Episode 118: The Truth About Hip and Knee Replacements

Joint pain can make everyday activities difficult, but surgery isn't always the first answer. In this episode of Informed Aging, Robin Rountree talks with orthopedic surgeon Dr. Armin Arshi about arthritis, treatment options, and when hip or knee replacement may be worth considering. They also discuss recovery, rehabilitation, and how long today's joint replacements typically last.

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Transcript

[00:00:04] Welcome to Informed Aging, a podcast about health, help, and hard decisions for older adults. I'm Robin Rountree, a former family caregiver. I've worked in the home care industry and now work for the Alzheimer's and Dementia Resource Center. The thoughts and opinions expressed on the podcast belong to me and my guest, not our wonderful employers and sponsors.

[00:00:27] Before making any significant changes in your life or your person's life, please consult your own experts. Now, I'm getting to the age where I have friends who are getting replacement body parts. Yep, hip and knee replacement. Why do we need these new parts? Is surgery necessary? And if we do get a joint replaced, how do we get a better recovery?

[00:00:51] I'm talking to an expert about all of these things, so make sure you stay tuned

[00:00:59] 

[00:02:00] Robin Rountree: Today we're joined by Dr. Armin Arshi. Now, he is a board-certified, fellowship-trained orthopedic surgeon. He specializes in hip and knee replacement, minimally invasive joint replacement, and complex joint reconstruction. Now, medical education and residency at UCLA later served as chief resident, then completed advanced fellowship training in adult hip and knee reconstruction at the renowned Rothman Orthopedic Institute in Philadelphia.

[00:02:33] So obviously, this is the guy to answer our questions. I guess I wanna start with, why is it that we see a lot of people, as they get older, get knee and hip replacement surgeries? 

[00:02:51] Dr. Arshi: Well, good to be with you, Robin. First of all, thanks for putting this on, and a great topic.

[00:02:56] Obviously, it's the focus of my entire career, but one that affects a lot of people in their daily lives. So if arthritis is the norm of the human condition over time, so we are born with a set of bone and joints that once we reach skeletal maturity at around age 16 to 18 in adulthood, there's limited capacity to regenerate, particularly the cartilage of the joints.

[00:03:18] So the joints are, for example, your hips, knees, all the different individual joints in your fingers, your wrists, but these have a smooth cap lining called cartilage that allows your joint to glide smoothly and free of pain. And what can happen is that with age and activity, these smooth linings can wear out over time.

[00:03:39] Think of it as on a tire that eventually become worn out. The same thing happens for your joints. They do not have a capacity to regenerate. Cartilage shells do not grow back once we hit adulthood, and so what happens is that the smooth lining becomes filled with pits and eventually goes full thickness to being exposing only bone underneath, and that is source of pain and inflammation because it no longer glides smoothly.

[00:04:02] And with weightbearing activities, particularly for the knees and hips, can be a source of significant pain. So this is the norm of human aging. Like I said, it would be like asking not to have wrinkles or not to develop gray hair. It's just not possible. But we do have options to manage this, and it is something that a lot of people are living with as we live longer and healthier lives.

[00:04:23] Robin Rountree: So you said not an option to have wrinkles, but like for Botox, right? To stop the wrinkle. Is there not something we can inject more cartilage? 

[00:04:34] Dr. Arshi: Great question, and I'm gonna continue that analogy by saying those Botox injections don't give a permanent solution.

[00:04:40] Similarly, when you lose the cartilage, you can't inject cartilage because it has to bio-integrate. But we have ways of managing symptoms. Therapy often works to manage and deal with lost cartilage. We can give anti-inflammatories to manage the symptoms of it.

[00:04:55] And then when that doesn't work, there are things that are injectables, but they don't regenerate cartilage per se. So it falls into two main categories for me. Cortisone injections, which are a potent anti-inflammatory that can relieve pain from the underlying arthritis, and then gel injections.

[00:05:12] Both of these are approved by major insurance carriers and Medicare, and they allow a gelatinous synthetic version of your body's own lubrication to fill the joint space, and that can make the gliding feel more natural. It can reduce the pain for people with mild to moderate arthritis. But no,

[00:05:28] the, the cartilage is not fully restored. There's no way to do that. 

[00:05:32] Robin Rountree: So you said we can't inject it because it's not bio something. 

[00:05:37] Dr. Arshi: It, well, it cannot bio-integrate, so what happens is if you just inject cartilage, it won't stick to the smooth lining and recreate that.

[00:05:44] Ah. There are some techniques for very localized cartilage loss, so for example, if you have a specific pothole, this is typically in younger folks from injury or from sports, you can fill that defect, and that stuff has shown some promise. But when you have-- When I'm talking arthritis, I'm talking diffuse thinning of the tire.

[00:06:00] So for example, if your tire has a puncture in it, you can fill that puncture. Okay. But if it's balding diffusely, you can't just recap that with new tire treads. What you need to do is replace the tires. And in the case of advanced arthritis, when it doesn't respond to other things, you replace the joint with metal and plastic, which is really my career.

[00:06:22] Robin Rountree: Metal and plastic. That's crazy to me. Let's go back 150 years. If I had arthritis, significant pain, I would just be limping and putting up with it? 

[00:06:35] Dr. Arshi: That's a good question, and the answer is probably yes. So I think arthritis is probably less prevalent 'cause we know it's an age-related thing. There's a variety of ways you can lose cartilage, okay?

[00:06:45] Robin Rountree: Okay. 

[00:06:45] Dr. Arshi: You can have trauma, so you can have injuries that cause cartilage to be lost. You can have congenital conditions that make your cartilage more likely to be susceptible to damage by the way your anatomy is, or you just age, and 150 years ago, life expectancy was not what it is today. 

[00:07:03] Robin Rountree: True. 

[00:07:03] Dr. Arshi: And so people would not live as long, and 

[00:07:05] Robin Rountree: so 

[00:07:05] Dr. Arshi: Arthritis was probably much less prevalent at the time. But even as late as the 1800s, people were attempting ways of treating people with advanced arthritis, and, using one of the first replacement materials was actually ivory from an elephant's tusk to be the synthetic replacement for a prosthetic hip.

[00:07:21] Robin Rountree: Okay. All right, so we've come a long way, obviously, from putting a elephant tusk in our bodies. 

[00:07:27] Dr. Arshi: Yes. 

[00:07:27] Robin Rountree: You said physical therapy is where we start, but how does working muscle help that little shrinking ligament?

[00:07:38] Dr. Arshi: Yeah, so I'll start from the beginning.

[00:07:39] We have to assess each patient individually. The-- There, there's a, there's sort of a ladder that we go up, and that starts with physical therapy, which as you asked, to answer your question, you strengthen the muscle which helps compensate for a bad joint.

[00:07:54] So think of it if you're driving on four bad tires, you will be still driving on bad tires, but a good engine could compensate for that, and that's what quadricep strengthening for the knee, for example, does, or abductor strengthening does for the hips. It compensates for an arthritic hip, and we know that from a lot of cases.

[00:08:09] Now, there are cases where you're so advanced bone on bone that no amount of pills, injections, therapy will make any difference. You need surgery. It's a mechanical problem. But we do follow the same ladder for most people, and where they get off is very much an individualized discussion for me based off how severe their arthritis is and what their goals of treatment are and how much they've been able to tolerate so far in their treatment.

[00:08:33] When we talk about the next steps, so anti-inflammatories like ibuprofen, Motrin, Aleve, these all fall into the categories of NSAID medications, and then Tylenol are the mainstay of treatment for osteoarthritis. A lot of people may be familiar with topical creams such as 

[00:08:51] Voltaren Gel.. so Voltaren Gel is a topical anti-inflammatory. It's basically ibuprofen, Motrin, and that is the exact same medication that you take by pill that can be injected topically onto an area. When you rub it on your knees, it doesn't have the side effects of being absorbed by your gut, by your bloodstream, and that has some benefit.

[00:09:12] Robin Rountree: Okay. So you go with those, and maybe it works for years, and that's the hope? And then if it gets to a point where it gets much worse, they're coming back to you and possibly discussing replacement. 

[00:09:27] Dr. Arshi: That's correct. Yeah, and at any point you can make that decision when people aren't meeting their functional goals, and some people last for many years.

[00:09:34] I have plenty of patients who don't feel ready for surgery or feel that it's too high-risk for them, and we treat them with continued injections, alternating cortisone and gel injections multiple times a year. That's enough to give them sufficient relief in doing the activities they like to do. It's a very much individualized discussion.

[00:09:52] Robin Rountree: And is there ever a point where a person has waited too long to have the surgery? 

[00:09:58] Dr. Arshi: So that's a great question, and one that comes to me in one of two flavors, but mainly one way. So some people think that if you wait long enough, you're gonna damage the joint irreversibly, that you can't do a replacement.

[00:10:10] That is neither true nor is that something that I really have concern about. Because if it's gonna get to the point that it's gonna absolutely destroy a joint and make my reconstruction possible, you would be unable to walk or tolerate anything before that. So that, that's not what typically happens.

[00:10:26] The more common way this question gets asked is I have patients who put it off, wait for many years, they do injections, and then eventually now you're 85, 90 years old, and you may not be as fit to undergo surgery as when you were 65, 70 years old. This is extremely advanced, and the pain is so severe that you can no longer tolerate it.

[00:10:45] So we're in this condition where you may not be able to tolerate walking or basic activities, but you have more concerns about the risk of surgery. The good news is that we've gotten better and more efficient at this operation. I've done patients who are well into their 90s who have had excellent results, for elective hip and knee replacement And I think a big reason for that is we've gotten faster and better at the surgery.

[00:11:08] We've gotten more precise with it. And a big part of it is the anesthesia techniques going around it, so we're doing more and more of these under spinal anesthetic, which makes the procedure much lower risk. And I think that's good major advances. So it's rare that I say it's too late or it's gone on for too long, but most common that's because people become less physically fit for surgery.

[00:11:30] Robin Rountree: And I, I know you do specialize in the hip and the knee, and those are things that we use a lot every day if we're just up and walking around. So if you do have this, I think it's a major surgery, but you may be able to go home the same day because of the advances.

[00:11:49] What does the recovery look like? You've replaced a part of your body. That seems pretty major to me. 

[00:11:56] Dr. Arshi: Yes. It is a major operation no matter how you skin it, okay? This is not a simple bedside procedure. This is a major operation done by someone who's done a lot of training and thought into this. But that has helped make it more efficient and predictable in the recovery.

[00:12:10] So after the surgery, about 50% of my patients go home. The number's a little bit less nationally, but I think it just depends on your comfort or your demographics of who you're taking care and treating. Everything is halved for a hip than it is for a knee, and what I mean is just a hip replacement is an easier recovery.

[00:12:25] It's just easier, quicker, less pain. That's just the way it is, and I think probably always will be A knee replacement, average time to recovery is about two to three months to be fully recovered. And for hip replacements, about six to eight weeks. But in terms of the early recovery, patients will often go home the same day.

[00:12:42] At the very minimum, you will get up and walk with a walker the very same day, going up and down the hall with a stable new joint. And you will be able to, in cases of people who need to go home, clear a flight of stairs, too. My patients will then go home and then have a physical therapist and a nurse visit them at the home that's covered by your insurance.

[00:13:04] That helps you with the early phases of recovery, making sure that things are being done appropriately, there's no major early complications, progressing your functional goals. By about two weeks, people transition to outpatient physical therapy, where they start going to a physical therapist's office.

[00:13:20] That's after they see me or their other surgeon in the office and make sure that things are going well. And at that point, people begin to make their way towards recovery. By about six to seven days, people get rid of the walker and switch to a cane. They have enough independent functional strength. And things go pretty much downhill from there.

[00:13:39] From a hip, again, like I said, it's just much quicker. By six to eight weeks, people are fully back to themselves for the most part. For a knee, that can take closer to two to three months, but people are able to drive within two to three weeks, depending on if it was a left or right hip or knee. So you can see how this sounds like a big operation.

[00:13:55] It is. There's no question about it. But overall, people are able to bounce back from this relatively quickly and notice the functional gains.

[00:14:03] Robin Rountree: - Now I'm thinking that older people get this surgery 'cause they can actually take that much time off work.

[00:14:09] But you're not saying six months until you can go back to work, maybe three weeks? 

[00:14:13] Dr. Arshi: No. No, yeah, it depends on the nature of your job. So actually this is- Right ... while I was at NYU, we studied this. Average time to return to work is about two to three months. It can be shorter for people doing primarily home-based desk work, as short as three to four weeks. Average time was in the two to three-month range. Manual laborers and people undergoing knee replacement more quickly need more time, but you're looking at about the two to three-month range for your average job with some physical activity, semi-sedentary.

[00:14:40] But true sedentary jobs can get back sooner, and more physically laborious jobs might take longer. Like you said, many patients undergo the surgery by the nature of the fact that they're typically older. - But I have plenty of patients in their 40s and 50s who do this and get back to physical jobs of very significant physical activity.

[00:14:56] Robin Rountree: Okay. Are you at greater risk for needing a, a hip or a knee replacement if you're a marathon runner? The pounding on the pavement. On one hand, you're healthier, your heart is healthier, but does that cause damage to your cartilage?

[00:15:15] Dr. Arshi: Yeah, so it's a fine balance. Certainly, people who are very physically active predispose themselves both to acute injuries from specific accidents, but also through cumulative trauma from high-impact loads. So if you're doing frequent running, frequent sports, it's not infrequently that you will have arthritis at an earlier age.

[00:15:35] Of course, I could tell you that some of my least active, least physically active patients are the ones with the worst arthritis because weight, general metabolic function does play a risk into developing arthritis at a younger age for people as well. So I think the general trend is yes, but it depends on the type of sport, and certainly being active generally has net benefits for people to the fact that it's not a problem. 

[00:15:57] Robin Rountree: That makes sense. Let's talk about recovery. I know a lot of your patients are going home, and I would think that is if they have the support at home. I know someone about my age recently posted on Facebook that he had to have his hip replaced, and he was in rehab, and I'm assuming that's because he's single, no kids at home, no support.

[00:16:21] So if you don't have the help at home, are you more likely to be in rehab for a little bit? 

[00:16:26] Dr. Arshi: Yeah, absolutely. So the biggest predictor is your functional status and your home support status to predict what happens. 50% of people in my practice end up going home same day. About 40-ish% of people stay one night, maybe another 5% stay two to three nights.

[00:16:41] Small percentage end up going to a rehab facility after surgery. That's probably about 5%. The national number's probably about 10%. A big factor in that is, yes, simply just the amount of support you have at home. So you don't need 24/7 assistance, but I often tell my patients that are going to have hip and knee replacement, for the first few days it might be nice to have someone around to help you with basic house things, cooking, cleaning, et cetera, because you're not gonna be in great shape to do those things.

[00:17:04] You're certainly gonna be able to walk up and down to the bathroom, take care of yourself. You're certainly gonna have nursing and therapy coming to check on you to make sure things are going well. So it just depends on how much you will individually need.

[00:17:15] Robin Rountree: Okay. And any tips for making your rehab better? Um, what can you do to increase your healing? 

[00:17:25] Dr. Arshi: So I think being in the best shape you possibly can going into surgery is important. That involves both your physical health and your nutritional health. I don't necessarily need people to go buy a gym membership prior to having hip or knee replacement, but I think doing as simple as a couple weeks of a home exercise program, we give the package so you can get preconditioned with quad strengthening going into the surgery, can make it easier, for example, after a knee replacement coming out.

[00:17:50] And so prehab is something we often recommend. The other thing is nutritional support, so having a well-balanced diet prior to surgery is important, so having high proteins, which are the building blocks for rebuilding muscle and fibrous tissue after surgery is very important. For many of my hip and knee replacements, my partners and I recommend a nutritional program that's about two to three weeks, two weeks before and one week after surgery, to help with giving them those structured building blocks with nutritional supplements.

[00:18:18] By no means an absolute requirement, but these things have been shown in small studies to make differences in patients' recovery and outcomes.

[00:18:25] And then lastly, having your medical comorbidities in order. Again, one of the, surgery has very high rates of success, 85% on average in knee replacement of high satisfaction, 95 to 98 in hip replacement. Hip replacement has outstanding outcomes. 

[00:18:40] Robin Rountree: Nice. 

[00:18:40] Dr. Arshi: But complications can and do happen to all of us as surgeons and to a small percentage of our patients, unfortunately.

[00:18:47] The biggest predictor of those things is your health status going in. If you are diabetic, if you have rheumatoid arthritis, if you are a smoker, there are things you can do to optimize and make your surgery more successful. Getting your blood sugars under control, quitting smoking and stopping nicotine around the time of surgery, having your rheumatoid arthritis under control, having your blood thinners pro- properly managed.

[00:19:09] These are all things that's where I spend most of my time in the office, actually trying to think about and optimize. And I have a team who helps me with that to make sure patients have the best chance coming out of surgery. 

[00:19:19] Robin Rountree: Okay. And then once you've had the replacement of the knee or the hip, are you good for the rest of your life, or you get after 200,000 miles, you gotta turn it in for a 

[00:19:29] Dr. Arshi: new one?

[00:19:29] That's a good question. So there's no warranty on these, and there's no set lifetime. So people often say, "Well, I don't want to have a hip replacement at 60, because then at 75 I'll need a redo." That, that just simply is not true.

[00:19:41] So the survivorship of a hip replacement going in today, in 20 years is about 95%, which means if you had a hip replacement today, in 20 years there's a 95% chance that hip replacement would still be in you and functioning just fine.

[00:19:56] Robin Rountree: Oh, wow. 

[00:19:57] Dr. Arshi: For knee replacement, that number is about 90 to 95%. There's been multiple factors as to why this is happening, and a big one is we've just gotten better with our implant design. We have transitioned to using robotics and advanced technologies, which help us position these precisely.

[00:20:13] We've gotten better with our plastics, so those plastics that act as the liner for the joint do not wear out as easily. They're more durable and resistant, which is very good. And we have gotten better about our fixation techniques, how we put these implants in and fix them to bone.

[00:20:30] Robin Rountree: Okay. Now that we've had these improvements, do you think in the next 40 years there's gonna be even better improvements and better outcomes? 

[00:20:39] Dr. Arshi: I think when you look at joint replacement as a whole, I'm a hip and knee specialist, I'm gonna focus on that. I think for hip replacement, to be quite honest with you, Robin, I don't see tremendous change happening. I think it is one of the most successful surgeries in all of medicine. It is predictable, it has a quick recovery, it has a good outcome.

[00:20:56] So I really don't see a lot changing with how hip replacement is done. Knee replacement, I think, is pretty close as well.

[00:21:05] Everyone's alignment is different. Everyone's soft tissue envelope is different. There's now increasing recognition of maybe nine different phenotypes or types of knees that people can have.

[00:21:15] I think this is the way that this is headed, is personalized medicine, but for the knee. 

[00:21:20] Robin Rountree: Okay. Thank you so much. This is fascinating. My fingers are crossed I will never

[00:21:24] Have one of these surgeries, but I feel much better about it if I do need to have one.

[00:21:30] Dr. Arshi: Like we said earlier, surgery is not needed for the vast majority of patients. You can h- be managed, and that's a big part of my job is keeping people out of the operating room with all the modalities we talked about. But once, once you get there, we have good solutions, and again, that's an individualized discussion for all.

[00:21:46] Robin Rountree: Thank you so much.

[00:21:47] Please make sure to subscribe to our podcast, Informed Aging. Tell your family and friends about us. Today's episode was recorded at ADRC's podcast studio. That's it for now. I'm looking forward to our next visit