. That being said, if a patient like yourself reports a nickel allergy, we use nickel-free implants. They are still metal but contain no nickel. This is true for both hip and knee replacements.

wellman: There are many types of knees used for replacement. Is there a lot of difference between them when it comes to life and durability?

Trevor_Murray,_MD: Essentially, all contemporary knee replacements are the same. They are all made for high demand patients and made to be durable.

wellman: Have you heard of the custom knee replacement, Conformis? What are your thoughts on that?

Trevor_Murray,_MD: I have heard of Conformis. I think it is an interesting concept. My main concern is lack of historical data on the implant and, therefore, there is some question concerning its performance over the mid and long term. However, all new implants have this concern, but many of the new implants are based off of historical designs known to function well.

SATURN9: Is it true there are different shapes of knee replacements, such as oval or round? There are different brand names. Who determines these things, or is it not a choice? Thanks.

Trevor_Murray,_MD: In short, the surgeon chooses the implant. Some hospital systems have a limited vendor contract, which dictates what the surgeon uses. All contemporary replacements are very similar, and none have been shown to be superior to the others.

Tadpole325: Which device does Cleveland Clinic use for total knee replacement, and what is the success rate?

Trevor_Murray,_MD: There are different devices used by different surgeons. They all have similar high success rates.

Sorting Through Symptoms

Formula28: I am 62 and have been active all my life. I do have some arthritis that I live with and some upper and lower spine compression and herniation that I also live with. In the last few years, I have been having pain in my legs that seems to move around and comes and goes. Sitting seems to make it worse and I suspected sciatica. The worst is what I can only describe as a shin splint (but is not) and pain in the muscles and tendons. The right side is worse. My knees are also painful and are aggravated by going down stairs. The right one pops loudly when extended. The last few months have been really bad, to the point where work is at risk and quality of life has diminished greatly. I am trying Celebrex again this week and using my teeter, as the pain drugs were not working anymore. How can I ascertain the source of the pain and what, if anything, needs replaced? Thank You.
Trevor_Murray,_MD: It is not infrequent that patients will have overlapping conditions. The combination of history, physical exam and radiographic findings would help determine what needs addressed first and how.

rang645: My wife had been diagnosed with breast cancer (Stage 1) in 2008, and she has been treated well throughout these seven years by her physician with AROMASIN® (exemestane) tablets 25 mg after undergoing a surgery, chemotherapy and radiation. She is being checked by the physician periodically and is free from the disease. However, recently she has been experiencing severe joint stiffness/pain in the knees and lower back and has had other joints symptoms that are considered to be possible side effects of this medicine. Is it safe to stop AROMASIN, which may reduce the joint pain symptoms? If not, what should be her first step to treat these symptoms? Thank you.

Gregory_J._Gilot,_MD: Arthralgias (joint pain) and myalgias (muscle pain) are possible side effects of certain medications that your wife may be experiencing. She should be evaluated by her medical oncologist and/or primary doctor.

Karenc: Can calcification in the labrum cause severe acute pain? Treatment with oral prednisone took care of most of the pain, but I still have some mild pain. I am taking Celebrex and Tylenol. Will I need a hip replacement eventually? I'm 71.

Gregory_J._Gilot,_MD: Great question. If your symptoms are improving, joint replacement may not be required. However, calcification within the labrum, while it can be associated with hip arthritis, alone is not an indication for hip replacement.

Wellman: I am a 58-year-old male. I have bone-on-bone in both knees on the inside as well as arthritis in three to four compartments in both knees. I have received Orthovisc injections every six months for the past five years that provided relief. Approximately five days after the last round, I was walking and all of a sudden a very sharp pain started in one knee. It was like that for a week, and now I can only walk "gently" and stiff legged. Is it time to proceed with the replacement?

Gregory_J._Gilot,_MD: At this point, evaluation with standards radiographs would be the next appropriate step. Worsening arthritic symptoms can be an indication for evaluation for a knee replacement.

cyclist: I had hip replacement in 2003. I've had no problems until recently. A lump in the area of the incision caused the surgeon think that polyethylene from the replacement joint may be disintegrating. Upon opening the area, he found that the problem did not go down to the bone, so he cleaned up everything and closed it again. The problem is that since the middle of June when this last surgery took place, the incision has been bleeding. He checks every two weeks to see if it heals itself but I am concerned. I would appreciate your answer to my question.

Trevor_Murray,_MD: A wound that has not healed in that period of time is concerning. Further evaluation with a physical exam and some labs would be necessary to know what, if anything, should be done.

bigal: I had a total knee replacement three years ago, but have chronic pain in the knee as well as popping and cracking noises in the knee. I have been told an arthritic hip is probably referring pain to my knee. If I have a hip replacement, what are the chances that the knee pain will lessen, and the popping and cracking will go away?

Trevor_Murray,_MD: Many knee replacements "crack and pop." They are metal and plastic and, therefore, make noise. I would have an injection of local anesthetic into your hip joint prior to surgery. If that injection takes away your knee pain, then you know what to expect from a total hip replacement. We will often see referred pain from the hip to the knee.

Rmaraz: According to my doctors, I should have knee replacement surgery in my right knee, and possibly later in the left one. In the meantime, I have been diagnosed with small fiber neuropathy. It is most uncomfortable and affects both legs and feet from the knees down. My question is: could knee replacement surgery negatively affect the small fiber neuropathy? Could it get worse? Thanks.

Trevor_Murray,_MD: My sense is that it could become worse in the postoperative period, but I would not think it would have any long-term effects.

Replacement Alternatives

trishp267: I've read recently about knee surgery that, instead of replacement, is knee resurfacing. Does Cleveland Clinic do this type of surgery?

Trevor_Murray,_MD: There are some alternatives to knee replacement for a small group of patients. If there is only a small area of cartilage disease, you may be a candidate for a focal resurfacing procedure. Dr. Miniaci at the Cleveland Clinic performs this surgery. Again, this is reserved for a select group of patients based on their cartilage issue. It should also be stated that a knee replacement itself should be called a knee resurfacing. We do not replace the entire knee, we simply resurface the entire knee.

inomis: I am a 64-year-old male with early stage Parkinson's disease. I was having pain in the right knee and had an MRI in March 2015 that shows:

  1. A horizontal tear involving the posterior horn of the medial meniscus
  2. Medial joint compartment arthrosis with articular cartilage thinning and reactive subchondral marrow signal changes
  3. A moderately sized joint effusion with a suspected 3mm loose body
  4. 4 x 2.5 x 2.0 cm popliteal cyst

My orthopaedic surgeon gave me a steroid injection in March and recommended that I consider Supartz therapy and or complete knee replacement. Since the steroid injection, I have had no pain in over five months. I'm unsure of what to do next. I welcome your opinion.

Trevor_Murray,_MD: Oftentimes, a steroid injection in this setting brings significant relief for a long period of time. Given your five month relief from the injection, when/if it wears off, I would recommend a repeat injection. Given your findings on MRI, if the steroid injections stop providing relief, you may be a candidate for arthroscopic debridement of your meniscal tear and removal of the loose body.

SarcoidLady: What are some alternative treatments for hip joints that are bone-on-bone?

Gregory_J._Gilot,_MD: Conservative treatment options include guided injections of a steroid or viscosupplementation (gel injections). However, the efficacy of such treatments is less reliable in advanced arthritic disease.

Formula28: What do you think about the new injections of stem cells I hear about lately?

Eric_Ricchetti,_MD: As it relates to the shoulder, there is not yet clear evidence on its benefit. But it may be an option for pain relief if other non-surgical options fail and you are not yet ready for a joint replacement.

Summing-up Surgery

rxbobt: 1) Is there any age limit as to when a person is too old to have knee replacement surgery, or too young? And is there any danger in putting it off or waiting to have the surgery? 2) Is there anything that can be done before surgery to make it more successful, like physical therapy at a facility or in a home program? 3) What are the risks of the surgery and the expected recovery time? 4) What medication will be given during surgery, after and at home for pain relief? How long will the pain last? 5) One article I read mentioned the use of a CPM (continuous passive motion) machine at home.
Is this something that you recommend? 6) What are your thoughts about bilateral knee surgery? I keep getting questions as to why I am not having both done at the same time.

Trevor_Murray,_MD: There are no hard and fast age limits or requirements. It is based on the severity of the arthritis and the health of the patient. Doing low-impact exercises prior to surgery is recommended. Improving quad strength can be beneficial. Surgical risks include but are not limited to infection, blood clots, knee instability, knee pain, knee stiffness and nerve injury, but fortunately, even when combined, they occur at a low frequency. Recovery time differs between patients. Usually, a cane or walker is used for three to four weeks, and 90 percent are recovered by 10 to 12 weeks. We use a combination of nerve blocks, anti-inflammatories, Tylenol and low-dose narcotics for pain control. I do not use a CPM. There are no convincing articles supporting its use. I reserve bilateral knee replacements for patients who are healthy, motivated and have straightforward arthritis. Risks of bilateral replacement are more than double those of a unilateral.

capezz: I would like to know if there is anyone in the Cleveland area who does minimally invasive knee replacement surgery. If so, how would I find out more information about these surgeons?

Trevor_Murray,_MD: Most of our joint replacement surgeons perform "minimally invasive" surgery. This term refers not only to the surgery, but more importantly to the pain control and therapy strategies. Many of our patients go home within 24 hours. This is mostly done at Lutheran Hospital in the Cleveland area.

Gregory_J._Gilot,_MD: We have similar strategies in Florida as well.

teddya1: I am 77 and have arthritis in my left and right knees but worse in my left, causing pain. I have heard that there is research into using cadaver or animal cartilage for replacement. Is this true and would a man of my age be considered?

Trevor_Murray,_MD: There are certain specific situations where cadaver bone and cartilage are used to treat patients with knee issues. However, it is not an option for someone who has diffuse arthritis in the knee. It is reserved for a cartilage lesion that has happened secondary to a trauma.

MarL: Hi. I would like to know how a doctor determines whether a patient would need a partial or a total knee replacement. I realize every patient is different, but I was just interested in how that is determined. I will be facing this surgery later this year. Also, on the average (again realizing everyone is different) what is the average down time? Thanks.

Trevor_Murray,_MD: This is based on x-ray findings and exam findings. The knee is essentially three compartments. If the patient has pain and arthritic changes in only one compartment, they are likely a candidate for a partial knee replacement. Recovery is six to eight weeks for partial and 10 to 12 weeks for a total knee.

mamazipp: I am on apixaban for A-fib. What is the protocol regarding anti-coagulation during surgery when having a knee replacement? Is spinal anesthesia possible?

Trevor_Murray,_MD: The protocol is patient specific. We enlist the help of cardiology colleagues to guide us. Typically, in the setting of A-fib you are able to come off the anti-coagulant for the perioperative period and undergo spinal anesthesia.

rxbobt: Do you play music during surgery? I heard this helps with the recovery.

Gregory_J._Gilot,_MD: I do play music in my operating room. Unfortunately, I get outvoted by the OR staff in terms of the genre. Good indications, good patient selection and good technique help with outcomes.

Candidate Considerations

KJ: I am a 60-year-old male with a history of problems with my left knee. Many years ago (late 1970s and early 1980s), I had surgery on this knee, one was a cartilage repair and the other was a tendon repair (if I remember correctly).  For the last three years, I have had issues with increasing pain and swelling in this knee. Initially, it was drained and injected with a steroid, but this had minimal effect after trying it twice. I have also had physical therapy, again with minimal benefit. I was prescribed a brace to wear (a down-loading type to shift the weight off the inside of the joint). Initially, it helped, but not as much lately. I'm told that ultimately I will need to have a total knee replacement.
My question is: am I too young for this surgery? My quality of life is affected, but on the other hand, I don't want to undergo a second replacement surgery down the road as, hopefully, I will live for many more years! What are my options please? Thank you.

Trevor_Murray,_MD: The short answer is you are not too young. You have done all the appropriate treatments prior to undergoing knee replacement. One option is to continue the brace and activity modification. The other option is to discuss knee replacement with a specialist. Knee replacements today will hopefully last 20 to 25 years. I always tell my patients that if they are miserable from their knee arthritis and they have exhausted other treatment options, then it makes sense to proceed with knee replacement to regain quality of life now when their health is good.

don: I'm 42 and my knee is getting worse every year from arthritis and prior injuries, with activity becoming more difficult. Why is it that doctors want to wait to do a joint replacement until I am older. I have had multiple surgeries and even tried platelet-rich plasma (PRP) therapy. With everyday tasks getting more difficult, this is very frustrating. Thanks.

Trevor_Murray,_MD: This often depends on the degree of arthritis seen on x-ray. Patients who are young and have had multiple surgeries on their knee and experience pain without severe arthritis on x-ray often have poorer outcomes. Age is not a hard stop to surgery, whether it is old age or young age. The entire picture is what determines whether someone is a good candidate for surgery.

inomis: In your experience, do early stage Parkinson's disease patients have a longer recovery time with knee replacement surgery? Is there a cut-off point in the disease progression of PD that you would not do a knee replacement?

Trevor_Murray,_MD: Parkinson's disease can lead to a longer recovery. It is based on the severity of the disease and is therefore patient specific.

Risks and Complications

rcicc: I had a hip replacement and developed heterotopic ossification (HO), which has since matured. It has affected some nerves in my leg and minor range of motion in the hip. I experience pain after strenuous walking, and I take ibuprofen and Tramadol as needed. My question is: Is there anything else I can do to reduce the effects of HO? Is there any way to tell if a person is pre-disposed to this condition so they can irradiate the area within 72 hours of surgery?

Trevor_Murray,_MD: In select cases, surgery can be performed to remove the heterotopic ossification. Only when it is severely debilitating due to decreased range of motion is surgery considered. There are some predisposing factors for its development such as ankylosing spondylitis or hypertrophic arthritis. That being said, it can develop in anyone.

msmary: I am eight and a half months post total knee replacement of the right knee. Since the very beginning, I have experienced pain, stiffness, swelling and difficulty walking. I have been negative on testing for infection, but have tested positive for prosthetic loosening and allergic reaction to the benzoyl peroxide ingredient in the bone cement. I have only been offered consult to pain management and told "it will take a little while longer." My left knee was done in 2009, with a stellar outcome. What relief can I hope to get for this bad surgical outcome?

Trevor_Murray,_MD: First, patients can continue to see improvements in their knee replacements for 18 to 24 months after surgery. Pain and stiffness within the first year is sometimes seen and resolves with time. However, if you truly have loosening of your implant, I would recommend consultation with a specialist to discuss revision surgery. I would not make much of the allergy, as you probably have bone cement in the other knee and have had a great outcome. Knee replacements can get loose for a myriad of reasons. A full work-up for those reasons is indicated.

anson3: In a previous question you mentioned three risk factors associated with anterior hip replacement. How can the surgeon control these risks? I am scheduled for an anterior procedure, and the three risk factors you mentioned were not discussed.

Trevor_Murray,_MD: Surgeon experience coupled with patient size are probably the best ways to minimize those risks. There are risks of any hip replacement, but they seem to be a bit higher in the anterior approach.

Making the Decision

ARDr: Please list the appropriate steps to selecting a surgeon/medical center for knee replacement surgery. What statistics should I expect to see? Are there any unbiased sources of information? Are there any recognized centers for excellence?

Trevor_Murray,_MD: Both hospital and surgeon volume have been shown to impact outcomes. More and more outcomes are being publicly reported. It is very difficult to get "unbiased" information, as it is very difficult to adjust for complexity of surgery and patient in these outcomes. For example, a place that does a high proportion of complex cases in medically complex patients may have different outcomes than places that do not. I would discuss with your surgeon and ask others who have had the procedure done.

arms: X-rays show bone-on -bone in both of my knees. The right one is worse and there is a lot of pain in the hip, knee and ankle. I can walk better in orthopaedic shoes but it's still painful. Is replacement a good idea or am I just opening a Pandora's box to more problems? I am 79 and do not want to spend the rest of my life in a nursing home recuperating. I am also a diabetic. What should I do?

Trevor_Murray,_MD: Certainly, meeting with a joint replacement surgeon is a good idea. Knee replacements are great at relieving pain and improving function. Complications can occur, but the chances are very low. The vast majority of our patients do not go to a nursing home. They recuperate at home with therapy at home for the first three weeks then at an outpatient facility. Diabetes does increase the risk of complications, but these risks are greatly reduced if you an HgbA1c that is 7 or lower.

EPN2015: If you're a very healthy 66-year-old male and can manage hip osteoarthritis with exercise and activity modification along with use of naproxen and/or diclofenac (only when needed before more athletic activity), is it wise to DELAY hip replacement until your mid 70s? I'm concerned about surgical risks and post-op infection risk.

Trevor_Murray,_MD: It is wise to delay surgery if you are relatively symptom free with exercise and activity modification. Hip replacements are very successful at alleviating pain and improving function. There are risks but these are very, very low in a typical healthy patient. However, I would not wait until you have significantly modified your activities to the point that you do not do many of the things you used to enjoy.

nutzy: My husband is 70 years old and still working every day. He was told that he must undergone a total knee replacement. How can he know it is time to do it? He is using medicines like Voltaren 100mg, but only for limited periods, and once he had a cortisone injection, which helped him for a while. He was a very active man. What can he do until the surgery, injection with hyaluronic acid, maybe? Last question: if we have steps in the house, will he need more time to be hospitalized? Will he need to be in a special (rehabilitation) unit? Thank you.

Trevor_Murray,_MD: He will know when he is ready. Once his knee negatively impacts him on a daily basis then he will likely be ready. If he is getting good relief with injections and Voltaren, then he can keep managing that way. Hyaluronic acid is an option, but studies don't show any overwhelming benefits. That being said, it is very low risk and therefore an option. Steps can be difficult but I would still expect and recommend he go home after surgery as opposed to a rehab facility.

willes: If one has spinal stenosis and severe osteoarthritis in the right hip and both knees, which would you recommend being done first?

Trevor_Murray,_MD: I would start with whichever one is most symptomatic.

Allergic1: Can I be tested prior to surgery for allergies (other than my known metal allergy) that might be problematic to a person inclined to be allergic, such as to the glue? Thank you.

Trevor_Murray,_MD: There are no great tests for this. Skin testing can be done but it does not correlate to true allergy. There is a blood test at Rush in Chicago that is the best available. Again, we do not know the correlation between those allergies and the outcome of a total joint replacement.

minna98: I was evaluated by an orthopaedic surgeon a year ago. I have had osteoarthritis in both knees for about 15 years and lately have had some hip problems. I have taken glucosamine and meloxicam for years and have no pain except when walking several miles. It was suggested to start with the hip surgeries. What is the reason for this thinking? I am not ready to give up two years of my life to surgeries at my age of 77. I can get around fairly well and do not have pain other than when walking a lot. I do warm water exercises mostly.

Trevor_Murray,_MD: It sounds to me that you are functioning at a high level and do not need surgery at this time. Typically, we do start with the hips because they have a more reliably good outcome and some knee pain can be referred from the hip.

Follow-up and Recovery

cgr111: I had a hip replacement approximately 15 years ago. I'm not experiencing any pain and have it checked once per year. Are there any special symptoms I should be aware of (other than pain) that would indicate the need for treatment? Thanks.

Trevor_Murray,_MD: You are doing the right thing. At this point, x-ray surveillance each year is the best way to monitor the status of your hip replacement.

JoeyD: I am scheduled for left knee replacement in October. How long should I expect before I can start walking without the aid of a walker or cane?

Trevor_Murray,_MD: About four weeks.

chickbull: I am 81 and had hip replacements, 13 years ago for one hip, 12 years ago for the other hip. What will happen next if another replacement is needed? Anything I should be doing or not doing now?

Trevor_Murray,_MD: If the replacement wears out, oftentimes the only thing that needs to be done is a head and liner exchange. It's like a re-treading procedure. If there is significant bone loss, a larger surgery may be necessary. At this point, you should get an x-ray of each hip every year to monitor them.

Procedure Approaches

porching: Please discuss anterior versus posterior hip replacement. People seem to feel the recovery from the anterior is much easier and quicker.

Trevor_Murray,_MD: There are different anterior approaches to the hip, some of which require a special table. We have surgeons at Cleveland Clinic Florida that perform this type of surgery. Each approach has its advantages and disadvantages. Hip replacement is a great surgery when done right through any approach. It is done as an outpatient (23-hour stay) through anterior and posterior approaches.

LJC: I would like to know if the anterior hip replacement option can be performed at Cleveland Clinic. I understand maybe it requires a special operating table and doctors trained in this approach. I'm not sure if everyone/anyone can do this. If it's an option, how do I find those doctors that specialize in this? Thanks.

Trevor_Murray,_MD: See previous answer.

Gregory_J._Gilot,_MD: We offer anterior approaches to hip replacement in Florida. We do have surgeons trained in this approach with dedicated anterior hip surgery tables and instruments.

anson3: Can you discuss the pros and cons of anterior versus posterior total hip replacement. It appears that for most patients anterior is the way to go because there is less muscle trauma and faster recovery. Are there any risks to the anterior approach?

Trevor_Murray,_MD: In addition to pros and cons previously discussed in another question, there is an increased risk of fracture, heterotopic ossification and nerve injury with an anterior approach. There is a lower risk of dislocation. Both posterior and anterior approaches recover very quickly.

elley: Is minimally invasive hip replacement the same as the anterior approach? What are the pros and cons of minimally invasive hip replacement versus traditional total hip replacement?

Trevor_Murray,_MD: Minimally invasive and anterior hip replacement are not the same. A posterior approach to the hip can be minimally invasive as well. What we have learned is to damage as little soft tissue as possible to do the surgery safely. We have better instruments, better pain control and better therapy protocols that allow quicker and easier recovery.

Before and After

sberl: I'm 49 and have had three knee surgeries [ACL(hamstring), two meniscus/cleanup]. I have arthritis, swelling and an ACL that doesn't function any longer. How long should I prolong a knee replacement? And will I continue to have swelling even after I do have a replacement? Can I do running, jumping, lateral movements if I proceed with the replacement or are there any other alternatives for me?

Trevor_Murray,_MD: As stated in another question, treatment depends on the degree of arthritis seen on x-ray. Patients who are young and have had multiple surgeries on their knee and experience pain without severe arthritis on x-ray often have poorer outcomes. Age is not a hard stop to surgery, whether it is old age or young age. The entire picture is what determines whether someone is a good candidate for surgery. With regard to swelling, some patients will still experience swelling after knee replacement. As far as activities, we recommend low-impact activities such as cycling, swimming or elliptical machines.

biodee: What types of activities/motions would not be possible post total knee replacement surgery? I have heard that kneeling is no longer possible. Is this correct? How many miles would it be reasonable to assume a person could hike/walk along maintained trails post surgery if this was a hobby/vacation choice pre-surgery? What happens if a person falls on the knee that has been replaced? Thank you.

Trevor_Murray,_MD: As far as activities, we recommend low-impact activities such as cycling, swimming or elliptical machines. I think it is very reasonable to expect to be able to hike several miles on well maintained trails. My patients are allowed to kneel on their knees, but many do not like the way it feels. Certainly, you can injure the knee with a fall. The bone around the implant can break, but unless your bone quality is poor, it usually takes a pretty significant injury to cause problems.

Grad: Good afternoon. I am scheduled for a hip replacement in about six weeks, and I am hopeful you can comment and advise on two fronts: 1) Would it be beneficial for me to ride an exercise bike for an hour a day up to the day of my surgery in order to be as fit as possible going into the procedure. I can ride the bike with less discomfort than walking. Would this help in the subsequent rehabilitation? 2) After the rehab period (which may be how long? ), will I be able to comfortably resume normal activities such as hiking, biking, skiing, golfing, etc. Also, we are planning a three-day driving trip in January, and I am not sure what to expect or if this plan is even realistic. Your comments and advice, please.

Thanks very much for doing this chat. It is very difficult to remember to ask your doctor all these things, let alone to get answers to questions that pop into your mind the minute you leave his/ her office. I look forward to hearing your replies to theses and other queries. Thanks again.

Trevor_Murray,_MD: 1) Yes. Any low-impact exercise you can do leading up to surgery will be beneficial. 2) Rehab is typically eight to10 weeks. I would expect you to be able to resume all of those activities. You should be ready for the three-day trip in January.

sberl: I'm a 49-year-old female and am contemplating a knee replacement. What would be my activity restrictions? Right now, my doctor restricts me from running or jumping. Would that still be the case if I had a replacement? Also, what is "complex primary and revision knee surgery"?

Trevor_Murray,_MD: That is somewhat surgeon specific. I recommend low-impact activities. Knee replacements are done to get patients back to an active lifestyle, but it is reasonable to make some concessions to improve the longevity of the implant.

Shoulder Specific

pumpkin1: I have severe glenohumeral joint osteoarthritis with very limited range of motion. I was told by an osteoarthritis surgeon that since pain is not a factor, an operation is not advised, as it would not improve range of motion. On your website, you told of a newer operation that is described as: "more adaptive, made up of several smaller pieces. Modular implants are inserted." With this operation, what are the odds of my regaining normal range of motion? If so, I would appreciate more information on all aspects.

Gregory_J._Gilot,_MD: Different joint replacement implants are offered for different arthritic conditions. I would recommend an evaluation with one of our orthopaedic surgeons. The evaluation will start with x-rays and include a thorough history and physical examination.

Wadegolf8: Does shoulder replacement restore the nerves and muscle attachment to the synthetic used?

Gregory_J._Gilot,_MD: Great question. In most cases, the goal of joint replacement is to resurface the arthritic portions of the joint and not to detach muscles and nerves.

pumpkin1: This is an addition to my previously typed chat question in which I asked if I was a candidate for the new shoulder operation to regain range of motion. If your answer is yes:

  1. Is it an outpatient operation. If not, how long are you in the hospital?
  2. Is therapy begun immediately?
  3. What are the chances of success to regain normal range of motion, and if it is unsuccessful, can I be in worse shape?

Gregory_J._Gilot,_MD: Most shoulder replacements performed result in a minimum of one night of hospitalization. Therapy is initiated in the early postoperative period in a gentle fashion. In the right patient, a return of a functional range of motion can be expected.

rcala: Please discuss reverse shoulder replacement when rotator cuff repair is not an option.

Gregory_J._Gilot,_MD: Reverse shoulder replacement is a surgical option in patients who suffer from irreparable rotator cuff tears with or without arthritis who have poor function and/or pain who have failed a course of non operative treatment.

Wadegolf8: I am 68 years old and have bone-on-bone arthritis in both shoulders (the right one is worse). I have been exercising with weights for most of my life. Now, it is necessary to "work around" different exercises because of my problem shoulders. Is there any alternative to a shoulder replacement? Mine are pretty bad, and another orthopaedic surgeon has suggested replacement. So if replacement is imminent, will I likely be able to return to resistance exercises and build up the muscle at my age? Thank you.

Eric_Ricchetti,_MD: If your arthritis is severe enough, the most reliable surgery is shoulder replacement. Once fully recovered from shoulder replacement, you can get back to an active lifestyle, but we generally recommend against heavy weight-lifting to avoid the replacement parts wearing out too early. Light resistance exercises are good to maintain strength, but weight-lifting hundreds of pounds may be harmful to the implant.

louis: I've been diagnosed with a small tear in my rotator cuff and have gone through physical therapy. The pain now seems to be virtually gone. I no longer do the exercises at home that I learned at the PT facility. Should I continue the PT exercises I did to reach this improved level or do I risk increasing the tear? Can PT solve a rotator cuff tear situation as a replacement for surgery or am I just putting off the inevitable?

Eric_Ricchetti,_MD: It is best to continue with the PT exercises to avoid developing symptoms again in the future, although you may not need to do them as frequently. The PT exercises are designed to help the shoulder, not cause further tearing. A small rotator cuff tear may not require surgery if the symptoms do not return. A small tear would not require replacement surgery, but may need surgery to fix the tear if symptoms do not resolve or if they worsen.

pumpkin1: I have been diagnosed by an orthopaedic surgeon as having severe glenohumeral osteoarthritis. Since I do not have pain in general, unless trying to raise it, he advised against surgery and to just adjust to the loss of range of motion. However, I recently saw on your website a newer, innovative way to address this problem. "Shoulder Replacement made up of several smaller pieces. Modular implants are inserted on both sides of the joint. This allows the implants to exactly replicate the patient's anatomy." It mentions this is possible in even SEVERE cases. Is this possible for me?
Eric_Ricchetti,_MD: Yes, it would be. The main reason for shoulder replacement surgery is pain relief, so a shoulder replacement such as this would be an option for you if your pain complaints are bothersome enough for you and effect your daily life enough.

5jake: I am considering shoulder surgery. Presently I am having hyalanortis shots. I have had three so far with little improvement. I am scheduled for five shots. Can I expect improvement?

Eric_Ricchetti,_MD: If you are in the middle of getting your series of shots, I would complete the course. You do not always have immediate relief with the first few injections and may not notice the effect until the course is fully completed.

pumpkin1: Previously, I submitted a question but got no confirmation it was received. Again, I was diagnosed by an orthopaedic surgeon as having severe glenohumeral osteoarthritis. The doctor said since I'm having no pain, an operation would not correct the loss of range of motion, so he would not operate. On your website, I read of a newer, innovative way that would restore range of motion using "modular implants that are inserted on both sides of the joint, allowing the implants to exactly replicate the patient's anatomy." Would I be a possible candidate for this. I do so want to get back my range of motion. If so, where could I get more information on this?

Eric_Ricchetti,_MD: Yes, you would be a candidate, but the main reason for shoulder replacement surgery is pain relief. So, a shoulder replacement such as this would be an option for you if your pain complaints are bothersome enough for you and it affects your daily life enough.

pumpkin1: No it has not. I have said pain is not a factor. Your website says range of motion can be restored with this NEW operation. That is all I'm hoping for. Sorry to be so much of a problem, but I have such high hopes for this NEW procedure. Again, no pain. This comment would be for Dr Ricchetti.

Eric_Ricchetti,_MD: Even that type of operation is typically not done just for range of motion. It is done for pain, and then range of motion also improves with the surgery.

General Information

KJ: Thanks for providing these web chats. This is a great road map to help figure out next steps!


That is all the time we have for questions today. Thank you, Dr. Murray, Dr. Ricchetti and Dr. Gilot for taking time to educate us about the different types of joint replacements.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative.  If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

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