What to Expect When You’re Having a Total Joint Replacement with Dr. Trevor Murray

Podcast Transcript

Nada Youssef: Hi, thank you for joining us. I'm your host, Nada Youssef. Today we have with us our orthopedic surgeon, Dr. Trevor Murray, and we'll be discussing joint replacement. Before we begin, please remember this is for informational purposes only, and it's not intended to replace your own physician's advice.

Thank you so much for being here today. If you want to just take a few minutes to introduce yourself to our audience.

Dr. Murray: Sure, thanks for having me. I'm looking forward to it. As she said, my name's Trevor Murray, I'm an adult reconstruction surgeon here at the Cleveland Clinic. Little background, I was actually a resident here from 2004 to 2010, where I did a residency in orthopedic surgery, and then I went to Chicago for a year to do a fellowship, which was a year of specialization in total hip and total knee replacements. I've back been here on staff since August of 2011, so almost seven years.

Nada Youssef: Wow.

Dr. Murray: Yeah, it goes really fast. I specialize in total hip and total knee replacements, including partial knee replacements, and then also revision surgery, trying to take care of hip and knee replacements that aren't working appropriately.

Nada Youssef: Great, well thank you for being here today. I want to start off with general question. What is osteoarthritis, and why knees and hips are affected by it.

Dr. Murray: In short, osteoarthritis is the loss of cartilage on the end of our bones. Typically, cartilage is a very frictionless, smooth surface which allows us to move our joints freely and without pain. Osteoarthritis is when we start to lose that surface on the end of our bones. It can affect any joint in the body. It's common in the hip and knee, it's actually most common in the knee due to the fact that they're weight bearing joints. The etiology, or where it comes from we're not exactly sure. There are certainly environmental factors, but mostly it's in our genetic code. We'll see patients of all shapes and sizes, and activity levels develop arthritis.

Nada Youssef: Does it get worse with age then?

Dr. Murray: It does. It is a degenerative process by definition, and over time that condition will worsen. Something interesting about osteoarthritis is that patients will go through periods of time where they have very mild symptoms, followed by times of severe symptoms. Then, actually, a loss of symptoms again, so it can be a little confusing for patients. Over time, if you charted, they get worse as time goes on.

Nada Youssef: Okay. Now, who is a candidate for this surgery?

Dr. Murray: If we're talking about hip and knee replacements, the imaging has to match the patient. I tell my patients all the time, we don't treat x-rays, we treat patients. They need to have end stage arthritis on x-ray, they need to have tried non-operative management, whether it's through activity modification, formal physical therapy, anti-inflammatory medications, giving that a good effort, and then be medically appropriate to undergo hip and knee replacement. Those are conversations that you would have with your own surgeon.

Nada Youssef: Obviously, the pain level needs to be pretty high.

Dr. Murray: Absolutely. Yeah, thank you. If a patient comes to me and has x-rays that show end stage arthritis, that patient, if they're doing well, and is functioning well, certainly does not want surgery. This is an elective procedure, this is not a clogged artery in your heart, this is not a tumor, this is a quality of life decision, so pain needs to be part of it for sure.

Nada Youssef: Right, now let's talk about the surgery itself. Are there new joint replacement technologies that we should be talking about?

Dr. Murray: There are. It seems like every day there's new technology. I think in a place like the Cleveland Clinic we need to be responsible about how we manage that technology and introduce that technology to our patients. I think we do a good job of that. One currently is robotic surgery. I'm sure a lot of people watching this have heard of that. We have robotic capabilities here. Like any new technology we're trying to figure out exactly where it fits, for which patients.

It certainly seems promising. It allows us to make very precise cuts. We know that it enables us to hit the target better, but sometimes we don't know exactly what the right target is, and that's where that divide can occur between, we have this great technology, but does that correlate to better outcomes for the patient. Certainly, early on we think it's going to, but like anything time will tell, and we're responsibly adding that into our practices.

Nada Youssef: Is the robot itself helping or guiding the doctors for the incision? Because, it's not actually doing the surgery, right?

Dr. Murray: One day it probably will, which I'm a little nervous about.

Nada Youssef: If you're robotic, who knows?

Dr. Murray: It does not help with the incision. The incision and what we call the approach to the knee is the same, but what's interesting about the robot is that we're able to map the patient's anatomy pre-operatively through advanced imaging, like a CT scan, so it does require more imagine pre-operatively. Then, once in the operating room we register the patient's anatomy, and we're able to, basically, virtually implant the joint replacement, and to see what that's going to function like. We can add stress to the knee, and balance the knee virtually.

Then, once we decide on that plan, which is where the surgeon comes in, and hopefully our expertise comes into play, the robot arm actually comes in with the saw, we're holding that saw, but it has what's called haptic technology so it won't allow us to cut outside of the safe zone that we've created. It helps us make the boney cuts, but none of the soft tissue work.

Nada Youssef: Okay, that sounds painful.

Dr. Murray: The implants we put in are the same implants we would use if we did not use a robot.

Nada Youssef: Right. What does a total hip or a knee replacement look like? What do we expect.

Dr. Murray: Sure, I have models to show you.

Nada Youssef: Great. Yeah, let's do that.

Dr. Murray: We were talking about knees, so let's start with knees. Put this on camera. This is what a knee replacement looks like from the front. Am I doing well?

Nada Youssef: Yeah.

Dr. Murray: I think it's more important to look at it from the side, frankly, and I tell patients all the time, it should really be called a knee resurfacing. As you can see, we don't cut here, here, take the knee out and put a new knee in. We actually, no more than about a centimeter anywhere, do we make a boney cut, and then resurface the bones with metal on the end of the thigh bone, metal on the top of the shin bone. Then, this piece of plastic snaps in between, and that becomes your new joint surface. That's a total knee replacement.

Nada Youssef: Is that where the cartilage would usually be?

Dr. Murray: Typically be, yeah. What you see as silver and gray, that's where cartilage usually would be.

Nada Youssef: Okay.

Dr. Murray: Okay?

Nada Youssef: Okay. Great.

Dr. Murray: Then, with a hip replacement, I don't have boney models to go with it. A little bit different is, this is the femoral stem. It goes down inside the thigh bone. It's hollow, kind of like a PVC pipe. Then, it has a ball that snaps onto the end of it. Then, on the pelvis, there's a metal cup that goes into the pelvic bone. Again, where the surface of the bone can grow into it. A piece of plastic that snaps into that, which becomes your new joint lining, and then the new joint is a ball and socket. That's how the patient has a nice, pain-free joint afterwards.

Nada Youssef: That's awesome. Let's talk about recovery from this kind of surgery. Can I go home, or do I need to go to rehab after this?

Dr. Murray: Sure. The short answer is go home.

Nada Youssef: Go home?

Dr. Murray: You go home.

Nada Youssef: Okay.

Dr. Murray: This has changed dramatically over time. I started my training in 2004, so 14 years ago. Over that relatively short period of time, we've seen a drastic change in how soon patients can go home, and the fact that they are going home. We developed care paths here, myself and several of my colleagues, to standardize the care. Still, with specifics for each individual patient, but to try to standardize the things that we can standardize.

With that has come a significant reduction in length of stay. Whereas, it used to be 3.5, some of our institutions, Lutheran Hospital being one of them, our length of stay is down to 1.2 days. The vast majority of our patients are going home the next day. Then again, that discharge to home as opposed to a rehab facility is upwards of 80% to 90% of patients going home now, which is a big shift. It was a cultural shift for our patients, as well as everybody who's part of the healthcare team, but realizing that's a very safe way to do it.

If patients need to go to rehab, whether they don't have any help at home, or they're extremely de-conditioned before surgery, we still set that up and it's still a viable option. Certainly, for the vast majority of patients it's a one-night stay in the hospital. Some of them actually go home the same day, but that's a bit different. But, one-night stay in the hospital and home.

Nada Youssef: On crutches, or no crutches?

Dr. Murray: Patients will need what we call assist device. Crutches can be a little cumbersome. Most of our patients will use a walker, and that's usually a three to four week timeframe. Then, they transition to a cane for another week or so. You're looking anywhere from three to six weeks with some type of assist device, and then nothing. Barring any certain special circumstances, most of our patients can put their full weight on it right after surgery.

Nada Youssef: Sure, and I'm sure, individually, everybody's different, but what is the best recovery for a patient? What are they supposed to be doing, what do you expect them to be doing after a few months?

Dr. Murray: Sure, along those lines, again, to kind of go out further, it's like I said, four to six weeks with an assist device. I tell patients, and what we see is about three months you're 90% recovered. The biggest thing they do from a recovery standpoint is really engage in the process. It's not a passive process, this is an active process. I tell patients, I worked really hard for an hour to an hour and a half. They're job's tougher, and they have to work really hard for six to eight weeks. In the end, we're both happy and get a really good outcome.

The key is social supported home. If you can, have people around. You're not going to be 100% dependent on them, but having someone around to help out is going to be important. Again, within one to two weeks, especially with hip replacements, patients are getting around very well. Now, there are some precautions we put on them early on, but I think most patients, again, especially with hip replacements, are surprised at how quick that recovery goes.

Nada Youssef: How fast is the pain supposed to go away?

Dr. Murray: It's variable. I wish everybody, it went away really quickly. I wish I could put my finger on it. We do a lot of things now that we did not do in the past, as far as helping with post-operative pain management, with local injections, different blocks that our anesthesia colleagues do, which has helped tremendously. It helps reduce the amount of pain medications patients need. There are still these outliers, where patients will have pain for a long period of time, but we manage them through that. By and large, the first four weeks or so would be pretty difficult, but it is really patient dependent. If we could figure how to put our finger on that, it would be nice.

Nada Youssef: Yeah, my mother got a full knee replacement, I think a few months ago, maybe even last year by now, but she still has some pain going up and down the stairs, and whenever she bends the knee all the way back. I never know, is this normal, should she go back?

Dr. Murray: These are questions we get a lot, and I would tell you it's normal. I wish I could tell you that all of my patients have zero pain following knee replacement, but that's just not the case. In fact, some studies will show us that one out of twenty patients not only have some pain after knee replacement, but actually are somewhat dissatisfied. I think part of that is with the expectations that are set.

We look at the knee, it's a very complex joint, so replacing a knee has a lot of variables at play. A lot of patients will have some residual pain after surgery. We looked at our own results, unfortunately we found that 98 plus percent of patients here have a clinically significant reduction in pain, but that does not mean zero out of ten pain.

When you look at total hips, again, we'll have some patients with residual pain, but the vast majority of total hip replacement patients have little to no pain following that surgery.

Nada Youssef: Now, with limitations after surgery, can patients still kneel, can they do sports for hip replacement, can they still have sex? Are these limited?

Dr. Murray: Yes. In short is yes. When we look at knee replacements, the limitations are really what the patient can tolerate, for the most part. We get that asked a lot, can we kneel on it, the answer is yes. A lot of patients do not like the way that feels. The old dogma was, you can't kneel on these, they're going to explode. That's not the case. Most of us allow our patients to. Again, going back to the fact that a lot of patients don't necessarily like the way that feels.

It's kind of a corny analogy, but I use it a lot. If you take a car and you put new tires on the car, and you drag race, you're going to have a lot of fun, but you're going to need new tires soon, right?

Nada Youssef: Sure.

Dr. Murray: If you part it in your garage, you're never going to need new tires, but that's not really why you put new tires on in the first place. That activity level, those restrictions, it's somewhere in the middle. The more you use it, the quicker it's going to wear out, but we do this to get patients back to active lifestyles. As an aside, I used to jokingly say, "Well, don't bungee jump or jump out of an airplane." Nobody's going to.

Nada Youssef: You never know.

Dr. Murray: I swear, I literally had a patient come back about two months ago. She had done both, and she had bilateral knees in and everything went well.

Nada Youssef: Okay.

Dr. Murray: I don't recommend that.

Nada Youssef: Great, don't recommend that, no.

Dr. Murray: Then, with hips, you can dislocate a hip, so there are some precautions for the first three months or so that we put on patients as far as extremes of motion that the therapist go over with them. Again, after that, by and large, I tell my patients to do what they want, live their life, this is why we did it.

Nada Youssef: Okay, great. Now, looking at these models, a lot of metal pieces involved. Is security going to stop me when I go through the system, do you have to let them know?

Dr. Murray: They can, yeah. They can set off metal detectors.

Nada Youssef: They can, for sure.

Dr. Murray: Pre-9/11, actually, we used to give out, and some folks still do, and some patients really request it, in which case I will, but we used to give out cards to patients saying that they had a total joint in, which helped expedite their movement through security. That does not help anymore. In fact, I was at the airport recently, and saw this poor woman going through her bag, trying to find her letter to say that she had a joint replacement. It, in fact, caused increased time to get through security. Yes, you can set off metal detectors. There's, unfortunately, no way to circumvent that.

Nada Youssef: So, just let them know on your way in.

Dr. Murray: Just let them know. There are millions of people out there with joint replacement, so they're well aware of this.

Nada Youssef: Okay, good. I'm going to ask you one more question before we go to live.

Dr. Murray: Sure.

Nada Youssef: If we have two knees, both knees are in pain, or need replacement, do you recommend one at a time, then, or how does that work?

Dr. Murray: That's patient dependent. A fair amount of data in the literature shows there's increased complication risk with that, and it's more than double in a lot of studies, so it needs to be the right patient. We actually developed criteria here to look at patients undergoing what we call simultaneous bilateral total knee replacements, and we actually just are in the midst of publishing that study. The criteria that we set, it shows that if the patients are within those criteria, and they have to do with age, BMI, no active medical conditions. If they're diabetic, extremely well controlled diabetes. Those patients within that capsule do well. If you're outside of that they have more complications.

Nada Youssef: I see.

Dr. Murray: It's a long-winded answer to say, if the patient fits the mold, they're extremely healthy, then they may be a candidate for both at the same time.

Nada Youssef: It all depends.

Dr. Murray: Most patients we recommend staging them.

Nada Youssef: I'm going to go ahead and jump to some live questions that we're getting in. First one here is Ann. "Have there been any new treatments developed for ..." Oop, that just went away.

Dr. Murray: Ann left.

Nada Youssef: Sorry. Okay, let's go to Liz. "Hello, what can you suggest for my right shoulder? I have had one injection in it, but I have been told I have moderate to severe arthritis on both shoulders. Do I need more injections?"

Dr. Murray: Similar to hips and knees, when you're looking at end-stage arthritis of a shoulder, at some point injections are going to fail to provide you the relief you're looking for. If you've reached that point, Liz, I would recommend seeing, preferably one of our surgeons here, but any shoulder specialist to go through the same kind of conversation here about hip and knees about the shoulder. There are shoulder replacements that do very well, and again, if you've exhausted non-operative management for that it may be time to see a surgeon.

Nada Youssef: Great. Then, I have Steve. "Do you believe that knee replacement should be done at earlier ages than previous beliefs? Mine was at 59, though my quality of life was horrible."

Dr. Murray: That's a great question, and it's a question I get a lot. Again, going back to this kind of old dogma that was passed down, was you had to wait as long as you can. What's frustrating for me is, I'll see these kind of arbitrary numbers set for patients where you have to wait until you're 50, or whatever that number is set. I don't think that makes sense. I think we have to be careful about how aggressive we are about putting these into patients, but at the end of the day, again, if the x-rays match the symptoms, meaning they have end-stage arthritis, it greatly negatively impacts their activities of daily living, then I don't see any benefit in, if you're 42, somehow waiting until you're 52 to do it.

The problem is, you're probably going to need a second surgery down the road. Let's, for arguments sake, say that contemporary total knee replacements are going to last 20, hopefully 25 years. If we say the average life expectancy is 85, so now you need to be 60 or older to where we say, you're probably not going- There's still no guaranty, but probably not going to need a second replacement, and you're 45, why wait 15 years of misery for this theoretical gain down the road. I don't think there's a strict age. Again, we have to look at it responsibly and understand, we don't just put them in anybody, but if you have end-stage arthritis, you've tried everything and you're miserable, at least have the conversation about joint replacement.

Nada Youssef: Do most patients, or how many patients out of the ones that you do, actually come back for a second surgery?

Dr. Murray: Given the fact that I've only been in practice seven years, so not many, hopefully, right? What we see, our predecessors, our mentors, folks who were doing surgery here 20 to 25 years ago, those are the patients that we're seeing. With some of the developments, especially in the plastic that we use in the joint replacements, when we have to redo them we're seeing less drastic of problems, more manageable, what we call revision surgery. Hopefully, we'll continue to see that. So, when you need it redone, hopefully it's not a huge surgery.

Nada Youssef: All right, excellent. Then, I have Judy. "I had partial knee replacement on both knees, and I'm in serious pain. What can I do for this?"

Dr. Murray: That stuff, there's many reasons why you could still be in pain. Sometimes the implant itself fails, so typically they're glued into place. Actually, it's called bone cement. If that bond isn't working, then it could be due to the implant itself. With a partial knee replacement, and I love partial knee replacements, I think it's great surgery in the right patient, the fact of the matter is, your knee has three compartments. You've only replaced one of the, so underneath the kneecap, or on the outside or inside part of the knee, depending on which partial you had done, can develop arthritis and be causing pain. It would require in-office evaluation, x-rays to try to determine what's the source of that pain.

Nada Youssef: Did you all that knee cement? Is that what it's called?

Dr. Murray: Bone cement is what it's called.

Nada Youssef: Bone cement? What is that made out of? Just curious.

Dr. Murray: That's poly methyl methacrylate. It actually comes from the world of dentistry, is where we borrowed that from.

Nada Youssef: Oh, very interesting. All right, then I have Mary. "Hi, so glad to see this feed. I had a total hip replacement eight weeks ago, been going better than expected, but my foot on my surgical side has been off and on swollen since surgery. The doctor said it's normal, however the past week or so my foot has turned red like a sunburn. Is this also normal?"

Dr. Murray: That's another tough one. I mean, eight weeks out it can be. We certainly will see patients have swelling in the operative limb due to some of the things that we do during surgery. On and off swelling is not uncommon, but you also can develop things like gout, which will cause a red swollen foot, and painful. Surgery puts you at risk for developing those types of things. We worry about blood clots. Typically, if it's a blood clot it's not just the foot, you see more swelling, a more diffuse swelling pattern. Again, very hard to say exactly what's going on here. It may absolutely be normal. If there's any concern, certainly my belief is that's what our office is there for. If I operate on a patient, and they've called in and they're concerned, we get them in and we take a look, and we see what we can see.

Nada Youssef: Excellent. Cindy, "How long does a knee replacement last?"

Dr. Murray: We kind of touched on it. I wish I knew for sure. Again, going back to my whole car analogy, some of it depends on how much you use it. The other issue with orthopedics is, typically the contemporary replacements we're putting in have not been around for 15 to 20 years, they're based on their predecessors that we think we've made improvements to. Long-winded answer, I tell patients, and it's a big wind, anywhere from 15 to 25 years. I would say average, 20 is our hope. We'll see some fail early for reasons we're not clear, and then I'll see patients who had their knees replaced 30 years ago and they're still functioning well.

Nada Youssef: They're still good. Amazing.

Dr. Murray: It's hard to know for sure.

Nada Youssef: Great. I have Cindy again. "How do you know the right age to do a knee replacement?" We just talked about this earlier.

Dr. Murray: Yeah, I wouldn't put an age on it. I have patients who are actually 50 who aren't healthy enough to undergo joint replacement, because the patient's also worried about getting too old. I have 85 year old patients who are in tip top health, and absolutely a good candidate. It depends on the whole picture. There's no absolute number you can put on that.

Nada Youssef: And, you're quality of life, right?

Dr. Murray: Correct.

Nada Youssef: Melanie, "I think it's better to stay in the hospital for two to three nights given the medication they're taking. I think the stay has shortened due to insurance, and the quick recovery of the surgery." I guess that's kind of more of a comment.

Dr. Murray: We get that a lot, and I understand that sentiment. First and foremost, I would tell you that, certainly, my goal as a surgeon, and I would like to think that the goal of the Cleveland Clinic as an institution is, we put it as one of our main things, that patients first.

Some decisions, I think, can look that way, but we've looked at our own data, and other places have looked at their data and shown that the shorter length of stay, and the higher rate of discharge to home absolutely has improved outcomes. That's not to say there aren't patients that get readmitted for one reason or another, and we're working very hard to reduce that even further. But, we certainly saw no uptick in readmissions as we shrunk our length of stay, in fact a decrease.

There are some patients who medically, for whatever reason, or depending on what happened in surgery, or what's transpired over the 10 hours after surgery, to stay two or three nights. We don't put every patients, discharge them post-op day one, the day after surgery, regardless. I hear that sentiment. We try to assess each patient and do what's right for them for sure.

Nada Youssef: Just like you mentioned, if there's nobody home, or if they need more care they can go to a rehab center.

Dr. Murray: Correct.

Nada Youssef: Then Paul, "Do cortisone shots accelerate the degeneration of joints?"

Dr. Murray: That's a good question. You can see in patients who have had multiple steroid injections, deposits in throughout their joint. I think, for me, when I use that as a treatment option, and for how long I'm going to do that kind of depends on what we're using it for. If a patient has moderate to severe arthritis, not to sound crass, but the horse is kind of out of the barn, so to speak.

Even if it's causing some degradation of the joint, but in the meantime providing them significant relief to avoid surgery for whatever reason ... Maybe they can't fit it in their schedule, don't want to do it. I think that's fine. If we're using it for something more upstream. So, they have knee pain, x-rays look really good, I will give patients a corticosteroid injection. But, to your point, I will not repetitively inject that knee.

Nada Youssef: It's a one time kind of injection-ish?

Dr. Murray: Again, depending on what we're treating.

Dr. Murray: We have some patients ... We can't do them any closer together than every three months. We'll have some patients who, every three months, come in. Maybe they're not medically appropriate for surgery, they get 10 to 12 weeks of relief from their steroid injection, and we inject that joint. I think that's okay too. Again, patient dependent.

Nada Youssef: Sure. Carol, "What are the odds of good results from bilateral knee surgery?"

Dr. Murray: Very good. Again, if you look at quality of life improvement from surgery, number one is open heart surgery, you save a patient's life. Number two is cataract surgery. Number three is total hip, and behind it is total knee. It is great surgery, and including bilateral knee surgery. Again, I like to think that the criteria that we've set in place here helped pad those results, if you will, knowing which group of patients are going to do well from bilateral knee surgery. So, the results are very, very good.

Nada Youssef: Excellent. And, Jan says, "My daughter has rheumatoid arthritis, she has gone in for multiple torn labrum. Her femoral head is a bright red from inflammation. She's asked for a hip replacement, but her doctor says it won't help her if they remove the inflamed ..."

Dr. Murray: Femoral head.

Nada Youssef: Would that not stop the pain?

Dr. Murray: In that setting, rheumatoid arthritis and other inflammatory arthritides are different than osteoarthritis. That being said, if you have end-stage rheumatoid arthritis with loss of cartilage, again the mechanism by which you lose cartilage is different. Typically, you are looking at joint replacement.

There are other biologic medications that affect your immune system that a rheumatologist would manage, not an orthopedic surgeon that would have a lot of patients on, that have some risks, but have done wonderful things for that patient population in general as far as saving their joints, and allow them to maintain their activity levels.

Again, I say it's a case by case basis. It would depend on what the x-rays look like. If those x-rays show end-stage arthritis of that joint, I don't think going in and resecting that synovium is going to be of benefit.

Nada Youssef: Okay, great. Mark wants to know, "Is it possible to avoid a hip or knee replacement? What are other treatments options?"

Dr. Murray: The best way to avoid is to just be able to tolerate ... Again, because it's a quality of life decision. If you can tolerate the symptoms you're having, barring a couple of exceptions, there's no really harm in waiting, and holding off and not doing surgery. As far as upstream, it's weight management, it's low-impact exercising, it's good nutrition, all those types of things that are, frankly, good for every condition that we suffer from.

There are other non-operative modalities we talked about, steroid injections. Again, doing nothing to change the trajectory of the disease, really, it's just trying to decrease the symptoms that the patient suffers from. There are things like stem cells. There are people working very hard here to look at those. There are some clinically available. Insurance does not cover that, it is out of pocket expense. I think there's very little risk, but there certainly is not science to date to show any improvement.

I can pretty much with no uncertainty say that it's not going to grow cartilage back on the knee, but it may provide symptomatic relief, so that's an option. Other things, PRP, platelet-rich plasma. Again, to try to improve the symptoms. We have not figured out how to stop the process, or reverse the process for that matter.

Nada Youssef: Very good point. Amy, "What do I need to do to prepare for surgery?"

Dr. Murray: Any medical comorbidities, get absolutely optimized. There are risk factors that we cannot change, and there are modifiable risk factors. Any modifiable risk factor, whether it's heart disease, weight, diabetes, smoking, all those types of things that can be modified, modify them to put yourself in the best position to not have any complications following surgery.

Stay as active as you can. Sometimes that becomes difficult with a painful joint, which is why you're having the surgery. Then again, try to recruit social support for when the time of surgery comes, that you're ready. It's probably going to be eight weeks or so off of work, if you're employed, just to keep that in mind as far as preparing.

Nada Youssef: Eight weeks off of work?

Dr. Murray: I tell folks eight weeks, I've had patients go back after four. I've had patients need twelve weeks. We did a study here at the Cleveland Clinic. He's a hand surgeon now, he's one of our ex-residents, actually looked at it, and it wasn't what job patients had, it's actually what resources they had when they weren't working. Self employed patients got back to work really quick, whether they own their own construction company or they were accountants. When they weren't working, they weren't being paid, which makes sense. Again, the patient has a lot to do with when they get back to work, but I think a reasonable estimate is eight weeks.

Nada Youssef:   Okay, great. Marilyn, "I just had a knee replacement last July. What kind of bend should I have. It's about 105 now, should I have more? Can do everything but kneel. Thank you."

Dr. Murray: I would tell you that, if you had it a year ago, that 105 is going to be what you're going to have. What we know is that typical American life, 105 degrees of flexion is plenty to typically do most the activities that we enjoy doing. What it should do or shouldn't do, I don't know. The big thing that predicts how much it moves after surgery is how much it moves before.

Some patients who have bad arthritis, and they'll have full range of motion of their knee, those patients typically get a lot of range of motion following surgery. Before surgery, if you had very limited range of motion, there's a good chance that impacted the fact that you have 105 of motion. Implants themselves can tolerate and see up to 140. Those are outliers, though, the vast majority of patients do not get that much flexion, nor need it.

Nada Youssef: Okay, good to know. Dan, "What are the best exercises to perform after surgery?

Dr. Murray: Again, I would say low-impact exercises. Early on, especially with knee replacements you're going to look at quad strengthening, so your thigh muscles. When we do something as small as a knee scope, that muscle can shut down, so this is a much bigger surgery than that. It can take patients a long time to get their quadricep muscle built back up, so focusing in on those exercise post-operatively are important. Not to mention that pre-operatively, arthritis starts to shut those muscles down too.

Short of that, I recommend cycling, swimming, which can be somewhat cumbersome, but is a great exercise, it's low-impact. Walking. Patients relax until they can run. Again, going back to that car analogy. You can, but I would love to see you do ellipticals, or like I said, cycling or something like that.

Nada Youssef: How about water aerobics? I think underwater is-

Dr. Murray: Great, absolutely. Perfect.

Nada Youssef: All right, got it. Ann, "Have there been any new treatments developed for chronic bursitis?"

Dr. Murray: Chronic bursitis is tough, and we'll see that in patients who do or do not have arthritis. A lot of patients get sent to me to have their hip replaced, and they have what's called trochanteric bursitis, which is lateral based hip pain. You can see that after surgery as well. The short answer is no, unfortunately. That's one of those conditions that seems to be recurrent. Again, the treatment really hinges on physical therapy, stretching, ice, non-operative modalities.

There are certain times where we'll take the bursa out. I'm not seeing good results with that. If you've had that done, I'm not saying it's a terrible way, I think, unfortunately, it's often a recurring kind of chronic issue. Try to do low-impact exercising, over the counter medications as needed. We do some injections at times.

Nada Youssef: I'm back to Liz. "I read about a knee replacement surgery that does not cut tendons or ligaments. Is that common now?"

Dr. Murray: I think this gets to the responsibility of us as orthopedic surgeons, just being careful about how we word things. There are certain techniques that we've learned to make the surgery less invasive. Minimally invasive surgery was all the craze, and I think a lot of good things came out of it. We have better instruments, we just have a better know-how of how to do the surgery with less damage to the tissues.

I think it's semantics if you can be comfortable saying, "I don't cut across tendons, I cut alongside tendons." The fact of the matter is, we have not discovered a magical way to put this implant in through a hole that's this big. We still have to get into the knee joint. There are certainly ways to do it where we damage muscles and tendons and ligaments less than others. I think most contemporary surgeons today respect and understand that, and do that.

Nada Youssef: Great. Lucille, "How long does a knee replacement last? I had mine done about 20, 25 years ago, and now it clicks now and then."

Dr. Murray: That's a great example, right? It's 20 to 25 years, and if all you're having is a little bit of clicking that's great, it seems like it's doing well. All total knee replacements, whether the patient notices it or not, will click, because they're metal and plastic, so they'll go apart and then come together. That makes a click. The reason, Lucille, you may be noticing it more now than you were before is, what wears out is that plastic. That plastic fills a space, and as that plastic wears out, that space gets looser.

Patients will report more clicking, a sense of instability, maybe not trusting the knee. Certainly, 20 to 25 years out ... I don't know when the last time you had an x-ray is. I would recommend getting in to see somebody. I don't want you to think it's an emergent thing, but I would, in the near future, have an x-ray just to see what the status of the knee replacement is for sure.

Nada Youssef: Great. Jason, "Are you familiar with the Arthrosurface conversion to total knees? If so, what are the results?" What is that?

Dr. Murray: I think I know what that is. Arthrosurface is a way to treat ... Arthritis, what we're talking about here today, is kind of a diffuse loss of cartilage throughout the knee, either one side or all three parts of the knee. Arthrosurface is designed to treat patients who have a focal lesion of cartilage, typically from a trauma.

Just as we talked earlier about a partial knee replacement, where the rest of the knee can wear out, with the Arthrosurface you have even more of your knee that can wear out. At times, that Arthrosurface needs to be taken out and converted to a total knee. I don't know of any studies looking exactly at that. If you look at the results of a primary total knee, meaning first time around, and then you look at the results of what's called a revision total knee, going back in to a total knee and having to redo it, a primary total knee results are much better.

Something like taking an Arthrosurface to a total knee are going to be closer to that primary total knee result than to a revision. It's a pretty easy surgery, there's little difference in whether we're doing it the first time around, but I can't give you the exact results. But, they're good.

Nada Youssef: Okay, good. Robert, "What hip replacement options are there?"

Dr. Murray: That's like saying what car could you buy? There are multiple makes and models, but they all function pretty much the same way. I think hip resurfacing is a divide. We have one of the most prolific hip resurfacing surgeons here at the Cleveland Clinic, his name's Peter Brooks. There's a select patient population that's appropriate for. These aren't exact, but in general, 55 year old men and younger. It's only for men.

Short of that, the hip replacement options, there's different bearing systems. Most of us this day in age use a ceramic ball on a plastic liner. I'm sure you've seen metal on metal hips, and all the problems that have come forth with that. Again, the options are subtle. It's like deciding between a Ford or a Chevy, sort of, so lots of options, very similar in the way they function.

Nada Youssef: You said it's only for men. The hip replacement pieces, are they all separate female/male, or ...

Dr. Murray: That's hip replacing, just to say, is different than total hip replacement. Just for me, I want to be careful what I'm saying.

They're not different, but we have a multitude of sizes. I call it off the shelf customization. They're all on the shelf, but we have 1 through 22 as far as sizes are concerned, so we can fit any patient's anatomy. Obviously, typically for women we're using smaller sizes in general, but we have sizes to fit any individual.

Nada Youssef: Linda, "What about scar tissue on a knee replacement? Does it have an impact?"

Dr. Murray: It does. For one reason or another, some patients will keloid, which you'll see big scars on their skin. Sometimes we'll see that type of process occur within the knee joint itself. We call that arthrofibrosis. There are some ways to manage that. Sometimes it's a very difficult problem to manage. Typically, what stems from that is a knee that's stiffer than you would like, so decreased motion. Again, there are patients who develop scar tissue rapidly and aggressively, and some that don't. I don't think we necessarily have a good handle as to why some do and some don't.

Nada Youssef: And, Wanda wants to know if there are any concerns with Type I diabetes, having hip replacements.

Dr. Murray: Absolutely. Unfortunately, diabetics are at an increased risk for complications, specifically infection. Infection is this terrible thing that can come from joint replacement. Fortunately, it's very rare, it's somewhere around 1% chance. Diabetes puts you at increased risk for that, being an insulin-dependent diabetic certainly does. We look at hemoglobin A1c, which is a decent test to look at the overall management of blood sugars on a daily basis over an extended period of time.

There's no hard number. We like it certainly to be seven or better. The closer to six the better. Again, it's kind of a complete picture. If a patient is a Type I diabetic, their A1c is 7.2, but they don't smoke, they're not overweight, then I think it's okay. If you have those other risk factors, then you really, like I said before, those modifiable risk factors, you really have to try to manage those as best you can before surgery.

Nada Youssef: Sure, because they apply everywhere, right?

Dr. Murray: Correct. The key is tight glucose control.

Nada Youssef: Okay, great. Then, Pam, "How bad does your knee have to be before you can consider replacement? Mine is bone to bone."

Dr. Murray: If you're x-ray shows bone on bone arthritis, and you can go job five miles, don't get your knee replaced. If you're x-ray showed bone on bone arthritis, and you second guess whether you're going to go out to dinner with your significant other, or your children, or your friends, then that's time to start contemplating knee replacement. I'll have patients who come in and say, "My knee is killing me. I play 18 holes of golf, and by the end I need to take an ibuprofen." I say, "I don't think that's reason to have a knee replaced. I feel for you, but I take them too."

Other patients, who their family's like, "They stopped getting off the couch, they won't do anything." That patient you need to help feel better and more comfortable about the results of joint replacement. Again, going back to your question, those x-ray findings have to match what impact it's having on your daily life.

Nada Youssef: Sure, and your symptoms. Great. I'll have two more questions for you before I let you go.

Dr. Murray: Okay.

Nada Youssef: Brenda, "What would swelling and pain behind the knee indicate?"

Dr. Murray: A lot of times that's what we call a Baker cyst, or a popliteal cyst, that popliteal cyst is the posterior part of the knee. That's typically from inflammation from within the knee, and then there's an anatomical variant that allows that tissue to get out onto the back of the knee. Sometimes we'll see that rupture on the patients will all the sudden have calf swelling. Again, typically the issue is within the knee.

A lot of times, again, the treatment for that is to try to treat the underlying condition. If it's arthritis, low impact exercising, maybe an injection. On occasion, we will actually go after the cyst. I have some colleagues, I don't do it myself, but under ultrasound we'll aspirate that cyst, or suck the fluid out of it, and maybe inject something. In the back of the knee, that's where your blood vessels and your nerves are, so you have to be careful. Again, it's more of a symptom of what the underlying issue is.

Nada Youssef: All right. Then, I have the last question, from Gracie, "Is it true that you can only have two replacements in your lifetime? If so, why?"

Dr. Murray: It's not true. You can run out of real estate, so to speak, so it's one of the reasons that you do ... You don't want to embark down that road, and start down that road until your symptoms warrant it. We have patients, unfortunately, who have undergone multiple, multiple, multiple surgeries for one reason or another. You start to run out of bone. Each time we have to go in and have to redo it we run out of bone. In this day and age we have quite a few tools in our belt to replace bone. What also becomes a problem is the soft tissue surrounding that implant. There is a limitation, it's certainly not two, and it's different for everybody, once again.

Nada Youssef: All right, great. That's all the time we have for today, but before I let you go, anything you want to tell our audience, something we haven't touched on? We've talked about a lot.

Dr. Murray: No, I think so. Yeah, I've enjoyed my time. I think you guys had great questions. I appreciate it.

Nada Youssef: Great, thank you so much. For more information on knee or hip replacement, go to ccf.org/treatmentguides for a full selection of health guides. Then, look for knee pain, hip pain, or joint replacement guides.

For more health tips and information please follow us on Facebook, Twitter, Snapchat and Instagram, @clevelandclinic, one word. We'll see you again next time. Thank you.

This concludes this Cleveland Clinic Health Essentials podcast. Thank you for listening. Join us again soon.