Joint replacement
1,001 patients tell you what your doctor can't
Each year, more than 600,000 Americans with injured or diseased hips or knees go under the knife for the ultimate treatment:
a joint replacement. While researchers have lavished attention on the surgery itself, we know much less about the experience
from the patient's point of view. How much does it hurt? How long before you can walk comfortably? Go back to work? Throw
away your pain pills?
The Consumer Reports National Research Center's exclusive telephone survey of a nationally representative sample of 1,001 knee- and hip-replacement
patients fills in many of those blanks.
Our survey found that although the surgery can have serious complications and does not always return patients to a state of
perfect mobility, it succeeds at the most basic level: pain relief. Even patients who were the most disabled going into surgery
reported that on average, they had minimal pain in their new joints six months afterward.
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| NEW HIP The new joint (solid white in foreground X-ray) replaces the femur head of the old joint (background).
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That degree of pain relief may explain why 82 percent of our respondents described themselves as “very” or “completely” satisfied
with their new joint.
But not all of our survey results were so encouraging:
• Recovery is long, and sometimes painful. While most people stopped taking their pain medication (including over-the-counter
pills) after two months, 12 percent were still taking it after a year. And although 90 percent or more of patients could perform
routine activities such as getting out of a bed or chair after a month, one-third of hip patients and one-quarter of knee
patients said they still couldn't perform the more challenging task of walking a half-mile as late as one year after the surgery.
• Five percent of respondents reported getting an infection shortly after surgery, a significantly higher rate than reported
in some major studies. We can't tell from our survey whether those were serious deep-tissue infections or less worrisome surface
infections. But those rates are consistent with what Consumer Reports has found when we surveyed subscribers about their hospital stays for various procedures in the past.
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| NEW KNEE The new joint (solid white in foreground) replaces the painful rubbing surfaces of the old joint (background).
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| Illustrations by Tom White |
• Secondary complications were relatively common. Thirteen percent of respondents suffered a seriously weakened or contracted
muscle, a problem that usually requires extensive physical therapy or, in some cases, additional surgery to correct. Thirteen
percent of hip-replacement patients and 7 percent of knee-replacement patients said they ended up with legs of unequal length,
and 5 percent of all patients required another operation to correct problems caused by the first one.
The voice of experience
Our survey, conducted in February 2006, included 1,001 adults who had received a new hip, knee, or both knees at any time
between 2000 and 2004. (We did not ask about shoulder replacement, a less common procedure, nor about partial knee replacements.)
More than 70 percent had the surgery because of osteoarthritis; other reasons included fractures, traumatic injuries, and
rheumatoid arthritis, a less common form of arthritis that stems from autoimmune causes.
In line with population-wide figures, about 40 percent had hip replacements and 60 percent were given new knees. The average
age was 71 for both hip and knee patients, but 15 percent were under age 60 and 3 percent were under 50. Two-thirds were women.
Don't wait too long. The conventional medical advice has been to delay joint replacement as long as possible to avoid a second operation when
the original artificial joint wears out, typically within 10 to 20 years. Our survey suggests this strategy may have disadvantages.
Respondents with the most severe and long-standing disabilities at the time of their surgery fared much worse than people
who underwent surgery when they were less impaired. The group whose severe arthritis-related disabilities dated back a decade
or more before surgery had greater pain during recovery, were more than twice as likely as everyone else to still be using
pain medication a year after surgery, and were significantly less able to walk even a short distance after a month.
Recent improvements in implant design and materials, including a stronger, more durable type of plastic called cross-linked
polyethylene, have made premature wear-out and the risks of subsequent surgery less of a concern. And new evidence of safety
risks from popular anti-inflammatory drugs, such as rofecoxib (Vioxx), now off the market, and celecoxib (Celebrex), still
available, has made patients uneasy about staying on such drugs for years at a stretch.
“You certainly don't want to rush to having surgery without going through the normal algorithm of treatment first--lifestyle
changes, some use of anti-inflammatory medications,” says Richard Berger, M.D., an orthopedic surgeon at Rush-Presbyterian-St.
Luke’s Medical Center in Chicago, who replaces some 800 knees and hips per year. “But if the joint is still bothering you
every day, or most days, it's probably time to do something.”
He added: “If you wait too long, it not only becomes harder to fix, but you may do permanent and irrevocable damage to the
joint, and it may never function as well or feel as good again as it used to. What I tell my patients is that when you stop
running your life and your knee or your hip starts dictating to you what you can and can't do, that's a good time to have
surgery.”
Berger says it's not uncommon for him to operate on a 45-year-old with knee arthritis from an old sports injury who has opted
for surgery instead of enduring another decade or two of popping pain pills and restricting leisure activities.
In general, you should discuss surgery with your doctor, or see an orthopedic surgeon, if you experience the following:
• The pain makes it difficult or impossible to sleep at night.
• Medication doesn't alleviate the pain or has produced unacceptable side effects, such as stomach bleeding or ulcers, increased
blood pressure, fluid retention, or reduced kidney or liver function.
• You have trouble with basics such as getting out of a chair or off the toilet, using the stairs, or taking a bath.
• The pain rules out everyday activities such as visiting friends, shopping, taking a trip, or doing low-impact exercise.
Lose weight if you need to. Some surgeons won't operate on patients above a certain body-mass index (BMI). That has sparked some controversy because
obese individuals often have the direst need for a new joint--because of the added strain the extra weight puts on the worn-out
one--and the least ability to exercise to burn calories. (Indeed, 53 percent of our respondents were obese, with a BMI of
30 or more.) The surgeons' rationale is that obesity increases the risks of surgery and slows recovery.
Other studies have shown that the heaviest patients, with a BMI of 35 or more, have more postsurgical complications or worse
outcomes than thinner people. In our survey, respondents in that weight category didn't report more immediate postsurgical
problems, such as infections or blood clots, than svelter respondents, nor more long-term complications. However, we don't
know what their BMIs were at the time of surgery, only at the time we surveyed them one to six years later.
People in that heaviest group took significantly longer after surgery to negotiate stairs or walk a half-mile, and were overall
not as healthy as the others. Still, they were just as satisfied with their operations in the long run.
The bottom line is that if you're obese, presurgical weight loss may enhance your recovery. If pain makes most physical activity
impossible, focus on cutting calories. Experts also recommend substituting water exercise or riding a stationary bike for
painful weight-bearing activity.
Incidentally, don't expect to magically lose weight after surgery just because you can move more easily on your new joint.
Studies show that weight gain often occurs after joint-replacement surgery, regardless of mobility. Researchers aren't yet
sure why, but “it's probably the same factors that caused them to become obese in the first place--dietary patterns and lifestyle
choices,” says Thomas R. Turgeon, M.D., an orthopedic surgeon in Winnipeg, Manitoba, who has researched joint-replacement
surgery in obese populations.
Recovery Rate After
Hip or Knee Replacement
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Percent able to do specific activities on their own
1 month after surgery
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Ask your doctor or physical therapist to help you devise a program of joint-safe daily aerobic exercise, and watch your calorie
intake. Many studies have shown that short of taking up marathon running, it's nearly impossible to lose a significant amount
of weight through exercise alone. People with long-standing severe obesity might also consider joining a formal, medically
supervised weight-loss program.
Find a qualified surgeon. About 5 percent of our respondents required additional surgery to fix a problem arising from the original operation; not
surprisingly, they were among the least satisfied with the surgery. That highlights the importance of finding a surgeon who's
qualified and experienced with the procedure you need.
Our medical consultants recommend choosing a surgeon who does no fewer than 50 per year of the procedure you're seeking. Another
useful strategy: Look for someone who does only hips and knees, and nothing else--or at least whose practice focuses on those
joints. Be suspicious if the doctor's office doesn't provide that information or gives vague answers.
Choosing an experienced surgeon is especially critical if you're contemplating a new, relatively uncommon type of procedure
called minimally invasive joint-replacement surgery, which involves smaller incisions and the use of remote viewing scopes.
Some, though not all, studies have shown it may quicken recovery and reduce pain, but it's more difficult to perform because
the surgeon can't directly see the joint.
Don't worry about these things. One surprising finding from our survey was that certain factors we thought might have a bearing on pain or long-term outcomes
didn't seem to make much difference. Whether patients had regional or general anesthesia had no bearing on their postsurgical
complications, short-term pain relief, or ultimate recovery. (Other research suggests that patients given regional anesthesia
recover more quickly.)
Patients reported the same degree of postoperative pain relief from oral medication, an intravenous pump they could control
themselves, or intravenous medication administered by a nurse.
Though other research has found that having one knee replaced at a time results in fewer complications than having both done
at once, our respondents who had both knees replaced at the same time had an experience almost indistinguishable from that
of single-knee recipients.
Take steps to prevent infection. Precautions include making sure you receive an intravenous dose of preventive antibiotics in the hour before surgery--a crucial
step that's timed wrong in about half of cases, research suggests--and more antibiotics for the first 24 hours afterward.
Anyone who touches you should first wash their hands with soap or an alcohol-based solution, even if it means reminding them
directly. Ask your doctor whether it makes sense in your case to use a special surgical blanket or other techniques to keep
you warm, since the drop in body temperature that occurs during surgery can impair immune function and make infection more
likely.
Because you're bound to be somewhat groggy for at least part of your hospital stay, try to have a friend or family member
on hand to run interference for you.
Plan for your discharge. However well you ultimately recover, you can expect to be at least somewhat disabled the first week or two after the surgery.
If you live alone or have a partner with limited ability to assist you, you may require a stay at an inpatient rehabilitation
center after your hospital discharge, as about a third of our respondents did. Otherwise, you'll need a friend or relative
with you at home to help with basic tasks such as bathing, dressing, and meals. Make sure someone at the hospital briefs you
and your caregiver on your postoperative care and medication regimen and that you understand exactly where and when you'll
have physical therapy.
Physical therapy is all-important. Of all the variables we asked about, complying with the exercises and activity prescribed by the physical therapist was one
of the strongest predictors of how patients fared after the surgery. Respondents who said they followed the physical therapist’s
advice “completely” were only half as likely to still need pain medication after a year as those who followed the therapist's
advice “somewhat” or “not at all.” They also walked on their own considerably sooner, suffered fewer complications during
recovery, and were significantly more satisfied with the surgery overall.
If you find an assigned exercise painful, ask your therapist to watch you to make sure you're doing it correctly, or to prescribe
alternative moves. Warm up before a home-exercise session with 10 minutes of gentle aerobic movement, such as riding a stationary
bike or walking in place; a cold pack can help soothe discomfort afterward. If you're using pain medication, time the dose
to coincide with your exercise sessions.
If motivation presents the biggest barrier, enlist a friend or relative to provide gentle reminders. Most importantly, accept
that to get the most out of your therapy, you have to make an effort. “It's hard work. That's the bottom line,” says Kirsten
Moisio, P.T., Ph.D., an assistant professor in the Department of Physical Therapy and Human Movement Sciences at Northwestern
University.
Also see our reports on arthritis and arthritis supplements.
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